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Laser myringoplasty for tympanic membrane retraction.

Only selected patients are good candidates for this procedure. Patients who are able to lift their TM with the Valsalva maneuver are ideal.

Otoscopic Clinic

A 41-yar-old man, a member of the U.S. Air Force, presented with bilateral hearing loss and aural fullness that worsened when he flew. On examination, he was found to have bilateral posterior tympanic membrane (TM) retractions with incudopexy (figure 1, A). He was able to lift the retractions off the incus with the Valsalva maneuver, which temporarily alleviated his symptoms. He denied a history of recurrent ear infections or ear surgeries. His audiogram showed normal bone thresholds with a mild air-bone gap.

Because of the safe appearance of his retraction, the patient was offered observation in lieu of interventions such as a laser myringoplasty or a formal tympanoplasty, which were also discussed. Because of his profession, he was constantly dealing with pressure changes that exacerbated his symptoms, so he decided to undergo a CO2 laser myringoplasty. Two months postoperatively, examination revealed a resolution of his posterior TM retractions (figure 1, B). His aural fullness had also diminished, and there was a mild improvement in his hearing.

The atelectatic TM is a challenging entity to treat. Conservative management with frequent examinations or tympanostomy tubes is commonly tried first to prevent progression, but this does not reverse the morphology of the atelectatic TM. (1) In this disease entity, the middle fibrous layer of the TM becomes stretched and disorganized, and it will not spontaneously improve. (2) Ultimately, if conservative management fails and the ear is deemed unsafe, a reinforcement myringoplasty is required. (3)

Other authors have used a laser to resurface atelectatic tympanic membranes with good effect. (4,5) This technique is particularly useful for those patients who have a retracted TM but no active disease. The ultimate goals are (1) to restore the tension of the TM and (2) to prevent progression to active disease or the worsening of the conductive hearing loss secondary to ossicular chain erosion.

This procedure is completed in the operating room. Nitrous oxide is used during the induction of anesthesia to lift the atelectatic portion of the TM (figure 2, A). The laser fiber is simply held in the operating hand and brought into the ear about 1 to 2 cm away from the TM. We always start with the laser set at 1.0 W on continuous pulsations and begin treating the TM at the farthest possible distance, slowly moving closer until we see contraction.

As the TM responds, it will exhibit a slight change in color, becoming slightly pale and opaque. Occasionally, adhesions to the incudostapedial joint will not lift with the nitrous oxide, so they are addressed through a small tympanomeatal flap that is lifted with a Rosen pick. Through this flap, we are able to dissect the TM from the incus. Once the TM has returned to a more native shape and position, or if progress is no longer visualized despite increasing the wattage, the procedure is concluded. We are very cautious not to overtreat, especially in thin areas (i.e., the monomeric membranes), to prevent iatrogenic perforations.

Only selected patients are good candidates for this procedure. Patients who are able to lift their TM with the Valsalva maneuver are ideal (figure 2, B). This ensures that the TM will lift spontaneously during surgery when the anesthesiologist administers nitrous oxide. Furthermore, the ability to lift the TM with the Valsalva maneuver is imperative postoperatively to prevent a recurrence of the retraction.

In our hands, this is a straightforward procedure that can resolve symptomatic TM retractions with minimal morbidity and postpone the sequelae of retracted TMs when applied to the correct patient.

References

(1.) Luntz M, Eisman S, Sade J. Induced atelectasis of the middle ear and its clinical behavior. Eur Arch Otorhinolaryngol 1991; 248 (5): 286-8.

(2.) Sade J. Atelectatic tympanic membrane: Histologic study. Ann Otol Rhinol Laryngol 1993; 102 (9): 712-16.

(3.) Dornhoffer JL. Surgical management of the atelectatic ear. Am J Otol 2000; 21 (3): 315-21.

(4.) Brawner JT, Saunders JE, Berryhill WE. Laser myringoplasty for tympanic membrane atelectasis. Otolaryngol Head Neck Surg 2008; 139 (1): 47-50.

(5.) Ostrowski VB, Bojrab DI. Minimally invasive laser contraction myringoplasty for tympanic membrane atelectasis. Otolaryngol Head Neck Surg 2003; 128 (5): 711-18.

From House Clinic, Los Angeles (Dr. Chen and Dr. House); and the Department of Otolaryngology-Head and Neck Surgery, Madigan Army Medical Center, Tacoma, Wash. (Dr. Crawford).

February 24, 2016 by Brian S. Chen, MD; John W. House, MD; James V. Crawford, MD

Caption: Figure 1. A: Preoperative photograph shows the retracted posterior TM with incudopexy (arrow). B: When nitrous oxide induction of anesthesia is administered, the atelectatic portion of the TM lifts off of the incus. This is similar to what is expected when a patient performs the Valsalva maneuver.

Caption: Figure 2. A: At the 2-month postoperative examination, the preoperative incudopexy is no longer present. B: When a patient performs the Valsalva maneuver, the TM retraction is vastly improved.
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Author:Chen, Brian S.; House, John W.; Crawford, James V.
Publication:Ear, Nose and Throat Journal
Date:Feb 1, 2016
Words:835
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