E n d o s c o p i c Ma n a g e m e n t o f

C h ro n i c O t i t i s Me d i a a n d
Tym p a n o p l a s t y
Muaaz Tarabichi, MDa,*, Stéphane Ayache, MDb,
João Flávio Nogueira, MDc, Munahi Al Qahtani, MDd,
David D. Pothier, MBChB, MSc, FRCS(ORL-HNS)e

KEYWORDS
 Tympanoplasty  Endoscope  Tympanic perforations  Chronic otitis media

KEY POINTS
 The endoscope allows for better inspection for cholesteatoma in cases with chronic otitis
media.
 The endoscope increases the odds of preoperative detection of ossicular chain disruption
associated with perforations.
 The endoscope allows better access to selective epitympanic poor ventilation and
secondary selective chronic otitis media.
 The endoscope allows for better visualization of anterior poor ventilation of the mesotym-
panum and reestablishes adequate ventilation to the mesotympanum.
 The endoscope allows better visualization and reconstruction of anterior tympanic
membrane perforations.
 The endoscope allows use of Sheehy’s lateral graft tympanoplasty through a transcanal
approach.

Videos of endoscopic detection of stapedial reflexes; endoscopic medial graft

tympanoplasty with ossicular reconstruction; two for endoscopic medial graft
tympanoplasty; endoscopic butterfly button tympanoplasty; endoscopic lateral
graft tympanoplasty; and interlay tympanoplasty techniques accompany this
article at http://www.oto.theclinics.com/

Disclosures: No disclosures.
a
Center for Ear Endoscopy, Kenosha, WI, USA; b Department of Otolaryngology, ORPAC,
Clinique du Palais, Grasse, France; c Department of Otolaryngology, Hospital Geral de Fortaleza,
Fortaleza, Brazil; d Department of Otolaryngology, Riyadh Military Hospital, Riyadh, Saudi
Arabia; e Department of Otolaryngology Head and Neck Surgery, Toronto General Hospital,
University Health Network and University of Toronto, Ontario, Canada
* Corresponding author.
E-mail address: [email protected]

Otolaryngol Clin N Am 46 (2013) 155–163

http://dx.doi.org/10.1016/j.otc.2012.12.002 oto.theclinics.com
0030-6665/13/$ – see front matter Ó 2013 Elsevier Inc. All rights reserved.
156 Tarabichi et al

INTRODUCTION

As discussed in the article elsewhere in this issue by Tarabachi, Marchioni, Presutti,

and Nogueira, Endoscopic Transcanal Ear Anatomy and Dissection, the endoscope
allows greater access to the tympanic cavity1 and therefore offers a fresh outlook
on conditions that affect this space and offers distinct advantages in the under-
standing of this condition and the management of its sequela.

