The Laryngoscope
C 2009 The American Laryngological,
V
Rhinological and Otological Society, Inc.
Effect of the Tympanostomy Tube on
Postoperative Retraction of the Soft Posterior
Meatal Wall Caused by Habitual Sniffing
Tomomi Yamamoto-Fukuda, MD; Kenji Takasaki, MD; Haruo Takahashi, MD
Objectives/Hypothesis: To evaluate the effect
of the tympanostomy tube (TT) on postoperative
retraction of the soft posterior meatal wall caused by
habitual sniffing following ear surgery, including a
mastoidectomy and soft-wall reconstruction of the
posterior meatal wall.
Study Design: Retrospective chart review.
Methods: Sixty-six ears of 64 patients with
acquired cholesteatoma who underwent staged ear
surgery with a soft-wall reconstruction method and
mastoidectomy were enrolled; 26 out of 66 ears had
habitual sniffing (sniffing positive[þ]), underwent TT
placement (TT positive[þ]) during surgery, and were
followed up for at least 8 months after surgery. Sixty-
six ears were divided into sniffingþ/TTþ, sniffing neg-
ative(
)/TTþ, and sniffing
/TT
groups, and the
degree of the retraction was compared among the three
groups.
Results: The distribution of the grades of the
postoperative retraction of the soft posterior meatal
wall was almost the same among the three groups
(P ¼ .60). Ears with severe retraction were found in
19.2% (5/26), 33.3% (7/21), and 15.8% (3/19) in the
sniffingþ/TTþ group, sniffing
/TTþ group, and
sniffing
/TT
groups, respectively.
Conclusions: The TT was found to be effective
in preventing the development of postoperative
retraction of the reconstructed soft posterior meatal
wall and tympanic membrane among cases with
habitual sniffing. We would suggest that TT place-
ment is recommended during surgery for cholestea-
toma if a patient was found to engage in habitual
sniffing.
Key Words: Habitual sniffing, tympanostomy
tube, soft-wall reconstruction, attic-type cholesteatoma.
Laryngoscope, 119:2037–2041, 2009
From the Department of Otolaryngology–Head and Neck Surgery,
Nagasaki University Graduate School of Biomedical Sciences, Nagasaki,
Japan.
Editor’s Note: This Manuscript was accepted for publication May
22, 2009.
Send correspondence to Tomomi Yamamoto-Fukuda, MD, Depart-
ment of Otolaryngology–Head and Neck Surgery, Nagasaki University
Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki
852-8501, Japan. E-mail: tomomiyf@net.nagasaki-u.ac.jp
DOI: 10.1002/lary.20604
Laryngoscope 119: October 2009 Yamamoto-Fukuda et al.: TT Prevents Soft Meatal Wall Retraction
INTRODUCTION
Middle ear cholesteatoma is a pathological condition
associated with chronic otitis media,1,2 accompanying
hearing loss and occasionally serious complications such
as facial palsy,3 and recurrence after surgery is not
uncommon.4 The goals of surgery for cholesteatoma are
complete removal of the cholesteatoma and the prevention
of recurrence. One of the surgical methods for cholestea-
toma, the soft-wall reconstruction (SWR) method, was
first reported by Smith and colleagues in 1986.5 It
presents a canal wall down procedure and reconstruction
of the external auditory canal (EAC) wall with only soft
tissues, such as remnant EAC wall skin and a piece of
temporalis fascia (Fig. 1). Generally recognized advan-
tages of this procedure include a wider surgical view, as in
the canal wall down procedure, little additional time and
effort during surgery for reconstruction, less formation of
a narrow-neck retraction pocket after surgery compared
to other hard-tissue reconstruction methods, and earlier
wound healing compared to the canal wall down pro-
cedure.5–9 One of the characteristic features of the
postoperative course after surgery utilizing this procedure
is that the soft posterior EAC wall takes different atti-
tudes (shapes) after surgery, depending on middle ear
pressure and the condition of the mastoid. When middle
ear pressure can be kept at atmospheric or positive after
surgery, the posterior wall is kept in the proper position
without retraction. When middle ear pressure is negative,
the wall retracts to form a large cavity, as seen after the
canal wall down procedure.10,11
On the other hand, habitual sniffing associated with
closing failure of the eustachian tube (ET) is believed to
be closely related to the etiology of retraction-type choles-
teatoma.12–14 It seemed that such sniffing induces a high
negative pressure in the middle ear and may sometimes
cause cholesteatoma or its recurrence after surgery.13–16
In patients with acquired cholesteatoma who underwent
the SWR method, Kawase and colleagues17 indicated a
significantly frequent association of severe postoperative
retraction of the soft wall with negative pressure caused
by habitual sniffing, and concluded that habitual sniffing
was one of the important causal factors for retraction-type
recurrent cholesteatoma.
2037
 Department of Otolaryngology, Nagasaki University Hospital.
The study included 26 males and 38 females ranging in age
from 6 to 81 years, with an average of 45.2 years (Table I).
Patient selection criteria were as follows. A history of
habitual sniffing was obtained and preoperative ET function
tests were done. Staged surgery was performed, which included
tympanomastoidectomy at the first-stage operation and revision
with ossicular reconstruction at the second-stage operation at 8
to 45 months (12.1 months on average) following the first-stage
operation. During the first-stage operation, an SWR procedure
was done after a mastoidectomy (excavation of mastoid air cells
from the epitympanum to the mastoid) in all patients. Subse-
quently, we developed a large 0.5-mm-thick silicone sheet18 that
has a unique shape and covers the whole area from the ET,
mesotympanum, and epitympanum to the mastoid, which was
placed during the first-stage operation and removed during the
second-stage operation in all patients. Patients with congenital
cholesteatoma were excluded.
In 47 of 66 ears, the TT was used during surgery in
patients who had a sniffing habit or a stenotic ET on ET func-
tion tests (absence of increase in the sound pressure level in the
EAC during swallowing on sonotubometry or higher than 800
mm H2O of passive opening pressure on the inflation-deflation
test).19 All aspects of the study were performed in accordance
with the guidelines of the Declaration of Helsinki and approved
by the Human Ethics Review Committee of the Nagasaki Uni-
versity School of Medicine.

