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A 42-year-old man presented with a preauricular subcutaneous pulsating node which had appeared a few weeks after a middle ear operation. CT angiography revealed an aneurysm of the superficial temporal artery. The diagnosis was histologically confirmed after surgical resection of the finding. This is the first description of an aneurysm of the superficial temporal artery as a rare complication of a tympanoplasty. In the presented case, the aneurysm must have been caused either by the surgical trauma of the endaural tympanoplastic incision or the sharp retractors.

Due to the unusual anatomical situation in the middle ear, there are a variety of possible complications that may occur during tympanoplasty. Dislocation of the ossicular chain with and without opening of the labyrinth, injuries to the facial nerve and hemorrhage from large arteries and veins may occur. Adequate management of these complications is necessary in order to avoid further damage for the patient. The first question in case of an acute complication is always whether it is possible to stop the operation. It is also important to determine the time to react, e.g. if an injury of the facial nerve is assumed, when a revision needs to be performed. It also should be considered to refer the patient to a colleague who is not as emotionally involved in the case as the primary surgeon.

During tympanoplasty, the stapes is often exposed to considerable manipulations, i.e. the dissection of cholesteatoma matrix from the oval window niche or the insertion of a prosthesis for ossicular chain reconstruction. Too much strain may rupture the annular ligament resulting in an opening of the inner ear. Furthermore it is conceivable that microperilymphatic fistulas, which remain undetected, may develop prior to a visible luxation of the stapes. Therefore, temporal bone experiments with definite manipulations on the stapes were performed to study the rupturing strength of the annular ligament. Increasing the pressure of the methylene blue dyed perilymphatic fluid facilitated the detection of even smallest ruptures. A leakage occurs only in case of a complete rupture of all fibres. Further findings of clinical interest, gained from these experiments with different directions of stapedial manipulation, are discussed.

Closed tympanoplasty techniques greatly increase the risk of recurrent cholesteatoma. This is obvious as many surgeons using these methods insist on a necessary obligatory control operation as a "second look". In this paper cholesteatomata are classified according to their tendency to extend within the petrous pyramid and the subsequent danger of invading semicircular canals, cochlea or cranial fossae. The predisposition to this type of growth is present in the well defined "medial" type of epitympanic cholesteatoma, and more in the anteriorly than the posteriorly placed ones. As infection becomes less prominent in countries with advanced medical services, especially otology, the cholesteatoma hidden behind a small dry epitympanic perforation and those even with no perforation termed "hidden primary cholesteatoma" become more frequent. They cause their own special symptomatology, not infrequently a slowly progressive facial palsy. Every cholesteatoma requires mandatory prophylactic surgery. This means the complete exposure of the danger area, the epitympanum, and nowadays the possibility of the syncronous complete reconstruction of a normal middle ear and external canal, i.e. osteoplastic epitympanotomy.

Two patients with squamous cell carcinoma of the middle ear appearing 8 years after a tympanoplasty for cholesteatoma are reported. The tumours presented as a recurrent cholesteatoma and a temporal lobe abscess. The pathogenesis of these tumours is discussed.

Middle ear pressure after rhinoplasty surgery was determined by tympanometry. Measurings were done in 94 patients (total of 177 ears) before the rhinoplasty operation and during the following 6 days respectively in special cases up to three weeks. In 153 ears normal middle ear pressure was found before the operation. After the rhinoplasty in about 2/3 of all cases negative pressure up to 300 mm Ws developed. This negative pressure was equalized in the vast majority of cases (84.3%) after the tamponade was removed. In some cases negative pressure persisted for 6 days after the operation (9.8%); in few cases (5.9%) up to three weeks. In 13 out of 24 patients having negative middle ear pressures together with rhinomanometrically objectified impaired nasal ventilation rhinoplasty led to normal middle ear pressure. Reasons for the development of negative pressures in the middle ear are discussed. The results of the investigations lead to consequences concerning tympanoplasty in connection with rhinoplasty operations. Rhinoplasty and tympanoplasty should not be performed on the same day--there should be an intervall of 4--6 days between these operations. Negative pressure in the middle ear in cases of impaired nasal ventilation can be improved by rhinoplasty.

The middle ear mucosa of rabbits was studied experimentally. After tympanoplasty inflammatory changes were observed together with an epithelial metaplasia, and the appearance of ciliated and goblet cells was noted. These changes disappeared very slowly over the course of a year when almost normal epithelium was found. Epithelial metaplasia in cholesteatoma was similar to that found following surgery.