ASSESSING STATUS OF MIDDLE EAR VENTILATION

Although the cause of chronic otitis media without chlolesteatoma is poorly under-
stood, poor ventilation of the different air spaces within the temporal bone is believed
to be at the center of this disease process. Combined tympanomastoidectomy with
exenteration of air cells is considered the treatment of choice. Failure to exenterate
tegmental cells from disease is a common cause of failure.2 The endoscope allows
for expanded access to the attic, especially anteriorly, and this allows for removal of
any granulation tissue in that area.1 Beyond any Eustachian tube dysfunction, there
are multiple opportunities for obstruction within the narrow ventilation pathways of
the tympanic cavity, which result in selective poor ventilation of the areas proximal
to these sites. The 2 main areas lie anteriorly within the anterior mesotympanum and
posteriorly and superiorly within the epitympanic diaphragm, 2 areas that are more
accessible with the endoscope.1 Classic surgical approaches to the attic with micro-
scopic transmastoid technique results in poor access to the anterior attic and exten-
sive removal of much of the associated anatomy to access these areas. In contrast, the
endoscope offers clear glimpses of the anatomy and disease without undue disruption
of the anatomy, making it easier to understand both the underlying anatomy and any
disease process within this area.1–6 This situation is particularly true when considering
the tensor fold. Because of the location and orientation of this fold, it is a structure that
cannot be seen through traditional microscopic transcanal and transmastoid
approaches to the anterior attic.7 The only exception to this situation is a widely
opened facial recess, and only after removal of the incus. It is often helpful to push
the handle of malleus laterally for a more open view. This observation of the tensor
fold is usually made more difficult while operating on diseased ears because of the
existing medialization of the handle of malleus and the fact that blood tends to pool
in this area because of the position of the head in traditional mastoid surgery. The
endoscope allows for inspection of this fold in healthy ears by using a 30 endoscope
and looking through the isthmus (Fig. 1). In diseased ears, the isthmus is obstructed
and narrow because of medialization of the handle of malleus, and the tensor fold
can be visualized endoscopically either by looking superiorly and posteriorly with an
angled scope that is positioned anterior to the handle of malleus (Fig. 2) or by looking
forward with an angled scope after removal of the incus and ahead of malleus (Fig. 3).
Examination of the tympanic cavity in the clinic through perforations is helpful in assess-
ing the status of the middle ear mucosa beyond the perforation and the presence of
inflammatory webs in the anterior epitympanum as well as any obstruction of the isthmus,
which can result in recurrent episodes of drainage or poor response to local treatment.3
The endoscope allows for better surgical access to the tensor fold and the anterior
epitympanic space to establish ventilation without disrupting the ossicular chain.1

ASSESSING THE STATUS OF THE OSSICULAR CHAIN

The incudostapedial joint and the stapes suprastructure are almost universally
accessible for inspection endoscopically through a perforation or a thin retracted
 Endoscopic Tympanoplasty 157

Fig. 1. Right ear: peaking through the isthmus with a 30 endoscope. CO, COG; HM, handle
of malleus; IS, incudostapedial joint; RE, the recess formed through the insertion of the fold
anterior to the COG; TF, tensor fold; TT, tendon of the tensor tympani.

Fig. 2. Right ear intraoperative view of the tensor fold, which has an almost-horizontal
orientation without any formation of supratubal recess. (A) General view; (B) close-up
view. ABA, anterior bony annulus; arrow, Eustachian tube; HM, handle of malleus; TF,
horizontal tensor fold; TTM, tensor tympani muscle canal; TTT, tendon of the tensor tympani.
158 Tarabichi et al

Fig. 3. Left ear intraoperative view. The incus and the head of malleus is removed and look-
ing forward with a 30 scope toward the anterior attic at a tensor fold with almost-vertical
orientation. COG, COG; CT, transected corda tympani; FN, horizontal segment of the facial
nerve; HM, handle of malleus; TF, tensor fold; TT, tensor tympani tendon.

membrane.8 Even with the use of a 0 endoscope, the endoscopic view allows for
a better inspection of the ossicles (Fig. 4). The lack of stapedial reflexes in the presence
of an intact tympanic membrane and good bone thresholds had been a useful way of
detecting fixation of stapes and other ossicles. The presence of tymphanic membrane

Fig. 4. (A) Overall endoscopic picture of perforation that is without the visualization of
ossicular chain, probably similar to what is visible with microscope. (B) Close-up endoscopic
view with visualization of the stapes. (C) Further close-up view showing the incudostapedial
joint; all with 0 endoscopes.
 Endoscopic Tympanoplasty 159

perforation precludes this useful test. Endoscopic detection of stapedial reflexes

through perforations allows for the identification of stapes fixation.9 It also tests the
integrity of an eroded, visually connected incudostapedial joint (Video 1).

