Tympanoplasty

In order for a person to hear well, his tympanic cavity must be closed from the side of the external auditory canal and not contain foreign structures, tissues or bodies, except for the auditory ossicles. The tympanic membrane should be intact, moderately stretched, elastic. The auditory ossicles (hammer, anvil and stirrup) are normally connected to each other by easily movable joints, the oval window is connected to the base of the stirrup by an elastic ring. The round window is covered by a distensible secondary tympanic membrane. The auditory (Eustachian) tube, which communicates the tympanic cavity with the nasopharynx, must be passable.

If at least one of the above conditions is not observed, patients experience hearing loss of varying degrees. The restoration of these conditions is the task of the tympanoplasty operation.

The name of the operational technique “tympanoplasty” comes from two words: “timpo” (Greek) – to strike and “plasticus” (Lat.) – forming.

This surgical operation is aimed at reconstructing the anatomical structure of the tympanic membrane, the sound-conducting structures in the middle ear and restoring their physiological ability to transmit sound from the tympanic membrane to the cochlea.

Types of operations and their methods

Tympanoplasty is a surgical procedure performed using a microscope. With a particular disease of the middle ear, one of five types of tympanoplasty is performed. According to the volume of surgical intervention, the degree of integrity of the structures in the middle ear and the method of performing the operation, tympanoplasty of types I, II, III, IV and V are distinguished.

Type I surgery (myringoplasty)

Myringoplasty is a surgical reconstruction of the integrity of the eardrum. It is performed either independently (if the auditory ossicles are not involved in the pathological process), or as the final stage of tympanoplasty with transmeatal access (through the natural external auditory canal).

The essence of the operation is that the edges of the perforation are “refreshed”, that is, dead tissue is removed, after which the septal defect is closed with a skin flap.

Operation type II (large tympanic cavity)

Type XNUMX tympanoplasty is a variant of ossiculoplasty, an operation to repair the auditory ossicles. Such an operation is performed when the handle of the auditory malleus is damaged, the sequence of the auditory ossicles chain is disturbed, but with the anvil and stirrup preserved.

The essence of the method is that the tympanic membrane is artificially attached to the junction of the malleus with the anvil, thereby restoring the mobility of the ossicular chain. At the same time, the tympanic cavity is slightly reduced in size.

Type III surgery (small tympanic cavity)

This surgical intervention is also called the “columella effect” by ENT surgeons. An operation is performed for damage to the malleus and anvil, when there is no way to restore them or their reconstruction is impractical. As a result of the procedure, the anvil and malleus are removed and only one stirrup remains in the tympanic cavity. Thus, a sound-conducting system similar to that of a bird is recreated: birds have only one auditory ossicle, the columella, in the tympanic cavity. With this type of surgical intervention, the tympanic region is significantly reduced in size, so the operation is called the “small tympanic region.”

Operation type IV (reduced tympanic cavity)

This type of surgical intervention is performed in the absence of all the auditory ossicles in the tympanic cavity, except for the movable base of the stirrup, which covers the oval window of the cochlear vestibule. The essence of the operation is to create a new tympanic cavity with the help of a flap (skin, remnants of the tympanic membrane), into which only the auditory tube and the round window of the cochlea open. At the same time, the oval window remains unshielded, which increases the pressure of sound vibrations on it.

Type V operation (fenestration)

The fifth type of tympanoplasty is performed in the case of immobility of the base of the stapes, which covers the oval window, but the mobility of the secondary tympanic membrane, which covers the round window of the cochlea, must be preserved. During the operation, fenestration (from the Latin word “fenestra” – “window”) of the horizontal semicircular canal of the cochlea is performed, that is, a new oval window is artificially formed in the wall of the canal, which communicates with the fluid of the cochlear labyrinth. The newly formed window is covered with a plastic flap, which acts as a tympanic membrane. There are two types of this operation – V-A and V-B. In the first case, in addition to fenestration, the cochlear window is shielded, and in the second case, the base of the stirrup is removed and the vestibule window is filled with adipose tissue. Currently, classical type V tympanoplasty is rarely performed due to its low efficiency.

On the basis of the listed types of tympanoplasty, modern types of operations have been developed, such as ossicular interposition, maleostapedopexy, stapedoplasty, and prosthetics of the auditory ossicles. Feedback on the results of modern types of tympanoplasty is positive both in patients and otosurgeons.

Indications and contraindications

Indications for surgical intervention on the structures of the tympanic cavity can be conditionally divided into four main groups:

1. Dry perforations (perforations) of the tympanic membrane while maintaining the functions of the auditory ossicles.
2. Uncomplicated inflammatory diseases in the middle ear (epithympanitis, mesotympanitis) in combination with granulations, polyps or cholesteatoma (benign neoplasm). With these diseases, the auditory ossicles remain intact, and their chain is not broken.
3. Purulent inflammation of the middle ear, leading to the destruction of the auditory chain or the melting of the auditory ossicles themselves.
4. Adhesive (adhesive) otitis, the result of which is the fusion of the walls of the middle ear after inflammation – tympanofibrosis or tympanosclerosis.

The operation is contraindicated in patients who are in a serious general condition, in the presence of purulent complications and sepsis, with exacerbation of chronic infectious diseases (up to their remission). It makes no sense to perform such operations on patients with complete deafness. Persistent disturbances in the patency of the auditory tube (congenital malformations of the middle ear, adhesions, scars) are also contraindications for tympanoplasty.

