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ORL 36 : 170 178 (1974)
Permanent Middle-Ear Aeration in Tympanoplasty
M irko T os
ENT Departments of the Glostrup Hospital (Head: Dr. S. J ohnsen ), Glostrup, and
the Gentofte Hospital (Heads: Prof. N. R iskaer, Dr. G. Salomon and Dr. M. Tos),
Abstract. Tympanoplasty was combined with tubu­ Key Words
lation of the drum remnant with grummets in 74 Tympanoplasty
patients with severe adhesive changes in the middle
Middle-ear aeration
ear. 40 ears were dry at the time of operation, 34 were Tubulation
chronically discharging, and in such cases mastoidec­ Grummets
tomy with cavity obliteration and tympanoplasty were Late results with tubulation
performed in the same session. The initial results Late results in adhesive ears
(3-9 months after the operation) and later follow-up
results (18 months to 4 years later) are presented and discussed in relation to tubal
function. As a rule, the tubule was expelled 2—4 months after the operation, but
during the postoperative period it contributed to aeration of the middle ear and
prevented atelectasis, especially in patients whose Eustachian tube was not passable
in Valsalva’s maneuver after the operation. Initially after the operation the mean
hearing was 29.7 dB, at late follow-up 33.2 dB. The relatively slight decrease in
hearing at late follow-up may be ascribed to the favorable effect of tubulation
during the postoperative period.
Reccived: October 31, 1973; accepted: November 2, 1973.
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The main problems in tympanoplasty are a reduced tubal function and
an abnormal middle-ear mucosa. Owing to a compromised aeration of the
posterior part of the tympanic cavity, this site is apt to develop adhesions,
retraction, and fixation of the new drum with aeration of the niches lack-
ing. Reduction of tubal function and abnormality of the mucous mem­
brane often coexist and are interdependent. A thickened, swollen, and
secretory mucosa in the tympanic cavity and Eustachian tube will ag­
gravate tubal function, and reversely a chronic reduction of tubal
function will lead to metaplasia of the mucosa with formation of
mucous glands, an increased goblet-cell density, and an increased secre­
tion of mucus.
The risk of adhesions due to reduced tubal function is particularly
marked during the first weeks after tympanoplasty, and several methods
for improving tubal function during this period have been suggested. One
is insertion of a polyethylene tubule from the tympanic cavity through
the Eustachian tube and nose [Z ollner, 1963], It may be imagined that
the tubule will suffer damage due to pressure necrosis, aggravating tubal
function after removal of the tubule. Another method calls for retroauricular insertion of a polyethylene tubule into the antrum [Siirala,
1964] or further through the chorda-facialis angle to the mesotympanum
[Pt.ESTER, 1971], Both methods presuppose mastoidectomy. The tubule
may be inserted into the antrum [Silversiein , 1970] from the auditory
canal through an opening in the posterior osseous meatal wall but with­
out mastoidectomy. In cases of a completely blocked Eustachian tube,
a tympano-maxillary shunt has been tried [D rettner and E kvall,
1970], inserting the tubule from the antrum anterior to the ear
through the posterior wall of the maxillary sinus. Transtemporal widen­
ing of the osseous Eustachian tube has been attempted by H ouse el al.
Since 1969, I have used tubulation of the drum remnant by grummets,
widely employed since A rmstrong [1954] first described it in treatment
of chronic secretory otitis media in the stage of secretion. This paradoxical
treatment, in which the drum perforation is closed with fascia and a new
perforation is created simultaneously at another site of the drum, has the
great advantage of being simple. Due to encouraging primary results in
20 patients with typical adhesive otitis in the terminal stage treated by
tympanoplasty and tubulation [Tos, 1972], this method was used on other
groups of patients, especially those with discharging ears. The initial and
late results of this treatment are presented below. It is important to
establish whether tubulation at the time of tympanoplasty prevents
occurrence of adhesive changes in this material, which has a doubtful
prognosis, or whether occurrence of adhesive changes is merely delayed
to a later date after the tubule has been expelled.
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The malarial comprises 74 patients. 40 had dry ears at the time of operation.
