Type I Tympanoplasty Meta-Analysis: A Single Variable Analysis

Chronic otitis media

Chronic otitis media, defined as persistent or recurrent inflammation of the middle ear mucosa, is a frequent entity in primary and secondary care. This disease causes otorrhea and hearing loss that significantly affect the quality of life of patients. In recent years, there have been new developments in its diagnosis, prevention and treatment. In this last aspect, pharmacological treatment, surgical techniques and hearing rehabilitation through implants have shown significant advances. On the other hand, chronic otitis media complications continue to occur in emergency services and have to be kept in mind because of their potential seriousness. The objective of this work is to offer the reader an update in chronic otitis media, so it may help improving the care of affected patients.

Endoscopic Fat Graft Myringoplasty Augmented With Hyaluronic Acid for Managing Large-Sized Eardrum Perforations; A Prospective Comparative Randomised Study

OBJECTIVES

We aimed to assess the outcomes of fat graft myringoplasty augmented with hyaluronic acid in closing large-sized eardrum perforations compared to the traditional underlay cartilage-perichondrium composite myringoplasty (CPCM).

STUDY DESIGN

It was a prospective randomised comparative study.

SETTINGS

It was held in tertiary referral institutions between May 2020 and April 2022.

PARTICIPANTS

We included 100 patients with a large-sized eardrum perforation (50%-75% of the eardrum surface area). Using the endoscopic transcanal approach, 50 patients were managed by fat graft myringoplasty augmented with hyaluronic acid, while CPCM managed the other 50 patients.

MAIN OUTCOME MEASURES

We evaluated the closure rates 1, 6 months and 1 year after surgery. Also, we assessed the audiological performance of the patients with a successful closure before and 1 year after the operation.

RESULTS

Fat graft myringoplasty operation was statistically shorter than the CPCM. The closure rate 1 year after surgery was 92% in the first group and 86% in the second group, without a statistically significant difference between both groups. Successful air-bone gap closure to less than 10 dB occurred in 93.5% of group A and 81.4% of group B without a statistically significant difference. The mean postoperative air-bone gap was 5.3 ± 3.95 dB in the first group and 7.95 ± 5.17 dB in the second group, with a statistically significant difference.

CONCLUSIONS

Fat graft myringoplasty augmented with hyaluronic acid was a reliable, safe, simple, and effective manoeuvre to close large-sized eardrum perforations compared to the conventional CPCM.

Endoscopic annular chondroperichondrial tympanoplasty, technical description

PURPOSE

Tympanoplasty is a surgical procedure performed to cure middle ear infections and restore normal middle ear function. It is one of the most common procedures in otological surgery. Since Wullstein described tympanoplasty, the microscope has been a widely used surgical tool in otological surgery. Transcanal endoscopic ear surgery (TEES) has come to the forefront as an alternative option due to the various limitations of microscopic surgery and the development of otological surgical techniques. When reviewing the types and tecniques of grafts used in tympanoplasty in the current literature, it is clear that the ideal graft material and tecnique to meet all needs has not yet been found. The objective of this study is to describe a novel graft technique, a modification of the cartilage-perichondrium graft obtained from tragal cartilage, which is believed to represent an optimal solution for the desired graft technique at the highest level.

MATERIAL&METHOD

The study included 40 patients who underwent endoscopic annular chondroperichondrial tympanoplasty at Hatay Mustafa Kemal University Hospital between 2015 and 2022. All patients underwent clinical otological examination and pure tone audiometry before and after surgery. Hearing results were expressed as pure tone mean air-bone gap (ABG) at 4 frequencies (500,1000,2000,4000 Hz). For all operations, the primary surgeon was the second author. Patients with inadequate follow-up, revision surgery, inflammatory middle ear mucosa, perforation etiology other than chronic otitis media were not included in the study.

RESULTS

No complications were observed in the patients included in the study. Accordingly, the graft was intact at the end of the 6th month in 38 of the 40 patients operated on. The graft success rate was 95%. The mean preoperative PTA-ABG was 22.1. The mean post-operative PTA-ABG was 5.7. Mean closed PTA-ABG was 16.4.

CONCLUSION

In parallel with the development of otological surgical technologies, endoscopy is becoming increasingly important in tympanoplasty. We believe that our technique, endoscopic annular chondroperichondrial tympanoplasty, will be an important step in the search for the ideal grafting technique.

Myringoplasty Using Human Birth Tissue Allografts to Repair Large Tympanic Membrane Perforations

OBJECTIVE

Examine outcomes among a series of pediatric patients who underwent myringoplasty using human birth tissue (BT) for repair of large tympanic membrane (TM) perforations.

STUDY DESIGN

Case series.

SETTING

Single-institution pediatric hospital.

METHODS

Retrospective chart review of patients treated with BT during a 4-year study period. Subjects who underwent myringoplasty for large (size 40% or greater) TM perforations were included for this study. Patients with a stable perforation of at least 1 month's duration preoperatively who then followed up for at least 3 months postoperatively met inclusion criteria.

RESULTS

Six subjects were included in this study. One subject underwent bilateral repair; thus, this series includes a total of 7 perforations. TM perforations ranged from 40% to 70% of the TM. At initial follow-up (median of 2 months), 5 of the 7 perforations had healed. One of these 5 had evidence of a 10% recurrent perforation at 5 months, which subsequently healed. Of the 2 patients not healed at initial follow-up, 1 had only a residual pinpoint perforation that subsequently healed; the other had a persistent 30% perforation that was possibly related to their postoperative recovery period, which was complicated by a respiratory viral illness.

CONCLUSION

For large TM perforations, myringoplasty with BT grafts may be a viable alternative to longer, more invasive procedures like tympanoplasty. Larger, randomized, prospective studies are needed.

The Prognostic Value of Active Otitis Media on Tympanoplasty Success Rate-A Systematic Review

OBJECTIVES

The aim is to investigate the influence of an active otitis media on the success rate of tympanoplasty in patients with a chronic otitis media (COM) and a tympanic membrane perforation.

DATABASES REVIEWED

PubMed, Embase and the Cochrane Library.

METHODS

The inclusion criteria were studies on closure rates of tympanoplasty performed in COM patients of any age with a tympanic membrane perforation caused by COM. The exclusion criteria were studies on patients undergoing concomitant mastoidectomy, ossicular chain reconstruction, tuboplasty, adenoidectomy, revision tympanoplasty, patients with perforations due to other conditions than COM, and letters to editors, commentaries, conference abstracts and case reports. The included articles were critically appraised using the QUIPS tool. Data on tympanic membrane closure rate were extracted, odds ratio (OR) and 95% confidence intervals (CI) of the closure rate with a wet versus a dry ear were calculated.

RESULTS

The search was performed on 1 February 2023. Of 4671 articles, 16 studies were included and critically appraised. Of these observational studies (nine prospective, seven retrospective), with a total of 1509 patients (dry ear group n = 1003; wet ear group n = 506), two studies stated a significant difference in success rate, one in favour of a dry ear and one in favour of a wet ear at time of surgery. All other studies did not show a statistically significant difference. Overall, the risk of bias was considered moderate to high.

CONCLUSIONS

We found no significant prognostic value of having an active otitis media during tympanoplasty on tympanic membrane closure rates. Because the overall risk of bias was considered moderate to high, no strong conclusions can be made. To be able to answer this question with higher levels of evidence, high-quality prospective or randomized studies are needed.

Comprehensive management of chronic ear disease: Consecutive patient analysis at a tertiary children's hospital

OBJECTIVE

To characterize medical complexity and advanced interventions necessary to treat pediatric patients with chronic ear disease.

METHODS

A retrospective case review of children who received surgery for chronic otitis media, cholesteatoma, or tympanic membrane perforation at a tertiary children's hospital from 2020 to 2024 was performed. The frequency and type of medical complexities as well as distribution and success of advanced otologic interventions were recorded.

