eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Middle Ear & Mastoid
Middle Ear, Chronic Suppurative Otitis, Surgical Treatment: Treatment
Updated: Oct 22, 2009
Treatment
Medical Therapy
In patients with infected ears or ears with discharge, medical treatment includes antibiotic eardrops. Ciprofloxacin and hydrocortisone are typically used and provide good antibacterial coverage; these agents are not ototoxic. Oral antibiotics should be prescribed to patients with severe infections and to those who are systemically ill. Medical treatment should be accompanied by aural toilet.Surgical Therapy
Chronic otitis media without cholesteatoma
Myringoplasty is the operation specifically designed to close tympanic membrane defects.
The approach to the ear can be transcanal, endaural, or retroauricular. The transcanal approach requires less surgical exposure and leads to a faster healing. The downside is the potential limitation of exposure. The endaural approach can improve exposure in ears with a lateral soft tissue or cartilage overgrowth but, again, tends to limit the surgical view. The retroauricular approach allows for maximal exposure but requires an external skin incision.
Two main surgical techniques of tympanoplasty are commonly used, the underlay and the overlay. The underlay technique involves placing the graft material underneath (or medial to) the eardrum.
The overlay technique involves grafting lateral to the eardrum. Various graft materials may be used. The most common materials are temporalis fascia, tragal perichondrium, and vein graft. An additional technique is the "stuff through." This may be useful for small perforations in otherwise healthy ears. This procedure essentially freshens the edges of the perforation and then fills it with a plug of tissue, usually fat.
The underlay technique requires dissection and elevation of a tympanomeatal flap. The margins of the perforation are freshened by removing the epithelium from the edges of the hole. The graft material is tucked underneath the eardrum and is sometimes supported with Gelfoam. Then, the reconstituted eardrum is flipped back to its normal resting position, and the ear canal is filled with packing material. The lateral graft technique requires removal of the ear canal and tympanic membrane epithelium, as well as a canaloplasty. This technique is particularly well suited to revision tympanoplasty or ears with narrow canals. It is somewhat more technically demanding but has a very high success rate, particularly in scarred tympanic membranes.
Chronic otitis media with cholesteatoma
A range of surgical procedures are available for the management of chronic suppurative otitis media with cholesteatoma, and the choice of procedure depends on the extent and the severity of the disease and the hearing of the individual. The ultimate aim of the procedure is to provide the patient with a safe dry ear. Hearing improvement is a secondary consideration and, if attempted, is usually performed during a second-stage surgery. Hearing reconstruction should not be performed at the cost of or by compromising the clearance of the disease in the patient.
The following definitions are used for middle ear surgery and mastoid surgery:
- Tympanoplasty is performed to eradicate disease from the middle ear and to reconstruct the hearing mechanism, with or without grafting of the tympanic membrane. As described by Wullestein, 5 different types of tympanoplasties have been defined. These are primarily of historical interest.
- Type 1 is simple closure of the tympanic membrane perforation without reconstructing the ossicular chain.
- Type 2 is any kind of ossicular reconstruction involving the malleus, the incus, or both. The stapes head is intact.
- Type 3 involves putting the tympanic membrane graft over the head of the stapes.
- Type 4 occurs when the stapes head is absent but the footplate is present. The stapes footplate is exteriorized to the mastoid cavity, and the graft is placed over the rest of the middle ear cavity, including the round window; hence, the phase difference is maintained.
- Type 5 is also called the fenestration operation. It involves making a fenestra in the lateral semicircular canal and then putting a graft over it. This is not often performed today.
- Today, tympanoplasty is broken down into 2 primary types: lateral grafting or medial grafting. In the lateral graft technique, the graft material is laid laterally to the annulus after the remnant of squamous tissue is denuded. In medial grafting, the annulus is raised and the graft slipped medially.
