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oplasty/Ossiculoplasty

Z Core Messages • Preoperative assessment of the patient as well • • • •

as the hearing loss is important to determine the need for surgery. Control of the disease process is necessary before reconstruction of the sound transmission system. Medial onlay grafting of the tympanic membrane is preferable to lateral onlay techniques. Reconstruction of the middle ear is based on ossicular or acoustic coupling. Bone is preferred as a graft in ossicular coupling.

Numerous techniques have been described for repair of the sound conducting mechanism. However varied these techniques are, those that are successful adhere to certain basic principles. These principles are outlined in this chapter and the surgical technique illustrated with videos. The principles of tympanoplasty/ossiculoplasty can be divided into five sections: (1) evaluation of the patient, (2) Eustachian tube function, (3) control of middle ear and mastoid disease, (4) repair of the soundconducting mechanism, and (5) postoperative care.

2.1

Evaluation of the Patient

For patients who are over the age of 65–70 years, medical status is of prime importance. The presence of coexistent disease such as diabetes mellitus, cardiovascular disease, neurologic disease, etc., would affect the feasibility of elective tympanoplasty. A patient who represents an anesthesia risk is not a candidate for elective surgery. Medical conditions associated with small-vessel compromise may deter healing and the functional result. The coexistence of a significant sensorineural hearing loss component, with the conductive compo-

nent caused by the middle ear pathology, limits the auditory rehabilitation provided by successful middle ear reconstruction. This leaves a patient still dependent on amplification for communication purposes. A decision to perform elective surgery is an individual consideration between the patient and surgeon, and the patient’s expectations should be based on an honest and realistic presentation of the proposed surgery and what it can provide.

2.2

Eustachian Tube Function

Since a practical reliable test of Eustachian tube function is not available [7, 12, 20], one must rely on other factors such as history and the ability of the patient to autoinflate the middle ear space to gain insight to this important factor. In patients with a repaired cleft palate, the likelihood of poor Eustachian tube function usually represents a contraindication to elective surgery. In patients with normal palatal anatomy—the ability to autoinflate the middle ear—may indicate a patent Eustachian tube, which can maintain an aerated middle ear space. The response to autoinflation by the patient may be detected by the use of an ear insert connected by an auditory tube to the examiner’s ear, or may be visible movement of a residual tympanic membrane segment. Although the ability to autoinflate the middle ear does not imply normal Eustachian tube function, the failure to detect such a response should be a contraindication to elective surgery.

2.3

Control