three flap tympanoplasty
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Three Flap TympanoplastyThree Flap Tympanoplasty
Saurav Sarkar, MD1; B. K. Roychaudhuri, MD2
Calcutta Medical College
INTRODUCTION DISCUSSIONRESULTS
0
100
200
300
400
500
600
700
800
<10 dB 10 to 20 dB 20 to 30 dB 30 to 45 dB 45 to 60 dB
Pre operative
Post operative
Author Type No. Success rate AB gap <10 FU month Healing time Complications
Sakagami Underlay 391 77.7%: Initial 75.6% >6 6 months Rare
(2007) 95.7%: Reclosure
Schraff Window shade 164 94.5% 82% >6 6 weeks Epithelial pearl
(2005) (1%)
Kartush Over-under 120 100%: Early Average 5.3 dB >6 NR Epithelial pearl
(2002) 90%: Late (2%)
Rizer Underlay U: 554 U: 89% U: 85% >1 3 weeks Rare
(1997) O: 158 O: 96% O: 80%
Farrior Sandwich graft 499 98% NR >6 4 weeks Epithelial pearl
(1989) (2%)
Schwaber Swing door 100 95% NR >3 NR No
(1986) lateralization
Gibbs Underlay 365 89% NR >1 NR Rare
(1982)
Sheehy Overlay 472 97% 80% >2 NR blunting,
(1980) lateralization
(2%)
3 flap tympanoplasty 858 97.90% 84.14% 6months 3weeks anterior blunting
(0.82 %)
Chart 1. Pre and post operative hearing comparison.
Table 1. Comparison of tympanoplasty techniques..
Fig 1. The 3 radial incisions along the
Membrane remnant and canal wall.
Fig 2. The 3 tympanomeatal flapsSuperior, anterior and
posterior
ABSTRACT
Objective:
To report our experience with 3
flap tympanoplasty, a modified
over-underlay technique with 3
laterally based skin flaps, for the
reconstruction of anterior, subtotal
or total tympanic membrane (TM)
perforations.
Methods:
Prospective study of patients
undergoing “Three flap
tympanoplasty” from May 2005 to
May 2009. Eight hundred and fifty
eight patients who underwent
“Three flap tympanoplasty” and
then follow-up visits scheduled at
intervals for a period of 1 year after
surgery are included in this study.
Hearing test results were reported
using a four-frequency (0.5, 1, 2,
and 3 kHz) pure tone average air–
bone gap. The outcome was
considered successful if the TM
was intact without lateralization,
anterior blunting the last follow-up
visit.
Results:
There was a 97.9 % success rate.
There was no graft lateralization,
neocholesteatoma, or
sensorineural hearing loss. The
mean preoperative to
postoperative four-tone air–bone
gap improved from 26.18 to 8.89
dB, with an average gain of 17.29
dB; this was statistically significant.
Conclusion:
The Three flap technique is a safe
and effective technique for
reconstruction of anterior, subtotal
or total TM perforations, with
excellent graft take and significant
improvement of hearing.
Age – 15-70yrs
Male – 505 – 58.86%
Female – 353 – 41.14%
Pathology of patients pre-operative:
Anterior perforation – 510 (59.44%)
Subtotal perforation – 290 (33.80%)
Total perforation – 50 (6.76%)
Procedure:
Additional mastoidectomy – 65 (7.58%)
Ossicular reconstruction – 37 (4.31%)
Graft uptake with successful outcome –
840 (97.90%)
Graft failure – 11 (1.28%) –
reasons - 6 (54.55%) – post op infection
5 (45.45%) – acute otitis
Anterior blunting – 7 (0.82%)
Average – Pre op AB gap – 26.18 dB
Post op AB gap – 8.89 dB
Average hearing gain – 17.29dB
In this the temporalis fascia graft is placed
lateral to the long process of and medial to the
tympanic membrane remnant and anterior
annulus. The advantages of this technique are:
1) can be performed in all types of perforations,
2) the exposure of the anterior middle ear is very
good, 3) anterior blunting not present, 4) good
success rate, 5) relatively simple to perform, 6)
middle ear space is not reduced . The total
elevation of the tympanic membrane remnant
from the malleus has the following advantages:
1) the overlap between the graft and drum
remnant is increased, 2) the graft bed is better
prepared, 3) the graft placement is precise
unhindered by the malleus and 4) a very good
medial support provided by the handle of
malleus. It is well suited for use in ossicular
reconstruction surgeries by the virtue of its graft
position.
