INTRODUCTION DISCUSSION

RESULTS

METHODS AND MATERIALS CONCLUSIONS

REFERENCES

CONTACT

Objectives: To evaluate the anatomical and audiological results of the endoscopic tympanoplasty with tragal perichondrium graft. Methods: A case series in patients with chronic otitis media, treated with transcanal endoscopic tympanoplasty by the technique under-over, followed by six months post treatment clinical and audiometric evaluations, in the Department of Otolaryngology, National Hospital Arzobispo Loayza, Lima - Peru between 2007 and 2011. Results: Of a total of 64 patients, 31 met the inclusion criteria. 20 were males (64.5%), the mean age was 43,3 years. The left ear was the most affected with 61.3%. Only 12.9% had retraction pocket. Perichondrium graft was used in 87.1%, and tragal cartilage with perichondrium with the others. There was complete closure of the perforation in 93.5% and only 2 complications, infection and perforation. The difference of the mean of the audiometries by air previous (39.1 ± 5.8) and posterior (30.2 ± 7.2) of surgery was significant (p = 0.0001). The difference of the air-bone gap previous (13.1 ± 4.9) and posterior (4.3 ± 2.3) of the surgery was significant (p = 0.0001). Conclusions: The endoscopic tympanoplasty improves the audiometric levels and the gap in post-surgery patients, allows the complete closure of the perforations and less complications in the present series. This work bears no conflict of interest.

From a total of 64 patients, 31 met the inclusion criteria. 20 were male (64.5%), mean age was 43.3 years, with a range of 8-67 years. The left ear was the most affected with 61.3%. Only 12.9% had bag retraction. Regarding the type of graft, perichondrium was used in 87.1%, and cartilage with perichondrium with others. There was complete closure of the drilling 93.5% and only 2 complications (one case of infection and one residual drilling). The mean of the difference of audiometry by air, was pre (39.1 ± 5.8) and post surgery (30.2 ± 7.2) was significant (p = 0.0001). The difference in the gap between air and bone pathways pre (13.1 ± 4.9) and after (4.3 ± 2.3) surgery was significant (p = 0.0001).

The tympanoplasty type I is a surgical procedure often used in our specialty, of which there are many technical variations with corresponding results. In our study we used the endoscopic surgery performed through the external auditory canal, and is applicable to any type of perforated eardrum. The under-over technique has advantages over other techniques, can be used in tympanic perforations of all sizes and from all quadrants, provides an excellent exposure of the anterior middle ear without blunting, and has a high success rate without reducing the middle ear space. We got complete closure of the perforation (anatomical success) in 93.5%. Two cases were complicated, one with a infectious process and the other with remaining drilling, which was treated in a surgical review. We obtained 100% of auditory success, with a gain between the airway, and narrowing of the gap between pre and postoperative, statistically significant. The results have been very satisfactory compared to other techniques reported.

We evaluated patients with chronic otitis media, operated by transcanal under - over endoscopic tympanoplasty technique, with a minimum follow up of six months after surgery, all of them at the Department of Otolaryngology, National Hospital Arzobispo Loayza, Lima - Peru, between the period of January 2007 and December 2011. We conducted a pure-tone audiometry prior to surgery and other postsurgical, at least six months after the same. To calculate the functional outcomes, we examined differences between pre and postoperative outcomes, as well as the gap between the airways and pre-and postoperative bone. The sequence analysis included descriptive analysis of the variables determining proportions and frequencies, and contingency tables (2x2). Inferential analysis was performed to determine the complications of both surgical techniques through Chi square test.

The endoscopic tympanoplasty improves the audiometric gap between pre and post tympanoplasty patients, and allows the complete closure of the perforation, with the minor complications of the studied series. This study bears no conflict of interest.

The frequency of perforation of the tympanic membrane is estimated between 1-3% of the general population, with a significant hearing loss, being the most widely accepted treatment with tympanoplasty for closure of the perforation and hearing improvement. In tympanoplasty type I or myringoplasty, classically has been done with the use of the surgical microscope and one of the three types of approaches: mainly retroauricular incision in the anterior quadrants drilling, endaural in central perforations or posterior quadrants, and the transcanal approach in smaller and middle holes.

