Franklin M. Rizer

Overlay Versus Underlay Tympanoplasty. Part I: Historical Review of the Literature

The history of otology is the history of the successful treatment of infections of the middle ear and the eardrum. Otologists have sought to restore hearing lost to infections of the eardrum since the 1600s. The development of instruments, techniques, and materials to treat infection is fascinating because of the serendipitous nature of the discoveries and the insight of the discoverers. This historical review describes the history of the treatment of infections of the ear and the development of modern techniques of ear surgery. Two contemporary methods of tympanic membrane repair are then described.

Overlay versus underlay tympanoplasty. Part II: the study.

This report compares two contemporary techniques of tympanic membrane repair. The prospective comparison study included 712 cases over 9 years. Whether the tympanic membrane was repaired by an underlay or an overlay technique, results were reliable. By making a postauricular incision, greater visibility of the operative site can be obtained. Larger perforations can be closed more reliably when greater exposure is obtained. The placement of the graft above or below the annulus is not the issue. Careful technique and precise work are the keys to successful tympanoplasty. Thus otologic surgeons should cultivate effective techniques, attempting to continuously improve their results to achieve perfection.

Practical Use of Total and Partial Ossicular Replacement Prostheses in Ossiculoplasty

The use of porous polyethylene total and partial ossicular replacement prostheses (TOPs and POPs) for ossicular reconstruction in middle ear surgery was retrospectively reviewed at the Warren Otologic Group, a tertiary referral center for otologic problems. Extrusion rates, lower than those previously reported, and improvement in hearing results were found in 250 cases. Follow‐up ranged from 6 months to 8 years. This paper details the optimal placement and relationships of the prosthesis, the interposed tragal cartilage, and the drum. Modifications to the prosthesis have increased stability and ease of reconstruction. The hearing results of both TOP and POP reconstruction, and comparison with the literature, will be presented. With TOPs, the air‐bone gap was closed to within 20 dB in 67% of cases. With POPs, similar results were obtained in 81% of cases.

Staging for Cholesteatoma in the Child, Adolescent, and Adult

A closed tympanomastoidectomy with subsequent staged surgical procedures leading to the excision of cholesteatoma was validated as described. All elements of staging with a 10-year experience of 354 patients are covered according to categories of child (0 to 9 years), adolescent (10 to 15 years), and adult. The child differed from the adolescent and adult in the following manner: More recurring cholesteatomas, greater ossicular necrosis, poorer hearing results, less aggressive residual cholesteatoma, and significantly poorer results with pars flaccida cholesteatoma than pars tensa cholesteatoma. After the end stage, 90% of the cases remained closed, with acceptable hearing in 60% of the patients.

Perilymph fistulas: the House Ear Clinic experience.

The diagnosis, evaluation, and surgical treatment of perilymph fistulas has recently been the focus of a great deal of attention in otology. Authors have focused on perilymph fistulas as the cause of hearing loss and vertigo in many diverse situations. Additionally, surgical repair has been suggested when there is little objective support for intervention. To address some of the problems inherent in the diagnosis and treatment of perilymph fistulas, records of patients operated on at the House Ear Clinic during the past 12 years were reviewed retrospectively. Eighty-six patients were surgically explored for fistulas during this period. Thirty-five (40.7%) fistulas were found, and 51 ears were patched whether fistulas were found or not. Of the 80 patients who were seen for follow-up, 35 (43.8%) were subjectively better, and 45 (56.2%) were the same. Although the number of fistulas found and the number of patients improved were similar, the composition of the two groups was different. On the basis of audiometric results, improvement in hearing occurred in only 18.7% of the patients. None of the demographic factors or diagnostic tests were predictive of either the presence of a fistula or the therapeutic outcome. Further work is required to facilitate the preoperative diagnosis of fistulas and to design appropriate surgical Intervention.

A Postoperative Audiometric Evaluation of Cochlear Implant Patients

As the benefits of the cochlear implantation become more defined, many investigators hope that these devices can be offered to patients with a lesser degree of hearing loss. Accordingly, it is necessary to investigate the audiometric thresholds in the implanted ear after surgery. Preservation of the residual hearing after implantation would support the claims that surgery and the presence of a cochlear implant do not adversely affect the implanted ear.