- Mastoidectomy
- Cortical mastoidectomy is also known as the Schwartze operation. It consists of the removal of the outer wall of the mastoid cortex and the exteriorization of all the mastoid air cells. This may be performed immediately in coalescent mastoiditis, in which case a drain may be left postoperatively.
- Canal wall-up mastoidectomy refers to the removal of mastoid air cells while retaining the posterior canal wall. Using this approach with a facial recess (drilling the bone of the posterior mesotympanum or facial recess between the incus, the chorda tympani nerve, and the facial nerve), the middle ear structures can be accessed for careful dissection of the cholesteatoma. This approach leaves the normal ear canal anatomy intact, preventing the potential problems seen with a mastoid cavity. This is also the common approach for cochlear implantation.
- Modified radical mastoidectomy differs from radical mastoidectomy in that the ossicles and the tympanic membrane remnants are preserved for possible hearing reconstruction at a later stage.
- Radical mastoidectomy involves eradication of all disease from the middle ear and the mastoid and exteriorization of these structures into a single cavity. It also includes removing the entire tympanic membrane and the ossicles (except the stapes footplate) and closing the eustachian tube opening. Currently, this procedure is performed only in very unusual situations.
Postoperative Details
With mastoidectomy/tympanoplasty, ear packing can be removed after 3 weeks (earlier if infected). Often, ear drops are prescribed to be started 3 weeks after surgery, and the packing is then removed at 5-6 weeks postoperatively, particularly in the lateral graft tympanoplasty, which requires additional healing time. The patient receives follow-up care regularly until the canal or cavity is well epithelialized. At each follow-up visit, any signs of recurrent cholesteatoma are noted. If any hearing reconstruction/ossiculoplasty has been performed, an audiogram is indicated at 3 months. Once the canal is healed, water precautions can be stopped. If a canal wall-down mastoidectomy is performed, water entrance may still be discouraged. The mastoid cavity can be irrigated with a solution of alcohol and vinegar, as needed. Routine cleaning of the mastoid cavity may also be indicated if canal wall-down procedures are performed.Follow-up
Complications
Complications of tympanoplasty may include the following:
- Graft failure: The failure rate ranges from 10-20% depending on the technique used and the experience of the surgeon
- Infection: A potential complication with any surgical procedure, it is rare in tympanoplasty. Some surgeons recommend perioperative antibiotics, though little data to support their use.
- Bleeding: Hematomas can develop with postauricular approaches.
- Taste disturbance: This occurs secondary to damage to the chorda tympani nerve. It tends to be self-limiting but can be disturbing to patients.
- Ear numbness: The postauricular incision can sever peripheral sensory nerves, leading to some numbness of the pinna and lobule. This can be particularly disturbing to people with pierced ears who depend on the feeling in the lobule to place earrings.
- Hearing loss: Both conductive and sensorineural hearing loss can occur. Conductive loss can occur secondary to ossicular disruption or sclerosis. Scarring of the neo-tympanic membrane that leads to lateralization can also cause a conductive loss. Sensorineural hearing loss is a rare but serious complication.
- Vertigo: This can occur during any middle ear procedure and is usually self-limiting; however, if it is severe or persistent, further workup may be in order.
- Facial paralysis: This is also a very rare occurrence. Facial paralysis is sometimes seen secondary to local anesthetic infiltration, though anesthetic-related paralysis usually resolves soon after surgery.
Complications of mastoidectomy or tympanomastoidectomy include those listed above and the following:
- CSF leak: If the dura is encountered and violated during the dissection, CSF may leak. If recognized during surgery this can often be repaired.
- Intracranial complications: These can include brain abscess, meningitis, or physical damage to the brain itself.
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References
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Further Reading
Keywords
chronic suppurative otitis, chronic suppurative otitis media, otitis media, myringoplasty, tympanoplasty, mastoidectomy, ossicular reconstruction, ossiculoplasty, ossicular chain, tympanic membrane, malleus, incus, stapes, fenestration operation, semicircular canal
