INTRODUCTION
Since Wullstein and Zollner first introduced the classical methods of tympanoplasty in the 1950s, numerous alternatives have been explored, many of which have proven even more promising. Methods of tympanic membrane (TM) perforation restoration can be generally categorized into two patterns: the overlay and the underlay, with their respective merits and flaws (Laryngoscope. 1997;107:25–29). Numerous techniques used today are evolved versions of these original approaches, such as LMUT (lateral-to-malleus underlay tympanoplasty), double layer tympanoplasty, loop underlay or overlay technique, butterfly myringoplasty, swing-door tympanoplasty, circumferential sub-annular tympanoplasty, and three-point fix tympanoplasty. All these techniques need to make an incision in the external canal. For patients who merely need perforation repair, our method spares a canal incision, which favors blood supply to the TM and simplifies wound dressing. Besides this advantage, by innovatively combining the “sleeve” canalplasty together with a tongue-shaped fascia covering the perforation in the over-underlay pattern, we have successfully obtained a desirable outcome even for the relatively difficult large and/or anterior perforations.
METHOD
First, a postauricular incision was made to harvest the temporalis fascia graft with a diameter of about 1.0–1.5 cm. A “U”-shaped myoperiosteal flap was created, and its pedicle was connected to the subcutaneous tissue posterior to the external meatus.
Second, approaching the myoperiosteal flap, the external canal skin was separated from the bony canal in an encircled manner and headed forward until it reached the tympanic annulus. It is noteworthy that there were no incisions in the skin of the external auditory canal, and caution was taken to reduce tension during the procedure to form a complete “sleeve” of the skin of the external auditory canal. We used a diamond bur and kept enough safety space to avoid a canal skin tear. Therefore, a 270°–360° canalplasty was conducted to ensure a wide operative vision. If a bulging anterior bony canal limits the exposure of the front edge of the perforation, 360° canalplasty should be performed.
Third, there was still no incision, starting from the annulus, and the epithelial layer of remnant TM was elevated toward the edge of the perforation, except at the 2–5 o’clock position (right ear), which was left intact for subsequent process. In case of a posterior perforation, the epithelial layer can also be elevated 360° around the perforation. After de-epithelization of the perforation edge, the ossicular chain was inspected and the lesions were treated accordingly.
Afterward, the end of the manubrium of the malleus was excised approximately 0.5–1.0 mm in patients with remarkable inward malleus. If left untreated, it is likely that the adducted umbo of the malleus will press the fasci against the promontory, resulting in adhesions and even atelectasis.
Subsequently, three slits were prepared onto the fascia (Figure 1). Two of them formed a “tongue” in the front, which was about to fit into the space beneath the anterior 2–5 o’clock annulus (right ear). The third one was carved posteriorly near the malleus handle, so as to better accommodate the fascia medial to the manubrium of the malleus, while covering the neck and head of the malleus laterally. Gelfoams were stuffed into the tympanic cavity to provide support.
Afterward, the “sleeve” flap with the epithelial layer of remnant TM in the center was re-positioned and overlapped with the brim of the fascia. As is demonstrated by the above steps, this method is particularly suitable for anterior perforation, as it is much easier to tuck the fascia tongue under the anterior annulus when the perforation edge locates anteriorly. As for large perforations, because there is a less epithelial layer to separate from the remnant TM in large perforations, this method can actually be simplified when dealing with such lesions as long as a sufficiently large fascia is procured.
Ultimately, tightly rolled iodoform rosebuds were firmly stuffed in the ear canal, so as to press the canal skin onto the enlarged wall of the bony canal.
RESULTS
Complete medical records were collected from 86 patients, including 37 males and 49 females. The average follow-up period was 16.21 ± 13.06 months. Graft taken rate was 94.2% (81/86), three cases were reperforated due to infection, one case was reperforated due to poor ventilation, and one case might be related to some particularly thin area of fascia. No anterior blunting, lateralization, or fascia falling off was witnessed. There were 61 cases of anterior large/subtotal perforations, and 59 (96.72%) cases showed complete closure.
The sleeve and tongue tympanoplasty can be a trustworthy alternative for TM perforation repair, especially for large anterior perforations. According to our experience, it’s rarely essential to make an auxiliary intra-canal incision with this technique, as it has already provided sufficient exposure. Additionally, the sleeve flap ensures favorable blood supply in the external meatus, and tongue-shaped fascia not only seals the perforation solidly but also maintains the anterior acute angle and maximizes the physiological appearance of the TM.