Tympanoplasty

• Definition

• Classification

• Definition– Surgery for reconstruction of tympnic

membrane and/or ossicles

• Classification– Wullstein (1956)– Austin and Kartush

Wullstein

1

2

3

4 5

Middle ear risk index

• MERI to predict the success rate.

• For accurate prediction of the results of ossiculoplasty the status of middle ear and its ossicles must be ascertained. – Austine Kartush classification– TM perforation– Cholesteatoma– Belluci classification

Austine Kartush

• Group A - Malleus and stapes present

• Group B - Malleus and foot plate of stapes present

• Group C - Malleus absent and stapes present

• Group D - Malleus and stapes suprastructure absent

Austine Kartush

• Kartush added 3 more classes as a modification of this scheme in include ossicular fixity even when all three ossicles are present.

• O - Intact ossicular chain

• E - Ossicular head fixation

• F - Stapes fixation

Belluci classification

MERI

• Indications

• What are you trying to achieve?

Indication

– TypeI-perf/ discharge/ conductive loss/

– Types II-IV-perf/ significant conductive loss/ part of middle ear surgery for cholesteotoma/ CSOM/

– TypeV-stapes footplate fixation

Contracindiction– no cochlear function– Neoplasm of middle

ear or EAC– Malignant OE – Only hearing ear or sig

better H Ear

• Relative contra – EU dysfunction, very

young– Chonic ear discharge– If no sig hearing

improvement possible with no hx of CSOM

– Pt factors-smoker etc, diabetes

• Patient assessment– History– Examination– Investigations

What is:

• Belfast rule of thumb?

• Glasgow benefit plot

What are these?

What is a TORP? PORP?

Common situations - options

• Simple perforation (1)

• Austin A M+S+ (1)

• Austin B M+S- (?)

• Footplate fixed (3)

• Austin D M-S- (4)

• What are prognostic factors?– Black SPITES– Or MER

Prognosis

Risk Factor Risk Value

Otorrhea (Belucci)

I. Dry 0

II. Occasionally wet 1

III. Persistently wet 2

IV. Wet, cleft palate 3

Perforation

Absent 0

Present 1

Cholesteatoma

Absent 0

Present 1

Ossicular status (Austin/Kartush)

O: M+I+S+ (intact ossicular chain) 0

A: M+S+ (malleus present, stapes present) 1

B: M+S- (malleus present, stapes absent) 2

C: M-S+ (malleus absent, stapes present) 3

D: M-S- (malleus absent, stapes absent) 4

E: Ossicle head fixation 2

F: Stapes fixation 3

Middle ear - Granulations or effusion

No 0

Yes 1

Previous surgery

None 0

Staged 1

Revision 2

Prognosis/Risk MER Index

Best prognosis (normal ear) 0

Mild risk 2

Moderate risk 5

Severe risk 7

Worst prognosis (end stage) 12

• Postoperative care

• Results

• Complications