Surgical Treatment: The Ear

Chapter 83

Surgical Treatment: The Ear Tobias Kleinjung

Keypoints  1. Surgical restoration of hearing can improve tinnitus complaints in patients with tinnitus associated to conductive hearing loss. 2. Tinnitus is most likely to disappear after stapes surgery. 3. New-onset tinnitus or worsening of a pre-existing tinnitus can occur as an unwanted side effect of middle ear surgery. 4. Some patients with advanced Ménière’s disease might benefit from a surgical approach to their tinnitus. Keywords  Tinnitus • Ear surgery • Tympanoplasty • Stapedotomy • Stapedectomy • Ménière’s disease

order to treat conductive hearing loss. The text will describe surgical procedures involving the middle ear that are indicated for treatment of different forms of objective tinnitus. Finally, it will also discuss otological surgery techniques used in the management of Ménière’s disease. The topics of cochlear implant surgery (see Chap. 77) and surgery of the internal auditory canal (see Chap. 85) are dealt with in separate chapters. If the accompanying tinnitus is due to hearing loss, irrespective of its duration, then restoration of hearing can be beneficial to management of tinnitus, in addition to improving hearing (see Chap. 10).

Surgery of the External Auditory Canal

Abbreviations PORP TORP

Partial ossicular replacement Total ossicular replacement

Introduction Any kind of conductive hearing loss may be accompanied by tinnitus, as outlined in detail in Chap. 34. Surgical efforts to improve hearing loss can, in some cases, also bring about the partial or complete remission of tinnitus. This chapter will discuss the possibility of reducing tinnitus through surgical operations in

T. Kleinjung (*) Department of Otorhinolaryngology, University of Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany e-mail: [email protected]

Space-occupying lesions that completely or partially obliterate the external auditory canal and lead to conductive hearing loss must be removed. This applies both to benign changes, such as auditory canal exostoses, and to malignant tumors. If normal hearing is restored after uncomplicated healing, any tinnitus that may have been present preoperatively can also be expected to resolve completely.

Middle Ear Surgery Myringotomy with Tube Insertion Myringotomy, followed by aspiration of fluid build-up in the middle ear and insertion of a small tube in the opening of the tympanic membrane, brings immediate relief of symptoms in cases of otitis media with

A.R. Møller et al. (eds.), Textbook of Tinnitus, DOI 10.1007/978-1-60761-145-5_83, © Springer Science+Business Media, LLC 2011

663

T. Kleinjung

664

e­ ffusion. This procedure may also result in remission of tinnitus along with a reduction of aural fullness and conductive hearing loss. Myringotomy, with or without tube insertion, can also positively influence the course of acute otitis media that does not respond favorably to pharmacological therapy.

Tympanoplasty “Tympanoplasty” is the term used to describe the surgical repair of the tympanic membrane after a perforation. This process includes inspection of the ossicular chain and, if necessary, its reconstruction by ossiculoplasty. According to Wullstein, depending on the extent of reconstruction involved, there are five different types of tympanoplasty [1]. Tympanoplasty Type I merely involves the restoration of the perforated tympanic membrane by grafting. The ossicular chain is intact. In Type II and III procedures, ossiculoplasty is an integral part of tympanoplasty. Tympanoplasty Type II is a procedure in which the patient’s own auditory ossicles (parts of the incus or the head of the malleus), i.e., organic material, are used for the reconstruction. In tympanoplasty Type III, alloplastic materials are used. The defective ossicles are repaired using synthetic prostheses that replace the incus and are placed on the intact stapedial head (partial ossicular replacement prosthesis, PORP) or by prostheses that replace the incus and stapedial suprastructure and are placed directly on the intact stapes footplate (total ossicular replacement prosthesis, TORP). Tympanoplasty Types IV and V no longer play a role in middle ear surgery today. The techniques of tympanoplasty have an application in the treatment of chronic otitis media. In chronic mesotympanic otitis media (chronic suppurative otitis media), reconstruction of the sound conduction mechanism is necessary in 20–25% of cases. In cholesteatoma, 80% of patients require tympanoplasty Type III [2]. Depending on the underlying pathology, the ­technique of tympanoplasty may be combined with procedures Table 83.1  Effects of tympanoplasty on tinnitus Complete n remission (%) Baba et al. [3] 151 24.5 Helms [5]   59 33.3 Lima Ada et al. [4]   23 34.8