RESULTS

Operations were performed on 80 ears. Forty-five percent were in medically complex patients. Twenty-five percent had a syndrome, 13 % had American Society for Anesthesiologists Severity Class 3 or more, and 38 % attended multi-disciplinary programs. Advanced audiology testing protocols were utilized in 53 % of patients, and multiple children received complex sleep and airway operations. Advanced surgical techniques were required in 58 %. Post-operatively, an intact tympanic membrane was achieved in 95 % of operated ears (p < 0.01). Residual and recurrent cholesteatoma were each present in 5 % of cases, with mean follow-up of 11.6 months. Otorrhea reduced from 64 % of patients pre-operatively to 2 % post-operatively (p < 0.01), including cessation in all individuals who reported social/bullying issues related to ear drainage/odor. Unrestricted water exposure was achieved in 99 % of individuals (p < 0.01). Patients showed a mean improvement after surgery of 7.6 dB, as measured by the change in air-bone gap (p < 0.05).

CONCLUSIONS

Comprehensive treatment of otologic conditions included care that was holistic of all medical needs, integrated with other services, developmentally appropriate, encompassing of non-otologic procedures, technically advanced, effective, and functionally-focused. Surgical teams should endeavor together to provide this combination of services.

Tympanic Membrane Regeneration Therapy for Pediatric Tympanic Membrane Perforation

OBJECTIVE

To evaluate tympanic membrane regeneration therapy (TMRT) for pediatric tympanic membrane perforations (TMPs).

STUDY DESIGN

Intervention study.

SETTING

Research institute hospital.

PATIENTS

In this study, 20 patients with chronic TMP (M/F: 13/7, 13/8 ears, age 0-15 years) treated with TMRT were evaluated. As comparison, 20 pediatric patients with chronic TMP who underwent myringoplasty/tympanoplasty were included.

INTERVENTIONS

For the TM repair procedure, the edge of the TMP was disrupted mechanically, and gelatin sponge immersed in basic fibroblast growth factor was placed inside and outside the tympanic cavity and covered with fibrin glue. The TMP was examined 4 ± 1 weeks later. The protocol was repeated up to four times until closure was complete.

MAIN OUTCOME MEASURES

Closure of the TMP and hearing improvement were evaluated at 16 weeks after the final regenerative procedure. Adverse events were monitored.

RESULTS

The mean follow-up period was 427.1 days. The TM regenerated in all cases, but pinhole reperforation occurred in two cases, and the final closure rate was 90.5% (19 of 21). Hearing improved to 24.9 ± 7.6 dB on average before surgery and to 13.8 ± 5.4 dB after surgery. The AB gap improved from 12.9 ± 8.0 to 5.2 ± 3.5 dB.The myringoplasty/tympanoplasty group had significantly lower AB gap improvement compared with the TMRT group. There were no adverse events.

CONCLUSIONS

TMRT can be expected to regenerate near-normal TMs with a high closure ratio, resulting in better-hearing improvement compared with the myringoplasty/tympanoplasty group, and is an effective treatment for children with long life expectancy.

Platelet-Rich Plasma in Fat Graft Type-1 Tympanoplasty - Should We or Should We Not?

Introduction  Fat grafts have been in used since 1962 for small central perforations, with a success rate ranging from 86 to 100%. Platelet-rich plasma (PRP) containing platelet concentrations greater than 1 million platelets/μL assist the healing process by various means. Current data suggests improved healing when tympanoplasty is performed using temporalis fascia grafts if PRP is added during surgery. Objective  To assess the effect of PRP on fat grafts in small and moderate-sized central perforations. Methods  The present prospective observational study was conducted with 36 patients who underwent fat graft tympanoplasty with PRP under local anesthesia. Clinical and audiological observations were carried out after 4, 8, and 12 weeks, and a statistical analysis of the observations was performed. Results  We assessed 23 patients with small central perforations and 11 patients with moderate central perforations. An overall success rate of 76.4% was observed, with an 82.6% success rate among patients with small central perforations and 63.6% among those with moderate central perforations. There was no statistically significant difference in the uptake regarding the location of the perforation, but a statistically significant difference was found in terms of hearing improvement following the procedure. Conclusion  The morbidity of conventional tympanoplasty in cases of small-to-moderate central perforations in patients with chronic otitis media vis a vis the results of the procedure needs to be revisited, as in the present study fat grafts placed with PRP under local anesthesia could lead to surgical and audiological outcomes that are as good as those reported in the literature.

Microbiome and Otic Quinolone Levels Following Tympanoplasty Assessed by Gelatin Sponge Analysis

OBJECTIVE

To determine if absorbable gelatin sponge (AGS) can be used to assess the posttympanoplasty microbiome and otic antibiotic exposure.

STUDY DESIGN

Prospective.

SETTING

Tertiary hospital.

METHODS

Patients undergoing tympanoplasty were prospectively enrolled. Intraoperatively, AGS was applied to the medial ear canal/tympanic membrane (TM) for 1 minute after canal incision, then saved for analysis. Ear canals were packed with AGS at the end of surgery. Otic ofloxacin was administered until the first postoperative visit, when AGS was collected. Microbial presence was assessed by culture. Ofloxacin levels were assessed by liquid-chromatography mass-spectrometry.

RESULTS

Fifty-three patients were included. AGS was collected in 92.9% of patients seen within 21 days compared to 70.8% of those seen at 22 to 35 days. At surgery, AGS yielded bacteria and fungi in 81% and 11%, respectively, including Staphylococcus species (55%) and Pseudomonas species (25%). Postoperatively, AGS yielded bacteria in 71% and fungi in 21% at the meatus, (staphylococci 57% and pseudomonas 25%). TM samples yielded bacteria in 69%, fungi in 6%, staphylococci in 53%, and pseudomonas in 19%. Ofloxacin concentration at the meatus was 248 μg/mL (95% confidence interval [CI]: 119-377) and at the TM was 126 μg/mL (95% CI: 58-194). Ofloxacin-resistant colonies were found in 75% of patients.

CONCLUSION

Analysis of AGS is a viable technique for noninvasively studying healing metrics posttympanoplasty, including the microbiome and otic antibiotic exposure. Despite exposure to a high concentration of quinolones, the tympanoplasty wound is far from sterile, which may impact healing outcomes.

Endoscopic Versus Microscopic Tympanoplasty: A Systematic Review and Metanalysis

OBJECTIVE

Endoscopic ear surgery is no longer a promising technique, but a well-established one. This study aims to compare endoscopic and microscopic tympanoplasty based on current literature evidence, in terms of their efficacy and safety characteristics.

DATA SOURCES

We conducted a systematic literature search of four medical databases (Pubmed, Cochrane Library, Scopus, ClinicalTrials.gov), focusing on randomized controlled or observational studies comparing microscopic to endoscopic tympanoplasty.

REVIEW METHODS

Data related to the efficacy and safety of each technique were extracted. Outcome data were summarized using pooled mean differences or pooled odds ratio along with their 95% confidence intervals. The risk of bias was estimated, by using the ROBINS-I and RoB-II assessment tools, while the overall quality of evidence was evaluated according to the GRADE working group.

RESULTS

Thirty-three studies, with 2646 patients in total, were included in the meta-analysis. Success rate was evaluated by estimating tympanic graft failure (pooled mean difference:-0.23; 95% CI: -0.61, 0.14, I2 = 33.42%), and air-bone gap improvement (pooled mean difference:-0.05; 95% CI:-0.23, 0.13, I2 = 52.69%), resulting in comparable outcomes for the two techniques. A statistically significant difference favoring the endoscopic technique was detected regarding postoperative wound infection (OR: -1.72; 95% CI: -3.39, -0.04, I2 = 0%), dysgeusia (OR: -1.47; 95% CI: -2.47, -0.47, I2 = 0%), otitis externa development (OR: -1.96; 95% CI: -3.23, -0.69, I2 = 0%), auricular numbness (OR: -2.56; 95% CI: -3.93, -1.19, I2 = 0%), as well as surgical duration (OR: -1.86; 95% CI: -2.70, -1.02, I2 = 43.95%), when compared to the postauricular microscopic approach.

