New surgical approach for lateralized tympanic membranes.
Yuya Narui, MD, PhD, Hidenaga Yamamoto, Tao Yang, Maya Oishi, Shuichiro Hayashi, Ken Hayashi, Sayuri Yano, Yuko Miyamoto, Atsushi Shinkawa
Shinkawa Clinic
ABSTRACT
Lateralization of the tympanic membrane (TM) is a
condition in which the visible surface of the TM is
located lateral to the bony annular ring and loses
contact with the ossicular chain of the middle ear. This
condition typically occurs as a complication of
otological surgery.
Surgical correction of the lateralized TM and
restoration of hearing may pose some problems
because the grafts tend to re-lateralize after the
revision. Though we have been performed that
surgical correction in our hospital, we haven't had
good success.
Therefore we have changed our way of technique.
We now use a custom-made ceramic columella which
is 2 times longer than the one we had previously used.
It now directly reaches the lateralized TM from the
stapes, instead of changing the position of the
lateralized TM.
The merit of this approach is that re-lateralizing never
occurs because we don't change the position of the
TM. Some patients hearing have improved over 30dB.
The demerit of this approach is that the columellae
sometimes fall or break through the eardrum because
it is difficult to adjust the length due to long distance.
So we have tried to work out the solution by
accurately measuring the distance in units of 0.1 mm
between the lateralized TM and stapes by using a 3D
Cone-Beam CT. We also measure the distance
throughout the operation.
Though there is a short observation period, we have
had good success with this approach. We will report
our new surgical approach details with some case
reports.
INTRODUCTION
This is ‘The lateralized tympanic
membrane’.
It is located laterally to the bony annular
ring and loses contact with the ossicular
chain.
This condition occurs as a complication of
otological surgery.
Previous reports about the treatment of lateralized TM are few. Therefore,
the results of conventional surgical approach are insufficient.
1
2
Conventional surgical
approach for lateralized TM.
Problems regarding conventional
surgical approaches.
The lateralized TM and fibrous
tissue are completely removed.
New grafts tend to relateralize
after the revision.
been removed.
He had undergone a tympanoplasty about 40
years ago.
The lateralized TM
The lateralized TM
pure tone audiometry
pure tone audiometry
After the
procedure
Fibrous and epithelial tissue under
the lateralized TM was removed.
pure tone audiometry
After the
procedure
After the
procedure
We confirm the stapes.
Pre-op 75.0dB
6 months later
Post-op 30.0dB
Pre-op 71.8dB
Post-op
6 months later
Post-op 36.7dB
Post-op
Pre-op 73.3dB
6 months later
Post-op 38.3dB
Post-op
A long columella has been inserted which bridges the
lateralized TM and stapes.
Hearing improvement
Pre-op
4) A long columella has been
1) The Canal Wall Down
inserted which bridges the lateralized
technique has been performed.
TM and the stapes. We never
2) Incus and change the position of the lateralized
malleus have TM.
He had undergone a tympanoplasty about 20
years ago.
Case 3 (64 y.o. male)
Some frame of this technique
This is the air-conduction pure-tone average in pre and post-op state.
Here are 15 cases who have undergone our procedure from Oct. 2010 to May. 2011.
Hearing tends to revert to pre-op
state.
Case 2 (73 y.o. male)
The lateralized TM
•Boone R. et al,『Surgical correction of the lateralized tympanic membrane.』 Laryngoscope 2002
•Sperling NK. et al, 『Diagnosis and Management of the Lateralized Tympanic Membrane.』
Laryngoscope 2000
•Segal S. et al, 『Surgical correction of lateralized ear drum.』 Journal of laryngology and otology 1981
3) Fibrous and epithelial tissue under
the lateralized TM was also removed.
Poster Design & Printing by Genigraphics® - 800.790.4001
1
2
He had undergone a tympanoplasty about ten
years ago.
Previous reports
New surgical approache developed at Shinkawa Clinic.
Yuya Narui
Shinkawa Clinic (Kanagawa, Japan)
Email: [email protected]
Phone: 81-90-7425-2515
1：Original ceramic columella
length (P ceramic, T ceramic)
2：New longer ceramic
columella.This is 4mm longer
than the original.
P ceramic T ceramic
Case 1 (59 y.o. male)
There is empty space or fibrous tissue behind the lateralized TM. In
some cases, there may be an iatrogenic cholesteatoma between the
original position of the TM and the lateralized TM.
The skin and fascia grafts are
placed into the original position.
CONTACT
An enlarged photo of the long columella
Pt.No.
(average of
500Hz,1kHz
and 2kHz)
Post-op
Hearing
(6 months
improve-
later)
ment
Hearing improvement（dB)
1
45
28.3
-16.7
2
68.3
33.8
-34.5
3
65
51.7
-13.3
4
83.3
75
-8.3
5
75
30
-45
6
71.8
36.7
-35.1
7
115
88.3
-26.7
8
65
70
5
9
78.3
63.3
-15
10
73.3
70
-3.3
11
58.3
48.3
-10
12
71.7
43.3
-28.4
13
108
85
-23
14
73.3
38.3
-35
15
73.3
33.3
-40
<10 10‐19 20-29 30-39 ＞40
3
4
66% of our patients
（ten cases） have
improved over 15dB.
3
3
5 cases have
improved
over 30dB
2
Problems and countermeasure
There were some cases with little hearing improvement. We
mentioned the problem during our procedure.
The main problem is that It is very difficult controlling the long
columella length due to distance bridging the lateralized TM and stapes.
If the columella is too long, it will puncture the TM and if the columella
is too short, sound vibrations cannot conduct.
Therefor we now use 3D image processing with a Cone-Beam CT. We
have started measuring the distance in units of 0.1 mm exactly
between the lateralized TM and the stapes during every surgery.
In this case, distance
between lateralized TM and
the stapes is shown at
about 9.2mm on the 3D CT.
In the near future
The long columella is heavier than the original due to
its size and prone to slippage.
We require titanium long columella because they are
lighter than ceramic and less prone to slippage.
Problem in Japan
Unfortunately, we are unable to use titanium
columellas easily due to Japan’s insurance system.
We hope this will change in the near future.
Thank you very much
for your attention.
Yuya Narui MD. PhD.
Shinkawa Clinic
(Kanagawa, Japan)