involving the external auditory canal (e.g., canaloplasty) and mastoid (e.g., mastoidectomy). The technique of tympanoplasty is used to correct malformations of the middle ear and following persistent traumatic eardrum perforation. Since the advent of microscopic middle ear surgery in the 1950s, many tympanoplasty techniques have been described. The techniques differ in terms of the approach, such as transcanal, endaural, retroauricular, graft material, used for tympanic membrane replacement (e.g., temporalis fascia, cartilage), and the design of the prosthesis and materials used (e.g., homologous incus, hydroxyapatite, gold, titanium) [2]. All metho ds aim at achieving complete eradication of infection, repairing the defective tympanic membrane, and improving hearing. These are the topics primarily addressed in the literature. Publication of results regarding relief of preoperative tinnitus has been few (summarized in Table  83.1). Nevertheless, results currently available show approximately 30% of patients who had tympanoplasty are no longer aware of tinnitus. In two of the three published studies, complete remission of tinnitus was achieved [3, 4] in about one-third of patients and more than 40% had partial remission and 4–8% became worse (Table  83.1). The assessment offered by Helms in an older study from 1981 [5] showed that one-third became worse. The improvement in tinnitus symptoms after surgery may be attributed primarily to closure of the airbone gap. Accordingly, Lima Ada et al. [4] found a good correlation between postoperative hearing improvement and the reduction in tinnitus. In those patients who continue to suffer from tinnitus despite adequate hearing improvement, there must have been other causes for the reduced sound stimulation of tinnitus [4].

Stapes Surgery Conductive hearing loss and tinnitus are the main symptoms of otosclerosis. With the development of microscopic middle ear surgery in the 1950s, surgical mobilization of the stapes in otosclerosis became the

Partial remission (%) 41.7 47.8

No change (%) 25.9 33.3 13

Worse (%) 7.9 33.3 4.3

83  Surgical Treatment: The Ear

focal point of interest among middle ear surgeons. In 1958, Shea performed the first stapedectomy, where the stapes was replaced by prosthesis [6, 7]. In the following years, the technique of stapedotomy has evolved into a standard procedure, where only the suprastructure of the stapes is removed, a perforation of the footplate is made, and a piston prosthesis is attached to the long process of the incus extending into the perforation of the stapes footplate (for review, see [8]). The introduction of laser surgery permitted “no-touch” perforation of the stapes footplate [9]. The main objective of stapes surgery is to improve hearing. The most published studies regard hearing improvement achieved from different techniques. Hearing is improved in about 90% of patients [10] and approximately 60% of patients have an air-bone gap of between 0 and 10 dB [11]. No improvement in hearing occurs in approximately 8% of patients and a deterioration of hearing loss, including deafness, occurs in 2% of patients [10]. Few studies regarding the effect on tinnitus from stapes surgery have been published. Table 83.2 provides a summary of comparable studies conducted since 1990. On the average, complete remission of tinnitus was achieved in approximately half of patients from stapes surgery. Partial remission was achieved in 30% and approximately 80% of those who had stapes surgery benefited from the operation. Most of the remainder had no change, and fewer than 5% of patients reported worsening of their tinnitus. Many studies showed improvement regarding tinnitus that was independent of the hearing improvement [12, 13], but one older study by Glasgold et  al. [14] showed a correlation between hearing improvement and tinnitus improvement. Ayache et al. [15] found no difference in reduction of tinnitus between stapedotomy and stapedectomy. Sakai et al. [16] and Gersdorff et al. [12], on the other hand, noted better results after Table 83.2  Effects of stapes surgery on tinnitus Complete n remission (%) Ayache et al. [15] 48 56.3 Da Silva Lima et al. [47] 23 39.1 Gersdorff et al. [12] 50 64 Oliveira [48] 19 52.6 Ramsay et al. [49] 268 48.2 Sakai et al. [16] 22 27 Sparano et al. [50] 40 52.5 Szymanski et al. [13] 149 73