Fig. 1. Schematic representation (A) and intraoperative view (B) of
the soft-wall reconstruction method. See text for details of the
procedure.
Habitual Sniffing
Habitual sniffing was investigated using a questionnaire,
and any information regarding the assessment of postoperative
configuration of the reconstructed posterior meatal wall was
blinded during the survey of habitual sniffing. The presence of
habitual sniffing was confirmed when both uncomfortable symp-
toms (autophonia) and a history of habitual sniffing to alleviate
such aural symptoms were observed.

To prevent the recurrence of cholesteatoma, we use a Measurement of Postoperative Retraction

tympanostomy tube (TT) (modified Goode T-tube; Med-
tronic Xomed, Inc., Jacksonville, FL) during surgery in
patients with negative middle ear pressure caused by
habitual sniffing, and in those who have a stenotic ET. In
the present study, we investigated the effect of the TT upon
the prevention of retraction of the posterior meatal wall in
ears after SWR surgery, and also compared the recurrence
rate between those with a TT and without a TT.
In the present study, postoperative configuration was eval-
uated based on the otoscopic findings, intraoperative findings at
the second-stage operation, and on an axial image of the high-
resolution computed tomography (CT) findings just before the
second-stage operation. We used CT scan findings mainly in
the grading of retraction of the soft wall. On the CT findings,
the retraction of the posterior canal wall and the recovery of
mastoid aeration were assessed by using on the level, at which
the lateral semicircular canal was most clearly seen.
The grades of retraction were classified as follows:

MATERIALS AND METHODS 1. No retraction: No apparent postoperative change in the

reconstructed posterior meatal wall (otoscopic and intraoper-
Patients and Surgery ative findings) (Fig. 2A-1), and air space found formed
The study examined 66 ears of 64 patients who underwent throughout the entire mastoidectomized cavity or up to the
ear surgery between August 2002 and January 2008 at the mastoid antrum (CT finding) (Fig. 2A-2).

