Myringoplasty with Valsalva – June 20, 2024

Myringoplasty with Valsalva – June 20, 2024

An exhibitor at the American Academy for Pediatrics (AAP) conference in Toronto stopped by the WiscMed trade show booth. He had heard from other attendees that WiscMed was showing people what their ear drums (Tympanic Membranes, TM) looked like using the WiscMed Wispr digital otoscope. He explains that he had an ear injury that required surgery. The recovery was complicated but at his last visit with otolaryngology (ENT), the physician assured him that his ear was repaired. He’s curious to see what the repair looks like and to know if the repaired TM is intact. The following image of his right ear is obtained.

In this setting, what is the fastest way to determine if the repair is intact?

  1. Visual inspection
  2. Tympanometry
  3. Irrigation
  4. Valsalva maneuver

Answer: 4. Valsalva maneuver

In the primary care setting, or this case at a trade show, and with a cooperative patient, the Valsalva maneuver is the fastest way to determine if the tympanic membrane (TM) is intact. The Valsalva maneuver is performed by pinching the nostrils closed and applying pressure from the lungs to the mouth area. This is the procedure that is performed when you need to “pop” your ears, for example in a descending airplane. When a Valsalva is performed, the increased pressure in the mouth area is communicated to the middle ear space via the Eustachian tube. The result is that you can clearly see the movement of the ear drum. If the ear drum is not intact (i.e. there is a hole), there will be no movement. Here is the video of the individual performing the Valsalva maneuver. Note the clear outward movement of the TM, indicating that the TM is intact.

Video of exam with Valsalva

Visual inspection alone is not enough to determine if the TM is intact. Even a small defect can cause an air leak. Tympanometry would be the definitive test to interrogate the eardrum. However, it requires a specialized instrument, a tympanometer, that is generally only available in an ENT or audiologists’ office. If there is concern for a TM defect, irrigation would be contraindicated along with being useless for determining the condition of the TM.

Cartilage myringoplasty may be performed for several indications including chronic perforations or conditions causing TM collapse. With its perichondrium intact, cartilage provides a good balance of stiffness to support the TM and elasticity to conduct sound. The surgeon may choose to harvest cartilage from a few sites, including the patient’s own tragus or concha. Once the graft has been attached to the remnant TM, peripheral micro-vessels provide nutrients and help to minimize reabsorption. Hearing often improves with time as the graft continues to soften, enhancing its elasticity and sound conductive properties. The subject of this case reports significant hearing improvement following his surgery and was amazed at the Wispr otoscope being able to visualize the results of his procedure.

Here is the complete video exam without the individual performing the Valsalva.

Video of exam without Valsalva

Shekharappa MK, Siddappa SM. Cartilage Myringoplasty: An Ideal Grafting Technique for Complex Perforations. J Clin Diagn Res. 2017 Jul;11(7):MC06-MC08. doi: 10.7860/JCDR/2017/26877.10264. Epub 2017 Jul 1. PMID: 28892941; PMCID: PMC5583939.