Type I Tympanoplasty Meta-Analysis: A Single Variable Analysis

Risk stratification in endoscopic type I. tympanoplasty

PURPOSE

Several risk factors were studied in endoscopic type I. tympanoplasty, however, an easy-to-use risk stratification model is still missing.

METHODS

Retrospective chart review, focusing on individual risk factors and middle ear risk index (MERI). Patients who underwent endoscopic type I. tympanoplasty were included.

RESULTS

Closed tympanic cavity was succesfully created in 88.1% of the 42 cases, the overall 21,5 dB air-bone gap (ABG) was reduced by 9,8 dB. The average MERI score of the patients was 2.1 ± 1.5. 78.6% of the patients were categorised into the mild, while 21.4% into the moderate risk group. The perforation was considered small in 81.0% of the cases, while large in 19.0%. The size of the perforation and the preoperative ABG, but not the MERI status were the only single predictors of success. Using a risk stratification model that is based on the size of the perforation, the preoperative ABG and MERI status, patients could be referred into two distinct groups of risk: the majority expecting excellent outcomes with maximum one risk factor present, and patients with deteriorated rate of success when having two or three risk factors.

CONCLUSIONS

Endoscopic type I. tympanoplasty with underlay perichondrium graft can be performed with good chance of success. However, if more than one risk factors are present, the chance of residual perforation becomes great. In addition to the established risk factors, our results point out that despite its strong correlation with perforation size, ABG may have a predictive role.

Effect of middle ear gelfoam on hearing and healing process after tympanoplasty: A prospective randomized case-control study

PURPOSE

This prospective randomized case-control study was performed to compare the surgical outcomes of our swing-door overlay tympanoplasty with or without absorbable gelatine sponge (AGS, gelfoam) packing in the middle ear cavity, according to the surgical procedure.

METHODS

Fifty-seven patients who underwent swing-door overlay tympanoplasty by a single surgeon were enrolled in the study. The data of 30 patients of the gelfoam-packing group (GPG) and 27 patients of the non-gelfoam-packing group (NGPG) were prospectively collected and compared.

RESULTS

Closure of the tympanic membrane was found to be successful in all patients at postoperative 3 months evaluation. NGPG showed a statistically better healing process compared to GPG; earlier epithelialization and less fascia edema in NGPG than in GPG (P < 0.05). The air-bone gap (ABG) measured at postoperative 1 and 2 months was smaller in NGPG than GPG, although there were no statistical differences.

CONCLUSION

This study revealed earlier healing process and faster recovery of ABG in NGPG, thereby indicating that the gelfoam in the middle ear may interfere with both hearing recovery and the healing process of neodrum.

Pediatric type 1 tympanoplasty - Does age matter?

INTRODUCTION

Tympanic membrane perforations might have a negative impact on the patient's quality of life, especially in the pediatric population. Surgery is therefore often required. The most adequate age for surgery remains unclear and is debated in the current literature. The aim of this study was to investigate outcomes of type I tympanoplasty in children and examine the impact of age on surgical outcome.

METHODS

Retrospective cohort study. All patients under the age of 18 undergoing type I tympanoplasty at Regional Hospital West Jutland, Denmark, from 1/1-2013 to 31/12-2017 had their medical files reviewed. The primary endpoint of interest was tympanic membrane closure rate six months following surgery, i.e. surgical success. Secondary outcomes were air-bone-gap reduction and the correlation between age and surgical success.

RESULTS

A total of 180 patients undergoing 197 procedures met the predefined criteria. Age at the time of surgery ranged between five and 17 years. Mean age at the time of surgery was 10.1 years (95% CI 9.1-11.2). Surgical success was achieved in 91,3% of the cases. No correlation between age and surgical success was found. Mean air-bone gap was reduced from 19.8 dB (95% CI 18.5-21.0) preoperatively, to 6.9 dB (95% CI 6.1-7.7) at follow-up, p < 0.05. Air-bone gaps ≤10 dB at follow-up were achieved in 155 of the cases (78.6%). Postoperative infection seemed to increase the risk of surgical failure, RR 2.80 ((95% CI 1.06-7.38), p = 0.037).

CONCLUSIONS

Type 1 tympanoplasty in children is an effective treatment in terms of achieving an intact tympanic membrane and improved hearing. No correlation could be found between age and surgical success. Postoperative infection influences surgical outcome negatively.