Within this group 38 had chronic adhesive otitis in the terminal stage, and 2 had
sequelae to otitis. All were treated by tympanoplasty without mastoidectomy. The
principle of tympanoplasty in patients with adhesive otitis was: (1) radical removal
of the retracted, thin and inelastic drum which was replaced by fascia; (2) preservation
of as much mucosa as possible, even though it was invariably abnormal; (3) inspection
and opening of the tubal orifice and bouginage of the tube by a 0.5-, 0.75-, or 1-mm
soft rubber bougie; (4) mobilization of the ossicles and ossiculoplasty enlarging the
tympanic cavity; (5) careful removal of adhesions and cholesterol granulomas,
especially around the stapes which was enveloped by two small pieces of Silastic film,
and (6) inspection of the antrum or attic in half the cases, removal of adhesions
mobilization of ossicles.
34 patients had chronic discharge which had refused to yield to conservative
preoperative management. Of these 34 patients, 15 had cholesteatoma and 19 had
chronic granulating otitis. Both groups showed a high predominance of adhesive
middle-ear changes with retraction of the drum remnant, adhesions, cysts, and
cholesterol granulomas in the middle ear, granulating thickened and secretory mucosa,
and the presence of mucopurulent secretion. These cases had mastoidectomy with
total or partial removal of the posterior osseous metal wall, but the bridge was
often preserved as a narrow rim. Tympanoplasty was always carried out in the
same session; the auditory canal was often widened and reconstructed with fascia,
the cavity obliterated by a pedicled flap of subcutis muscle.
The ossicular chain was intact but fixed in 22 ears. Type I tympanoplasty was
performed. The long process of the incus was absent in 35 cars. Type II tympano­
plasty was performed, as a rule with interposition of the incus. The long process
of the incus as well as the stapes superstructure were missing in 17 ears. Type III
tympanoplasty was performed, as a rule using the incus as columella between the
footplate and drum.
Tubulation was carried out before perforation of the drum was closed by fascia.
In cases with large perforations, the tubule was inserted quite peripherally, often just
below the anterior fold of the malleus at which site it was attempted to preserve
the drum. In other cases it was inserted inferiorly, anteriorly, or quite posteriorly
to aerate the posterior part of the tympanic cavity. The drum was not de-epithelialized
at the site where the tubule was inserted, and the fascia was placed at a certain
distance from the tubule. Epithelialization of the fascia from the drum remnant
could proceed unhindered.
From the 7th postoperative day, the patients ventilated the middle ear twice
daily by means of Valsalva's maneuver. As a rule, the tubule was expelled between
the 2nd and 4th months after the operation. The patients were followed for 3-9
months and then dismissed. The last audiogram at the end of this follow-up period
in the 500-2,000 cps frequency group forms the basis of the initial result. From
October, 1972, to March, 1973, the patients were seen again. Thus, the briefest
follow-up period was 18 months after the operation and 1 year after expulsion of
the tubule. The longest follow-up period was just over 4 years. The audiogram
taken at this follow-up examination forms the basis of the late result.
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Material and Operative Methods
Permanent Middle-Ear Aeration in Tympanoplasty
The initial and late results are presented in table 1. The late results
were somewhat poorer than the initial ones. In particular, the percentage
of patients who obtained social hearing fell from 64 to 50. The hearing
gain method showed that 34% primarily attained a hearing gain in the
500-2,000 cps frequency group of more than 30 dB and 87 % of more
than 10 dB. At the late follow-up, 23% still had a hearing gain exceeding
30 dB and 68% of more than 10 dB. In the case of speech audiometry,
65 % of the patients had an SRT (speech reception threshold) of 30 dB
or more at the late follow-up examination. Functional success of the
tympanoplasty was found at the late follow-up in 60 patients (81 %).
These were patients who obtained either social hearing (37 patients),
closure of an air-bone gap within 15 dB (10 patients), or a hearing gain
of more than 20 dB within the 500-2,000 cps frequency group (10 pa­
tients) or an SR I' of 30 dB or more (3 patients).
Initially after the operation, the mean postoperative hearing was
29.7 dB, the mean hearing gain 24.5 dB (table II). At the late follow-up,
the mean hearing was 33.2 dB and the mean hearing gain 20.8 dB as
compared with the hearing prior to operation (table III). The fall in the
initially tested mean hearing was only 3.5 dB, possibly because tubulation
prevented occurrence of adhesive changes in the middle ear.
