Managing Pervasive Eustachian Tube Dysfunction

We have developed distinct criteria for primary intubation of cartilage tympanoplasties that comprise craniofacial abnormalities, including Down syndrome; previous head and neck cancer involving

the nasopharynx; and patients with a history of multiple ear surgeries with demonstrated eustachian tube dysfunction.

The perichondrium/cartilage island graft is harvested and prepared as previously described. Using a round knife, a window that is large enough to allow placement of a Xomed Modified Goode T-tube is cut into the anterior cartilage island. A straight pick is then placed into the cartilage window to dilate the perichondrium to allow tube placement. Using scissors, the tube is remodeled by trimming the flanges to approximately 3 to 4 mm. Prior to insetting the graft, the tube is placed into the cartilage window and brought out through the perichondrial surface. If the malleus is present, the end of the tube is first angled under the manubrium with small alligator forceps. After hooking the tube under the malleus, the graft is slid forward into place. If the malleus is absent, the graft/tube complex is slid directly into its final position (Fig. 6-13).

Should the tube be removed either accidentally or purposely, the TM heals with a monomeric membrane; however, the cartilage defect remains. If tube reinsertion is needed, a myringotomy is first performed through the monomeric membrane. The tube is then re-inserted at the original site by grasping the end of the T-tube with alligator forceps and pushing the flanges through the cartilage defect. Because the TM is relatively rigid from the cartilage reconstruction, it does not medialize when pressure is placed laterally. This increased rigidity greatly facilitates secondary tube insertion. The procedure is well tolerated by the patient because the island flap remains insensate after healing, possibly due to the cartilage preventing reinnervation from the carotico-tympanic plexus.

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