MATERIAL AND METHOD
This was a prospective study carried out between January 2019 to January
2020.
INCLUSION CRITERIA
- Patient with H/O ear discharge
- All Tubo- tympanic diseases
- Young adults to age up to 70 years
- Dry/ mucoid /mucopurulent discharge
- Conductive, Mixed or Sensorineural hearing loss
EXCLUSION CRITERIA
- Attico antral disease
- Ossicular chain dislocation
- Ossicular chain fixation
METHODS
All patients with history of ear discharge were given a course of Tab
Amoxycillin+ Clavulanic acid 625 mg three times daily for five days.
Aural swab was sent for culture and sensitivity. Pure Tone audiometry
and Eustachian tube function test was done in all cases. All cases
underwent X-ray Mastoid (Lateral Oblique view). The antibiotic was
switched as per the culture and sensitivity report and continued for
next five days, although dryness of ear was not a criterion for surgery.
Patients underwent Endoscopic myringoplasty with intravenous antibiotic,
oral antihistamine one day prior to surgery in wet ear cases. The
patients were followed up one week, one month and three months
post-surgery. Endoscopic examination of the patient post one month and
three months. Intact graft after 1 month of surgery was taken as
anatomical success [1]. Audiometric evaluation was
done on third month post op.
PROCEDURE
All cases were done under general anaesthesia. Rigid endoscope
00 ,2.5 mm was used to visualize the tympanic
membrane. We had used the same microsurgery instrument that were used
for Microscopic Myringoplasty. Patient were laid in supine position,
head rotated to the opposite side and supported with a head ring.
Separate incision, post auricular just adjacent to the hairline
measuring 2.5 to 3 cm was given to harvest the Temporalis facia. The
graft was “paper dried”. All cases were supervised by a single surgeon
and performed by postgraduate residents.
TECHNIQUE
The external auditory canal was infiltrated with 2% 1:200,000 xylocaine
with adrenalin using Insulin syringe just distal to the hairy part along
the circumference until one can notice the blanching of the skin. A
maximum of 5ml was used for infiltration. We had used ample of adrenalin
soaked cotton balls to achieve haemostasis and in all cases, we have
achieved bloodless field which is very important for endoscopic
myringoplasty other than the technicality. Tarabichi suturing at the
concha was done to straighten the cartilaginous external auditory canal.
All cases were done with surgeon in sitting position with the elbow of
the endoscope holding hand resting on the table which provided
stability. Margins of the Tympanic membrane remnant was freshened with
curved pick or sickle knife. Tympanomeatal flap raising was tailor made
as per the site of the Tympanic membrane perforation as illustrated in
the diagram below. Diagram1 depicting a perforation in the
anterior quadrant with sufficient anterior margin, here an anterior
tunnel was created just close to the annulus with Tympanomeatal flap
raised from 12 ‘o’clock to 6 ‘o’clock and the part of the graft was
taken out from the tunnel to prevent anterior blunting. Diagram
2 a condition where the perforation was in the posterior quadrant, here
the tympanomeatal flap was raised from the 12’o’clock to 6’o’ clock and
the graft was placed medial to the malleus. Diagram 3 showing a
subtotal perforation with very thin anterior remnant, here the
Tympanomeatal flap was raised from 11’o’ clock round the circumference
to 2 ‘o’ clock and a big graft was placed resting over the bony canal
throughout the circumference. The eustachian tube opening was packed
with gelfoam and gelfoam bed was prepared over the middle ear. The dried
graft was placed over the gelfoam bed and was laid throughout the
circumference of the bone external canal. The tympanomeatal flap was
reposed back and again supported with a layer of gelfoam.