cleansing mechanism of the unoperated ear and the accumulated wax and epithelial debris need to be twice a year. Failure to service the cavity or the introduction of water may result in loss of the lining epithelium with accompanying pain and discharge. Tympanoplastic surgery is a logical development of the modified radical techniques and aims to avoid their main disadvantages--deafness and an open cavity in the mastoid-by creating a functioning middle ear in a healthy closed system. The principles of reconstructive surgery of the middle ear are by no means new, but it was only the advent of antibiotics and the widespread use of the operating microscope which led WULLSTEiN2and ZOLLNER3to advocate tympanoplasty in 1955. Impressively good results were soon being enthusiastically reported from many parts of the world. The number of cases was often small, while the complications, limitations, and failures were understated or ignored. It was not long before the cries of enthusiasm were accompanied by murmurings of disappointment, often from centres with a reputation for outstanding surgical technical skill and large series of well-documented operations. Tympanoplasty was not, after all, going to produce ahealed, trouble-free ear with good hearing in all, or even most, cases. Having imported into Brooklyn some of the present British enthusiasm for examining the trend of various activities over the past
Surgery in Chronic Otitis Media SUCCESSFUL management of chronic otitis media depends on accurate assessment of the disease. The tubotympanic variety, with its characteristic central perforation of the drum, is not subject to complications and most patients respond to simple cleaning and avoidance of water. Myringoplasty may then be undertaken as an elective procedure on a stable ear, enabling the patient to enjoy water sports and usually improving the hearing as well. Grafting the drum constitutes the simplest and most successful form of tympanoplasty. The second variety of chronic otitis media presents with scanty offensive otorrhoea, through an attic or high posterior perforation of the drum, and increasing deafness. Cholesteatoma is often present in the middle ear giving rise to complications by destroying the ossicles, eroding the labyrinth, and sometimes penetrating into the cranial cavity. Otogenic meningitis and brain abscesses still happenindeed, their incidence seems to be increasing. A fifth of all these infections originate in the ear or the nose.l It is therefore important to diagnose the presence of such a potentially lethal erosive middleear disease as early as possible and to deal with it without delay. Thorough surgical eradication is the only reliable treatment of cholesteatoma since the smallest flake of keratin left behind in the middle ear will lead to recurrence. Radical mastoidectomy, and especially modified radical mastoidectomy, adapted to the needs of each individual case has proved a satisfactory procedure for eradicating erosive middle-ear disease. It has been in common use for most of the twentieth century and is solidly reliable-witness the small number of modifications in the past fifty years. The hearing may be surprisingly good afterwards but, not uncommonly, conductive deafness persists after successful surgery and, if bilateral, constitutes a severe disability; the patient is often young. Surgical repair of the sound-conducting mechanism after radical operations is technically difficult and is seldom very successful. A mastoid cavity no longer has the self1.
Whittaker, C. W. Laryngoscope, 1971, 81, 1375.
of the possibilities as well as an exhaustive catalogue of the hazards and complications of tymment
panoplasty. failure of tympanoplasty is a of otorrhcea. This may be caused by external factors such as sinusitis,nasal allergy, or obstruction of the eustachian tube, but local factors are much the most important. Closed techniques with extensive disease involving inaccessible areas may lead to incomplete removal of cholesteatoma. The incidence of recurrence is especially high in children,s and two-stage operations have been advised for this reason. 6,7 Procedures to obliterate the mastoid segment with muscle, bone, or other grafts have been largely abandoned because of the high rate of infective complications.8 The creation of an aerated middle-ear space remains a difficult problem in tympanoplasty, and a functioning eustachian tube is essential for the successful restoration of hearing. Surprisingly, eustachian function is difficult to test and some authorities do not even try to assess it.9 Tube malfunction is fortunaThe
2. 3. 4. 5. 6. 7. 8. 9.
Wullstein, H. Acta otolar. 1955, 45, 440. Zollner, F. Laryngoscope, 1955, 69, 637. Wolferman, A. Ann. Otol. Rhinol. Lar. 1977, 86. Suppl. 37. Goodey, R. J., Smyth, G. D. Laryngoscope, 1972, 82, 166. Smyth, G. D. J. Laryng. 1977, 91, 501. Morgenstern, K. Ann. Otol. Rhinol. Lar. 1974, 83, 648 Beales, P. H. Archs Otolar. 1969, 89, 196. Sheehy, J. L., Crabtree, J. A. Laryngoscope, 1973, 83, 1594.
