Codifying Lateral Graft Tympanoplasty: A House Clinic Legacy

Michael Hoa, MD; Eric P. Wilkinson, MD; and John W. House, MD House Research Institute and House Clinic, Los Angeles, CA The conceptual origins of the lateral graft tympanoplasty exist in early approaches to the repair of tympanic membrane (TM) perforations with artificial drumheads as reviewed extensively by E.A. Chu, MD, and Robert K. Jackler, MD. Of note, physicians Marcus Banzer, James Yearsley, and Joseph Toynbee all proposed and utilized various artificial drumheads to TM perforations (pig bladder, cotton-wool pellet, and India rubber disc, respectively). Subsequently, C. J. Blake utilized a paper patch in 1875 to occlude a TM perforation. The use of the paper patch presaged the first true tympanoplasty—”myringoplasty”—performed in 1878 by E. Berthold, who described two essential elements of the technique: preparation of the margin of the perforation and application of the graft. This technique languished in obscurity due to an inability of Berthold’s contemporaries to replicate his results until 1952, when Horst Wullstein and Fritz Zöllner, who coined the term tympanoplasty, popularized the technique using split-thickness and full-thickness skin grafts. The advent of sulfonamide antibiotics in the 1930s and advances in surgical technique to control infections of the middle ear and mastoid, along with the use of operating microscopes in the U.S., set the stage for development, refinement, and codification of the modern technique for lateral graft tympanoplasty. While Americans Howard P. House, MD, William F. House, MD, and James L. Sheehy, MD, were not the first to detail aspects of the lateral graft tympanoplasty technique, particularly considering German literature, these individuals were innovative in detailing the lateral graft or overlay approach. In particular, Drs. Bill House and Sheehy codified the technique into four distinct steps: Raising the vascular strip, Removal of the canal wall skin and the squamous layer of the TM remnant, Enlarging the ear canal, ensuring that the entire TM annulus is visible, and Application of ear canal skin. While some controversy exists in the English literature on the origin of using temporalis fascia as a graft for perforation repair, this use of temporalis fascia is attributed to J. Heermann in Germany and Lloyd A. Storrs in the U.S. in 1963. Dr. Sheehy acknowledged this advance and transitioned from canal skin grafts to temporalis fascia grafts, with dramatic improvement in surgical results. This resulted in the final codification of the modern lateral graft tympanoplasty technique, replacing application of ear canal skin to the perforation with placement of the fascia graft and replacement of the ear canal skin. This article was presented as an Otolaryngology Historical Society paper in 2010. For sources and further reading, visit www.entnet.org/Bulletin for a longer version of the article. William F. House, MD, 1923-2012. Besides his later work with cochlear implants, William House helped codify technical aspects of the lateral graft tympanoplasty. James L. Sheehy, MD, 1926-2006. Dr. Sheehy brought an outcomes research approach to the realm of otologic surgery and helped define how otologic research is conducted today. His codification of lateral graft tympanoplasty made the technique more accessible to later generations of surgeons.