ALL PROVED OF VALUE & ARE STILL IN CURRENT USE IN VARIOUS CENTERS

Transcription

1 OPERATIVE OUTCOME AND AUDIOLOGICAL EVALUATION OF FAT MYRINGOPLASTY A. Prof. HANI EL GAREM University of Alexandria INTRODUCTION 2

2 AETIOLOGY OF TYMPANIC MEMBRANE PERFORATION INFECTIOUS 1. Acute suppurative otitis media: results in small perforations through which purulent materials discharge. These usually heal spontaneously unless complicating factors exist. 2. Acute necrotizing i otitis media: characterized by ischemic necrosis leading to sloughing of a large portion of the drum 3. Mycobacterial: Usually results in multiple small perforations that subsequently coalesce. 3 AETIOLOGY OF TYMPANIC MEMBRANE PERFORATION TRAUMATIC 1. Penetrating trauma from manipulation of the ear canal. 2. Blunt trauma;from sudden alterations in air pressure (blasts,slap to auricle) 3. Iatrogenic: most common is after tympanostomy tube insertion. 4

3 HEALING OF TYMPANIC MEMBRANE PERFORATION Stenfors et al.: Healing is a three-stage process: 1. First, the hyperplastic p squamous epithelium exhibits excessive keratin production resulting in a keratin- covered gap. 2. Second the perforation is closed by proliferation of squamous epithelium. 3. In the third stage, the three-layered structure of the tympanic membrane is re-established. 5 HEALING OF THE GRAFTED TYMPANIC MEMBRANE Reijnen and Kuijpers 1971 noted that, in grafted tympanic membrane, mesenchymal growth into the graft precedes proliferation of the overlying epithelium that bridges the gap. 6

4 HISTORICAL REVIEW Banzer 1640: Closure of the perforation with a graft from pig's bladder. Toynbee 1852: Repair using gutta percha,a sustance similar to rubber. Berthold ld : Full llthi thickness skingraft graft. Introduction of the term myringoplasty. Wullstein and Zollner 1951: Re-introduction myringoplasty and tympanoplasty. 7 of GRAFT MATERIALS AUTOGRAFTS Periosteum(Claros-Domenech 1959). Autologous vein (Shea 1960). Fat (Ringenberg 1962) Perichondrium (Goodhill 1963). Connective tissue (Portmann 1964). All proved of value and are still in current use in some centres. ALL PROVED OF VALUE & ARE STILL IN CURRENT USE IN VARIOUS CENTERS 8

5 Cadaveric GRAFT MATERIALS ALLOGRAFTS AND HOMOGRAFTS Leigh 1966). dura (Preobrazkenski 1961,Allbrite Homologous pericardium (Trombetta 1963). Homologous vein (Nickel 1963) and Cadaveric tympanic membrane (Chalat 1964,Marquet 1966). Formaldehyde preserved fascia. Sclera (Pope 1977). 9 NEWER GRAFT MATERIALS Alloderm: treated acellular human dermis that does not carry the risk for disease transmission. Gelfilm: has been used for small post- tympanostomy tube perforations. 10

6 FAT MYRINGOPLASTY Ringenberg g 1962,Sterkers 1964: used compressed fat as underlay or overlay graft. Ringenberg noted that ear lobule fat contained more fibrous tissue than either abdominal fat and buttocks fat. This should provide a denser scaffold for healing. Subsequent studies used the fat plug technique using fat from the ear lobule, abdominal wall, upper thigh and pretragal area. 11 FAT MYRINGOPLASTY Success rates in published series: 1. Ringenberg 1978:86 86% 2. Terry et al.: 1988:76 76%. 3. Gross et al : 84.7% 4. Kaddour et al. 1992:80 80%. 5. Deddens et al. 1993:89 89% 6. Mitchell et al. 1997: 92% 7. Ayache et al 2003: 91%(endoscopic appraoch 12 using abdominal fat)

7 FAT MYRINGOPLASTY HISTOLOGY OF FAT MYRINGOPLASTY Gold and Chafoo 1991: cross section of healed guinea pig tympanic membrane after fat myringoplasty consisted of a normal looking outer epithelial and inner mucosal layer around a thick bulge of fat cells with avariable amount of fibrous tissue. 13 AIM OF THE WORK 14

8 AIM OF THE WORK To evaluate the operative outcome and audiological results of fat myringoplasty. To compare two different types of fat (ear lobule fat and abdominal wall fat) as a graft material. 15 PATIENTS AND METHODS 16

9 PATIENTS AND METHODS THE STUDY WAS CARRIED ON THIRTY PATIENTS SELECTED AMONG PATIENTS ATTENDING THE ENT OUTPATIENT CLINIC,ALEXANDRIA UNIVERSITY HOSPITAL. 17 STUDY GROUPS The study was carried on two randomly selected groups 1. Group A: fifteen patients who have undergone fat myringoplasty y using ear lobule fat. 2. Group B: fifteen patients who have undergone fat myringoplasty using abdominal a wall fat. 18