CONCLUSION

Endoscopic tympanoplasty is an innovative alternative to the microscopic technique, resulting in commensurate outcomes regarding success rate. Furthermore, it offers superior results concerning postoperative complications, while it presents a significant reduction in the duration of surgery, mainly when it is compared to the postauricular microscopic approach.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:3466-3476, 2024.

Pediatric Myringoplasty using the Periosteum: An Institutional Overview

Introduction  Myringoplasty is a common otologic procedure to restore the integrity of the tympanic membrane in cases of traumatic or pathologic perforations. Many grafting materials have been used with different techniques. Objective  In the present work, we evaluate the surgical and audiological outcomes of periosteal graft overlying the mastoid cortex through a retroauricular incision in a pediatric cohort. Methods  A retrospective study was carried out involving all children aged ≤ 16 years who underwent periosteal graft myringoplasty for the treatment of chronic suppurative otitis media with dry central perforation in our hospital from April 2019 to April 2021. All patients were followed up for one year to assess the anatomical success and functional outcomes by comparing the preoperative and postoperative (after six months) results of pure tone audiometry (PTA). Results  The sample was composed of 36 patients; 20 of them were female (55.6%) and 16 were male (44.4%) subjects, with ages ranging from 7 to 16 (mean: 12.7) years. Four patients underwent surgery in both ears (with an interval of 6 to 9 months). Out of 40 surgeries performed, 38 ears have shown anatomical success (95%). A highly significant improvement in hearing was obtained (the mean difference between the pre- and postoperative results of the PTA was of 14.6 ± 3.45 dB ( p  < 0.001). Conclusion  We advocate the use of periosteal graft in the pediatric population as a good alternative for other types of grafts, with comparable and even better functional and anatomical outcomes.

Chronic suppurative otitis media

Chronic suppurative otitis media (CSOM) is a leading global cause of potentially preventable hearing loss in children and adults, associated with socioeconomic deprivation. There is an absence of consensus on the definition of CSOM, which complicates efforts for prevention, treatment, and monitoring. CSOM occurs when perforation of the tympanic membrane is associated with severe or persistent inflammation in the middle ear, leading to hearing loss and recurrent or persistent ear discharge (otorrhoea). Cholesteatoma, caused by the inward growth of the squamous epithelium of the tympanic membrane into the middle ear, can also occur. The optimal treatment of discharge in CSOM is topical antibiotics. In resource-limited settings where topical antibiotics might not be available, topical antiseptics are an alternative. For persistent disease, surgery to repair the tympanic membrane or remove cholesteatoma might offer long-term resolution of otorrhoea and potential improvement to hearing. Recent developments in self-fitted air-conduction and bone-conduction hearing aids offer promise as new options for rehabilitation.

A systematic review of otologic injuries sustained in civilian terrorist explosions

PURPOSE

Determine the prevalence of otological symptoms and tympanic membrane perforation, healing rates of tympanic membrane perforation with surgical and conservative management, and hearing function in civilian victims of terrorist explosions.

METHODS

A systematic review was conducted with searches on Medline, Embase, EMCare and CINAHL for publications between the 1st January 1945 and 26th May 2023. Studies with quantitative data addressing our aims were included. This review is registered with PROSPERO: CRD42020166768. Among 2611 studies screened, 18 studies comprising prospective and retrospective cohort studies were included.

RESULTS

The percentage of eardrums perforated in patients admitted to hospital, under ENT follow up and attending the emergency department is 69.0% (CI 55.5-80.5%), 38.7% (CI 19.0-63.0%, I2 0.715%) and 21.0% (CI 11.9-34.3%, I2 0.718%) respectively. Perforated eardrums heal spontaneously in 62.9% (CI 50.4-73.8%, I2 0.687%) of cases and in 88.8% (CI 75.9-96.3%, I2 0.500%) of cases after surgery. Common symptoms present within one month of bombings are tinnitus 84.7% (CI 70.0-92.9%, I2 0.506%), hearing loss 83.0% (CI 64.5-92.9%, I2 0.505%) and ear fullness 59.7% (CI 13.4-93.4%, I2 0.719). Symptomatic status between one and six months commonly include no symptoms 57.5% (CI 46.0-68.3%), hearing loss 35.4% (CI 21.8-51.8%, I2 0.673%) and tinnitus 15.6% (CI 4.9-40.0%, I2 0.500%). Within one month of bombings, the most common hearing abnormality is sensorineural hearing loss affecting 26.9% (CI 16.9-40.1%, I2 0.689%) of ears 43.5% (CI 33.4-54.2%, I2 0.500) of people.

CONCLUSION

Tympanic membrane perforation, subjective hearing loss, tinnitus, ear fullness and sensorineural hearing loss are common sequelae of civilian terrorist explosions.

Comparison of temporalis muscle fascia and cartilage grafts for primary type 1 tympanoplasty: a meta-analysis of randomized controlled trials

PURPOSE

To compare the efficacy and safety of temporalis fascia (TF) with cartilage grafts for primary type 1 tympanoplasty in chronic otitis media (COM) patients.

METHODS

Computerized search was performed in MEDLINE, Embase, and CENTRAL. Eligible for inclusion were randomized controlled trials (RCTs) comparing TF and cartilage grafts in individuals with non-cholesteatoma COM and intact ossicles requiring type 1 tympanoplasty. Primary outcomes were graft success and hearing improvement, measured by the air-bone gap (ABG) closure. The secondary outcome was the occurrence of complications. Standardized mean differences (SMD) and odds ratios (OR) with 95% confidence intervals were calculated.

RESULTS

Eighteen RCTs that enrolled 1273 participants were found eligible. Data were reported at follow-up periods ranging from 6 weeks to 24 months. The pooled effect estimate revealed a higher and statistically significant graft success favoring cartilage grafts at 12 months (OR = 2.24, 95% CI 1.33-3.78) and 24 months (OR = 2.96, 95% CI 1.18-7.43). There was no significant difference between both grafts in post-operative ABG closure across all follow-up periods (6 weeks to 12 months).

CONCLUSIONS

Compared to TF, primary type 1 cartilage tympanoplasty offers better graft uptake rates and comparable postoperative hearing outcomes for COM patients.

Overcoming barriers: a review on innovations in drug delivery to the middle and inner ear

Despite significant advances in the development of therapeutics for hearing loss, drug delivery to the middle and inner ear remains a challenge. As conventional oral or intravascular administration are ineffective due to poor bioavailability and impermeability of the blood-labyrinth-barrier, localized delivery is becoming a preferable approach for certain drugs. Even then, localized delivery to the ear precludes continual drug delivery due to the invasive and potentially traumatic procedures required to access the middle and inner ear. To address this, the preclinical development of controlled release therapeutics and drug delivery devices have greatly advanced, with some now showing promise clinically. This review will discuss the existing challenges in drug development for treating the most prevalent and damaging hearing disorders, in particular otitis media, perforation of the tympanic membrane, cholesteatoma and sensorineural hearing loss. We will then address novel developments in drug delivery that address these including novel controlled release therapeutics such as hydrogel and nanotechnology and finally, novel device delivery approaches such as microfluidic systems and cochlear prosthesis-mediated delivery. The aim of this review is to investigate how drugs can reach the middle and inner ear more efficiently and how recent innovations could be applied in aiding drug delivery in certain pathologic contexts.

