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Pediatric Tympanoplasty

Pediatric Tympanoplasty. Incisions and Decisions. Tympanoplasty. most common otologic procedure in children focus on success rates should focus on decision making timing of surgery technique Eustachian tube health. Tympanoplasty. pediatric tympanoplasty differs from adult: etiology

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Pediatric Tympanoplasty

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  1. Pediatric Tympanoplasty Incisions and Decisions

  2. Tympanoplasty • most common otologic procedure in children • focus on success rates • should focus on decision making • timing of surgery • technique • Eustachian tube health

  3. Tympanoplasty • pediatric tympanoplasty differs from adult: • etiology • growth • importance of audition • surgical results are variable • experiential data

  4. Definitions • myringoplasty • drum • tympanoplasty • drum • middle ear • mastoidectomy • drum • middle ear • mastoid

  5. Tympanic Membrane Healing • normal healing • epithelialization • contraction • growth inhibition

  6. Tympanic Membrane Healing • normal healing • epithelialization • contraction • growth inhibition

  7. Tympanic Membrane Healing • normal healing • epithelialization • contraction • growth inhibition

  8. Tympanic Membrane Perforation • middle ear needs aeration • ET dysfunction • recurrent OM • foreign body

  9. Tympanic Membrane Perforation • middle ear needs aeration • ET dysfunction • recurrent OM • foreign body

  10. Tympanoplasty • set-up for normal repair • initiate epithelialization • diminish obstacles • guide edges

  11. Tympanoplasty • set-up for normal repair • initiate epithelialization • diminish obstacles • guide edges

  12. Tympanoplasty • set-up for normal repair • initiate epithelialization • diminish obstacles • guide edges

  13. Top Ten Tympanoplasty Tips 1. upper respiratory system 2. define the outcome 3. age 4. otorrhea 5. characteristics affects decisions 6. mind the jugular 7. material 8. pull-up don’t push-up 9. craniofacial anomalies 10. durability results from decisions

  14. 1. Upper Respiratory System • ear is a component • Eustachian Tube • mucosa • allergy • irritative • environmental • immunologic

  15. Middle Ear Ventilation

  16. Contralateral Eustachian Tube ½ Pressure ½ Pressure Pressure with swallowing best predictor of success generally paired system

  17. 2. Define Outcome • quality of life • otorrhea • hearing • preservation • restoration

  18. “Successful” Tympanoplasty keratin growing from umbo into Right Ear Perforation, 8 year old boy • surgeon • intact drum • no morbidity • patient/family • ability to swim • symptom resolution • improved hearing

  19. Morbidity • taste disturbance • ear sticks out • noticeable scar • pain • allergic reaction • hearing loss • facial palsy

  20. Morbidity

  21. Relative Contraindications 13year old, stable dry perforation, ++++ anxiety about operations • asymptomatic perforation • unfit for surgery • repeated failures • unfavorable conditions • unstable contralateral ear • cleft palate(?) • smoking

  22. 3. Age age is the only factor which affects rate of success in children

  23. 3. Age 4 year old, no OME burned by arc welding spark 11year old, CLP, bilateral CSOM, failed repair age is the only factor which affects rate of success in children no it’s not!

  24. 3. Age percentage of success 5 10 15 20 age is the only factor which affects rate of success in children no it’s not!

  25. 3. Age age is the only factor which affects rate of success in children no it’s not! yes it is!!

  26. 3. Age age is the only factor which affects rate of success in children no it’s not! yes it is!!

  27. 4. Otorrhea 11year old, CLP, bilateral CSOM, failed repair is the otorrhea causing the perforation? is the perforation causing the otorrhea?

  28. Middle Ear Physiology? Temperature 38oC Temperature 5oC Humidity 30% Humidity 85%

  29. Middle Ear Physiology? Temperature 21oC Temperature 19oC Humidity 47% Humidity 49%

  30. 5. Characteristics of the Perforation • size, position, revision and tympanosclerosis • don’t impact success • impact selection of: • technique • material • timing of OR

  31. Characteristics • difficult characteristics • revision • total/subtotal TM perforation • anterior marginal perforations • tympanosclerosis

  32. Lateral Graft Tympanoplasty with Alloderm

  33. Lateral Graft Tympanoplasty • equal closure rate • “better” closure of air/bone gap

  34. 6. Mind the Jugular Vein elevating the annulus right > left

  35. Mind the Jugular Vein elevating the annulus right > left

  36. Mind the Jugular Vein elevating the annulus right > left

  37. 7. Choosing Materials anterior inferior • temporalisfascia • tragal perichondrium • tragal cartilage • allografts • Alloderm(human dermis) • Surgysis(porcine sub-mucosa)

  38. 7. Choosing Materials anterior inferior • temporalisfascia • tragal perichondrium* • tragal cartilage* • allografts • Alloderm(human dermis) • Surgysis(porcine sub-mucosa)

  39. Butterfly Graft Tympanoplasty • case selection: • <1/3 of drum • minimal contact with malleus • advantages • fast • efficacious

  40. Forming the Graft tragal cartilage one side with perichondrium form it into the shape of a ventilation tube

  41. Forming the Graft tragal cartilage one side with perichondrium form it into the shape of a ventilation tube

  42. Forming the Graft tragal cartilage one side with perichondrium form it into the shape of a ventilation tube

  43. Butterfly Graft Tympanoplasty great technique to have in your arsenal

  44. 8. Pull-Up Don’t Push Down • gelfoam causes middle ear fibrosis • reduced aeration? • prefer to suspend graft • clips • pegs

  45. 8. Pull-Up Don’t Push Down • gelfoam causes middle ear fibrosis • reduced aeration? • prefer to suspend graft • clips • pegs

  46. 8. Pull-Up Don’t Push Down • gelfoam causes middle ear fibrosis • reduced aeration? • prefer to suspend graft • clips • pegs

  47. Pegged Graft

  48. Lifting the Tympanic Membrane standard 12 to 6 tympanomeatal flap

  49. Lifting the Tympanic Membrane graft pulled into a straight line to peg

  50. Lifting the Tympanic Membrane standard 12 to 6 tympanomeatal flap extended flap for inferior perforations

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