RETRACTION POCKETS AND PERFORATIONSmanchesterchildrensent.com/.../2018/03/...TWITTER.pdfRETRACTION...
Transcript of RETRACTION POCKETS AND PERFORATIONSmanchesterchildrensent.com/.../2018/03/...TWITTER.pdfRETRACTION...
R E T R A C T I O N P O C K E T S A N D P E R F O R AT I O N S
B P O C , L O N D O N 2 0 1 8
P R O F I A B R U C E M D F R C S PA E D I AT R I C O T O L A R Y N G O L O G I S T, M A N C H E S T E R , U K
P E R F O R AT I O N S
• Sequelae of acute or chronic ear infection, physical trauma, barotrauma or iatrogenic
• Permanent perforation more likely with chronicity of ear disease & ETD
• 5 types of Tympanoplasty described, dependent upon integrity and mobility of the ossicular chain
• Choosing the technique for repair influenced more by perforation and patient factors than success for particular techniques
M Y R I N G O P L A S T Y / T Y P E 1 T Y M PA N O P L A S T Y
• TM repair when middle ear normal- no ossicular surgery
• Success in children varies widely (majority 50-95%), Mean on metanalysis 83.4% Hardman 2015
• Aims of myringoplasty:
Limit infections and impact on QoL
Prevent complications of recurrent ear infections
Improve hearing
Limit developmental consequences of hearing loss (HL)
Avoid behind-the-ear (BTE) HA
Avoid need for waterproofing / allow swimming
FA C T O R S A F F E C T I N G M Y R I N G O P L A S T Y S U C C E S S
• Patient factors
ET function, health of contralateral ear -Hardman 2015, (age)
• Perforation factors
No unequivocal evidence that infection affects outcome - Tan 2016
Size of perforation - Hardman 2015
Site of perforation
• Surgical factors
Surgical technique
Graft material
Adults & children Mean success 86.6% 5.8% higher failure rate in children Cartilage has superior closure rates (2.8% better than fascia) Success 6.1% better for perforations <50% No clear benefit from combined cortical mastoidectomy No superior graft placement technique (underlay etc.)
T I M I N G O F P E R F O R AT I O N R E PA I R
• How old? No current consensus, but trend towards younger ages Hartzell 2010
• How old? ETD commonest in 2-4 year olds…
…Consider in 4 + year olds if contralateral ear normal
155 children with 6 months FU
Success 2-4 yrs 50%, 5-7 yrs 61%, 8-13 yrs 74%
Mean improvement in ABG 9dB
• When? Initially wait for spontaneous closure (approx. 6 months) Duval 2015
• When? Initial conservative approach (waterproofing) allows for assessment of ET function in contralateral ear
Significant variability in success ratesS U R G I C A L T E C H N I Q U E F O R M Y R I N G O P L A S T Y
• Permeatal, post-auricular, endaural or endoscopic
• Choice influenced by surgical training / surgical preference and physical characteristics of the perforation
e.g. post-auricular for anterior, permeatal or endural for posterior Tan 2016
G R A F T M AT E R I A L F O R M Y R I N G O P L A S T Y
• autologous
fat- lobule, temporalis fascia, cartilage- tragus or concha
• xenografts (porcine or bovine)
• scaffolding materials (paper patch, gelatin sponge)
• (basic fibroblast growth factor (b-FGF)- stimulates cell proliferation and angiogenesis)
Autologous Graft Material Ethos Pros Cons Indication
Fat Graft
Promotes Angiogenesis And Neovascularisation
(Gun 2014)
Low Morbidity Harvest Rapid Surgery
Low-Invasiveness
Tends To Be Considered Only For Small
Perforations Avoid In Infected Ears
Central Perforation <25%
Grommet Removal
Temporalis Fascia Graft
ScaffoldStrong
Resistant To Infection
Low Morbidity Harvest
Retract Or Re-Perforate If Poor Eustachian Tube
Function
Any Size Perforation
Cartilage-
Underlay (Alone Or
Composite)
Reinforce Neotympanum
Very Strong High Success Rate
Resistant To Infection
Unable To Visualise Middle Ear
Larger Cartilage = Poorer Hearing Result
Any Size Perforation Younger Children
Revision Cases
Cartilage- Inlay (Butterfly)
Graft Anchored To Edges Of Perforation
No Need For
Tympanomeatal Flap (Avoid Flap When Extensive
Tympanosclerosis)
? Central Perforation 25 - 50%
Perforation History Relevance To Management & Decision Making
Age No Consensus 4+ Years If Ear Infections Have Significant Consequences On Development & Wellbeing
Symptoms Duration & Severity Of Symptoms Influence Decision To Operate Wait Approx. 6 Months For Spontaneous Closure
AetiologyEar Infection, Trauma, Iatrogenic Ear Infections May Lead To Adhesions. Trauma May Be Associated With Snhl
