Download Tympanoplasty

Tympanoplasty
SurgicalInformation
Tympanoplasty Purpose:
Tympanoplastyisasurgicalproceduretoreconstructahole(perforation)intheeardrum(tympanic
membrane).Thismaybeperformedinconjunctionwithreconstructionoftheossicularchain(middleear
bones)toimprovehearinglossresultingfromlossofconnectionbetweentheeardrumandinnerear.The
primarygoalofsurgeryistoprovideasafe,dry,healthyear.Thesecondarygoalistoimprovehearing,if
possible.
GeneralInformation:
Theeardrumisathinmembranedeepintheearcanalthatvibrateswhensoundwaveshitit.Vibrationofthe
membranetransferssoundenergythroughtheossicularchainintotheinnerear,whichallowsustohear.A
perforationofthemembranecanresultfromabadearinfection;asurgicalproceduresuchaseartube
placement,ortraumasuchasaQ‐tipjabbeddeepintotheearcanal.Typically,aperforationwillcloseallby
itselfwithouttheneedforsurgery.Ifaperforationhasbeenpresentformorethan3monthswithout
infectionordrainage,itisunlikelytoclosebyitself.Atympanicmembraneperforationcanresultinhearing
loss,recurringorchronicmiddleearinfectionwithadrainingear,orcholesteatomaformation.
Thehearinglossresultingfromatympanicmembraneperforationvariesdependingonsizeandlocationof
thehole.Theynevercausecompletedeafnessandthehearingusuallyreturnstonormal(orverycloseto
normal)whentheperforationisrepaired.
Tympanicmembraneperforationcreatesanincreasedpotentialformiddleearinfectionresultinginpus‐like
drainagefromtheear.Bacteriafromtheearcanalorfromdirtywatercanbecarriedintothemiddleear
throughtheperforation.Theinfectionanddrainagemaybeintermittentorchronic.Typically,theinfection
canbeclearedwiththeuseofantibacterialeardrops.Theearshouldbecompletelydryandfreeofinfection
priortoperformingatympanoplasty.Iftheinfectioncannotbecleared,thenanadditionalprocedure,called
amastoidectomy,mayalsoneedtobeperformedtoclearthechronicallyinfectedtissuefromthemiddleear
andmastoidcavities.Pleasenotifyyourphysicianiftheearstartsdrainingpriortoundergoinga
tympanoplasty.
Cholesteatomaisabenigntumorofthemiddleearthatcanresultfrommigrationofskinintothemiddleear
spacefromthemarginsofatympanicmembraneperforation.Asoldskinflakesoffandnewskincellsare
produced,acystfilledwithdeadskinisformedwhichprogressivelyenlargeswithinthemiddleear,eroding
anddestroyingeverythinginitspathincludingtheossicularchainand/orthewallsofthemiddleearspace.
DescriptionofProcedure:
Therearetwowaystorepairatympanicmembraneperforation:myringoplastyandtympanoplasty.Both
proceduresaretypicallyperformedunderageneralanesthesia,althoughmyringoplastycansometimesbe
performedonadultsintheclinicsettingwithalocalalocalanesthesia.
Patchmyringoplastyisaprocedureinwhichsomematerialisusedtocovertheperforationinaneffortto
encouragethebody’snormalhealingprocesstoclosethehole.Variousmaterialsincludingcigarettepaper,
gelfilm,orfatfromthelobuleoftheearcanbeusedforthepatch.Thisprocedureonlytakes10to15
minutestoperform.However,itisonlyusefulforverysmallperforations.
Tympanoplastyisalongerprocedureperformedthroughanincisionbehindtheear(postauricularincision).
Apatchoftissue,calledfascia,isharvestedfromamuscleabovetheeartorepairtheperforation.The
eardrumiselevatedlikeatrapdoorandthefasciapatchisslippedbehindtheeardrumtocoverthehole.The
eardrumisthenlaidbackinitsnaturalpositionoverthepatch.Absorbablepackingmaterialisplacedon
bothsidesofthereconstructedmembranetosecurethepatch.Ashealingoccursthefasciapatchbecomes
integratedintothetympanicmembrane.