665

stapedotomy than with stapedectomy. No significant correlation between gender, tinnitus frequency, tinnitus duration, or extent of hearing loss and the effect on the tinnitus from stapes surgery was reported [15]. These factors, therefore, do not have prognostic value for stapes operation. It is unclear whether the positive effect of the stapes surgery is due to the improvement of hearing or some other factors related to mobilization of the fixed footplate. The fact that many patients already experience an improvement in tinnitus immediately after surgery – i.e., in a state when the auditory canal is packed – favor the latter hypothesis.

Middle Ear Surgery for Objective Tinnitus Objective tinnitus may be either vascular or muscular in nature. Objective tinnitus often accompanies disorders such as glomus tumors. When patients with glomus tumors are treated surgically, complete eradication of the pathological process is the main aim in the resection of such tumors. The patient’s pulsatile tinnitus most often disappears, which is an additional benefit of the surgery. After embolizing the vessels feeding the tumor, resection of a glomus tumor located in the middle ear cavity is done using the same approaches as those for tympanoplasty. Reconstruction of the tympanic membrane and ossicular chain may be necessary. Surgery to excise glomus jugulare tumors is different and requires a wide approach via the lateral skull base [17]. Treatment of objective tinnitus, caused by contraction (repetitive myoclonus) of the middle ear muscles that results in rhythmic tinnitus, is to section the ­tendons of the stapedius or tensor tympani muscles [18, 19]. When the Eustachian tube fails to close normally, disabling breath-synchronous tinnitus may result.

Partial remission (%) 27.1 56.5 16 37 33.2 41 32.5 17

No change (%) 12.5 4.4 14 10.4 7.8 27 12.5 10

Worse (%) 4.2 0 6 0 10.8 5 2.5 0

666

The  first remedy may be inserting a tympanostomy tube [20]. Other surgical procedures aim at narrowing or occluding the Eustachian tube from the middle ear or the nasopharynx. These methods are in a preliminary trial phase. Irreversible measures, such as the paratubular implantation of a Teflon graft [21], may lead to chronic otitis media due to Eustachian tube dysfunction if there is overcorrection. Endoscopic application of absorbable substances (hyaluronic acid, collagen) into the tubal elevation may bring transient symptom relief and is easy to regulate [22, 23].

Tinnitus as a Risk in Middle Ear Surgery While middle ear surgery offers benefit regarding management of tinnitus, it can also, as a side effect, cause tinnitus or worsen existing tinnitus. Postoperative deafness is a serious complication of any middle ear surgery that can occur from intra-operative damage to cochlear structures. Together with deafness and vertigo, tinnitus may occur or pre-existing tinnitus may become worse [24]. The risk of serious postoperative inner ear damage in stapes surgery has been reported to be between 0.5 and 1% [2]. Operations for chronic otitis media extensive cholesteatoma resections, in particular, may have higher risks of postoperative tinnitus from damage to the inner ear from stapes luxation or development of a semicircular canal fistula [25]. In operations of large cholesteatoma involving the stapes, it is therefore recommended that some cholesteatoma be left behind. The remaining cholesteatoma then can be resected in a second operation after 6–9 months [26]. Surgical procedures directed at the middle ear or the external auditory canal involve extensive drilling which carries a risk of noise-induced hearing loss and increased risk of tinnitus. In addition, the effect of surgery and anesthesia on the central nervous system may explain postoperative increases in tinnitus.