HearingIncreasing Understanding Of Impact From Unilateral Hearing Loss Perforation In An Only Hearing Ear Is Not Absolute Contra-Indication To Repair
Tinnitus / Vertigo Association With Hearing Loss And Inner Ear Involvement In Disease Process
Contralateral Ear Indicator Of Eustachian Tube Function
Previous Ear Surgery Revision Surgery = Lower Success, Revision Surgery Influences Choice Of Graft Material, Previous Ear Surgery - ? Cholesteatoma
Co-Morbidities Relevant To Perforation
Craniofacial Abnormalities Associated With Poor Eustachian Tube Function (Cleft Palate, Achondroplasia, Craniosynostosis)
Co-Morbidities Relevant To Impact
Hearing Loss In Children With Syndromes Or Cognitive Impairment Ear Infection & Sepsis In Diabetes And Immune Deficiencies
Fitness For General Anaesthesia
Influences Decision To Operate
Water Precautions Adequacy Important If Too Young Or Preference To Manage Conservatively
Perforation Exam Description Relevance To Management & Outcome
Contralateral EarGlue Ear, Retraction, (Bilateral Perforation)
Indicators Of Eustachian Tube Function Poor Function = Lower Success
Oral Cavity/ OropharynxCleft Palate Repair, Bifid Uvula
Possible Poor Eustachian Tube Function Poor Function = Lower Success
Nasal Cavity RhinitisAssociation With Eustachian Tube Function Optimise Nasal Health
Ear- Perforation Size %Size Influences Surgical Technique Larger Size = Lower Success
Ear- Perforation SiteQuadrants + Attic Influences Surgical Approach, Technical Difficulty &
Success
Ear- Relation To AnnulusCentral / Marginal Marginal Granulations
No Such Thing As ‘Safe’ Perforation Marginal Granulations - ?Cholesteatoma
Ear- Middle Ear Otorrhoea, GranulationsDry Ear Preferred, But Not Mandatory Influence Surgical Technique
Ear- Atelectasis/Tympanosclerosis
Grade Retraction, Extent Of Tympanosclerosis
Indicators Of Eustachian Tube Function Influence Decision To Operate & Technical Difficulty
Ear- CholesteatomaPerforation At Base Of Retraction
Determines Extent Of Surgery
Howtoassessaperforation
PS
PI
AS
AI
Pars Flaccida
Pars Tensa
Howtoassessaperforation
Size
20%40%
PS
PI
AS
AI
Pars Flaccida
Pars Tensa
Howtoassessaperforation
Relation toAnnulus
CentralMarginal
PS
PI
AS
AI
Size
20%40%
Pars Flaccida
Pars Tensa
Howtoassessaperforation Size
20%40%
Relation toAnnulus
CentralMarginal
PhysicalCharacteristics
Tympanosclerosis
PS
PI
AS
AI
Pars Flaccida
Pars Tensa
Middle Ear Health
Otorrhoea +Granulations
Howtoassessaperforation Size
20%40%
Relation toAnnulus
CentralMarginal
PhysicalCharacteristics
Tympanosclerosis
PS
PI
AS
AIMiddle Ear Health
Otorrhoea +Granulations
Pars Flaccida
Pars Tensa
R E T R A C T I O N S
• Ultimate aim to prevent atelectasis and/or cholesteatoma
• Need to manage the retraction and associated hearing loss
• No management strategy unequivocally proven to prevent progression to cholesteatoma
• Strategies include (or combination):
Watchful Waiting with surveillance for progression
Ventilate the middle ear whilst waiting for maturation in Eustachian Tube function
Resect the retraction
Reinforce the retracted segment with cartilage
Grade Sade Tos
1 Retraction Over Annulus Retraction Towards Malleus
2Retraction Onto Long
Process Of IncusRetraction Onto Malleus
3Retraction Touches
PromontoryErosion Of Outer Attic Wall
4Retraction Adherent To
PromontoryUnable To Fully Visualise
Extent Of Deep Retraction
Is watchful waiting the best strategy for retractions adherent to the incus?
Retraction Exam Description Relevance To Management & Outcome
Contralateral EarGlue Ear, Retraction, Perforation
Indicators Of Eustachian Tube Function
Oral Cavity/ Oropharynx
Cleft Palate Repair, Bifid Uvula
Possible Poor Eustachian Tube Function
Nasal Cavity RhinitisAssociation With Eustachian Tube Function Optimise Nasal Health
Ear- Infection/Inflammation/ Glue Ear
Granulations In Retraction- ? Cholesteatoma Indication Of Eustachian Tube Function
Ear- Extent Of Retraction
Grading System Or Narrative Description
Fixation To Middle Ear Structures Risks Iatrogenic Cholesteatoma If Attempt To Elevate And Resect Retraction Role Of Ventilation Tubes In Early Progressive Retractions
Erosion Of Ossicular Chain
Ear- Extent Of Tympanosclerosis
Extent Of TympanosclerosisInfluence On Technical Difficulty To Elevate Increases Size Of Perforation If Resect
Ear- CholesteatomaCholesteatoma In Retraction Pocket
Determines Extent Of Surgery
ORCHID http://orcid.org/0000-0003-0831-4760
@Prof_IainBruce
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