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), Copenhagen 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. Introduction Reccived: October 31, 1973; accepted: November 2, 1973. Downloaded by: Vanderbilt University Library 18.104.22.168 - 10/29/2017 3:45:26 AM 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- Tos 171 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  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. Downloaded by: Vanderbilt University Library 22.214.171.124 - 10/29/2017 3:45:26 AM . 172 Tos 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. Downloaded by: Vanderbilt University Library 126.96.36.199 - 10/29/2017 3:45:26 AM Material and Operative Methods Permanent Middle-Ear Aeration in Tympanoplasty 173 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 Downloaded by: Vanderbilt University Library 188.8.131.52 - 10/29/2017 3:45:26 AM Results Tos 174 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, °/o Initial results, #/o Late follow-up, °/o 7 64 50 1 23 43 33 60 28 12 49 38 12 1 34 49 87 11 3 23 47 68 27 4 1 16 70 65 - 83 81 Social hearing (0-30) Air-bone gap 0-15 16-30 31-45 > 45 Hearing gain > 30 > 20 > 10 1-10 No gain Deterioration 1-10 SRT 0-30 - Success Valsalva’s maneuver Number of cases Mean post operative hearing, dB Mean hearing gain, dB Success Passable before and initially after operation 33 27.5 27.4 85 Not passable before, but initially after operation 22 33.1 27.6 77 Not passable either before or initially after operation 19 31.2 24.5 84 Total, mean 74 29.7 24.5 83 Downloaded by: Vanderbilt University Library 184.108.40.206 - 10/29/2017 3:45:26 AM 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 175 Number of cases Mean hearing, dB Mean hearing gain, dB Success, % 49 32.2 21.8 84 6 34.6 13.3 83 Not passable initially after operation but at late follow-up 13 26.7 13.6 92 Not passable either initially after operation or at late follow-up 6 54.0 10.0 33 74 33.2 20.8 81 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 Downloaded by: Vanderbilt University Library 220.127.116.11 - 10/29/2017 3:45:26 AM 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 176 Tos 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 Downloaded by: Vanderbilt University Library 18.104.22.168 - 10/29/2017 3:45:26 AM Discussion and Conclusion 177 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 , Sieverstein , and P lester . 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  and P alva and K arja  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. Downloaded by: Vanderbilt University Library 22.214.171.124 - 10/29/2017 3:45:26 AM Permanent Middle-Ear Aeration in Tympanoplasty Tos 178 References A rmstrong, B. W.: A new technique for chronic secretory otitis media. Arch. Oto- laryng. 59: 653-654 (1954). Bak-P edersen , K. and Tos, M.: Density of mucous glands in various chronic middle ear diseases. Acta Oto-laryng., Stockh. 75: 273-274 (1973). 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) Downloaded by: Vanderbilt University Library 126.96.36.199 - 10/29/2017 3:45:26 AM with a tympano-maxillary shunt. Acta oto-laryng., Stockh., suppl. 263, pp. 29-32 (1970). E kvall, L.: Eustachian tube function in tympanoplasty. Acta oto-laryng., Stockh., suppl. 263, pp. 33-40 (1970). F lisberg , K.; Ingelsted , S., and O rtegren , U.: Controlled ‘ear aspiration' of air. Acta oto-laryng., Stockh., suppl. 182, pp. 35-38 (1963). H ouse, W.; G losscock, M. E., and M iles , 1.: Eustachian tubaplasty. Laryngoscope 79: 1765-1782 (1969). P alva, A. and K arja, J.: Eustachian tube patency in chronic ears. Pre-operative evaluation correlated to post-operative results. Acta oto-laryng., Stockh., suppl. 263, pp. 25-28 (1970). P alva, T.; P alva, T., and Salmivalli, A.: Radical mastoidectomy with cavity obliteration. Arch. Otolaryng. 88: 119-123 (1968). P faltz, G. R.; L ü Scher , E.; V oegeli, R., and W ey, W.: Réévaluation of results in tympanoplasty. Arch. Otolaryng. 75: 405-414 (1962). P lester , D.: European tympanoplasty trends; in Paparella, H ohmann and H uff Clinical otology. An international symposium, p. 127 (Mosby, St. Louis 1971). R entzsch , G.: Tympanoplastik-Spâtergebnisse der Leipziger HNO-Klinik aus den Jahren 1958-1962. Hals-Nas.-Ohrenarzt 17: 70-74 (1969). Siirala, U.: Pathogenesis and treatment of adhesive otitis. Acta oto-laryng., Stockh., suppl. 188, pp. 9-18 (1964). S ilverstein , H.: Permanent middle ear aeration. Arch, otolaryng. 91: 313-318 (1970). T erkildsen , K.: Akustiske impedans-mâlinger og mellem0rets funktion, p. 24 (Univcrsitetsforlaget, Kpbenhavn 1962). Tos, M.: Tympanoplasty in chronic adhesive otitis media. Acta oto-laryng., Stockh. 73: 53-60 (1972). Tos, M.: Senresultater ved mastoidektomi og tympanoplastik vcd kronisk otitis media. Ugeskr. Læg. 136: 15-19 (1974). Z ollner , F.: Therapy of Eustachian tube. Arch. Otolaryng. 78: 394-399 (1963).