Ossicularchainreconstructionmaybeperformedinconjunctionwithtympanoplastytorepairthemiddle
earbones(ossicles)iftheyhavebeendisruptedordestroyedbyinfection,cholesteatoma,ortrauma.Oneof
thenativeossiclescanberemovedandmodifiedtoreconstructaconnectionbetweentheeardrumandthe
innerear.Alternatively,afabricatedprosthesismadefromhydroxyapetiteortitaniumcanbeimplantedto
reconstructtheconnection.
PotentialComplicationsofTympanoplasty:
Althoughtympanoplastyisrarelyassociatedwithcomplications,thereareseveralpotentialcomplications
thatcanarise.Descriptionoftheserisksisprovidedsothatyoucanmakeaninformeddecisionabout
proceedingwithsurgery.Yoursurgeonfeelsthatthepotentialbenefitsofsurgeryoutweighthepotential
risks.
Infectionandbleeding
Infectionandbleedingarerisksofmostanysurgicalprocedurebutrarelyoccurfollowingtympanoplasty.
Postoperativeinfectionsusuallyresolvewithappropriateantibiotictreatment.Bleedingusuallyeasily
controlledwithpressureappliedtothebleedingsite.
Tympanicmembraneperforation
Failureofthefasciapatchtohealtotheeardrumcanresultinapersistentperforationpostoperatively.The
successrateoftympanoplastyis90–95%.Thepresenceofinfectionatthetimeofsurgerydramatically
increasestheincidenceoffailure.Therefore,youshouldnotifyyourphysicianaboutanydrainagenotedfrom
theearpriortosurgery.Thesurgerymayneedtobepostponeduntiltheinfectionhascleared.Thesuccess
ratedecreaseinpatientswhohavehadpreviousfailedattemptstorepairtheperforation.
Alterationofsenseoftaste
Injury(stretchingorcutting)tothechordatympaninerveisnotuncommonintympanoplastyprocedures
becausethenervetravelsalongtheundersurfaceoftheeardrum.Thisnerveisoneoffournervesthat
providethesenseoftastetothetongue.Typically,injurytothenervedoesnotcauseanoticeablealteration
inthesenseoftastebecausetheothernervesprovideadequatecompensation.However,somepeoplemay
experienceanalterationinthesenseoftastethatusuallyresolveswithin3–4weeks.Thealteredsenseof
tastemaybepermanentinlessthan5%ofpatients.
Cholesteatomaformation
Cholesteatomacanformfromskinthatgetstrappedinthemiddleearspacebehindthereconstructed
eardrum.Thisisextremelyuncommonfollowingatympanoplastybutrequiresadditionalsurgeryfor
management.
Facialweaknessorparalysis
Injurytothefacialnerveisariskofanytypeofmiddleearsurgerybecausethenervetravelsalongtheinside
wallofthemiddleearspace.Insomepatients,thebonycanalthroughwhichthenervetravelshasbeen
destroyedbychronicinfectionorcholesteatoma,leavingthenerveexposedandatriskforinjury.The
incidenceoffacialnerveinjuryduringearsurgeryisextremelylow,occurringinlessthan1%ofpatients.
However,injurytothenervecanbeverydisfiguringresultingincompleteparalysisofonesideoftheface
withlossoftheabilitytoraisetheeyebrow,closetheeye,flarethenostril,andmoveonesideofthemouth.
Additionalsurgicalproceduresmayberequiredtoreanimatetheface.
Hearingloss
Hearinglossisariskofanytypeofearsurgery.Hearingwillactuallyimprovethehearinginmostpatients
undergoingtympanoplastyduetoimprovedamplificationofsoundenergybythereconstructedeardrum.
However,scartissuecanstiffentheeardrumorossicularchainresultingindecreasedhearing.
Dizziness
Dizziness,describedasaspinningsensation(vertigo)orlossofbalance(disequilibrium),maybeexperienced
afterundergoingmiddleearsurgery.Theincidenceofpostoperativedizzinessisextremelylowfollowing
tympanoplasty,butmorecommonfollowingossicularchainreconstructionormastoidectomy.Thedizziness
usuallyresolveswithin24hoursaftersurgerybutmaypersistuptoseveralweeksinsomepatients.Physical
therapyisrarelyrequiredtohelprecoverasenseofbalance.
Anesthesiarisks
Risksofgeneralanesthesiaareuncommonbutshouldbediscussedwithyouranesthesiaprovider.