In the endoscopic tympanoplasty, the external auditory canal is used as path in all types of perforations, without external incisions except for making grafts. It also allows a good exploration of the eardrum due to the different angles of the telescopes, which optimize postoperative outcomes. The aim of this study is to evaluate the results of endoscopic tympanoplasty using the technique under - over, as well as the perichondrium graft.

1. J. Karthush, MD et al. Over- Under Timpanoplasty. The Laryngoscope, 112:802-807, mayo 2002.

2. J. Prieto, MD et al. Timpanoplastia: Una visión práctica para el Otorrinolaringólogo general. XI Simposium Internacional de Avances en Otorrinolaringología, Arequipa-Perú, Abril 2003.

3. V. Valdivia MD. Timpanoplastia Under over, Revista Oficial de la Sociedad Peruana de Otorrinolaringología y Cirugía Facial del Perú, Abril, 2004.

4. Marchioni D. et al. Endoscopic tympanoplasty in patients with attic retraction pockets. Laryngoscope. 2010 Sep;120(9):1847-55.

5. R Garfias et al. Timpanoplastía: Revisión y experiencia de 4 años en el Hospital Clínico de la Universidad Católica de Chile. Rev. Otorrinolaringol. Cir. Cabeza Cuello vol.71 no.3 Santiago dic. 2011.

6. Santos S. et al. Criterios para valoración de resultados funcionales en la cirugía de oído medio. Acta Otorrinolaring Esp. 1996;47:15–20.

7. Landa Aranzabal M. et al. Miringoplastia: Onlay versus underlay. Revisión de 460 casos.Acta Otorrinolaring Esp. 1996;47:21–5.

Victor R. Valdivia Calderón Hospital Nacional Arzobispo Loayza

Universidad Nacional Mayor de San Marcos Clínica Internacional

Lima – Perú

Email: vvaldivia2000@gmail.com Phone: 00 511 996359797 Website: rinoplastiaperu.net

Surgical technique: Patient under general anesthesia, infiltration of lidocaine 2% with epinephrine. Tragus perichondrium is obtained as the graft, after suture with nylon 6/0. The entry of the ear canal is with a telescope 4mm, 0, 30, 45 and 70 degrees. After the edge of the perforation is revived (Fig.5), we make an incision and dissection flap tympanomeatal 4mm after the tympanic annulus. The tympanic membrane is raised, the middle ear is explored, and released the handle of the hammer (Fig.6) The graft is placed using the technique under-over, variant of the technique below (under lay). The graft is placed medial to the anterior tympanic remanent and lateral to the handle of the hammer. (Fig. 7, 8) The hemocollagene sponges is placed in layers, medial and lateral to the graft.

Exclusion Criteria

Reconstruction tympanoplasty secondary to radical

mastoidectomy

Exploratory surgery

Traumatic perforations

Fibroadhesive otitis

Inclusion Criteria

• Chronic otitis media without cholesteatoma

• Inactive infection (at least three months)

• All kinds of tympanic perforations

• Complete medical history, 6 months follow-up.

Figure 8. Flap in the under-over technique

Figure 6. incision and dissection of the tympanomeatal flap.

Figure 7. Release of the handle of the hammer.

Figure 5. Tympanic perforation . The edge of the perforation is removed.

Figure 1. Surgical team Figure 2. Post surgical control

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Airway Air-bone GAP

Pre surgery

Post surgery

Auditory gain before and after the surgery

Victor R. Valdivia Calderón, MD1, 2,3; Mónica Hidalgo Venegas, MD2; Juan C. Chaparro Morante, MD1 ,2,3

1Hospital Nacional Arzobispo Loayza, 2Universidad Nacional Mayor de San Marcos , 3Clínica Internacional

Transcanal endoscopic tympanoplasty with tragal perichondrium graft by the under-over technique.

ABSTRACT

Figure 3. Tympanic perforation during the surgery

Figure 4. Flap in the under-over technique