Myringoplasty without tympanomeatal flap elevation in children: A systematic review

OBJECTIVES

Systematic review of the literature on myringoplasty techniques without tympanomeatal flap elevation in children.

MATERIAL AND METHODS

A systematic review following PRISMA guidelines reported papers on patients under 18years of age undergoing myringoplasty for chronic tympanic perforation on a transcanal approach without tympanomeatal flap elevation. Tympanic closure rates and audiometric results were analyzed.

RESULTS

Twenty studies were included. Nine reported the butterfly technique, using a microscope or endoscope, with closure rate of 82.3% (246/299), for perforations of various sizes. Ten reported the fat-plug technique, with closure rate of 86.8% (869/1001), mostly for perforations of less than one-third of the tympanum. Both techniques improved audiometric results. Morbidity was very low. The absence of chronic otitis or co-morbidities (contralateral otitis media with effusion, craniofacial malformations, Down's syndrome) implies that patient selection technique may be necessary to obtain the best results.

CONCLUSION

Fat-plug myringoplasty, for small perforations, and butterfly cartilage myringoplasty seem to be reliable procedures in selected patients, with low morbidity in children.

Type I Tympanoplasty: surgical success and prognostic factors

OBJECTIVES

To evaluate success rate of type I tympanoplasty in adults and to investigate the importance of selected prognostic factors on graft uptake.

MATERIAL AND METHODS

Retrospective medical chart review of 155 patients who underwent Type I Tympanoplasty, in our department, from January 2013 to December 2017. Graft uptake rate was evaluated and the effects of prognostic factors on surgical outcome such as sex, smoking and otological surgery history, status of the contralateral ear, size and location of the perforation, middle ear mucosa status, surgical approach and graft material. Preoperative and postoperative audiometric data were collected, and the functional success was determined.

RESULTS

The overall surgical anatomical success rate was 75%. Analysis of the selected variables, identified as independent prognostic factors of anatomical unsuccess (95% CI): smoking (OR=3.29, p<.01), middle ear tympanosclerosis (OR=2.96; p=.04). Perforations above 50% of the tympanic membrane area had a borderline effect on graft uptake (p=.05). There was a significative improvement in the average air conduction thresholds of 7.44dB and an ABG closure rate at 10dB and 20dB was achieved in 47% and 84.5%, respectively. Patients who received temporalis fascia graft had similar hearing gain compared to patients who underwent cartilage tympanoplasty (7.7 vs. 7.3dB, p=.79).

CONCLUSION

Type I tympanoplasty is an effective and safe procedure with a high anatomical success rate in the treatment of mucosal COM. Poorer outcomes were found in patients with smoking habits, in those with tympanosclerosis of middle ear mucosa and in larger perforations. These prognostic factors should be considered in surgical planning and patients should be advised to quit smoking. Tympanoplasty with cartilage graft had a hearing outcome comparable to temporalis fascia graft and should be considered in high-risk patients.

State of the art regeneration of the tympanic membrane

PURPOSE OF REVIEW

One of the most common diseases of the tympanic membrane is a perforation, and tympanoplasty is one of the more common procedures in otolaryngology. Tympanic membrane regeneration and bioengineering aim to improve the success rate of the procedure, increase the availability of different scaffolds and provide innovative tools that will simplify the surgical technique and make it accessible for surgeons with varying expertise level. This review aims to raise awareness of current tissue engineering developments in tympanic membrane regeneration and how they may augment current clinical practices. We focus here on achievements in tympanic membrane cell cultures and on innovations in development of new scaffolds and growth factors that enhance regeneration of patient's native tympanic membranes.

RECENT FINDINGS

In recent years, great achievements were reached in the field of tympanic membrane regeneration in the three hallmarks of bioengineering: cells, scaffolds and bioactive molecules. New techniques for modeling normal tympanic membrane proliferation were developed, as well as for isolation and expansion of normal tympanic membrane keratinocytes from miniature samples of scarred tissue. Ongoing clinical trials aim to seal the perforation by applying different scaffolds infiltrated by growth factors on the tympanic membrane.