TABLE I.
Types of Cholesteatoma and Surgery in Patients With/Without Habitual Sniffing.
Cholesteatoma
No. of Patients Period From First to
Group (Male/Female) Age (yr) Second Operation (mo) Pars Tensa Pars Flaccida Other

Sniffingþ/TTþ 26 (15/11) 37.5 11 8 14 4

Sniffing
/TTþ 21 (8/13) 47.6 13 8 7 6
Sniffing
/TT
19 (4/15) 53.3 12 6 6 7

Laryngoscope 119: October 2009 Yamamoto-Fukuda et al.: TT Prevents Soft Meatal Wall Retraction
2038

Fig. 2. Typical examples of the postoperative configurations of the
reconstructed meatal wall (A-1—C-1) and axial CT images (A-2—
C-2) after surgery with soft-wall reconstruction of the posterior
meatal wall. A-1 and A-2: no retraction; B-1 and B-2: mild retrac-
tion; and C-1 and C-2: severe retraction. Asterisks: reconstructed
meatal wall; arrows: TT; arrowheads: soft posterior meatal wall;
EAC: external auditory canal accompanied by double-headed
arrow; m: mastoid. See text for details.
2. Mild retraction: The posterior meatal wall formed a balloon-
like retraction but was not adhered to the mastoid bone
behind the wall (otoscopic and intraoperative findings) (Fig.
2B-1) and an air space was found in the epitympanum or up
to part of the mastoid (CT findings) (Fig. 2B-2).
3. Severe retraction: Deeper balloon-like retraction with adhe-
sion of the reconstructed wall to the mastoid bone behind
the wall (otoscopic and intraoperative findings) (Fig. 2C-1)
and air space was seen only slightly in epitympanum but
not in anywhere in the mastoid (CT findings) (Fig. 2C-2).
Statistical Analysis
Grade of retraction results were compared between
patients’ ears with the TT and those without the TT. The Fisher
exact probability test was used for statistical analysis of the
data. All analyses were performed with a statistical software
package (Excel 2003; Microsoft Corp., Redmond, WA).
RESULTS
Twenty-five patients (26 ears) exhibited habitual
sniffing (sniffingþ), whereas the remaining 39 patients
Laryngoscope 119: October 2009 Yamamoto-Fukuda et al.: TT Prevents Soft Meatal Wall Retraction
(40 ears) did not (sniffing
). Forty-seven of 66 ears had
a TT; in 26 of 47 ears it was due to habitual sniffing,
and in the remaining 21 ears it was due to stenotic ET.
Consequently, the sniffingþ/TTþ group, sniffing
/TTþ
group, and sniffing
/TT
groups consisted of 26, 21,
and 19 ears, respectively. The type of cholesteatoma,
average age, and period from the first-stage operation
to the second-stage operation in each group are shown
in Table I.
Figure 3 shows the postoperative configuration of
the posterior meatal wall for the three groups. The num-
bers of ears showing no, mild, and severe retraction
were five (19.2%), 18 (69.2%), and 3 (11.6%) in the
sniffingþ/TTþ group; seven (33.3%), 10 (47.6%), and
four (19.1%) in the sniffing
/TTþ group; and three
(15.8%), 12 (63.2%), and four (21.0%) in the sniffing
/
TT
group, respectively. The Fisher exact test revealed
no significant difference in the incidence of severe re-
traction among the three groups (P ¼ .53).
Figure 4 shows the correlation between the postop-
erative configuration of the posterior meatal wall and
the types of cholesteatoma. Postoperative retraction was
less in ears with pars tensa cholesteatoma than in those
with pars flaccida cholesteatoma, but there were no sig-
nificant differences between them.
The incidences of residual and recurrent cholestea-
toma found at the second-stage operation were two
(7.7%) and one (3.8%) in the sniffingþ/TTþ group; two
(9.5%) and one (4.8%) in the sniffing
/TTþ group, and
one (5.3%) and one (5.3%) in the sniffing
/TT
group,
respectively, again with no significant difference among
the three groups (Fig. 5).
DISCUSSION
Balloon-like retraction sometimes occurs on the pos-
terior meatal wall after surgery using the SWR method,
but usually the entire soft posterior wall retracts in that
instance instead of forming narrow-neck retraction pock-
ets.8 This is one of the reasons why the incidence of
postoperative recurrent cholesteatoma is considerably
Fig. 3. Grade of postoperative retraction of the reconstructed
meatal wall in the three groups. The incidence of retraction was
almost the same in each group (P ¼ .53).
2039

