Surgery of the ‘only hearing ear’ with chronic ear disease

The management of chronic ear disease affecting the only hearing ear is a controversial subject. The relative scarcity of literature on the subject prompted us to prepare a questionnaire which was sent to European and American otologists and to review 19 cases operated at the ENT Clinic of the University of Parma, Italy, and 16 cases operated at The Baptist Memorial Hospital, Memphis, U.S.A. Surgery of cholesteatoma involving the only hearing ear is advised by all the interviewed otologists without exception, even in the presence of a labyrinthine fistula. The cases from the University of Parma were managed as follows: a classic modified radical mastoidectomy was performed in 10 cases, a staged intact canal wall tympanoplasty was done in four cases, an open tympanoplasty in three and a radical mastoidectomy in the remaining two cases. The cases from The Baptist Memorial Hospital were managed with an intact canal wall tympanoplasty (ICWT) in nine and with an open procedure in seven cases. All the otologists interviewed agreed that surgery of the only hearing ear requires particular attention and experience, and should be performed with extreme care by a very experienced surgeon.

Labyrinthine Fistula and Tympanoplasty

Three interdependent problems have to be solved by a surgeon in each case of middle ear cholesteatoma with a fistula of the horizontal canal: 1) Whether the matrix can be safely removed from fistula or should be left in place; 2) if the matrix is removed, whether the fistula should be covered or not and, in the positive case, by which kind of graft; and 3) whether closed or open tympanoplasty should be performed. In well selected cases the matrix can be safely removed from the fistula and some technique of closed tympanoplasty used. Suitable for this type of surgery are cases of superficial fistula of the horizontal canal, with preservation of the endosteal membrane, where complete removal of the matrix from the tympanic cavity is possible. Very poor hearing and obvious middle ear infection are apparent contraindications. Furthermore, this type of surgery should not be performed on a better hearing ear. If any difficuty in removal of the matrix from the fistula is encountered, the matrix should be left in place. Fistula cases which do not fulfill these criteria should be treated either by open tympanoplasty or by modified radical mastoidectomy, leaving the matrix on the fistula. A small series of five consecutive fistula cases treated by closed tympanoplasty, using intact wall technique or reconstruction of the bony canal wall, with removal of the matrix from the fistula, leaving it bare, is reported after a follow up of three to six years. The results indicate that, in selected fistula cases, this type of surgery seems to bring favorable late hearing results and to create good conditions for closure of the fistula, apparently not presenting any risk to the inner ear.