Success rates and predictors of outcomes of type I tympanoplasty performed by residents in a teaching tertiary hospital

Several technical variations of tympanoplasty have been reported, usually involving the type of graft and/or instruments used. Few studies have focused on the outcome of type-1 tympanoplasty specifically in teaching scenarios. We aimed to describe the results of type-1 tympanoplasty performed by residents, and to investigate potential predictive factors of surgical success. To do so, we did a retrospective analysis of medical records of patients who underwent type-1 tympanoplasty in a tertiary university hospital. We evaluated the tympanic membrane closure and audiometric outcomes during the first year of follow-up, and compared the results according to some clinical and surgical factors. 130 operated ears were included in the study. The closure rate reached 84.12% after one month and 72.72% after twelve months of surgery. The mean air-bone gap was 22.98 dB preoperatively, and reached 10.55 dB after surgery. Perforation closure rates were 85% and 57.14% for those operated by endoscopic and microscopic-assisted approaches, respectively (p = 0.004). The use of cartilage grafts and time without otorrhea of more than three months prior to surgery were also predictors of surgical success (p = 0.002 and 0.041, respectively). Gender, age, perforation size, contralateral disease, operated side, reoperation, and degree of hearing loss did not significantly interfere with outcomes. Tympanoplasty showed good overall results when performed by residents, although inferior to those reported by experienced surgeons. The use of the endoscope, cartilage grafting, and longer preoperative time without otorrhea were predictors of surgical success in this scenario.

Level of evidence

IIB.

Tympanoplasty Healing Outcomes With Use of Postoperative Otic Quinolones

OBJECTIVE

Tympanoplasty usually results in tympanic membrane perforation (TMP) closure, but healing may be suboptimal (e.g., excess scarring). Factors that have been linked to impaired TM healing have become widely adopted (especially, postoperative use of quinolone ear drops). The aim of this study is to assess the frequency of suboptimal tympanoplasty healing with the use of otic quinolones postoperatively.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary care facility.

PATIENTS

One hundred patients undergoing tympanoplasty for TMP.

INTERVENTIONS

Tympanoplasty +/- canalplasty.

MAIN OUTCOME MEASURES

Healing complications (e.g., granulation tissue, TMP, myringitis, bone exposure, lateralization, anterior blunting, medial canal fibrosis, and canal stenosis) and hearing loss.

METHODS

Charts were reviewed for postoperative healing issues and hearing outcomes at 1 to 2 years postoperatively.

RESULTS

TMP closure was found in 93.2%, but 34.2% had healing issues at 1 to 2 years postoperatively, with 20.6% having adverse healing outcomes (perforation (6.9%), granulation tissue (6.9%), medial fibrosis (4.1%), and myringitis, bone exposure, and webbing (all 1.4%). Another 13.7% had notable postoperative issues, such as protracted otorrhea (11.0%), otitis externa (9.6%), otitis media (1.4%), and atelectasis (2.7%). No medical, surgical, or patient factors impacted outcomes. Average air-bone gap at 1 to 2 years did not differ between patients with and without healing issues and patients with other postoperative issues (p = 0.5).

CONCLUSIONS

Suboptimal healing is common after tympanoplasty. There may be significant opportunity to improve post-tympanoplasty healing beyond improving the TMP closure rate.

Recurrent tympanic perforation after myringoplasty: a narrative literature review and personal experience

The aim of the work is to review the current literature concerning recidivism of tympanic perforation after myringoplasty and to give some tips to improve the chance of success and manage the possible scenario of failure. An analysis of the existing literature is presented and, based on it and on our experience, an algorithm of management of tympanic perforation recidivism is proposed.

Correlation of Eustachian tube function with the results of type 1 tympanoplasty: a prospective study

OBJECTIVES

This study aims to evaluate Eustachian tube (ET) function tests and their impact on outcomes of tympanoplasty in patients with inactive chronic suppurative otitis media.

MATERIALS AND METHODS

A prospective study was conducted involving patients diagnosed with chronic suppurative otitis media (CSOM) and having a central dry perforation. Assessment of the ET function was done for all included cases by three tests; pressure swallow equalization test, saccharine test and methylene blue test. The primary outcome is the graft success rate defined as intact graft without any residual perforation at 6 months postoperatively. Secondary outcomes include hearing assessment and possible associated complications.

RESULTS

64 patients were included in the study with an average age of 36.59 ± 11.96 years. All patients underwent assessment of the ET function by saccharine test, methylene blue test and pressure equalization test (PET) followed by microscopic post-auricular tympanoplasty. Successful tympanoplasty is achieved in 93.75% of cases with residual perforation in four patients. Mean air-bone gap is significantly improved from 23.73 ± 2.80 preoperatively to 10.93 ± 5.46 postoperatively. Results of Methylene blue test has no statistical impact on graft take rate (p value = 0.379), while saccharine test and pressure equalization test results have statistically significant correlation with graft success (p value ≤ 0.001).

CONCLUSIONS

Saccharine and Pressure equalization tests have a good positive correlation with the graft healing in tympanoplasty, while methylene blue test was found to have no correlation with the success rate.

Current variations and practice patterns in tympanic membrane perforation repair

OBJECTIVE

Management of tympanic membrane perforations is varied. This study aimed to better understand current practice patterns in myringoplasty and type 1 tympanoplasty.

METHODS

An electronic questionnaire was distributed to American Academy of Otolaryngology - Head and Neck Surgery members. Practice patterns were compared in terms of fellowship training, practice length, practice setting, paediatric case frequency and total cases per year.

RESULTS

Of the 321 respondents, most were comprehensive otolaryngologists (60.4 per cent), in private practice (60.8 per cent), with a primarily adult practice (59.8 per cent). Fellowship training was the factor most associated with significant variations in management, including pre-operative antibiotic usage (p = 0.019), contraindications (p < 0.001), approach to traumatic perforations (p < 0.001), use of local anaesthesia (p < 0.001), graft material (p < 0.001), tympanoplasty technique (p = 0.003), endoscopic assistance (p < 0.001) and timing of post-operative audiology evaluation (p = 0.003).

CONCLUSION

Subspecialty training appears to be the main variable associated with significant differences in peri-operative decision-making for surgical repair of tympanic membrane perforations.

Factors influencing successful reconstruction of tympanic membrane perforations: a systematic review and meta-analysis

PURPOSE

Based on a systematic review and meta-analysis, our study aimed to provide information about the factors that influence the success of tympanic membrane reconstruction.

METHODS

Our systematic search was conducted on November 24, 2021, using the CENTRAL, Embase, and MEDLINE databases. Observational studies with a minimum of 12 months of follow-up on type I tympanoplasty or myringoplasty were included, while non-English articles, patients with cholesteatoma or specific inflammatory diseases, and ossiculoplasty cases were excluded. The protocol was registered on PROSPERO (registration number: CRD42021289240) and PRISMA reporting guideline was used. Risk of bias was evaluated with the QUIPS tool. A random effect model was used in the analyses. Primary outcome was the rate of closed tympanic cavities.

RESULTS

After duplicate removal, 9454 articles were found, of which 39 cohort studies were included. Results of four analyses showed significant effects: age (OR: 0.62, CI 0.50; 0.78, p value: 0.0002), size of the perforation (OR: 0.52, CI 0.29; 0.94, p value: 0.033), opposite ear condition (OR: 0.32, CI 0.12; 0.85, p value: 0.028), and the surgeon's experience (OR: 0.42, CI 0.26; 0.67, p value: 0.005), while prior adenoid surgery, smoking, the site of the perforation, and discharge of the ear did not. Four factors: etiology, Eustachian tube function, concomitant allergic rhinitis, and duration of the ear discharge were analyzed qualitatively.

CONCLUSIONS

The age of the patient, the size of the perforation, the opposite ear status, and the surgeon's experience have a significant effect on the success of tympanic membrane reconstruction. Further comprehensive studies are needed to analyze the interactions between the factors.

LEVEL OF EVIDENCE

Not applicable.