ENDOSCOPIC MEDIAL GRAFT TYMPANOPLASTY

Medial graft tympanoplasty is a common and relatively successful procedure; central

to its success is adequate and relatively free exposure to the whole tympanic perfora-
tion. Unfavorable ear canal anatomy (overhanging anterior wall or a small canal) or
anterior perforations make for a technically challenging transcanal procedure, which
is reflected as a high rate of failure. Experience surgeons are usually more willing to
consider a postauricular approach in these limiting situations to provide adequate
microscopic exposure.10

OPERATIVE TECHNIQUE FOR ENDOSCOPIC MEDIAL GRAFT TYMPANOPLASTY

 The ear canal and the graft donor site are infiltrated with xylocaine 2% with 1 in
100,000 epinephrine (Videos 2, 3 and 4).
 A fascial graft is obtained from either the temporalis muscle fascia or tragal
perichondrium.
 The edges of the perforation are debrided and the undersurface of the tympanic
membrane is abraded.
 A wide tympanomeatal flap is elevated.
 The ossicular chain is inspected either through the perforation or directly after
elevation of the tympanomeatal flap.
 Appropriate ossicular reconstruction is performed.
 The graft is positioned just medial to the anterior rim of the perforation as it is
visualized through the tympanomeatal flap.
 If the anterior rim is not visible through the elevated flap, then a 30 endoscope is
used to perform that step and to pack Gelfoam (Pfizer Canada Inc., Quebec,
Canada) in the middle ear deep to the graft.
 The tympanomeatal flap is repositioned and the ear canal is packed with
Gelfoam.
The impact of the endoscope on tympanoplasty surgery needs to be considered
based on the surgical task contemplated and the importance of the advantages and
disadvantages in specific situations, such as:
1. Elevation of tympanomeatal flap: this is performed under direct vision with the
endoscope without the need for the continuous repositioning in microscopic
surgery. It is difficult to tear a flap because the angle of view includes both surfaces
of the whole flap. It is easy to identify and cauterize bleeding points along the
incised edge of the skin of the ear canal.
2. Inspection of the middle ear space: the endoscope is the better instrument here for
the reasons discussed earlier. This inspection includes operative evaluation and
treatment of disease within the facial recess, sinus tympani, hypotympanum, attic,
and the anterior part of the tympanic cavity.
3. Positioning of the graft: this task is easier with the endoscope, given its wide angle
of view, which includes the tympanic ring along with the whole perforation and graft
without the need for repositioning.
4. Positioning of a prosthesis: the unavailability of 2 hands (eg, to lift malleus) and the
lack of depth perception (assessing length of prosthesis needed) makes this task
more difficult with the endoscope.
160 Tarabichi et al

5. Butterfly button tympanoplasty with an anterior perforation is a particularly

manageable technique with the endoscope (Video 5).
It is difficult to use the endoscope and microscope to perform different tasks in the
same procedure, and different surgeons choose their instrument of choice based on
their comfort level.
The first report of endoscopic medial graft tympanoplasty in 1998 showed a high
success rate in 64 ears.11 The main point to be emphasized is how endoscopic tech-
niques reduced the rate of postauricular approach from 42% (before the use of the
endoscope) to 0%, without reducing the overall success rate and without increasing
the complication rate. The first author of this article has not performed any postauric-
ular or endaural incisions for tympanic perforations since that report.
Despite the safety of endoscopic ossicular chain reconstruction, there are no
compelling reasons for performing ossicular work with the endoscope.

ENDOSCOPIC LATERAL GRAFT TYMPANOPLASTY

A wide and complete view of the tympanic ring is an essential element in Sheehy’s
lateral graft tympanoplasty.12 This view is usually accomplished by enlarging the ear
canal and through postauricular exposure. The endoscope offers a comparable
wide view of the operative field through a transcanal approach.

