Lateral attic reconstruction technique: preventive surgery for epitympanic retraction pockets. Cartilage tympanoplasty for management of tympanic membrane atelectasis: is ventilatory tube necessary?
To provide an estimate of the reliability of a preventive surgical approach named lateral attic reconstruction (LAR) technique for the treatment of Type II epitympanic retraction pockets.
                From a cohort of 25 adult patients presenting with a Type II epitympanic retraction pocket, 2 groups were randomly formed: a first one, with 15 patients who underwent LAR technique, and a second one, in whom (10 patients) only observation was planned and was therefore used as control.
                University hospital as tertiary referral center.
                Selection criteria for composing the 2 groups of study were the presence of a Type II epitympanic retraction pocket and a normal audiogram.
                The surgical procedure (LAR) consisted of a retroauricular approach, removal of a small piece of tragal cartilage, cleansing of the epitympanic pocket until denudation of the ossicular components, and placement of the cartilage graft to reconstruct the lateral epitympanic wall.
                All the patients were controlled at different postoperative or postobservation times (1, 3, 6, and 12 mo) via otomicroscopic examination, pure-tone audiometry, and tympanometry.
                All operated patients showed a normal anatomic pattern starting from the first postoperative control (1 mo) with a normal or near-normal hearing threshold and a Type A or As tympanogram in most cases.
                Lateral attic reconstruction technique has proved to be a reliable preventive technique for impeding a Type II epitympanic retraction pocket to worsen because it was observed in a percentage, although small (33.3%), of patients in whom a wait-and-scope policy was applied. Cartilage/perichondrium composite graft with concomitant placement of a ventilation tube is a common practice among otologists to reverse atelectasis and to repneumatize the middle ear. We conducted this study to investigate the necessity of a ventilation tube primarily incorporated into the perichondrium/cartilage graft for reconstruction of the atelectatic tympanic membrane (TM).
                Prospective clinical trial.
                Forty-six patients with TM atelectasis and intact ossicular chain were randomized to 2 groups. In Group I, 23 patients underwent reconstruction of the TM with perichondrium/cartilage graft and intraoperative T-tube insertion and in Group II, 23 patients underwent reconstruction of the TM with perichondrium/cartilage graft without ventilation tube insertion. Outcome measures were as follows: graft success, improvement of hearing, and postoperative complications. Analysis of the results was performed by Student's paired t test. The level of significance was set at 5%.
                Significant postoperative improvement of pure-tone air-conduction threshold averages and air-bone gap averages were reported in the 2 studied groups (p < 0.001). The postoperative air-bone gap averages showed no statistically significant difference between Groups I and II (p > 0.05). Conductive hearing loss requiring revision developed in 2 patients (8.69%) in Group I and in 3 patients (13%) in Group II.
                In the atelectatic ear, cartilage allowed reconstruction of the TM with good anatomical and functional results. Primary insertion of a ventilation tube into the graft is not necessary.
No evidence currently exists to either support or refute the role of surgery in the management of tympanic membrane retractions. Higher quality studies are much needed to ascertain this.