Negative Outcome of Temporalis Fascia Graft in Tympanoplasty with Excessive Bleeding: A Retrospective Study

Background and Objectives: Non-autologous graft materials hold promise for tympanic membrane (TM) perforation closure. In the present manuscript, we aimed to evaluate the influence of clinical and surgical (i.e., graft materials) characteristics on tympanoplasty outcome in chronic otitis media (COM). Materials and Methods: We retrospectively reviewed clinical and surgical characteristics of COM patients with TM perforation treated with tympanoplasty and mastoidectomy. Univariate and multivariate appropriate tests were applied. Results: We used xenograft (porcine submucosal collagen) in 163 patients, and temporalis fascia in 210. The mean follow-up time was 37.2 months. Postoperative TM perforation (i.e., negative outcome) was detected in 11.6% of cases with xenograft, and in 12.8% with temporalis fascia. Performing uni- and multivariate analysis, we determined that large (three or all quadrants) TM perforation (p = 0.04) and moderate-to-severe intraoperative bleeding (p = 0.03) were independent prognostic factors of negative outcome. Considering the 197 patients with moderate-to-severe intraoperative bleeding, we disclosed that the use of temporalis fascia (p = 0.03) was an independent risk factor of postoperative TM perforation. Conclusions: According to our results, large TM perforation and moderate-to-severe intraoperative bleeding were independent prognostic factors of negative outcome in adult COM patients treated with tympanoplasty. In the sub-group of COM patients with excessive intraoperative bleeding, use of temporalis fascia was associated with negative outcome; these patients could benefit from xenograft materials. These findings should be tested in large randomized clinical trials.

Anatomic and audiometric outcomes of porcine intestinal submucosa for tympanic membrane repair

Objective

Surgical repair of tympanic membrane perforations has been traditionally performed with autologous soft-tissue grafts with high success rates. Newer allografts such as porcine small intestine submucosa (pSIS) have been employed as alternatives to minimize donor morbidity and surgical time, and in cases where autologous tissue may not be available. The comparative anatomic and audiometric success rates of these tissues is still unclear.

Study design

Retrospective case-control series of anatomic and audiometric outcomes of autologous soft tissue versus pSIS graft for primary, isolated transmeatal tympanic membrane repair.

Methods

Analysis of patients undergoing primary transmeatal tympanic membrane repair with autologous soft tissue or pSIS. Patients with otorrhea, cholesteatoma or retraction pockets, those who had cartilage grafts or ossicular reconstruction, and revision procedures were excluded. Pre- and post-surgery air-bone gaps (ABG) and pure tone averages (PTA) were compared. Graft success was defined as closure of the perforation at 2-month follow-up visit.

Results

The success rate for both the autologous soft tissue and the pSIS arm is 93.8%. There was no statistical significance (p < .05) between the post-op ABG, change in ABG, post-op PTA, change in PTA, or graft success rate between the two groups with either lumped cohort or matched-pairs analysis.

Conclusions

pSIS grafts are effective for repair of tympanic membrane perforations with hearing outcomes and graft success rates comparable to autologous soft tissue.

Lay summary

Repair of tympanic membrane perforations is traditionally done using a soft-tissue graft harvested from the patient at the time of surgery. pSIS is a newer graft material that is equally effective in terms of anatomical and audiometric outcomes.

Level of evidence

Level 3b.

Long-term anatomic and functional outcome of pediatric myringoplasty in primary and revision cases

OBJECTIVES

To evaluate the long-term anatomical and functional results of myringoplasty in a large cohort of children and analyse factors determining outcome of surgery.

METHODS

A retrospective analysis of 469 cases of primary and revision pediatric myringoplasties conducted between 2003 and 2018 at the Ghent University Hospital was performed. Anatomical success was defined as an intact tympanic membrane postoperatively. Overall success was defined as an intact tympanic membrane, preservation or improvement of hearing and an ear free from otitis media with effusion, atelectasis, ear discharge and myringitis. The impact of different variables on outcome was investigated by univariate analysis.

RESULTS

In primary cases, anatomical success was achieved in 96.8% and 94.3% at early respectively late evaluation (after 1 resp. 12 months). Overall success was achieved in 65.4% and 68.5% at early and late evaluation respectively. In revision cases, early anatomical and overall success were achieved in 96.8% and 53.8%, dropping to respectively 88.9% and 47.1% at late evaluation. In primary cases, presence of bilateral perforations was a significant predictor of a negative anatomical outcome. Further analysis of anatomical, audiological, and overall success rates in primary and revision cases could not withhold any significant predictors.

CONCLUSION

Anatomical success rates of myringoplasty in children are high, in primary as well as revision surgery. When taking the functional status in account however, success rates are lower. The presence of a bilateral perforation predicts a worse outcome with higher anatomical failure rates. No other factors with significant predictive effect on outcome were identified.

Current outcomes of myringoplasty in a European referral children's hospital

OBJECTIVES

Myringoplasty is a frequently performed procedure in children, with a heterogeneous failure rate. Our study aimed to evaluate the outcome of myringoplasty in a pediatric hospital and to identify which are risk factors for reperforation or poor hearing improvement after surgery.

METHODS

Preoperative and intraoperative variables between pediatric patients who had undergone myringoplasty with an intact tympanic membrane at follow-up and the cases with reperforation were compared. The same factors were investigated as potential predictors of audiological success. Pre and postoperative PTA and ABG were compared in the whole population, in structural success and failure groups and closure of ABG was calculated and used to compare the audiological outcomes between the two groups.

RESULTS

Parameters that affected the postoperative integrity of TM were age, the time between diagnosis and surgery, the intraoperative status of the middle ear, and secondhand smoke exposure. Early perforations occurred mostly after surgeries performed by trainees, while late perforations were more frequently in autumn. Myringoplasty, regardless of the structural outcome, can improve the ABG and PTA. No preoperative and intraoperative parameters affected the audiological outcome.

CONCLUSION

Pediatric myringoplasty is a safe and successful procedure that can improve hearing, regardless of the structural outcome. In light of our results, parameters to consider before surgery are age, the time between diagnosis and surgery, the intraoperative status of the middle ear, and secondhand smoke exposure.

Endoscopic transcanal tympanoplasty type I in children: Evolving experience in tragus perichondrium vs. acellular porcine small intestinal sub-mucosa grafts

OBJECTIVES

Endoscopic trans-canal tympanoplasty type I (ETT) is gradually diffusing worldwide. It mainly allows less invasive surgery in children with respect to a microscope approach by avoiding post-auricular access. The aim of this study is to illustrate our experience in endoscopic reconstruction of tympanic membrane, using autologous tragus perichondrium (TP) and non-autologous acellular porcine small intestinal sub-mucosa (SIS) as grafts.

METHODS

Between January 2011 and December 2020, the results of a prospective non-randomized series of consecutive ETT were analyzed. The primary outcome was closure rate at 6 months and secondary outcomes are closure rates associated with age, size of perforation, type of perforation and middle ear status, presence of myringosclerosis, type of graft, status of contralateral ear, adenoidectomy and pre-postoperative ABG change. Statistical analysis was performed using the SPSS statistical package.

RESULTS

One hundred and sixteen consecutive procedures, mean age 9.4 years (range 4-17 years), were evaluated. TP and SIS grafts were used in 65 (56%) and 51 (44%) procedures, respectively. Mean duration of surgical procedure was 53 ± 21 min for SIS and 77 ± 18 min for TP (P = 0.001) Total graft intake was 82.8%; TP and SIS intake were 86.2% and 78.4% (P = 0.3), respectively. Graft intake w.r.t. in age stratified age groups was not statistically significant. Average preoperative and postoperative air-bone gap was 12.1 ± 7.6 dB and 5.5 ± 3.8 dB, respectively (P = 0.001). The difference in closure rates was not significant. Neither intra- nor postoperative complications were observed.