10 SELECTION CRITERIA 1. Dry central tympanic membrane perforations not exceeding 30%of the pars tensa. 2. Pure tone audiometry showing conductive hearing loss with an ABG not exceeding 25 db in the studied ears. 3. Cases with history of previous myringoplasty or with uncontrolled systemic diseases were excluded. 4. All studied ears were dry for aleast two weeks before the operation. 19 SELECTION CRITERIA Otoendoscopic picture of a small anteroinferior i 20 perforation

11 PREOPERATIVE EVALUATION HISTORY: Aetiology and duration of the perforation. To exclude cases with previous myringoplasty in the studied ears. Systemic y diseases. EXAMINATION: Size and site of the perforation. Tuning fork Rinne and Weber tests. attempts 21 at PREOPERATIVE EVALUATION AUDIOLOGICAL ASSESSMENT: Pure tone audiometry using clinical i l audiometer Interacoustics model AC 33. Transient evoked otoacoustic emissions TEOAEs using ILO-96 Otodynamics analyzer. 22

12 OPERATIVE PROCEDURE ANAESTHESIA : All cases were operated under general anaesthesia. HARVESTING OF EAR LOBULE FAT: Ear lobule was infiltrated with 1% xylocaine with 1/100, adrenaline. Incision along the posterior aspect of the ear lobule. Fat was obtained by sharp dissecting scissors,the size of the graft taken was twice the size of the perforation. The ear lobule incision was closed using interrupted 4-0 silk sutures. 23 OPERATIVE PROCEDURE HARVESTING OF ABDOMINAL WALL FAT: A 1 cm transverse incision in the left lower abdominal quadrant. Fat was harvested by sharp dissecting scissors. Abdominal incision was closed in two layers. The fat plug harvested in either way was kept in sterile insertion. i saline solution until the time of 24 its

13 OPERATIVE PROCEDURE Technique of fat myringoplasty: Endomeatal approach via an ear speculum. The longest diameter of the perforation was measured using custom-made made calibres

14 27 OPERATIVE PROCEDURE The edges of the perforation were excised using a sharp needle and cup forceps. The fat plug was placed through the perforation and then pulled back partially to ensure eversion of the perforation edges. 28

15 OPERATIVE PROCEDURE The plug is thus positioned so that it fills the depth of the middle ear with asmall part lateral l to the tympanic membrane. The ear canal was packed with gel foam moistened with antibiotic solution. 29 POST OPERATIVE CARE Patients were discharged from hospital six hours following the operation. Post operative antibiotics were (ciprofloxacin 500 mg b. i.d for prescribed adults and amoxicillin-clavulanicclavulanic 625 mg t.i.d for cases <18 yrs).paracetamol was prescribed for analgesia. Sutures of either the ear lobule or abdominal incision i i were removed one week post operative. 30

16 POST OPERATIVE FOLLOW UP POST OPERATIVE VISITS WERE SCHEDULED AT THREE WEEKS, SIX WEEKS, THREE MONTHS AND SIX MONTHS POST OPERATIVE. 31 ASSESSMENT OF THE RESULTS Clinically: cases were examined as regards Graft take. Drum mobility. Tuning fork tests. Audiologically: cases were tested at six months post operative by Pure tone audiometry. Tympanometry. y 32 Transient evoked otoacoustic emissions.

17 RESULTS 33 Successes 80.0% Successes 73.3% 3% Group A Failure 20.0% Group B Failure 26.7% Comparison between the two studied groups regarding to the fate of the graft take.

18 Otoendoscopic picture of fth the fat plug at t3 weeks 35 post operative. Otoendoscopic picture of the fat plug at six months post operative. 36

19 Successes 50.0% Successes 90.0% Failure 10.0% 0% < 2 mm Failure 50.0% > 2 mm Graft take in relation to the diameter of the perforation Group A Group B Successful case Closed air bone gap 0 Residual ABG 5dB Residual ABG 10 db Comparison between the two studied groups regarding post operative pure tone audiometry.

20 Group A Group B % A B C Comparison between the two studied groups regarding post operative tympanometry at 6 months post operative. RECOMMENDATIONS 40

21 RECOMMENDATIONS Fat myringoplasty y can be safely performed in cases with small dry perforations and asmall air bone gap. The ear lobule constitutes a convenient source of the fat plug. Proper selection of cases is necessary to obtain satisfactory results. Cases with a large air bone gap or with an apparently atrophic drum remnant are better treated with formal tympanoplasty. 41 RECOMMENDATIONS Further studies are recommended to compare the fat plug technique with conventional myringoplasty y. 42

22 THANK YOU 43