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• W1599326160 abstract "We describe indications and surgical technique for dividing the stapedius and tensor tympani tendons during middle ear surgery. Middle ear muscle reflexes involve contraction of the tensor tympani muscle (TTM) and stapedius muscle (SM) to increase impedance of the middle ear, and may shield the inner ear from loud, continuous nonimpact noise.1, 2 Sectioning SM and TTM tendons has been advocated for a number of conditions, including improving access to anterior epitympanic (supratubal) recess, releasing a medialized malleus during tympanoplasty and ossiculoplasty,3, 4 tensor or stapedial myoclonus, reflexive vertigo, and Meniere disease.5 Cholesteatoma tends to spread contiguously, for example, from the epitympanum or protympanum to the anterior epitympanic recess. The tensor tympani tendon may become wrapped in cholesteatoma; and removal of the tendon and attached cholesteatoma, as well as the head of the malleus, may provide better visualization of the region and improve the chance for complete removal of the cholesteatoma. In long-standing chronic otitis media with perforation, the malleus long process can be medialized, often touching the promontory, by fibrotic contraction of the tensor tympani muscle. This can hinder proper graft placement during repair of anterior perforations. Division of the tensor tendon allows return of the long process to its natural position.6 Another example of ossicle displacement occurs during temporary separation of the incudo-stapedial (I-S) joint, which may be required while drilling an atresia plate that incorporates the incus (to reduce vibration damage to the cochlea), or in implantation of certain hearing instruments. After cutting the joint capsule and separating the joint, the pull of the stapedius tends to displace the stapes posteriorly. Dividing the stapedius tendon allows the stapes capitulum to align better with the lenticular process of the incus. A properly aligned I-S joint will heal spontaneously in most cases. The stapedius tendon is also sectioned during stapedotomy and in ossicular chain reconstruction to allow cap prostheses to fit over the capitulum. Likewise, the tensor tendon may be divided to improve hearing results of malleus-to-footplate incus replacement prosthetics. Tensor and stapedius myoclonus can produce a thumping, regular, or typewriter-like irregular clicking tinnitus. This may result from head trauma, brainstem tumors, anxiety, and primary neurological disorders. Conservative treatment with a benzodiazepine may be effective in some cases, and tenotomy is usually definitive, resulting in immediate cessation of myoclonic tinnitus.6, 7 Finally, in endolymphatic hydrops, labyrinthine fluid pressure is said to be adversely affected by sudden forces caused by middle ear muscle reflexes transmitted through the ossicles, which may lead to acute episodes.5 Corresponding to this theory, middle ear tenotomy has been used to treat Meniere disease, and is alleged to cause “a dramatic reduction in vertigo attacks” and improved audiologic function.5, 8, 9 In a related theory, reflexogenic vertigo caused by a large excursion movement of the footplate (e.g., middle ear muscle contraction in response to loud sound) can perturb the utricular macula and cause nystagmus and vertigo. In this disorder, evidence has been presented that sectioning the middle ear tendons can alleviate vertigo.5, 8, 9 It is unknown which vertiginous patients might benefit from tenotomy and at what point to offer the intervention. At this time, no prospective, randomized clinical trials have been conducted to quantify putative benefits of tenotomy as a surgical treatment for vertigo. Middle ear tenotomy usually requires less than 30 minutes under local or general anesthesia in an outpatient setting. In either case, the external auditory canal is infiltrated with lidocaine-epinephrine solution. Most cases are approached transcanal, but endaural approaches may be necessary. A traditional tympanomeatal flap, such as those used for stapedotomy or medial Tympanoplasty,10 is usually sufficient to expose both tendons from posteriorly (Fig. 1). The scutum may need to be reduced with drill or curette. Posterior tympanomeatal flap. The flap is reflected forward on the malleus showing the tensor tendon (thick arrow) arising from the cochleariform process and the stapedius tendon (thin arrow). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] The stapedius tendon is visualized between the pyramidal process and stapes capitulum/posterior crus and may be divided with a disposable cataract knife (e.g., Beaver 5910, Beaver-Visitec International, Waltham, MA) or middle ear microscissors. Visualizing the tensor tendon is somewhat more difficult as it runs from the cochleariform process to the malleus neck. It is seen in a view between the manubrium of the malleus and the long process of the incus in the superior most mesotympanum (Fig. 2). To avoid inadvertent misadventure with the facial nerve, a cataract knife is slid between the long processes of the malleus and incus and used under direct vision to divide the tensor tendon. Alternately, the superior arm of the tympanomeatal flap can be extended anteriorly to provide an anterior angle of approach to the tensor tendon (Fig. 3).10 In this approach, the tympanic membrane is sharply separated from the short process of the malleus, elevated inferiorly from the manubrium, and pedicled inferiorly on the umbo. The tensor tympani tendon is divided with a cataract knife inferior to the chorda tympani. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] Alternate approach to tensor tendon. The extended tympanomeatal flap is left attached to the umbo. A cataract knife is used to divide the tensor tympani tendon from an anterior angle. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] Middle ear tenotomy is performed during a number of procedures, including removal of cholesteatoma, tympanoplasty, stapedotomy, ossicular reconstruction, and atresia repair, as well as in the treatment of middle ear myoclonus, Meniere disease, and reflexive vertigo.1-5 However, this procedure may be prone to overuse, especially for vertigo and tinnitus, and self-critical surgical indications should be developed. The surgical technique is straightforward but complications are possible, including tympanic membrane perforation, facial nerve injury, infection, hearing loss, vertigo, and hyperacusis. Regarding hearing loss, up to 10 dB loss at certain thresholds has been reported in certain animal models, but to our knowledge, not in humans.11 Hyperacusis has been reported after stapedius tenotomy, due to elimination of the intensity modulation effect of the stapedius reflex.12 A surgical technique for middle ear tenotomy is described that has been useful to the authors (A.G., L.G., T.B.) in several pathologic conditions of the middle ear. Prospective studies are needed to determine safety and efficacy in treatment of Meniere disease and reflexogenic vertigo, and a conservative approach is recommended." @default.
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• W1599326160 date "2013-04-02" @default.
• W1599326160 modified "2023-10-14" @default.
• W1599326160 title "Adjunctive tenotomy during middle ear surgery" @default.
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• W1599326160 doi "https://doi.org/10.1002/lary.23827" @default.
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