OPERATIVE TECHNIQUE FOR ENDOSCOPIC LATERAL GRAFT TYMPANOPLASTY

 The ear canal and the graft donor site are infiltrated with xylocaine 2% with 1 in
100,000 epinephrine (Video 6).
 A fascial graft is obtained from either the temporalis muscle fascia or tragal
perichondrium.
 The skin of the ear canal is removed along with the epithelial layer of the tympanic
membrane remnant. The vascular strip is preserved.
 Overhanging bony ear canal is curetted out to obtain full endoscopic exposure to
the anterior sulcus.
 The ossicular chain is inspected either through the perforation or directly after
elevation of annulus if there is strong suspicion of disease based on preoperative
audiogram.
 Appropriate ossicular reconstruction is performed, the middle ear cavity is
packed with Gelfoam, and the facial graft and the skin are repositioned. The
ear canal is packed with Gelfoam.
The usefulness of the endoscope in lateral graft tympanoplasty must be considered
based on the surgical task contemplated and the importance of the advantages and
disadvantages in specific situations:
1. Removal of canal skin: the use of the endoscope allows canal skin to be removed
under direct vision without the usual need for continuous manipulation of the micro-
scope. It is difficult to tear the skin because the angle of view includes both
surfaces. It is easy to identify and cauterize bleeding points at the edges of the
incised skin as well as any anterior sulcus perforator vessels, which usually
produce significant bleeding.
2. Drilling and removal of overhanging bony canal: the ability to visualize past the shaft
of the drill into the surgical field makes the endoscope a useful instrument. The wide
angle of view of the endoscope might lead the surgeon to underestimate the depth
 Endoscopic Tympanoplasty 161

Fig. 5. Interlay tympanoplasty of left ear: the squamous layer is elevated off the fibrous
layer of the tympanic membrane, leaving the fibrous layer in situ.

of the anterior sulcus, which could lead to inadequate removal of overhanging bony
canal, which results in blunting of the anterior sulcus.
3. Inspection of the middle ear space: the endoscope is the better instrument here for
the enhanced visualization described earlier.
4. Positioning of the graft: this task is easier with the endoscope, given its wide angle
of view, which includes the whole tympanic ring.
The first report of endoscopic lateral graft tympanoplasty in 1998 showed a high
success rate in 32 ears, with 3 patients having blunting of the anterior sulcus and
1 patient having a cholesteatoma pearl within the tympanic membrane at 1 year post-
operatively.11 The primary investigator of that study has since relied more on this tech-
nique to improve success rate in tympanoplasty surgery.

Fig. 6. The squamous layer has been elevated beyond the margins of the perforation.
162 Tarabichi et al

Fig. 7. A graft is inserted between the squamous layer and the fibrous layer and the flap
replaced.

INTERLAY TYMPANOPLASTY

Most perforations of the tympanic membrane that are not associated with ossicular
abnormalities or the ingress of keratin into the middle ear are closed with an underlay
graft or a lateral graft tympanoplasty. The former is easier to perform, but the graft
lacks the support of the fibrous layer of the tympanic membrane remnant; the latter
provides a more robust support for the graft, but comes at the price of a substantial
amount of trauma to the skin of the ear canal that is explanted and replaced as part
of this procedure. This situation can cause blunting of the anterior recess of the
external ear canal and may cause problems with the transfer of sound energy.
Using an endoscopic approach, it is possible to perform a hybrid technique that has
not been easy to perform with the microscope, because of the difficulty with access to

Fig. 8. The graft is now sandwiched between the fibrous and the squamous layer, which
provides a robust support for the graft.
 Endoscopic Tympanoplasty 163

the anterior region of the tympanic membrane. The hybrid interlay technique involves
the raising of an extended tympanomeatal flap to the level of the fibrous annulus of
the tympanic membrane. At this point, rather than raising the flap along with the annulus
and the tympanic membrane, the squamous layer is elevated off the fibrous layer of the
tympanic membrane, leaving the fibrous layer in situ (Fig. 5). After the squamous layer
has been elevated beyond the margins of the perforation (Fig. 6), a graft is inserted
between the squamous layer and the fibrous layer and the flap replaced (Fig. 7). The
graft material can be temporalis fascia, perichondrium, or a composite graft.
The graft is now sandwiched between the fibrous and the squamous layer, which
provides a robust support for the graft (Fig. 8). This technique preserves the integrity
of the fibrous annulus and leaves the skin of the ear canal in position in the anterior
recess and still provides a stable bed for the graft. A potential drawback is the difficulty
in raising the squamous layer from the fibrous layer, but this is easier to perform with
wide access to the flap and the accurate and highly magnified view of the interface of
these layers afforded by the endoscopic view (Video 7).

SUPPLEMENTARY DATA

Supplementary data related to this article can be found online at http://dx.doi.org/10.

1016/j.otc.2012.12.002.

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