Prof. Dr. Şenol Polat

Tympanoplasty And Mastoidectomy

How is the structure of the ear?
The ear consists of 3 parts. Outer ear canal, middle ear and inner ear. The outer ear and middle ear are separated from each other by the eardrum. Subsequently, the first ossicular anvil (malleus) comes in the middle ear and transmits sound energy inside. We can think of the middle ear as a closed chamber. It is filled with air. Ventilation inside, regulating the pressure and evacuating the secretions inside takes place via the eustachian tube. The eustachian tube connects the middle ear to the nasal region. Any disruption in these systems leads to ear diseases. For example, problems that occur in the eustachian tube cause defects in the middle ear. Especially in the early period, fluid accumulation, retraction in the eardrum and prominent thinning in the eardrum are observed. If the underlying cause is not found and untreated, tearing, puncture and cavities begin to form in the eardrum.

What is chronic otitis media?
Inflammatory diseases that occur in the eardrum and / or in the middle ear, lasting more than 3 months and do not respond to the medical treatments given are called chronic otitis media. The most common complaints in these patients are intermittent discharge in the ear, pain, hearing loss, sometimes ringing and dizziness. The most common findings in the examination are holes, which can sometimes be very wide in the eardrum, collapse in the eardrum, pocket formation and fluid deposits inside. Sometimes middle ear structures can be seen through the hole. These patients may experience various levels of hearing loss.

What can be the complications of chronic otitis media?
The most important complications are hearing loss, which increases over time, melting in the ossicles in the middle ear, spread of recurrent infections to the inner ear (in this case, there may be permanent and irreversible hearing loss, severe dizziness, imbalance) inflammation of the meninges (meningitis), facial nerve retention, facial paralysis, spread of infection to other adjacent areas such as brain abscess (although very rare today) can be seen. Another complication is the accumulation of some destructive enzyme and keratin-producing cells that form the outer ear canal in the middle ear or in the thinned and formed membrane areas. This condition is called ‘cholesteatoma’. The disease is defined as chronic otitis media with cholesteatoma. It has destructive effects on the middle ear and surrounding tissues, which can be very difficult to recycle. It can be thought of as a tumor that grows and spreads to the environment.

How is the treatment of chronic otitis media?
The goal of treatment is to clear the disease in the middle ear, correct the underlying and present pathology, repair the eardrum and, if possible, improve hearing.

Good anatomical knowledge, surgical skills and experience are required to perform these surgeries. Tissue is taken from some areas for the hole in the eardrum. The most commonly used tissues are a small piece of ear cartilage, the thin membrane covering the cartilage, the membrane that covers the muscle behind or above the ear. These surgeries are defined according to the intervention to be performed. If there is only a hole in the eardrum, the middle ear is clean, if there is no significant decrease in hearing, only the eardrum repair may be sufficient. This surgery is called myringoplasty (type 1 tympanoplasty). It is a short-term operation and postoperative complication risk is low.

If there is an intervention in the middle ear structures (if there is a problem in the ossicles, cholestatoma and epithelium accumulation in the middle ear), it is called tympanoplasty. The duration of the operation may be longer and the risk of complications afterwards may be higher. If the disease has exceeded the middle ear (for example, it has spread to adjacent bone areas around the middle ear), much larger surgery such as mastoidectomy is required. We can perform these surgeries and interventions both with a microscope and with endoscopes.