Ossiculoplasty in canal wall down mastoidectomy

OBJECTIVE: The aim of this study was to evaluate the initial and longer term success of closing the air-bone gap (ABG) to 20 dB in ossiculoplasty with canal wall down mastoidectomy. METHODS: This study was conducted at a private otologic practice. Patients included those who underwent ossiculoplasty from 1989 to 1996 with canal wall down mastoidectomy, whether primary or revision (33 from a total of 387 tympanomastoidectomies). Outcome measures included ABG closure, long-term hearing stability, mastoid appearance, extrusion, and sensorineural hearing loss. RESULTS: Almost 64% of ABGs were closed to within 20 dB. The mean pure-tone average improvement was 12.3 dB. The mean PTA hearing decline in the years after surgery was slightly less than 1 dB/year. CONCLUSION: Hearing improvement with a stable long-term hearing result is possible with canal wall down mastoidectomy. The potential for hearing gain is greatest for patients having larger preoperative ABGs. (Otolaryngol Head Neck Surg 2000;123: 30-3.)

Short- and long-term results of stapedectomy in children.

Studies have indicated that stapedectomy can be an effective procedure in children for correcting conductive hearing losses due to juvenile otosclerosis. However, because childhood otosclerosis is rare and children commonly choose to use hearing aids in lieu of undergoing surgery, little outcome data are available. The purpose of this retrospective study was to provide additional outcome data in both the short and the long term. Stapedectomies were performed on 47 children. Preoperative hearing results were compared with 6‐month postoperative hearing results. Hearing results for the children who had long‐term follow‐up (5 years or more) were compared with the 6‐month postoperative results. Stapedectomy was successful (postoperative air conduction pure‐tone average [PTA] within 10 dB of the preoperative bone conduction PTA) in 91.7% of the cases. The mean over‐closure of the preoperative bone conduction PTA by the postoperative air conduction PTA was 0.2 dB. The mean PTA hearing improvement was 32.8 dB. Results from the 21 children (28 ears) who had long‐term follow‐up indicated an average 0.7 dB/year PTA worsening from the 6‐month postoperative PTA. Results from this study provide additional evidence that stapedectomy can be an effective procedure for correcting conductive hearing losses due to juvenile otosclerosis.

Prosthesis size in stapedectomy

Primary stapedectomies were performed on 60 patients with bilateral otosclerosis. Every patient had a 4 mm long Robinson prosthesis with a 0.4 mm wide shaft placed in one ear and a 4 mm long Robinson prosthesis with 0.6 mm wide shaft placed in the opposite ear. With the 0.4 mm wide prosthesis, 54 patients overclosed the air bone gap and 6 were within 10 dB of closing. With the 0.6 mm wide prosthesis, which was placed in the opposite ear, 51 patients overclosed their air-bone gap and 8 were within 10 dB of closing. We conclude that there is no statistical difference in hearing results between the 0.4 mm and the 0.6 mm wide Robinson prosthesis when they are used in a partial stapedectomy with a vein graft covering the oval window.

Partial ossicular reconstruction in children: A review of 62 operations†

Objective/Hypothesis: The published experience and audiometric results with ossicular reconstruction in children are limited. To better understand the role of ossiculoplasty in children, audiometric results were examined for partial ossicular reconstructions performed on a pediatric population. Study Design: Retrospective. Methods: Sixty‐two partial ossicular reconstructions performed on a pediatric population were reviewed for audiometric results, prosthesis extrusion rates, and mechanisms of failure at revision. Comparison of techniques and prosthesis types: porous polyethylene partial ossicular replacement prosthesis (POP), Schuring ossicle cup (SOC), and modified Robinson prosthesis (MRP) were also evaluated. Follow‐up ranged from 6 to 72 months. Results: Six‐month hearing results showed postoperative air‐bone gaps less than or equal to 20 dB in 77% of cases. Successful results at 1 and 2 years were retained in 66% and 63% of cases, respectively. Results for POPs at 1 and 2 years were 78% and 89%. Results for SOCs at 1 and 2 years were 61% and 55%. The overall extrusion rate was approximately 3%. Conclusions: These results compare favorably with those from other, mostly adult, studies. Comparison of prosthesis types revealed generally stable long‐term results with few significant differences. Success with ossiculoplasty in children can be obtained by applying the same principles and approach to ossicular reconstruction as used in adults. Ossicular reconstruction in children remains a secondary goal after establishing a safe, dry, and stable ear. A discussion of techniques and comparative literature review are presented. Laryngoscope, 108:1674–1681, 1998