Alternativestosurgery:
Notalltympanicmembraneperforationshavetoberepaired.Aslongasthemiddleearspaceisdrywithout
infectionordrainage,thenaconservativeapproachofobservationwithrepeatexaminationsevery6months
canbeconsidered.Thereisariskofdevelopingrecurrentorchronicmiddleearinfectionwithdrainingear
ordevelopingacholesteatoma,whichcanleadtohearingloss,facialparalysis,dizziness,meningitis,orbrain
abscess.Watershouldbekeptoutofanearwithtympanicmembraneperforationbyusinganearplugwhen
bathing,showering,orswimmingtohelppreventinfection.
PostoperativeInstructions:
WhatcanIexpectaftersurgery?
Tympanoplastyusuallyrequires1‐2hoursdependingonthedifficultyoftheprocedure.Aftercompletionof
theprocedure,youwillbetransferredtotherecoveryroomunderthecareoftheanesthesiastafffor45–60
minutestorecoverfromthegeneralanesthesia.Onceclearedbytheanesthesiologist,youwillbetransferred
tooutpatientsurgeryforcontinuedobservationuntildischargecriteriaaremet.Dischargecriteriainclude
abilitytobreathwithoutdifficulty,maintainadequateoxygenintheblood,tolerateliquidsbymouth,urinate,
andwalkwithassistance.Theobservationperiodisusuallyapproximately2hours.Mostpatientscanbe
dischargedhomeonthesamedayofsurgery.Somepatientsmayrequireovernightobservationinthe
hospitalifdischargecriteriaarenotmetorifthesurgeryiscompletedtoolateintheeveningtoanticipate
dischargehomeatareasonabletime.
WillIexperiencemuchpain?
Postoperativepainisusuallymildtomoderateandeasilycontrolledwithpainmedications.Theworstpainis
usuallyonthedayofsurgeryandthenfairlyquicklyimprovestomildpain.Mostofthepainhastypically
resolvedbythetimeofyourone‐weekpostoperativevisit.
Yoursurgeonwillmostlikelyprovideaprescriptionforanarcoticpainmedicationcombinedwith
acetaminophen(Tylenol).ChildrenmayreceiveTylenolwithcodeineliquid.AdultstypicallyreceiveTylenol
#3,Lortab,orPercocettablets.Pleasedonotusethesemedicationsmorethanthedosageprescribedbecause
thesemedicationscanbeverysedatingandtheTylenolcanbetoxictotheliverinexcessivedoses.You
shouldnotdriveoroperateheavymachinerywhentakingthesemedicationsbecausetheysignificantly
impairjudgmentandmayleadtoaccidents.Ifyourpainismild,Tylenolcanbeusedasanalternativetothe
narcoticmedications.
Donottakeanyanti‐inflammatorymedications,includingaspirin,ibuprofen(Motrin,Advil),naprosyn
(Alleve),unlessapprovedbyyoursurgeon.Thesemedicationsmayincreasebleedingrisks.
Isnauseaorvomitingexpected?
Itisverycommonforpatientstohavenauseaandvomitingfollowingageneralanesthetic.Thisusually
resolveswithinafewhoursafterthesurgerybutmaypersistfor12–18hours.Keepingthestomachempty
for2hoursfollowinganepisodeofvomitingfollowedbyaclearliquiddietfor6–12hoursisusually
adequatetocontrolthesymptoms.Phenerganmaybeusedatyoursurgeon’sdiscretiontohelpalleviate
symptoms.
Narcoticpainmedicationscanalsocommonlycausenauseaandvomiting.Eatingsomefoodbeforetakingthe
medicinemayhelp.Alternatively,Tylenolcanbeusedforpain,whichshouldnotcausenausea.
Arethereanydietaryrestrictions?
Aclearliquiddietshouldbefollowedforthefirstfewhoursafterthesurgeryuntilthenauseahasresolved.
Youcanadvancefairlyquicklytoanormaldietastolerated.
Arethereanyactivityrestrictions?
NONOSEBLOWING!!!!Blowingthenosecanforceairupthroughtheeustachiantubeanddislodgethefascia
patchusedtoreconstructtheeardrum.Youshouldkeepyourmouthopenwhenyousneezesothattheforce
ofthesneezepassesthroughthemouthratherthanthenose.
Nojumpingorcontactsportsforfourweeksifossicularreconstructionisperformedbecausethereisariskof
dislodgingtheossiclesbeforetheybecomefixed.