Tubal passage was assessed before as well as after the operation and
at follow-up by means of Valsalva's maneuver in which the indicator was
auscultation in the auditory meatus, otoscopy with or without Siegle’s
otoscope, or, as a rule, inspection under the operation microscope. It was
also possible to record slight changes of the drum by the last method in
cases with a very small tympanic cavity consisting of only the tubal
orifice. Tympanometry [T erkildsen , 1962] was performed on patients
with adhesive otitis without perforation and on atelectatic ears. It showed
a blind curve in most cases. However, an impassable tube in Valsalva’s
maneuver or a blind curve in tympanometry were not contraindications to
tympanoplasty, but suggested special attention to the findings in the tubal
orifice during the operation. Prior to the operation the Eustachian tube
was passable in Valsalva’s maneuver in 33 cases (table II) and early after
the operation in 55 cases, indicating that tubal function improved in quite
a number of cases. At follow-up, an impassable tube was found at Val­
salva’s maneuver in only 12 patients (table III).
The initial results were approximately the same in patients with and
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Table I. Initial and late results assessed by various criteria in 74 cases subjected to
tympanoplasty and tabulation (frequency range 500-2,000 cps)
Criteria, dB
Before operation,
Initial results,
Late follow-up,
Social hearing (0-30)
Air-bone gap
> 45
Hearing gain
> 30
> 20
> 10
No gain
Deterioration 1-10
SRT 0-30
Valsalva’s maneuver
of cases
Mean post­
hearing, dB
gain, dB
Passable before and initially
after operation
Not passable before, but initially
after operation
Not passable either before or
initially after operation
Total, mean
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Table II. Initial results of tympanoplasty with tubulation in relation to tubal passage
in Valsalva’s manoeuvre before and 3-9 months after operation
Permanent Middle-Ear Aeration in Tympanoplasty
of cases
gain, dB
Not passable initially after
operation but at late follow-up
Not passable either initially after
operation or at late follow-up
Valsalva's manoeuvre
Passable initially after operation
and at late follow-up
Passable initially but not at
late follow-up
Total, mean
without passable tube at Valsalva’s manoeuvre (table II). The good results
in patients who did not have a passable tube either before or initially
after operation must be due to aeration of the middle ear through the
inserted tubule during the first months after operation. The late results
(table III) were considerably poorer in patients whose tubes had not been
passable either initially or at late follow-up. Good results were found in
the 13 patients who did not have a passable tube initially but at late
follow-up; functional success resulted in 92% of these cases. Within this
group, tubulation presumably prevented atelectasis of the middle ear
during the postoperative period while tubal function was poor. When
tubal function improved spontaneously later, their hearing became
relatively good.
In all, then, only six patients did not have a passable tube either
initially after operation or at late follow-up. In one of them, there was an
anatomical obstruction at the isthmus. Another three had a stenotic tube,
but a 0.5-mm bougie could be passed with some resistance to the rhinopharynx. Stenosis was due to a considerably thickened mucosa.
All ears were dry at follow-up. There were seven (9 %) recurrent per­
forations. Five were at the site of the previous perforations and were due
to faulty closure by fascia. Two perforations were at the site of tubulation
and were the same size as the tubule. Both patients had good hearing. Two
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Table 111. Late results of tympanoplasty with tubulation in relation to tubal passage
in Valsalva’s manoeuvre 3-9 months (initially) after operation and at late follow-up
patients had had retubulation after the operation, one of them four times.
In both cases mucus was found in the middle ear. At follow-up, a total
of five patients exhibited signs of mucus accumulation in the middle ear.
At follow-up, the drum was normal and mobile in 39 cases. The mean
hearing was 25.4 dB and the hearing gain 26.3 dB. In 22 cases the drum
was slightly to moderately retracted but mobile. The mean hearing was
38.0 dB, the hearing gain 18.4 dB. In six cases the drum was severely
retracted and completely immobile. The mean hearing was 52.8 dB, hear­
ing gain only 12.7 dB.