CONCLUSIONS

In children, ETT is an applicable and less invasive technique compared to the microscope and offers less morbidity. The use of SIS contributes additional less invasiveness to endoscopic surgery by avoiding tragus harvesting with a comparable success rate and granting significantly less surgical duration.

The Development and Evaluation of a Smartphone-Aided Diagnosis Application to Measure Tympanic Membrane Perforations

OBJECTIVES

Chronic otitis media is a long-term infection of the middle ear. It is characterized by persistent discharge from the middle ear through a perforated tympanic membrane. It is one of the most common causes of preventable hearing loss, especially in developing countries. Precise estimation of the size of tympanic membrane perforation is essential for successful clinical management. In this study, we developed a smartphone-based application to calculate the ratio of the area of tympanic membrane perforation to the area of the tympanic membrane. Twelve standardized patients and 60 medical students were involved to assess the area of tympanic membrane perforation, in particular, the percentage of perforation size.

METHODS

In total, 60 student doctors (including year 5 and year 6 medical students, intern and post-graduate year training of doctors) were recruited during their rotation at the Otolaryngology department of Taipei Medical University Shuang-Ho Hospital. Twelve standardized patients with chronic otitis media were recruited through a single otology practice. Oto-endoscopic examination was performed for all patients by using a commercially-available digital oto-endoscope, and clinical images of the tympanic membrane perforation were obtained. To demonstrate the variability of perforation size estimation by different student doctors, we calculated the percentage of perforation using the smartphone-based application for 12 tympanic membranes objectively and compared the results with those visually estimated by the 60 student doctors subjectively.

RESULTS

The variance in the visual estimation by the 60 student doctors was large. By contrast, variances in smartphone-based application calculations were smaller, indicating consistency in the results obtained from different users. The smartphone-based application accurately estimated the presence of perforation for tympanic membranes with high consistency. The differences in visual estimations can be considerably great and the variances can be large among different individuals.

CONCLUSIONS

The smartphone-based application is a dependable tool for precisely evaluating the size of tympanic membrane perforation.

Endoscopic closure of tympanic membrane anterior perforation using a strip-type chondroperichondrial graft

Myringoplasty is a surgical procedure to reconstruct tympanic perforation. However, repair of anterior perforations is still challenging. To analyze the anatomical and hearing outcomes of myringoplasty with a new technique of chondroperichondrial graft via endoscopy, 23 adult patients were retrospectively analyzed. All patients had anterior perforations of tympanic membranes that were repaired with a composite strip-type cartilage-perichondrium graft through a total endoscopic transcanal approach. The anatomical graft success rate at postoperative 1 month was 86.96% (20/23) and reached 100% at the 6- and 12-month follow-up. Compared to the preoperative air conduction threshold (44.7 ± 13.56 dB) and air-bone gap (ABG) (22.35 ± 6.54 dB), the postoperative air conduction threshold and ABG decreased to 33.52 ± 10.88 dB and 12.52 ± 3.94 dB, respectively (P < .0001). Twenty-two (95.65%) patients had an ABG below 20 dB postoperatively. The mean ABG improvement in our cohort was 9.83 ± 5.00 dB. The functional graft success rate was 95.65% (22/23). The convenience, reliability, time, and labor savings accrued from the approach described here make it a good choice for repair of anterior perforation of tympanic membrane.

Use of nasal mucosa graft in tympanoplasty

INTRODUCTION

Tympanoplasty techniques with different types of graft have been used to close tympanic perforations since the 19th century. Tragal cartilage and temporalis fascia are the most frequently used types of graft. They lead to similar functional and morphological results in most cases. Although little published evidence is present, nasal mucosa has also been shown to be a good alternative graft.

OBJECTIVE

Surgical and audiological outcomes at the six-month follow-up in type I tympanoplasty using nasal mucosa and temporalis fascia grafts were analyzed.

METHODS

A total of 40 candidates for type I tympanoplasty were randomly selected and divided into the nasal mucosa and temporalis fascia graft groups with 20 in each group. The assessed parameters included surgical success; the rate of complete closure of tympanic perforation and hearing results; the difference between post- and pre-operative mean quadritonal airway-bone gap, six months after surgery.

RESULTS

Complete closure of the tympanic perforation was achieved in 17 of 20 patients in both groups. The mean quadritonal airway-bone gap closures were11.9 and 11.1 dB for the nasal mucosa and temporalis fascia groups, respectively. There was no statistically significant difference between the groups.

CONCLUSION

The nasal mucosa graft can be considered similar to the temporal fascia when considering the surgical success rate of graft acceptance and ultimate audiological gain.

Audiological and Surgical Correlates of Myringoplasty Associated with Ethnography in the Bay of Plenty, New Zealand

INTRODUCTION

This retrospective cohort study of myringoplasty performed at Tauranga Hospital, Bay of Plenty, New Zealand from 2010 to 2020 sought to identify predictive factors for successful myringoplasty with particular consideration given to the known high prevalence of middle ear conditions in New Zealand Māori.

METHODS

Outcomes were surgical success (perforation closure at 1 month) and hearing improvement, which were correlated against demographic, pathological, and surgical variables.

RESULTS

174 patients underwent 221 procedures (139 in children under 18 years old), with 66.1% of patients being New Zealand Māori and 24.7% New Zealand European ethnicity. Normalized by population demographics, New Zealand Māori were 2.3 times overrepresented, whereas New Zealand Europeans were underrepresented by 0.34 times (a 6.8 times relative treatment differential). The rate of surgical success was 84.6%, independent of patient age, gender, and ethnicity. A postauricular approach and the use of temporalis fascia grafts were both correlated with optimal success rates, whereas early postoperative infection (<1 month) was correlated with ∼3 times increased failure. Myringoplasty improved hearing in 83.1% of patients (average air-bone gap reduction of 10.7 dB). New Zealand Māori patients had ∼4 times greater preoperative conductive hearing loss compared to New Zealand Europeans, but benefited the most from myringoplasty.

DISCUSSION/CONCLUSION

New Zealand Māori and pediatric populations required greater access to myringoplasty, achieving good surgical and audiological outcomes. Myringoplasty is highly effective and significantly improves hearing, particularly for New Zealand Māori. Pediatric success rates were equivalent to adults, supporting timely myringoplasty to minimize morbidity from untreated perforations.

Circumferential subannular tympanoplasty: surgical and hearing outcome in 224 ears with subtotal perforation

BACKGROUND

Subannular tympanoplasty is a newer technique with limited research articles in the literature. These articles have limitation in terms of sample data. We reviewed outcome of subannular tympanoplasty performed during last five years in our center.

OBJECTIVE

To determine the surgical and hearing outcome of circumferential subannular tympanoplasty.

METHODS

A retrospective observational study was performed in a tertiary care academic center involving 224 subjects with mucosal chronic otitis media who underwent circumferential subannular type 1 tympanoplasty.

RESULTS

Complete neo-tympanum was found in 213 cases (95.1%) at the end final follow period of 12 months after surgery. Eleven tympanic membranes did not take up the graft and considered failure at the end of 6 months after surgery. All of them were subjected for revision surgery and showed intact neo-tympanum after 12 months of surgery. The hearing outcome showed significant improvement in air conduction thresholds from 42.54 ± 13.04 dB to 30.48 ± 10.61 dB at the end of one year. No surgical complication was observed in the study group.

CONCLUSION

The circumferential subannular tympanoplasty carries good surgical success and should be preferred in large and subtotal perforations. Randomized controlled trials are warranted to overcome the limitations in the present study.

SIGNIFICANCE

This is the first study showing outcome of subannular tympanoplasty in large sample size of more than 200.

Density of Health Workforce Correlates to Disease Outcomes: Evidence From Global Data in Otolaryngology

Objective

To better understand the impact of the otolaryngology-specific workforce on the burden of related diseases.

Study Design

Retrospective analysis of existing workforce density data as compared with the incidence, mortality, and morbidity data for 4 otolaryngologic diseases.