HowdoIcareformyearaftersurgery?
Youwillhaveamastoiddressingcuppedoveryourear,whichissecuredbyaVelcrostraparoundthehead.
Thedressingisfilledwithgauze,whichwillbecomepartiallysaturatedwithbloodydrainageonthedayof
surgery.Themastoiddressingshouldbecompletelyremovedonthefirstdayaftersurgery.Therewillbea
cottonballlyingovertheearcanal,whichwillprobablybesoiledwitholdbloodanddrainage.Thisshouldbe
removedandreplacedwithacleancottonball.Thecottonballcanbechangedasneededforsoilingafterthat
time.
Thegauzebehindtheearshouldalsoberemoved,uncoveringthepostauricularincision.Theincisionshould
becleanedtwicedailywithasolutionmadebymixingequalamountsofhydrogenperoxideandwater.A
cottonswabdippedinthissolutioncanbeusedtogentlycleanoldbloodanddebrisfromtheincision.The
incisionshouldbelightlycoveredwithBacitracinointmentaftereachcleaning(theointmentmaybe
providedtoyouatthehospitalbutcanalsobepurchasedover‐the‐counteratmostpharmacies).Theincision
doesnotneedtobecoveredwithanytypeofgauze.Continuetheincisioncareuntilyourone‐week
postoperativefollow‐up.
CanIwashmyhair?
Whenyoutakeabathorshower,youshouldplaceacottonballcoatedwithVaselineovertheearcanalto
preventwaterfromgettingintotheear.Itisokaytouseshampooandletwaterrunovertheear,butdon’tlet
waterspraydirectlyontheearorsubmergetheearunderwater.Aftercompletingyourbathorshower,
replacetheVaselinecoatedcottonballwithafreshdryoneandgentlyblotthepostauricularincisiondry
beforeapplyingtheBacitracinointment.
Isdrainagefromtheearnormalaftersurgery?
Youcanexpectsomemildbloodydrainagefromtheearforuptoaweekafterthesurgery.Justkeepacotton
ballovertheearcanaltocollectthedrainageandchangeitasneededforsoiling.
WillIbeabletohearaftersurgery?
Theearcanalandmiddleearspacewillbecompletelyfilledwithabsorbablematerialfollowingsurgery,
whichresultsinmarkedlydecreasedhearingintheoperatedear.Thepackingintheearcanalwillgradually
dissolveovera4‐weekperiodaftersurgery.Eardropswillbestartedatthefirstpostoperativevisittohelp
dissolvethepacking.Thepackingbehindtheeardruminthemiddleearspacetakes2–3monthstodissolve.
Thefinalpostoperativehearingresultwillnotbeapparentuntilthattime.Wewillobtainapostoperative
hearingtest2–3monthsaftersurgery.
WhatshouldIwatchforthatmightindicateaproblem?
Feverasdemonstratedbytemperatureover101.5degreesFahrenheitmaybeasignofinfection.Rednessof
theskinaroundthepostauricularincisionthatspreadsawayfromtheincisionisasignofinfection.
Progressiveswellingbehindtheearthatcausestheeartoprotrudeawayfromtheheadmaybeasignoffluid
orbloodcollectingundertheskin,whichmayneedtobedrained.
WhencanIreturntoworkorschool?
Usuallyoneweekofffromworkorschoolisrecommendedaftersurgery.Youcanreturnsooneraslongas
dutyislightandnarcoticpainmedicationshavebeendiscontinued.
WhenwillIseemyphysicianagain?
Apostoperativevisitshouldbescheduledoneweekaftersurgery.Itwillbeabriefvisitforevaluationof
healing.
WhoshouldIcallwithanyproblems?
Office:782‐7768orDr.SimsCell:270‐791‐1006
Thesenumberscanbecalledanytime24hoursaday.Ifyoucallatnighttimeoron
theweekend,youwillgetanansweringmachine.Thefirstoptiononthemachine
istoleaveamessageforthephysicianoncall.Justleaveyournameandnumber
andabriefdescriptionofyourproblemorquestion.Theon‐callphysicianwill
returnyourcallassoonaspossible.Ifyouthinkyouhaveanemergency,please
gostraighttotheemergencyroomatyourhospitalandaskthemtocontactyour
surgeon.