Surgical Treatment

An inherent problem in the surgical repair ofPLFs is the difficulty of getting graft tissue to heal securely to bone (the bony otic capsule), especially in the environs of a middle ear system, which is in constant motion. Modifications of technique in surgically treating PLFs have been aimed at solving these problems.62

We favor a post-auricular areolar tissue graft78 because, if placed into the oval and round window niches as very small pieces, areolar tissue conforms by capillary action to the underlying denuded bone. We use multiple small pledgets of postauricular areolar graft material, rather than a single large graft, which tends to quickly migrate or contract out of the oval or round window niche as healing commences. We use an argon laser to prepare the graft bed. Removing the mucoperiosteum is an essential prerequisite for optimal grafting of the oval and round window PLF. The graft can be further buttressed by congealing the graft in layers with an out-of-focus laser to weld the graft as the tissue pledgets are mounded up to fill the oval and round windows.

We strongly advise use of autologous cryoprecipitated fibrinogen adhesive.62 We have reduced our recurrence rate from about 25% to less than 8% using this technique combined with laser preparation (vaporization of the mucoperiosteum) of the graft site.62

Traumatic PLFs may be associated with stapes fractures and/or stapes footplate subluxations. In our experience, an oval window PLF complicated by a stapes footplate fracture (or a displaced stapes) will not close until a stapedectomy is performed and a prosthesis is placed over a tissue graft. However, if footplate fragments are not displaced, it is advisable to attempt closure of the PLF without stapedectomy.

Patients are admitted the morning of surgery and are discharged the next day. Before discharge, patients are evaluated by a trained physical therapist for safe ambulation, and are instructed on a bed rest regimen (see the previous section, Conservative Treatment) for 4 to 6 weeks. Stool softeners are prescribed, and antiemetics used as needed. External auditory canal packing is removed 7 to 10 days postoperatively by a caregiver.

In about 50% of patients with bilateral PLFs, the PLFs will close in the second ear during the period of bed rest after surgery on the first ear. In the event that both ears require tympanotomy, we recommend a minimum 3-month interval between operations.

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