Usefulness of the Attic Reconstruction Using the Tragal Cartilage and Perichondrium for Prevention of a Retraction Pocket

다국어 초록 (Multilingual Abstract)

Introduction



Canal wall up mastoidectomy surgery is performed to preserve the external auditory canal posterior wall in patients who have a destroyed epitympanum due to middle ear disease or other surgical procedures. One adverse side effect of this surgery is the possibility of formation of a retraction pocket in the tympanic membrane. The degree of Eustachian tube disability that may occur due to attic retraction after middle ear surgery is also an important consideration. A number of factors including defects in the external auditory canal, such as attic destruction, are major causes of retraction pockets.1) The occurrence of a retraction pocket in the attic can induce ossicle erosion, thereby causing conductive hearing loss and progression to repetitive otorrhea or cholesteatoma as the retraction pocket worsens.
Therefore, an appropriate treatment is necessary to prevent bone loss in the epitympanum and the formation of a postoperative retraction pocket. The tympanic attic is typically reconstructed using bone fragments2) or cavum conchae cartilage,3,4) or defects are treated with tragal cartilage5) or artificial implants.6) However, if maintenance of the normal structure of the attic fails after reconstruction, then canal down mastoidectomy surgery should be performed, which involves removal of the posterior external auditory canal posterior wall. Therefore, the choice of the appropriate method is important in handling bone defects of the epitympanum during the initial surgery.
In this study, the epitympanum was reconstructed using tragal cartilage and perichondrium in patients with attic destruction due to cholesteatoma. The effectiveness at preventing the formation of a retraction pocket was evaluated by observing and analyzing these patients postoperatively for more than a year. The findings reported here will help in the choice of an appropriate treatment method for attic destruction during the initial surgery.


Subjects and Methods

Subjects Attic reconstruction was performed using tragal cartilage from January 2005 to January 2009. Patients' medical records and surgical findings were reviewed retrospectively for 46 patients who were available for follow-up for more than one year. The patients were 27 men and 19 women aged 12 to 72 years old (average age 43.1 years).
Attic reconstruction was only performed when bone destruction by the attic cholesteatoma was confined to the epitympanum. Exclusion criteria included cases of adhesion or retraction pocket in the pars tensa of the tympanic membrane, cholesteatoma in the middle ear, perforation or reoperation, Eustachian tube dysfunction, or unidentified pnuematization in the middle ear [such as sclerotic pneumatization in the mastoid from temporal bone computed tomography (CT)].


Operation (Fig. 1)A posterior auricular skin incision was made and a musculoperiosteal flap (an anterior based flap) was formed. An external auditory canal skin incision was made in the direction of 5 o'clock to 10 o'clock for the right ear (2 o'clock to 7 o'clock direction for the left ear) at a distance of about 3 mm from tympanic ring. This incision was designed to pass the lateral portion of the bone destruction in the epitympanum area. A tympanomeatal flap was made to separate the tympanic membrane from the manubrium and to expose the destroyed bone area of the epitympanum. Mastoidectomy surgery and posterior tympanotomy was performed, and both cholesteatoma and granulation tissues were removed by removing the incus and malleus head, depending on the state of the cholesteatoma erosion. Cartilage was harvested from the ipsilateral tragus together with perichondrium. The harvested tissue was trimmed so that the perichondrium extended 2 mm beyond the cartilage border on one side, when designing cartilage to fit the size of the destroyed epitympanum. This tissue was placed between the bony portion of the external auditory canal and the temporalis fascia, for tympanic membrane inserti...

다국어 초록 (Multilingual Abstract)

Background and Objectives: Bone defect of the attic wall is a critical cause of the postoperative retraction pocket after canal wall up mastoidectomy. So, proper treatment of the attic defect is important and attic reconstruction is an acceptable procedure but it is controversial when the attic is reconstructed or not. The aim of this study is to analyze the usefulness of the attic reconstruction using tragal cartilage and perichondrium for prevention of retraction pocket and propose the indication to perform the attic reconstruction.


Subjects and Methods: We retrospectively reviewed the medical records of 46 consecutive patients who underwent tympanomastoidectomy and attic reconstruction using tragal cartilage between January 2005 and January 2009. The follow-up period varied from 12 to 65 months, with the average period of 34 months. We analyzed postoperative status of the scutum and the tympanic membrane, and development of the residual or recurrent cholesteatomas and evaluate development of the retraction pocket according to the preoperative size of the bony defect of the scutum and status of the ossicular chain.


Results: Retraction pocket was developed in the 13% of the operations and most of the cases had large attic destruction more than 3 mm and destructed ossicular chain.


Conclusions: Attic reconstruction using tragal cartilage is a simple method to repair the bony defect of the external ear canal and effective in preventing postoperative retraction pocket if the size of destructed scutum is less than 3 mm.

참고문헌 (Reference)

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