Relative contraindications for tympanoplasty include:

• functional obstruction of the auditory tube;
• ENT diseases, including acute non-purulent inflammation of the ear;
• allergic rhinitis in the acute stage;
• epidermization of the middle ear (replacement of the mucous membrane of the tympanic cavity with epidermal epithelium).

The issue of surgical intervention in patients with relative contraindications is usually decided collectively, depending on the degree of need.

Preparation for the operation and its implementation

Before the operation, a comprehensive instrumental and laboratory examination of the patient is carried out to identify concomitant pathologies that may be contraindications for tympanoplasty. The minimum required program includes:

• otoscopy (examination by an ENT doctor of the structures of the outer and middle ear using a special apparatus – an otoscope);
• testing with an artificial eardrum;
• audiometry and ear blowing;
• determination of the patency of the auditory tube;
• general and biochemical blood tests;
• determination of blood group and Rh factor;
• testing for HIV, hepatitis B and C, TORCH infections;
• coagulogram;
• bacteriological examination of a smear from the ear;
• fluorogram;
• electrocardiogram.

Additionally, other diagnostic methods or consultations of doctors of related specialties may be prescribed by the attending physician.

The patient must be prepared for the operation of tympanoplasty. It is necessary to sanitize the patient’s nasopharynx and, if necessary, remove adenoid growths that interfere with the patency of the auditory tube. A week before surgery, the patient, if possible, cancel anticoagulants (Warfarin) and antiplatelet agents (Aspirin). A few days before the procedure, broad-spectrum antibiotics, vasoconstrictor and anti-inflammatory drugs are introduced into the middle ear cavity. This is necessary for cleansing (sanation) of the open tympanic cavity, as well as to improve the healing of the postoperative wound and reduce the risk of postoperative complications. Vasoconstrictor agents contribute to the normalization of the patency of the auditory tube, which in the postoperative period will ensure normal communication between the tympanic and nasal cavities. At least 6 hours before the procedure, the patient should not eat or drink.

Pain relief is different for different types of surgery. For example, myringoplasty can be performed under local anesthesia, and more complex operations involving intervention in the structures of the middle and inner ear can be performed under general anesthesia. The volume and course of the operation depends on the tasks assigned to otosurgeons and, as a rule, is determined even before it begins.

The operation lasts an average of 40-60 minutes, after its completion, a drainage tube is installed in the wound, through which the discharge from the wound will be freely discharged to the outside. Wound drainage minimizes the risk of infectious postoperative complications (provided that the drainage tube is patency). Aseptic swabs are inserted into the external auditory canal.

Possible complications

In some cases, after surgery, patients may experience various complications:

• infectious (cause – non-sterile consumable surgical material or instruments, improper postoperative care);
• recurrence of purulent otitis media;
• mechanical damage to the nerve endings in the area of ​​operation, which leads to deafness;
• displacement of prostheses of the auditory ossicles;
• scarring of the sutures in the ear canal and tympanic cavity;
• vestibular disorders;
• rejection of implants.

To minimize the risks of complications, proper rehabilitation of patients after surgery is necessary.

Rehabilitation after surgery

After surgery, the patient should be under constant medical supervision for 1-3 days, depending on the type of operation. The patients are in the hospital. The treatment regimen is a general ward. There is no special diet in the postoperative period.

It takes some time (from several days to 4 or more weeks) for hearing to recover after middle ear surgery. During this postoperative period, the patient should refrain from blowing his nose, severe coughing and sneezing (during these acts, the pressure in the tympanic cavity increases significantly). The patient is forbidden to swim in reservoirs, pools, take lying baths. With great care, you need to wash your hair: it is impossible for water to get into an unhealed wound.

Physical activity and heavy lifting are also prohibited, as this affects the pressure in the tympanic cavity. For the same reason, patients should refrain from air travel, listening to loud music (especially with headphones) and attending noisy events during rehabilitation. It is advisable to refrain from them even after recovery.

Within 7-10 days after surgery, patients should take broad-spectrum antibiotics. It is strictly forbidden to remove tampons from the ear canal on your own, therefore, after discharge, the patient must regularly come for examination to the attending physician. The ENT will control the healing process and carry out all the necessary manipulations (removal or replacement of the tampon, sanitation of the ear canal, anemization).

For good healing of wounds in the middle ear, it is necessary to control that the auditory tube is completely patent.

In order to reduce its edema, it is recommended to undergo an anemization regularly (preferably daily).

Anemization of the auditory tube is an ENT procedure, which consists in the contact effect of vasoconstrictor drugs (Ephedrine, Adrenaline, Xylometazoline) on the nasal mucosa at the exit site of the nasal opening of the auditory tube. To do this, using a special probe directly to the opening of the auditory tube, a tampon is inserted, richly moistened with vasoconstrictors. After this, the patient is placed on the sore ear so that the solution flows down the auditory tube. After a few minutes, the probe with the swab is removed.

During the entire recovery period, the patient should carefully monitor the state of hearing and changes in their well-being. Hearing loss, ear pain, fever or chills are reasons to seek immediate medical attention.

The indisputable advantage of tympanoplasty, in comparison with radical surgery, is its cost. Depending on the complexity of the operation, its price in Moscow ranges from 20 to 90 thousand rubles.