Setting

An overall 138 countries with known otolaryngology-head and neck surgery workforce and epidemiologic data.

Methods

We obtained raw data on workforce estimates of ear, nose, and throat surgical specialists from the World Health Organization. Disease burdens for 4 conditions were estimated via 2 ratios, the mortality:incidence ratio (MIR) and YLD:incidence ratio (years lost to disability), as specified in the Global Burden of Disease database. These were correlated to country-specific otolaryngologist density data in univariate and multivariate analyses.

Results

Increased density of the ear, nose, and throat workforce correlated with better outcomes for otolaryngologic-treated surgical diseases. A 10% increase in otolaryngology workforce density was associated with a 0.27% reduction in YLD:incidence ratio for chronic otitis media, a 0.94% reduction in MIR for lip and oral cavity cancer, a 1.46% reduction in MIR for laryngeal cancer, and a 1.34% reduction in MIR for pharyngeal cancer (all P < .001)-an effect that remained after adjustment for health systems factors for all conditions but chronic otitis media.

Conclusion

The density of the surgical workforce is assumed to affect disease outcomes, but ours is the first analysis to show that increased workforce density for a specific surgical specialty correlates with improved disease outcomes. While there is a consensus to increase access to health care providers, quantifying the effect on disease outcomes is an important metric for those performing health economics modeling, particularly where resources are limited.

Pediatric Primary Tympanoplasty Outcomes With Autologous and Non-autologous Grafts

OBJECTIVE

To compare rates of successful tympanic membrane (TM) closure in primary pediatric tympanoplasty between various autologous and non-autologous tissues.

METHODS

A retrospective chart review was performed examining all primary pediatric tympanoplasties over a 20-year period at a single institution.

RESULTS

In 564 pediatric tympanoplasties, no statistically significant difference existed between success rates of autologous and non-autologous grafts (p = 0.083). Compared with fascia, the hazard ratios (and 95% confidence intervals [CI]) for failure for each graft were as follows: human pericardial collagen (HR 0.90, CI 0.54-1.50, p = 0.680), porcine submucosal collagen (HR 1.07, CI 0.56-2.05, p = 0.830), human acellular dermal collagen (HR 1.66, CI 0.95-2.87, p = 0.073), and "multiple grafts" (HR 0.72, CI 0.26-1.98, p = 0.520). Survival curves demonstrated that 75% of graft failures occurred by 6 months after surgery, the rest occurring between 6 and 12 months postoperatively. Larger perforations encompassing more than or equal to 50% of the TM had lower success rates (HR 1.50, CI 1.02-2.21, p = 0.041) than smaller perforations encompassing less than 50% of the TM. Age was not correlated with success (HR 0.98, CI 0.93-1.03, p = 0.390).

CONCLUSION

This study found that non-autologous collagen grafts provide equivalent rates of healing when compared with autologous tissue in primary pediatric tympanoplasty. In addition to the potential for reduced operative time and donor site morbidity, these materials provide a viable graft alternative in fascia-depleted ears.Level of Evidence: Level 4.

Myringoplasty for pediatric chronic otitis media: An uncritical closure of a natural middle ear drainage?

BACKGROUND

Performing tympanoplasty for tympanic perforations in children and adolescents is often considered to be less successful than in adults.

OBJECTIVES

The aim of our study was to evaluate the surgical outcome of tympanoplasty type I in patients under 15 years of age with chronic otitis media and to identify potential factors that influence the success rate.

MATERIALS UND METHODS

The present study was based on a retrospective analysis of the medical records of all patients under the age of 15 who were treated for chronic otitis media by means of type I tympanoplasty between 2005 and 2020. The minimum follow-up period was 6 months. The data were analyzed with regard to epidemiological parameters, tube-related pathologies in the contralateral ear, the local condition and the extent of the eardrum perforation as well as the extent of the surgical intervention (tympanoplasty type I with or without adenotomy).

RESULTS

83 cases were included in our study. The mean age at the time of the surgery was 8.9 years. The mean follow-up time was 46 months (6-182 months). The anatomical closure rate was 88.0%. Children with "dry" tympanic perforations tended to perform better (p = 0.052). The average improvement in the air bone gap was 2.0 dB.

CONCLUSION

Detailed preoperative counseling about the advantages and disadvantages as well as the expected success rate of an early myringoplasty in this age group is just as important as an individualized approach for a high level of patient satisfaction.

Surgical results of tympanoplasty after conversion to the endoscopic approach performed by a surgeon experienced in microscopic surgery

PURPOSE

The aim of this study was to analyze the surgical outcomes of endoscopic tympanoplasty (ET) type I, and to investigate the learning curve of ET type I in a surgeon experienced in microscopic surgery.

METHODS

We retrospectively studied patients with tympanic membrane perforations who had undergone ET type I from January 2015 to June 2020. All procedures were performed by a single senior surgeon with considerable microscopic experience. We compared the perforation closure rate in relation to age, previous ear surgery history, graft material, size, and location of perforation. We compared the operation time according to the number of operated patients.

RESULTS

A total of 399 patients were enrolled. The success rate of ET type I was 92.7%. Age, prior ear surgery, graft material, size, and location of perforation did not influence the surgical outcomes. The surgical time for the initial ten cases was the longest (78.3 min), and stabilized after the first 100 cases to under 60 min. The surgical success rate was 96.0% in the first 50 cases, and decreased to approximately 92% afterwards.

CONCLUSION

The surgical time largely decreased with the number of operated patients. Since the operations were performed by a surgeon experienced in microscopy, the success rate of initial cases was not low, even though the operation time of these initial cases was longer. We believe that endoscope provides a new perspective on ear surgery if it could overcome the difficulties in the early stage.

A design-thinking approach to therapeutic translation: tympanic regeneration

PURPOSE OF REVIEW

Clinician researchers face the pressures of meeting academic benchmarks combined with advancing new therapies to patients. The vast majority of drug discoveries fail in translation. A new method of meeting the challenges of preclinical therapeutic translation is presented using the example of tympanic regeneration.

RECENT FINDINGS

The key to a design-thinking approach to therapeutic translation is to 'begin with the end in mind' by widening the scope of the problem, with multiple points of view, to not only understand the disease but the context for the patient and the health system in which it occurs. Idea for therapeutics should be tested in relevant models early and once proof of efficacy is established, translational milestones that represent the greatest risk, such as safety and toxicity should be addressed first. It is important to seek the feedback of industry early to understand what milestones should be best addressed next with limited academic resources. Whenever proceeding, guidelines for maintaining scientific reproducibility should be followed to minimize risk of failure during transfer into industry.

SUMMARY

A Design-thinking approach addresses the potential failures in drug discovery and preclinical translation.

Meta-analysis of time to extrusion of tympanostomy tubes by tympanic membrane quadrant

OBJECTIVES

To investigate the published time to extrusion of tympanostomy tubes inserted in the various quadrants of the tympanic membrane.

METHODS

Publications were selected by a search with 'PubMed', 'Embase' and 'Web of Science'. A meta-analysis of time to extrusion as a function of tympanic membrane quadrant intubation was performed.

DESIGN, SETTING, PARTICIPANT-NOT RELEVANT MAIN OUTCOME MEASURED

Extrusion rate of tympanostomy tubes inserted in the various quadrants of the tympanic membrane.

RESULTS

Eleven studies describing 2232 tympanostomy tubes were enrolled into the quantitative meta-analysis. The extrusion rate was evaluated at 3-month intervals up to 24 months post-intubation, and it did not differ significantly at any of the time points tested for the superior and inferior anterior quadrants. The cumulative extrusion rates were as follows: 11 and 9%, 32 and 23%, 59 and 36%, 80 and 67%, 87 and 70%, 88 and 82%, and 96 and 89% in the superior and anterior quadrants, respectively, at 3, 6, 9, 15, 18, 21 and 24 months post-intubation, respectively.