Fig. 4. Postoperative retraction of the reconstructed meatal wall
according to the types of cholesteatoma.
lower following ear surgery using the SWR method than
after ear surgery using the intact canal wall technique
reported previously.20,21 Another advantage of this
method is that the condition of the mastoid remains
quite stable long after surgery, as this method allows the
mastoid cavity to retract or not on its own postopera-
tively, according to its residual ventilatory function.
Thus, the SWR procedure does not often show a problem
in terms of postoperative long-term stability. However, it
would be ideal if the posterior meatal wall maintained a
proper position without retraction accompanied by the
recovery of aeration and ventilatory function in the mas-
toid after surgery in every case.
One of the causes of retraction may be the condition
of middle ear mucosa after mastoidectomy. Takahashi
and colleagues6 reported that the presence or absence of
the mucosa in the mastoid (mastoidectomized or not)
was well correlated with whether or not the posterior
meatal wall retracted after surgery. The loss of the mu-
cosa and its function, along with scar contraction within
the postmastoidectomized cavity as a process of wound
healing, may induce the retraction of posterior meatal
skin toward the mastoid. Because the large silicone
sheet covering from the ET to the mastoid was used for
all patients in this study, adhesion within the mastoid
caused by scar contraction may have been prevented in
many cases. This seemed to result in good recovery of an
airspace continuing from the ET to the mastoid cavity,
and thus in the prevention of retraction of the posterior
EAC wall after mastoidectomy.18
Repetitive production of high negative middle ear
pressure caused by habitual sniffing could be another
cause of the retraction.17 In such cases, high negative
middle ear pressure and subsequent retraction of the
soft posterior meatal wall should happen frequently,
with little regard to the condition of the mucosa. The
results of this study indicated that the TT, a device that
constantly keeps the middle ear pressure at atmos-
pheric, could prevent posterior meatal wall retraction
Laryngoscope 119: October 2009
2040
even in patients with habitual sniffing. The TT naturally
extubated in five ears (four males and one female) of the
sniffingþ/TTþ group after second-stage surgery, and
three of five of those ears (60%) had mild retraction; the
remaining two ears (40%) showed severe retraction of
the soft posterior meatal wall from 6 to 18 months after
surgery (average 13 months). Consequently, reinsertion
of the TT was necessary in all of them (data not shown).
Therefore, in cholesteatoma patients who have a history
of habitual sniffing, TT placement during surgery is
highly recommended, regardless of the procedure the
surgeon may perform.
Retraction of the soft posterior meatal wall can be
seen also in cholesteatoma patients with fluid collection
and/or negative pressure in the middle ear. In these
cases, if the gas exchange function through the middle
ear mucosa were intact, the degree of retraction might
be lessened. However, in most of the cholesteatoma sur-
gical cases the mastoidectomy is necessary, as in this
study, and the gas exchange function through the middle
ear mucosa in the mastoid does not recover in the early
postoperative stage in such patients.
Patients in the sniffing
/TTþ group had TT inser-
tion during surgery because of their stenotic ET, and the
TT was also found to prevent retraction of the posterior
meatal wall. Three ears (three males, average age
50.7 years) of the sniffing
/TTþ group had natural
extubation of their TT after second-stage surgery, and
all had TT reinsertion because of severe retraction of
their eardrums and soft walls within 2 to12 months
(average 10.4 months) (data not shown). Thus, in choles-
teatoma cases with ET stenosis, TT placement is highly
recommended during surgery, particularly when a mas-
toidectomy is done.
The grade of retraction was determined at the sec-
ond-stage operation. In this study, the period between
the first-stage and second-stage operation ranged from
8 to 45 months (12.1 months on average). Considering
that the retraction of the posterior meatal wall occurred
mainly within 1 year after SWR surgery, judging from
Fig. 5. The incidence of residual and recurrent cholesteatoma at
the second-stage operation in each group.
Yamamoto-Fukuda et al.: TT Prevents Soft Meatal Wall Retraction
the measurements of the volume of the EAC after sur-
gery,8 the observation period after surgery in this study,
8 to 45 months, is not likely to cause an unfavorable
bias of the results among cases due to a too-short obser-
vation period.
The problems for patients with a TT include low-
frequency hearing loss at 250 Hz and 500 Hz22 and post-
TT otorrhea.23 The incidence of post-TT otorrhea may be
reduced by prophylaxis (antibiotic ear drops),22 but low-
frequency hearing loss does not recover unless the TT is
removed. Advice to patients to stop habitual sniffing is
one of the primary and important tactics for preventing
postoperative retraction of the tympanic membrane and/
or reconstructed posterior meatal wall, and the TT may
be removed if the patient can actually stop sniffing.
However, because such patients sometimes sniff uncon-
sciously even after being notified that sniffing is closely
related to the cause of retraction and cholesteatoma,
careful determination of the timing for removal of the
TT is required.
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