120 uncommon and there has been a shift in interfrom tubal function to the properties of the mucosa of the middle ear. A normal mucociliary system is important for the defence and function of the middle ear by its controlled secretion of mucus as well as antibodies. If the mucosa is destroyed by disease, or extensively removed, it is replaced by non-functioning fibrous tissue.10 Many chronic ears have patches of squamous epithelium, with or without cholesteatoma, and on the whole they do badly after tympanoplasty. Inlays of plastic or gelatin sheeting may help in cases with these mucosal
problems. In addition to a properly ventilated middle-ear space lined by a functional epithelium, a successful
tympanoplasty requires an intact and mobile tympanic membrane transmitting sound vibrations through a solid connection to the oval window. Here we encounter the second major problem in reconstructive middle-ear surgery. The hearing results are inversely related to the amount of surgical reconstruction required to fulfil these conditions. If the middle-ear structures are intact except for a perforation of the drum, a successful repair can be expected in nearly every case. Autografts or homografts may be used and the results of placing them under or over the remnant of the drum are very similar. Graft failures occur mostly in the older patient whose circulation and healing powers are less vigorous than those of the young. The results of reconstruction of the ossicular chain are also inversely related to the extent of the damage to be repaired. Because of their tendency to extrusion, foreign-body prostheses made of wire or plastic have been abandoned in favour of cartilage or bone used as homografts or autografts, individually fashioned to bridge the gap between the drum and the stapes or its footplate in the oval window. Problems arise with all the methods because of difficulties of anchoring the graft, which tends to separate from the stapes. The other snags are fixation of the well-positioned graft by fibrosis with a gradual loss of the original hearing gain, and impaction against the bony annulus, usually when the graft is too generously proportioned or too enthusiastically wedged into place. Good hearing results may be almost guaranteed in cases where the ossicular damage is limited to necrosis of the long process of the incus. In more advanced cases where repositioning of the incus is required, only half the patients achieved socially adequate hearing and a third closure of the air/bone gap within fifteen decibels. 11 In spite of its many limitations tympanoplasty represents a real advance in the treatment of chronic middle-ear infections. The outlook is par10. 11.
McGuckin, F. Archs Otolar. 1963, 78, 358. Cody, D. T., Taylor, W. F. Ann. Otol. Rhinol. Lar. 1973, 82, 538.
favourable in early and limited disease, but when the damage is more extensive the results are often disappointing and eradication of disease must take precedence over reconstruction. There is still a place for modified radical mastoidectomy operations, especially in unilateral, advanced erosive chronic otitis media.
Benyon’s Progress THE past weeks have seen further progress in Parliament for Mr WILLIAM BENYON’S Abortion (Amendment) Bill, which seeks to restrict the 1967 Abortion Act and which has aroused much anxiety and opposition amongst the public in general and amongst doctors in particular. The Bill’s progress past standing-committee stage is the more surprising since there is little support for it outside Parliament. Certainly doctors recognise that the Bill, based on the findings of the attenuated Select Committee on Abortion, would do nothing to improve the health and welfare of their patients. It would cripple the activities of the two main charitable organisations whilst at the same time introducing a mass of restrictive bureaucratic and punitive legislation which would deter doctors in the National Health Service from implementing the 1967 Abortion Act. Among the beneficiaries would be the small minority of doctors operating largely in the expensive private sector, and their numbers would inevitably increase. Women would once again be forced back to expensive or dangerous and illegal abortion. As the Health Visitors’ Association concluded, it would therefore be "the less well off, and less articulate women who would suffer if the bill became law". It is hardly surprising, therefore, that the Benyon Bill has few friends in the medical profession. Indeed, not one of the thirteen medical organisations consulted by the Department of Health and Social Security1 was in favour of the Bill as a whole, and some of the comments are worth repeating:
Royal College of Obstetricians and Gyncecologists.-"Although on this emotive subject the whole spectrum of opinion exists within the Council it is generally believed that the action taken by the DHSS to’ abuse to the 1967 Act has been effective. The amendments suggested in Mr. Benyon’s Bill would appear to serve little purpose". Royal College of Psychiatrists.-"The Bill would have the effect of restricting the availability of termination of remove
pregnancy". British Medical Association.-"...
the Bill would
1. Memorandum from Mr Roland Moyle, M.P., Minister of State D.H.S.S., to members of the Standing Committee on the Abortion (Amendment) Bill,
June 22, 1977.