Underlay tympanoplasty using anterior
and posterior flaps have been used by Al-Sheikh
et al in 1998, for subtotal perforations with
success. Kartush et al in 2002 elevated a
tympanomeatal flap posteriorly and dissected off
the entire drum remnant from the long process of
malleus anteriorly before placing the drum.
Thus the 3-flap tympanoplasty takes into
consideration the technicalities of both the
techniques and combines it making it simple yet
retaining the advantages of the above
techniques. Type of Study: Prospective study
Place of Study: Kolkata
Period of Study: May 2005 to May 2009
Inclusion criteria – Anterior, subtotal, total
perforation
Exclusion criteria – Chronic ear disease
with complications
Surgical Procedure:
Anesthesia: Local/General Anesthesia
Graft: Temporalis fascia
Approach: Endaural/ Post aural
Steps of surgery:
* De- epithelialization of perforation margin
* 3 radial incisions from within outwards
1 o’clock, 11 o’clock, 6 o’clock positions,
from the membrane remnant margin
outwards till the bony cartilaginous
junction
* 3 tympanomeatal flaps are thus created
– Superior, anterior and posterior
* These flaps are elevated along the bony
canal wall, laterally the superior and
anterior flaps forming the vascular strips
* Pathology in middle ear and mastoid if
necessary cleared, ossicles addressed
* Temporalis fascia graft placed lateral to
handle of malleus and spread on to the
walls
* The 3 flaps repositioned one by one
starting with the anterior flap
* Ear packed with gel foam
* Usual post operative care
Follow up: 1wk, 3wks, 6wks, 3mths, 6mths
“Three Flap tympanoplasty” is a thus a simple
and easy procedure which gives very good
results in terms of hearing specially in cases of
significantly big tympanic membrane
perforations.
The development of tympanoplasty
techniques were led by incidental and
inspirational contributions from surgeons over
the world. The discovery of the importance of
tympanic membrane and ossicles in hearing and
the advent of antimicrobials added up to better
understanding the diseases and their treatment
subsequently.
While the initial aim of tympanoplasty was
to successfully repair the tympanic membrane,
Wullstein in the 1950s prepared the grounds for
the operation to be performed with a goal to
improve hearing as well.
Since the time of Banzer when he first
attempted repairing a perforated tympanic
membrane, in 1640, tympanoplasty has come a
long way in terms of procedures and results.
Otolaryngologists have almost perfected the art,
but some conditions still challenge the skills.
Anterior perforations and total perforations still
bother otolaryngologists, specially beginners,
and threaten to give poorer results.
The objective of this study is to report our
experience with a new type of tympanoplasty, a
modified over-under tympanoplasty, with 3
laterally based skin flaps, for reconstruction of
tympanic membrane perforations.
METHODS AND MATERIALS
1. Jack M. Kartush; Elias M. Michaelides; ZoranBecvarovski; Michael J. LaRouere. Over-Under Tympanoplasty
Laryngoscope 112: May 2002, 802-807
2. Al-Shaikh A M, Reddy P V Bizrah M B. Underlay tympanoplasty with anterior and posterior flaps for subtotal
perforations. Otolaryngol Pol 1998; 52 (2) 137-40
3. B K Roychaudhuri. 3-Flap tympanoplasty – a simple and sure success technique. Indian Journal of Otolaryngology; 2004, Vol-56, No 3; 196-200
4. Sakagami M, Yuasa R, Yuasa Y. Simple underlay myringoplasty. J Laryngol Otol 2007;121:840–4.
5. Farrior JB. Sandwich graft tympanoplasty: experience, results, and complications. Laryngoscope 1989;99:213–7.
6. Sheehy JL, Anderson RG. Myringoplasty: a review of 472 cases. Ann Otol Rhinol Laryngol 1980;89:331–4.
7. Rizer FM. Overlay versus underlay tympanoplasty. Part II.
The study. Laryngoscope 1997;107:26–36.
8. ] Gibb AG, Chang SK. Myringoplasty; a review of 365 operations. J Laryngol Otol 1982;96:915–30
CONCLUSIONS
REFERENCES
Dr. Saurav SarkarCalcutta Medical College
Email: [email protected]
Phone: 513-257-5215
CONTACTCONTACT
Number of people
Fig 3. The 3 flaps repositioned after placing the graft