For what reasons can the patient experience hearing loss?
The ear consists of 3 parts, the outer ear canal and the auricle, the middle ear and the inner ear. Sound waves travel through the outer ear canal, causing vibration in the eardrum. The eardrum transmits this vibration (mechanical energy) to the ossicles and the ossicles to the inner ear. Fluid in the inner ear, ripple occurs due to the incoming mechanical energy. This fluctuation provides stimulation of hairy cells in the inner ear and auditory nerve endings that is contact with these cells. Thus, sound energy turns into neural energy. This warning, which proceeds from the auditory nerve, reaches the upper levels and the hearing center in the brain, making the hearing. Any malfunction in these systems causes hearing loss. Hearing deficits due to problems in the outer ear and middle ear are called conductive hearing impairment. In conductive hearing impairment, the inner ear auditory nerve and other upper centers are healthy, but sound energy cannot reach these areas. When the underlying cause of this type of hearing loss is detected, it can be treated to a large extent. In this case, the deterioration of hearing loss can be stopped and hearing may be brought back to normal or near normal level in some diseases. Hearing loss due to pathologies in the inner ear and upper centers is called sensorineural hearing loss. In this type of hearing impairment, there is a pathophysiology in the inner ear and / or higher segments that cannot process the incoming message. For example, in diseases where the inner ear (cochlea) is involved, the structures here are damaged and the sound energy cannot be converted into neural energy. In the treatment of sensorineural hearing loss, it is necessary to think on the basis of patient and disease. Hearing aids are a good option. Bionic ear (cochlear implant) should be considered in children and adult patients meeting certain criteria.

A condition in which both conductive and sensorinerol hearing loss is observed together is called mixed hearing loss. Treatment in this case is arranged according to the pathology.

Why does otosclerosis occur in the patient?
Ear calcification can occur in two cases. The first of these is the crust enriched with protein and calcium surrounding the eardrum or ossicles. In this case, the membranes and ossicles cannot vibrate and transmit sound waves to the inner ear. This disease is called myringosclerosis only if the membrane is involved, and tympanosclerosis if the ossicles are also involved. Its treatment is mostly surgery in suitable patients. Otosclerosis is the normal tissue that holds the inner ear and the stirrup bone in the inner ear, hardening (calcification) over time, causing hearing loss. It is not seen anywhere else on the body outside of this region. This hearing impairment is conductive hearing impairment, meaning there is no sensorineural (neural) hearing impairment because the inner ear and hearing nerve are intact. In some patients, the disease progresses and the entire inner ear can be involved, in which case neural hearing loss is also added. Otosclerosis is genetically transitive, but sometimes several generations can skip. It is a little more in women than in men, it is more common in women between the ages of 15 and 45. Pregnancy can also increase hearing loss. Although the exact cause is not known, hormones, genetic disorders or viral infections can be caused.

How is hearing impaired diagnosed?
Patients experience hearing impairment. Rarely, there may be complaints of tinnitus and dizziness. In the examination, the ear is natural, the eardrum looks normal and firm. Audiological examinations involving the hearing test are required for diagnosis. Hearing tests, tympanometry and acoustic reflex tests are sufficient for diagnosis, but tomography or MR may be required to demonstrate that there are no other potential diseases. Although very rare, similar hearing loss can be observed in diseases involving the middle ear, inner ear, or stirrup bone.

How is the treatment of hearing loss?
Surgical procedure or hearing aid may be considered in a patient with a conductive or mixed hearing type (both conductive and neural hearing loss). In surgery, the operation called stapectomy / stapedotomy is applied. Since the stirrup bone is involved in patients with otosclerosis, immobility is detected in the stirrup bone. This ossicle is removed. A small hole is drilled in the inner ear window (oval window). A prosthesis that will transmit sound energy-vibration is placed between this hole and the hammer.

Then the skin of the eardrum and the outer ear canal are laid back and the operation is terminated. The operation can be performed under local or general anesthesia. With the right surgery performed in the appropriate patient, the patient’s hearing deficiency is largely eliminated and this operation is a very delicate and technical operation. In rare cases, some complications may occur, such as infection occurrence, hole in the eardrum, facial nerve damage, poor hearing loss or complete loss of hearing (this is very rare), prosthesis dislocation or slipping.

What should the patient pay attention before and after the operation?
In the early period after the operation, the patient should not travel, lift heavy, cough and hard sledding. The resonance present in the patients before the operation and does not usually improve afterwards. Patients should be discussed in detail before the operation, the natural course of the disease should be explained and treatment options should be presented in detail. If surgery preference is chosen, complications and risks that may occur after surgery should be explained in detail. In patients who do not accept to be operated or have a health problem that prevents surgery, treatment is rehabilitation with a hearing aid.


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