CONCLUSION

Time to extrusion of tympanostomy tubes are similar for all 3 tympanic membrane quadrants. The anterior superior quadrant intubation has no superiority in terms of intubation time.

Mechanics of Total Drum Replacement Tympanoplasty Studied With Wideband Acoustic Immittance

OBJECTIVE

Poor hearing outcomes often persist following total drum replacement tympanoplasty. To understand the mechanics of the reconstructed eardrum, we measured wideband acoustic immittance and compared the mechanical characteristics of fascia-grafted ears with the normal tympanic membrane.

STUDY DESIGN

Prospective comparison study.

SETTING

Tertiary care center.

METHODS

Patients who underwent uncomplicated total drum replacement with temporalis fascia grafts were identified. Ears with healed grafts, an aerated middle ear, and no other conductive abnormalities were included. All patients underwent pre- and postoperative audiometry. Wideband acoustic immittance was measured with absorbance and impedance computed. Fascia-grafted ears were compared with normal unoperated ears.

RESULTS

Eleven fascia-grafted ears without complications were included. Postoperatively, the median air-bone gap was 15 dB (250-4000 Hz), with variation across frequency and between ears. Fifty-six control ears were included. Absorbance of fascia-grafted ears was significantly lower than that of normal ears at 1 to 4 kHz (P < .05) but similar below 1 kHz. Impedance magnitude demonstrated deeper and sharper resonant notches in fascia-grafted ears than normal ears (P < .05), suggesting lower mechanical resistance of the fascia graft.

CONCLUSION

The mechanics of fascia-grafted ears differ from the normal tympanic membrane by having lower absorbance at mid- to high frequencies and thus poor sound transmission. The lower resistance in fascia-grafted ears may be due to poor coupling of the graft to the malleus. To improve sound transmission, grafts for tympanic membrane reconstructions would benefit from refined mechanical properties.

Totally endoscopic tympanic membrane repair

BACKGROUND

Transcanal totally endoscopic ear surgery (TEES) has become increasingly popular internationally; however, for surgeons trained with a two-handed microscope-guided approach, the potential challenges of adopting TEES can appear off-putting.

OBJECTIVES

This article outlines the pros and cons of TEES for tympanic membrane repair and describes aspects of surgical technique relevant to those who might adopt this approach.

MATERIALS AND METHODS

Data are provided from the author's experience along with a review of relevant literature, including several meta-analyses of tympanoplasty outcome.

RESULTS

Meta-analyses show that TEES tympanoplasty is as effective at closing tympanic membrane perforations and improving hearing as microscope-guided surgery. Yet patients benefit from avoidance of a skin incision and faster recovery.

CONCLUSION

Repair of the tympanic membrane with TEES is feasible and effective. This minimally invasive approach is very appealing to patients.

Specific aspects of tympanoplasty in children: A retrospective cohort study of 95 cases

BACKGROUND

Paediatric tympanoplasty is now a common surgical procedure. The age from which it could be proposed varies regarding children specificities such as Eustachian tube dysfunction, the high incidence of upper airway infections and the immaturity of the immune system. The aim of this study is to describe the specific constitutional, epidemiological and operative aspects as well as the anatomical and functional results of tympanoplasty in children.

METHODS

From 2014 to 2018, a cohort of 95 patients with ages between 6 and 16 years, operated for a type I tympanoplasty, was reviewed by analysing the medical history, the epidemiological and clinical parameters, in addition to the operative features and the functional results.

RESULTS

The mean age at surgery was 11,7 years. The main risk factors of tympanic perforation were recurrent otitis (78,9%), auricular trauma (16,8%) and tonsillar and adenoid hypertrophy (7,4%). Good anatomical postoperative results with a closed and reinforced neo-tympanic membrane were seen in 90 (94,7%) cases, while a significant improvement of the hearing loss was observed in 87 (91.6%) patients, with a mean value of 34,23 dB HL before and 21,9 dB HL after surgery (p < 0,0001).

CONCLUSIONS

The indications of type I tympanoplasty in the paediatric population remain a subject of debate, but still offer good anatomical and functional results as long as it is adapted to each particular case.

The Pretragal Superficial Musculoaponeurotic System Fascia: A New Graft Material for Transcanal Tympanoplasty

OBJECTIVE

To compare outcomes of transcanal endoscopic tympanoplasty reconstructed using pretragal superficial musculoaponeurotic system (SMAS) fascia versus temporalis fascia.

STUDY DESIGN

Retrospective patient review and posttreatment questionnaire survey.

SETTING

Tertiary referral center.

PATIENTS

Sixty adult patients with chronic dry tympanic membrane perforation.

INTERVENTIONS

Patients underwent transcanal endoscopic type I tympanoplasty reconstructed using the SMAS fascia between September 2017 and May 2018; outcomes were compared with a matched cohort of patients where the temporalis fascia was used.

MAIN OUTCOME MEASURES

Tympanic membrane closure rate, audiogram threshold, duration of procedure, and donor site scar satisfaction survey.

RESULTS

Sixty patients were included in this study and were evenly divided into the SMAS and temporalis fascia groups. These cohorts were matched for age, sex, side of lesion, perforation size, and preoperative hearing level. The closure rate was 96.7% (29/30) and 93.3% (28/30) (p = 1.0), mean hearing gain was 8.3 ± 6.4 dB versus 8.2 ± 7.1 dB for air-conduction (p = 0.970) and 7.6 ± 5.1 dB versus 8.2 ± 6.8 dB for air-bone gap (p = 0.716), and mean surgical duration was 137.3 ± 23.0 versus 132.2 ± 27.3 minutes (p = 0.432) for the SMAS and temporalis fascia groups, respectively; there were no statistically significant differences for all the parameters listed. The posttreatment questionnaire survey revealed significantly higher acceptance of the SMAS fascia method.

CONCLUSION

This preliminary outcome report of SMAS fascia grafting in transcanal endoscopic type I tympanoplasty showed equivalent surgical outcomes and better cosmetic satisfaction compared with the temporalis fascia. The SMAS fascia is a reasonable alternative to conventional techniques for transcanal tympanoplasty.

Endaural Over-Underlay Cartilage Tympanoplasty for Repair of Dry Subtotal Perforations

OBJECTIVES

We explored the auditory and anatomical success of grafting when the cartilage perichondrium (CP) was prepared using two different methods.

METHODS

Patients with subtotal or total perforation underwent tympanoplasty with a CP graft. A V-shaped groove for the handle of the malleus was prepared for CP grafts in patients in group 1. Patients in group 2 did not have a groove on the graft. The anatomical success of the graft was evaluated as success, partial success, or failure. Results of auditory evaluations were compared between the two groups.

RESULTS

A total of 195 patients were included in the study. The total CP graft integration rate was 96% for both groups. Significant changes were detected in all hearing criteria evaluated 12 months after surgery compared to the preoperative period (P < .05). There were no significant differences between the groups in terms of the relationship between graft technique and postoperative hearing results. However, rates of partial success were significantly higher for group 1 than group 2 (P = .033).

CONCLUSION

Cartilage slice support offers an extremely reliable method for reconstruction of tympanic membrane in cases of high-risk perforation. Partial failures are rare, but when they occur, they most often involved anterior graft medialization. When a piece of cartilage is removed at the malleus interface there may be a higher rate of partial failure.

The inaugural World Report on Hearing: From barriers to a platform for change

The inaugural World Report on Hearing was recently published by the World Health Organisation, and outlines the burden of hearing loss, and strategies to overcome this through preventative and public health approaches. Here, we identify barriers to wide-scale adoption, including historic low prioritisation of hearing loss against other public health needs, a lack of a health workforce with relevant training, poor access to assistive technology, and individual and community-level stigma and misunderstanding. Overcoming these barriers will require multi-sector stakeholder collaboration, involving ear and hearing care professionals, patients, communities, industry and policymakers.