Ear Surgery and Ménière’s Disease Two kinds of surgical treatment for advanced Ménière’s disease are in use (see Chaps. 38 and 60). One is conservative and spares hearing while the other is a destructive

T. Kleinjung

procedure. Conservative procedures compromising endolymphatic sac decompression, gentamycin infusion, are indicated when the symptoms are dominated by a frequent occurrence of severe attacks of vertigo with some residual hearing preserved. A third conservative procedure is an application of air puffs to the inner ear via a ventilation tube in the eardrum [27]. Surgery on the indication of tinnitus is rarely performed, and only in connection with deafness and reduced vertigo, when the tinnitus is highly distressing and resistive to other treatments. Endolymphatic sac surgery is the most common surgical procedure for Ménière’s disease. Its purpose is to treat the endolymphatic hydrops by inserting a permanent drain from the endolymphatic sac to the middle ear space. This is achieved by wide exposure of the endolymphatic sac following decompression of the sigmoid sinus in a mastoidectomy [28]. After saccotomy, silicone sheeting is inserted into the sac lumen to allow permanent drainage. The risk of suffering additional sensorineural hearing loss with this technique has been estimated at less than 2% [29]. Some debate sur­rounds the success rates obtained with this procedure in terms of the control of vertigo and tinnitus. Most of the reports published in the literature relate to vertigo, with successful vertigo control claimed to be achieved in 70–90% of cases [30, 31]. The success rate for tinnitus control with endolymphatic sac surgery is lower than that for vertigo control, with improvement or complete remission of tinnitus being reported in the 30–40% range [32, 33]. These reported success rates of endolymphatic sac decompression are being questioned after studies by Thomsen et  al. [34] and Bretlau et  al. [35], which showed similar effect of a placebo (sham) operation involving a classic mastoidectomy without decompression as was obtained in real endolymphatic sac decompression. Both real and placebo operations had success rates of 75%. A similar placebo effect has also been attributed to insertion of a ventilating tube into the tympanic membrane with no additional measures [36], a technique that continues to find use in surgical practice [37]. Success rates for destructive procedures, such as labyrinthectomy, in improving tinnitus are not higher as compared with endolymphatic decompression. Labyrinthectomy is reported to improve tinnitus in 40% of the patients [38]. This rarely performed procedure may be considered for tinnitus and vertigo control

83  Surgical Treatment: The Ear

in patients with Ménière’s disease who have very poor hearing or are deaf. Higher success rates have been achieved when labyrinthectomy is combined with cochleovestibular neurectomy [39]. According to Jones et al. [40], good postoperative control of tinnitus can be expected with this technique in slightly less than 70% of cases. Effective control of vertigo symptoms can be achieved with this combination in nearly 100% of the patients [39]. Intratympanic gentamicin perfusion is designed to achieve chemical partial ablation of the vestibular system while still preserving cochlear function. For that, gentamicin is instilled into the middle ear cavity via a tube inserted in the ear drum or by direct puncture of the tympanic membrane. It diffuses across the round window membrane to reach the inner ear [41]. Several published studies have shown that good vertigo control can be achieved in 70–90% of the patients [28, 41, 42]. It is an advantage of this method that morbidity is low and the incidence of sensorineural hearing loss has been reduced to about 20% of all those treated [43]. This technique is currently regarded as the standard therapy for controlling vertigo attacks [42]. Little has been reported regarding the effect on tinnitus from gentamicin treatment. In one study, Lange et al. [44] reported improvement in tinnitus in 26 out of 56 patients treated (46%). Two small studies reported improvements in tinnitus in only 5 and 27% of patients, respectively [45, 46].

References 1. Tos, M, Manual of middle ear surgery, Volume 1 1993, Stuttgart: Georg Thieme 2. Hildmann, H, Sudhoff, H, Middle ear surgery 2006, Heidel­ berg: Springer 3. Baba, S, Yagi, T, and Fujikura, T, Subjective evaluation and overall satisfaction after tympanoplasty for chronic simple suppurative otitis media J Nippon Med Sch, 2004 71(1):17–24 4. Lima Ada, S, et al, The effect of timpanoplasty on tinnitus in patients with conductive hearing loss: a six month follow-up Braz J Otorhinolaryngol, 2007 73(3):384–9 5. Helms, J, Tympanoplasty and Tinnitus (author’s transl) Laryngol Rhinol Otol (Stuttg), 1981 60(3):99–100 6. Shea, JJ, Jr, Fenestration of the oval window Ann Otol Rhinol Laryngol, 1958 67(4):932–51 7. Shea, JJ, Jr, A personal history of stapedectomy Am J Otol, 1998 19(5 Suppl):S2–12 8. Hausler, R, General history of stapedectomy Adv Otorhi­ nolaryngol, 2007 65:1–5