In 71 patients with adhesive processes the development and rate of recidives after tymplasty is studied by clinical and tympanometric observation. The typical tympanogram in adhesive processes is flattened with a peak in the negative pressure area. Initially after tympanoplasty permanent aeration was secured by grommets. When these came out and the tympanic membrane was closed, most of the cases showed almost normal tympanograms. Within 3 months in most cases the preoperative tympanogram re-developed, regardless what the tube function was like. The typical peak in the negative area must not necessarily be caused by negative pressure in the middle ear - as we could demonstrate in model studies. These results correspond closely to the clinical findings. The enlargement of the middle ear cavity by tympanoplastics can only be obtained by permanent aeration. When the tympanic membrane is closed - regardless of the tube function - often new retractions occur, which can easily lead to recidives of the adhesive process. Hearing tests showed close correlations to the tympanometric findings. Hearing is improved as long as the grommet secure permenent aeration; when the tympanic membrane is closed, it may become worse during a very short period. Correlations between hearing and the mobility of the tympanic membrane and ossicles in adhesive processes could be shown in the tympanoaudiogram.

Report on a surgical technique to avoid strictures of the external auditory meatus with the enaural method on tympanoplasty. A pedicle flap is formed by a modified short Heermann's incision on the beginning of the bony and cartilagenous external auditory meatus. During the operation it is fixed by a retractor and it is readapted at the end of the operation. The skin of the external auditory meatus which is situated medial of this pedicle flap can be used for transplantation to replace the tympanic membrane without danger of stenosis. The authors has had 15 years of positive experience with this method.

Seldom tympanoplasty damages the inner ear in a substantial amount: From 1814 operations upon chronic inflamed ears 4 patients (0.22%) became deaf, among the other patients bone conduction (b.c.) in the mean increased at 1000 cps for + 0.8 dB and decreased at 4000 cps for - 2.2 dB. In 9.8% b.c. showed an improvement for 10 dB or more at 1000 and 4000 cps, 9.7% showed an corresponding deterioration. For patients it was confirmed on a statistical base, that the influence on bone conduction demonstrated by animal experiments (Tonndorf), was mainly the result of changing the compliance of oval window and of increasing ossicular inertia. By relieving a mobile stapes of an incus which was fixed in the attic, there results an improvement of mobility of the stapedial footplate with increasing b.c. at 1000 and 4000 cps. By interposition of an incus between tympanic membrane and stapes and by myringoplasty with fascia there results an increasing ossicular inertia with increasing b.c. at 1000 cps and decreasing b.c. at 4000 cps. Noise trauma, mechanical trauma and infection are only of slight importance, only in some single cases they will damage the inner ear in a substantial amount.

Tympanoplasty can produce a stable hearing improvement in many patients with chronically inflamed ears. In our series of patients, severe damage to the inner ear following surgery occurred in 3% patients and was associated with a hearing loss of greater than 15 dB. Complete hearing loss occurred in 0.2% of the patients reviewed. In patients with an intact ossicular chain, simple myringoplasty is associated with the best results. Loss of the stapedial arches affects the postoperative air-bone gap most significantly, while loss of the manubrium mallei or the creation of a radical mastoid cavity are additional negative factors. Extent or localization of ossicular fixation has no direct influence on hearing results when appropriate ossicular reconstruction is performed.

The inert gas SF6(Sulfur Hexa Fluoride) is resorbed very slowly by the middle ear mucosa. After insufflation of SF6 into the middle ear in cases of retraction of the tympanic membrane, respectively atelectasis, and in beginning adhesive processes after tympanoplasties, pathologic negative pressure, and the retraction of the tympanic membrane can be equalized for at least 6 weeks. A precondition for this treatment is an intact tympanic membrane besides the tube dysfunction. So a temporary tube dysfunction with all its negative effects to the middle ear can be bridged. In some cases this method is successful over a long period. In the other cases the gas insufflation with SF6 can be repeated. Also in the treatment of serous middle ear effusions in adults and in cases of tinnitus caused by middle ear diseases SF6 can be helpful.

A prospective study of chorda tympany was carried out on 76 patients aging from 14 to 71 years by performing qualitative taste examination and electrogustometry prior to and at regular intervals up to 1 year after tympanoplasty. In 16 cases of preoperative ageusia, the chorda tympany was found to have been destroyed by cholesteatoma or during a previous ear surgery. Out of 27 cases, in which the chorda tympany remained intact during the surgery, nine patients suffered a mild hypogeusia up to 3 months after the operation. In 13 cases, in which the chorda tympany was stretched or distended during the operation, there existed a marred correlation between the degree of its manipulation and the electrogustometric abnormalities. A chorda tympany section was always followed by a postoperative ageusia.

The reasons for failures in tympanoplasty are classified and discussed as anatomical or pathological ones and those, that rise from method and technique. A main cause insists in the pathopolymorphism of the chronic purulent otitis media and the discrepancy of clinical impression and pathological reality. The author wishes to encourage the surgeons to a more radical technique by these examples and to the use of new methods in the field of reconstructive surgery of the middle ear.