Tubulation combined with tympanoplasty seems to be able to help a
number of patients during the postoperative period and prevent renewed
retraction and fixation of the drum. The method is simple and does not
cause the patient discomfort. However, it is difficult to tell how often the
tubulation was of decisive importance, as the result was also influenced
by several other factors. At any rate, tubulation was of importance in
patients who were unable to ventilate the middle car by Valsalva’s
maneuver during the preoperative period (table II), and indeed the results
were fairly good in this group. By way of comparison, it may be mentioned
that a primary mean hearing gain of 29.9 dB and a functional success of
87% were found in six patients with chronic adhesive otitis whose
Eustachian tube was not passable at Valsalva’s maneuver after operation
and in whom tympanoplasty was combined with tubulation, whereas in
nine similar patients who did not have tubulation the hearing gain was
only 5.6 dB and functional success was obtained in only 35% [Tos, 1972],
The late results following tympanoplasty have been poorer than the
initial results in all reported series [P faltz et al., 1962; P alva et al.,
1968; R entzsch , 1969; Tos, 1974]. Therefore, particularly poor late
results would have been expected in the present difficult group of patients
in whom adhesive changes predominated. As demonstrated above, how­
ever, 80% of the patients still exhibited functional success and 68%
a hearing gain exceeding 10 dB at least 1 year after the tubule was ex­
pelled (table I). The initially attained mean hearing fell by only 3.5 dB
and the mean hearing gain was 20.8 dB at follow-up. This indicates that
tubulation prevented postoperative atelectasis of the middle ear in several
cases and that atelectasis did not occur in the great majority of cases after
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Discussion and Conclusion
the tubule had been expelled. After epithelialization of the medial aspect
of the fascia and of mucosal defects in the tympanic cavity as well as after
evacuation of the exudate and mucus, the risk of a renewed permanent
fixation was diminished, although tubal function again deteriorated. How­
ever, the late results were poor in patients who had never been able to
ventilate the ear by means of Valsalva’s maneuver (table III); in these
cases tubulation was unable to contribute to a major permanent hear­
ing gain.
Indications for tubulation were a reduced preoperative tubal function,
marked adhesive changes in the middle ear, and a severely abnormal and
secretory mucosa. More than 400 tympanoplasties were performed from
1969 to 1971. In many of these patients tubulation was desirable but not
practicable, since there was no drum remnant on which to place the
tubule. Extraannular tubulation was attempted in a few cases with total
perforations, but this requires a deep hypotympanum. An attempt was
also made to place the tubule in the fascia before or after it was inserted
into the middle ear. It is rather difficult to manipulate fascia with an im­
planted tubule, and this entails the risk of a larger perforation in the
fascia than required for the tubule, so that the tubule is apt to be expelled
very soon. In cases with total drum perforations, an attempt may be made
to place a tubule into the hypotympanum through a hole interiorly in the
osseous annulus or by one of the methods described by S iirala [1964],
Sieverstein [1970], and P lester [1971].
A secretory, mucus-producing mucous membrane must also indicate
permanent middle-car aeration after the operation. In quantitative studies
of mucous glands on more than 5,000 biopsies removed during tympano­
plasty and mastoidectomy on 491 patients [B ak-P edersen and Tos,
1973], we have found a great density of glands in secretory, adhesive,
and granulating otitis. These glands produce mucus which accumulates in
the middle ear. and patients with a poorly functioning Eustachian tube
may develop symptoms of typical secretory otitis after closure of the
drum perforation.
Tubal function was assessed by Valsalva’s maneuver, which is of great
importance to postoperative ventilation of the middle ear but a somewhat
rough test for finer assessment of function. However, E kvall [1970] and
P alva and K arja [1970] demonstrated that preoperative assessment of
tubal function by the considerably more sensitive aspiration test [F i.isberg et al., 1963; B ortnick , 1966] is unable to give a prognostic in­
dication as to tympanoplasty results.
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Permanent Middle-Ear Aeration in Tympanoplasty
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Bak-P edersen , K. and Tos, M.: Density of mucous glands in various chronic middle
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Bortnick , E.: Simple apparatus to measure Eustachian tube function. Arch, oto-
laryng. 83: 12-13 (1966).
D rettner , B. and E kvall, L.: Chronic obstruction of the Eustachian tube treated
Request reprints from: M. Tos, MD, ENT Department, Gentofte Hospital, 2900Hellerup (Denmark)
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with a tympano-maxillary shunt. Acta oto-laryng., Stockh., suppl. 263, pp. 29-32
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F lisberg , K.; Ingelsted , S., and O rtegren , U.: Controlled ‘ear aspiration' of air.
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H ouse, W.; G losscock, M. E., and M iles , 1.: Eustachian tubaplasty. Laryngoscope
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P alva, T.; P alva, T., and Salmivalli, A.: Radical mastoidectomy with cavity
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