667 9. Minovi, A, Probst, G, and Dazert, S, [Current concepts in the surgical management of otosclerosis] HNO, 2009 57(3):273–86 10. Shohet, JA, Middle ear, otosclerosis 2008 http://emedicinemedscapecom/article/859760-overview 11. Fisch, U, Tympanoplasty, mastoidectomy and stapes surgery 1994, Stuttgart: Georg Thieme 12. Gersdorff, M, Nouwen J, Gilain C, Decat M, and Betsch C, Tinnitus and otosclerosis Eur Arch Otorhinolaryngol, 2000 257(6):314–6 13. Szymanski, M, Golabek, W, and Mills, R, Effect of stapedectomy on subjective tinnitus J Laryngol Otol, 2003 117(4): 261–4 14. Glasgold, A and Altman, F, The effect of stapes surgery on tinnitus in otosclerosis Laryngoscope, 1966 76:1524–32 15. Ayache, D, Earally, F, and Elbaz, P, Characteristics and postoperative course of tinnitus in otosclerosis Otol Neurotol, 2003 24(1):48–51 16. Sakai, M, Sato M, Iida M, Ogata T, and Ishida K, The effect on tinnitus of stapes surgery for otosclerosis Rev Laryngol Otol Rhinol (Bord), 1995 116(1):27–30 17. Fisch, U and Mattox, D, Microsurgery of the skull base 1998, Stuttgart: Georg Thieme 18. Zipfel, TE, Kaza, SR, and Greene, JS, Middle ear myoclonus J Laryngol Otol, 2000 114(3):207–9 19. Golz, A, Fradis M, Martzu D, Netzer A, and Joachims HZ, Stapedius muscle myoclonus Ann Otol Rhinol Laryngol, 2003 112(6):522–4 20. Bluestone, CD, Eustachian tube Structure, function, role in otitis media 2005, Hamilton: BC Decker 21. Pulec, JL, Abnormally patent eustachian tubes: treatment with injection of polytetrafluoroethylene (Teflon) paste Laryngoscope, 1967 77(8):1543–54 22. Mees, K and Beimert, U, [Correction of the gaping eustachian tube osteum with injectable collagen] Laryngol Rhinol Otol (Stuttg), 1988 67(2):87 23. Grimmer, JF and Poe, DS, Update on eustachian tube dysfunction and the patulous eustachian tube Curr Opin Otolaryngol Head Neck Surg, 2005 13(5):277–82 24. Douek, E, Tinnitus following surgery, in Proceedings of the III International Tinnitus Seminar, H Feldmann, Editor 1987, Harsch: Karlsruhe 64–69 25. Weber, PC, Iatrogenic complications from chronic ear ­surgery Otolaryngol Clin North Am, 2005 38(4):711–22 26. Wiet, RJ, Harvet, SA, and Bauer, GP, Management of complications of chronic otitis media, in Otologic surgery, Shelton, C, Brackmann, E, and Bauer, GP, Editor 1994, Philadelphia:WB Saunders 257–76 27. Gates, GA, Green JD Jr, Tucci DL, and Telian SA The effects of transtympanic micropressure treatment in people with unilateral Meniere’s disease Arch Otolaryngol Head Neck Surg, 2004 130(6):718–25 28. Sajjadi, H and Paparella, MM, Meniere’s disease Lancet, 2008 372(9636):406–14 29. Paparella, MM and Fina, M, Endolymphatic sac enhancement: reversal of pathogenesis Otolaryngol Clin North Am, 2002 35(3):621–37 30. Ostrowski, VB and Kartush, JM, Endolymphatic sac-vein decompression for intractable Meniere’s disease: long term treatment results Otolaryngol Head Neck Surg, 2003 128(4):550–9

