AAO-HNSF Primary Care Otolaryngology Handbook

CHAPTER 4

Clinical Example A 14-year-old comes to your office complaining of painless right ear drainage. He is otherwise healthy, although he did have ear tubes that were placed in his ears as a 2-year-old. On examination, you find he has slightly turbid drainage coming from a hole in his right eardrum. You diagnose chronic otitis media and learn that he does not know he has a perforation and has not been using ear plugs. You assume he has a Pseudomonas aeruginosa infection and prescribe ofloxacin otic solution (0.3%) twice a day for 10 days. He returns in two weeks with a dry ear and a small residual eardrum perforation. You order an audiogram , or hearing test, which shows a 15-dB conductive hearing loss with normal discrimination (ability to understand words). You tell the patient to keep water out of his ear. He comes back in four to six weeks and has not had any more drainage, so you refer him for a tympanoplasty . Tympanoplasty Myringoplasty and tympanoplasty are operations to repair a hole in the eardrum. These surgeries can be performed either through the ear canal or via an incision behind the ear . The type of operation performed depends on such factors as the size and location of the hole. In patients undergoing myringoplasty , typically an inert material, such as paper, is placed over the perforation after the surgeon freshens up the edges of the hole to stimulate healing. Small fat grafts may also be used to plug the hole. Tympanoplasty, which is a slightly more extensive procedure, involves making small, semicircular cuts in the skin of the external audi- tory canal and elevating or scraping the skin and eardrum away from the bone to expose the medial aspect of the eardrum and the middle ear space. The middle ear is then filled with a sponge-like material made of hydrolyzed collagen, which acts as a scaffold to hold the graft up against the medial aspect of the eardrum perforation. Examples of grafting mate- rials for tympanoplasty include a piece of fascia temporalis (the fibrous connective tissue overlying the temporalis muscle) or tragal or conchal perichondrium (the lining overlying the tragus or conchal bowl ear cartilage). Then the eardrum and skin are laid back down and the ear canal is packed with a sponge-like material that eventually resorbs. During the healing process, the fibrous layer of the eardrum proliferates along the scaffolding of the graft to close the hole. Following these procedures, patients are typically instructed to keep water out of their ear until the eardrum has healed.

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Primary Care Otolaryngology