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Managment of Early Infection after Tympanoplasty

*O. Nuri Ozgirgin, †Tuncay Ozchelik

*Bashkent University Faculty of Medicine, Bahchelievler, Ankara, Turkey
†Bayandar Medical Center, Ankara, Turkey

ABSTRACT

Objective: Early infection after tympanoplasty must be treated aggressively because it threatens the reconstructed middle ear. Evidence indicates that this type of complication occurs regardless of whether the ear drains preoperatively. The individualized treatment modalities to eliminate the postoperative infection following tympanoplasty are described.
Study design: Retrospective case review.
Setting: Bayindir Medical Center.
Patients: 150 patients who underwent closed technique tympanoplasty. 43 of the ears – wet preoperatively.
Intervention: Closed technique tympanoplasty. In cases with seropurulent drainage – daily: removal of gelfoam from the external auditory canal; aspiration of the seropurulent material; rinsing of the canal with 2% boric acid in alcohol solution; re-insertion of gelfoam soaked with antibiotic ear drops to keep the tympanomeatal flap in place.
Results: Eight cases with early postoperative (two of these ears had been draining prior to the operation). Complete take graft was achieved in all 8 cases. Two cases of reconstructed ossicular chain.
Conclusions: There is no any significant relation between the preoperative state of the ear and early postoperative infections.
Key words: Tympanoplasty, Wet ear, Chronic otitis media.
Pro Otology 3: 115-116, 2002

INTRODUCTION

There is considerable debate about whether tympanoplasty should be performed on ears that are actively draining. It is generally preferred that drainage be controlled and the ear be dry at the time of surgery; however, this is not always possible. The main question is whether or not active drainage changes the outcome of tympanoplasty, and the answer depends mostly on the type of surgical technique that is used. It is widely accepted that preoperative bacterial contamination does not affect the outcome of tympanoplasty if the procedure is performed correctly.

In most cases, when infection of the middle ear mucosa responds to antibiotics, the discharge can be brought under control preoperatively. However, when cholesteatoma or significant amounts of granulation tissue are present, medical treatment does not achieve the desired effect. In our opinion, this is not a cause to postpone the surgery. In such cases, the mucosa involved with the irreversible pathology must be removed. This report describes our experience with early infection after tympanoplasty.

MATERIALS AND METHOD

Forty-three of the 150 patients who underwent closed-technique tympanoplasty at Bayandar Hospital between 1995 and 1999 had wet ears preoperatively. Eight of the 150 ears developed postoperative infection, and only two of these ears had been draining preoperatively.

The clinical approach for treating the eight cases that developed seropurulent drainage was as follows:

- Remove gelfoam from the external auditory meatus

- Aspirate the seropurulent material from the canal using low vacuum pressure in order to keep the graft intact

- Re-insert gelfoam to keep the tympanomeatal flap in position

The external canal was cleansed with 2% boric acid in alcohol solution. Before the gelfoam was re-inserted, it was soaked in topical antibiotic eardrops, usually ciprofloxacin. These steps were repeated daily until the discharge resolved. Cases that were draining through the skin incision required mastoidectomy cavity toilet, which entails flushing the cavity with ciprofloxacin solution. In these ears, the purulent debris in the mastoid cavity was aspirated, and then a combination of antibiotic plus saline was injected and aspirated repeatedly until the material aspirated was clear. Systemic antibiotics were administered according to the microbiological findings for each patient.

RESULTS

The combination of local treatment and systemic antibiotics was successful, and all eight cases were completely free of infection within the 15 days following surgery. There was no evidence of infection during the late postoperative course in any case.

The grafts took completely in all cases. The only unfavorable outcome was dislocation of the reconstructed ossicular chain, which occurred in two patients.

DISCUSSION

It is of no benefit to try to control the discharge in ears that are draining preoperatively, especially in cases of cholesteatoma and/or significant granulation tissue. As noted above, the preoperative status of the ear generally does not affect the outcome of surgery. A number of reports have stressed that the wet or dry condition of the ear is not a good predictor of the presence or absence of pathogenic organisms. (1,2)

Govaerts et al. (3) consider, the preoperative draining ears as dirty and assume that antibiotic prophylaxis may decrease the postoperative infection rate. Matino et al. (4) suggest using preoperative oral and topical antibiotics even in cases with cholesteatoma to decrease the postoperative infection incidence. Our policy for the timing of tympanoplasty is not linked to the status of the patient’s ear. We do not treat chronic draining ears manifested with irreversible tissue such as granulation tissue or cholesteatoma by using antibiotics preoperatively, yet most of our cases are infection-free after surgery.

Although it may not affect the timing of the operation, the preoperative status of the mucosa covering the middle ear and antrum is very important. Actively infected tissue may produce purulent drainage postoperatively. In addition to actively infected areas, all mucosal tissue involved with irreversible changes, such as granulation tissue or cholesteatoma, must be removed during tympanoplasty. If complete removal is not achieved, remnants in the recesses or in the tympanic orifice of the eustachian tube may generate purulent discharge. Also, in some cases, the ear canal skin may remain contaminated after the operation. Performing the procedure in a dedicated operating room reduces the incidence of airborne infection (5).

When infection does occur, various treatment issues must be considered. It is well known that, in cases of chronic otitis media, the bacterial flora of the external auditory canal differs from that in the antrum, aditus, and middle ear. Thus, antimicrobial treatment based on outer canal cultures may fail. Inserting a drain through the incision serves two goals. First, it prevents pressure buildup due to accumulation of blood in the mastoidectomy cavity and middle ear. In this way, the drain helps maintain the stability of the grafted membrane and can alert the surgeon to early postoperative infection. Second, such drains can facilitate rinsing of the infected cavity.

As described above, the steps we use for postoperative infection in these cases are removal of packing material, flushing of discharge, and re-insertion of gelfoam in order to keep the skin flap in its original position. In addition, the application of 2% boric acid in alcohol solution and antibiotic drops introduces antibacterial activity at the infection site. The medication is effective in the external canal, and the amount that penetrates the middle ear does not cause ototoxicity. The local treatment helps control the infection and facilitates epithelialization over the graft. Adding systemic antibiotic therapy increases the efficiency of the local treatment and helps eliminate the infection.

We find that our treatment approach leads to effective and rapid resolution of early postoperative infection in tympanoplasty patients. However, as demonstrated in two of the eight infected cases in our series, there is risk that these procedures may disturb the recently reconstructed ossicular chain.

In conclusion, we suggest that cases with chronic otitis media with cholesteatoma and/or granulation tissue undergoing surgery do not need preoperative antibiotic prophylaxis and there is no any significant relation between the preoperative state of the ear and early postoperative infections. In case of early postoperative drainage the use of systemic antibiotics as well as active local treatment as described above is able to treat the condition completely.

REFERENCES

  1. Carlin WV, Lesser TH, John DG et al. Systemic antibiotic prophylaxis and reconstructive ear surgery. Clin Otolaryngol 1987;12:441-6.

  2. John DG, Carlin WV, Lesser TH et al. Tympanoplasty surgery and prophylactic antibiotics: surgical results. Clin Otolaryngol 1988;13:205-7.

  3. Govaerts PJ, Raemaekers J, Verlinden A et al. Use of antibiotic prophylaxis in ear surgery. Laryngoscope 1998;108:107-10.

  4. Matino E, Venegas MP, Diez S et al. Antibiotic treatment in surgery for cholesteatoma. An Otorrinolaringol Ibero Am 1999;26:445-55.

  5. Fitzgerald DC. Use of prophylactic antibiotics in otologic and neuro-otologic surgery. Am J Otol 1985;6:121-5.

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