668 31. Huang, TS, Endolymphatic sac surgery for Meniere’s ­disease: experience with over 3000 cases Otolaryngol Clin North Am, 2002 35(3):591–606 32. Moffat, DA, Endolymphatic sac surgery: analysis of 100 operations Clin Otolaryngol Allied Sci, 1994 19(3):261–6 33. Quaranta, N, et  al, [Long-term audition results in patients with chronic endolymphatic hydrops after selective vestibular neurotomy and endolymphatic sac surgery] Acta Otorhinolaryngol Ital, 2001 21(3):131–7 34. Thomsen, J, et  al, Meniere’s disease: endolymphatic sac decompression compared with sham (placebo) decompression Ann N Y Acad Sci, 1981 374:820–30 35. Bretlau, P, et al, Placebo effect in surgery for Meniere’s disease: a three-year follow-up study of patients in a double blind placebo controlled study on endolymphatic sac shunt surgery Am J Otol, 1984 5(6):558–61 36. Thomsen, J, et al, The non-specific effect of endolymphatic sac surgery in treatment of Meniere’s disease: a prospective, randomized controlled study comparing “classic” endolymphatic sac surgery with the insertion of a ventilating tube in the tympanic membrane Acta Otolaryngol, 1998 118(6): 769–73 37. Smith, WK, Sankar, V, and Pfleiderer, AG, A national survey amongst UK otolaryngologists regarding the treatment of Meniere’s disease J Laryngol Otol, 2005 119(2):102–5 38. Pedersen, CB and Sorensen, H, Clinical effect of labyrinthectomy Arch Otolaryngol, 1970 92(4):307–10 39. Silverstein, H, Transmeatal labyrinthectomy with and without cochleovestibular neurectomy Laryngoscope, 1976 86(12):1777–91 40. Jones, R, Silverstein, H, and Smouha, E, Long-term results of transmeatal cochleovestibular neurectomy: an analysis

T. Kleinjung of 100 cases Otolaryngol Head Neck Surg, 1989 100(1):22–9 41. Light, JP and Silverstein, H, Transtympanic perfusion: ­indications and limitations Curr Opin Otolaryngol Head Neck Surg, 2004 12(5):378–83 42. Minor, LB, Schessel, DA, and Carey, JP, Meniere’s disease Curr Opin Neurol, 2004 17(1):9–16 43. Carey, J, Intratympanic gentamicin for the treatment of Meniere’s disease and other forms of peripheral vertigo Otolaryngol Clin North Am, 2004 37(5):1075–90 44. Lange, G, Mann, W, and Maurer, J, [Intratympanic interval therapy of Meniere disease with gentamicin with preserving cochlear function] HNO, 2003 51(11):898–902 45. Smith, WK, Sandooram, D, and Prinsley, PR, Intratympanic gentamicin treatment in Meniere’s disease: patients’ ­experiences and outcomes J Laryngol Otol, 2006 120(9): 730–5 46. Suryanarayanan, R, Srinivasan, VR, and O’Sullivan, G, Transtympanic gentamicin treatment using Silverstein MicroWick in Meniere’s disease patients: long term outcome J Laryngol Otol, 2009 123(1):45–9 47. Lima Ada, S, et al, The effect of stapedotomy on tinnitus in patients with otospongiosis Ear Nose Throat J, 2005 84(7):412–4 48. Oliveira, CA, How does stapes surgery influence severe disabling tinnitus in otosclerosis patients? Adv Otorhinolaryngol, 2007 65:343–7 49. Ramsay, H, Karkkainen, J, and Palva, T, Success in surgery for otosclerosis: hearing improvement and other indicators Am J Otolaryngol, 1997 18(1):23–8 50. Sparano, A, et  al, Effects of stapedectomy on tinnitus in patients with otosclerosis Int Tinnitus J, 2004 10(1):73–7