SUMMARY

Research efforts in tympanic membrane regeneration continue to seek the ideal single tissue-engineered substitute. Recent advances in tympanic membrane bioengineering include new types of scaffolds that may augment and provide a safe and effective alternative to the current gold-standard autograft. New bioactive molecules may simplify the surgical procedure and reduce surgical time by augmenting the native tympanic membrane regeneration. Several groups of bioengineering scientists and neurotologists are continuing to move forward and develop new strategies, seeking to create a fully functional tissue-engineered tympanic membrane.

En Hamac tympanoplasty and canalplasty for optimal type 1 tympanoplasty outcomes

OBJECTIVE

Multiple tympanoplasty techniques have been developed with numerous differences in grafting and approach. This study aimed to improve type 1 tympanoplasty outcomes by using the 'en hamac' technique as well as performing a complete canalplasty for anterior perforations.

METHOD

A retrospective review was performed using the prospective Otology-Neurotology Database tool for otological surgery. All primary type 1 tympanoplasty cases performed for tympanic membrane perforations from 2010 to 2016 were selected for analysis, all performed by one author. Minimal clinical and audiometric follow up was 18 months.

RESULTS

Tympanic membrane perforation closure was achieved in 62 of the patients (96.88 per cent). None of the en hamac cases had residual or recurrent perforation (p = 0.02). The mean remaining air-bone gap was 8.50 dB. The remaining air-bone gap was less than 10 dB in 72.55 per cent, 10-20 dB in 25.49 per cent and more than 20 dB in 1.96 per cent.

CONCLUSION

Using the en hamac technique for anterior perforations as well as systematically performing a complete canalplasty provides multiple surgical advantages with excellent post-operative results.

A comparative study of endoscopic cartilage myringoplasty used to treat wet and dry ears with mucosal-type chronic otitis media

OBJECTIVE

The outcomes of dry and wet ears were compared following endoscopic cartilage myringoplasty performed to treat chronic tympanic membrane perforations in patients with mucosal chronic otitis media.

METHODS

Patients with chronic perforations, and with mucosal chronic otitis media with or without discharge, were recruited; all underwent endoscopic cartilage myringoplasty. The graft success rate and hearing gain were evaluated at six months post-operatively.

RESULTS

The graft success rates were 85.9 per cent (67 out of 78) in dry ears and 86.2 per cent (25 out of 29) in wet ears; the difference was not significant (p = 0.583). Among the 29 wet ears, the graft success rates were 100 per cent in 11 ears with mucoid discharge and 77.8 per cent in the 18 patients with mucopurulent otorrhoea.

CONCLUSION

The wet or dry status of ears in patients with chronic perforations with mucosal chronic otitis media did not affect graft success rate or hearing gain after endoscopic cartilage myringoplasty. However, ears with mucopurulent discharge were associated with increased failure rates and graft collapse, whereas ears with mucoid discharge were associated with higher graft success rates.

A novel mouse model of chronic suppurative otitis media and its use in preclinical antibiotic evaluation

Chronic suppurative otitis media (CSOM) is a neglected pediatric disease affecting 330 million worldwide for which no new drugs have been introduced for over a decade. We developed a mouse model with utility in preclinical drug evaluation and antimicrobial discovery. Our model used immune-competent mice, tympanic membrane perforation and inoculation with luminescent Pseudomonas aeruginosa that enabled bacterial abundance tracking in real-time for 100 days. The resulting chronic infection exhibited hallmark features of clinical CSOM, including inhibition of tympanic membrane healing and purulent ear discharge. We evaluated the standard care fluoroquinolone ofloxacin and demonstrated that this therapy resulted in a temporary reduction of bacterial burden. These data are consistent with the clinical problem of persistent infection in CSOM and the need for therapeutic outcome measures that assess eradication post-therapeutic endpoint. We conclude that this novel mouse model of CSOM has value in investigating new potential therapies.

A Systematic Review of Nonautologous Graft Materials Used in Human Tympanoplasty

OBJECTIVES

Nonautologous graft materials may solve several dilemmas in tympanoplasty by obviating the need for graft harvest, facilitating consistent wound healing, and permitting graft placement in the clinical setting. Prior studies of nonautologous grafts in humans have shown variable outcomes. In this systematic review, we aim to 1) summarize clinical outcomes and 2) discuss limitations in the literature regarding nonautologous grafts for tympanoplasty in humans.

METHODS

A literature review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. The study size, etiology and duration of perforation, type of nonautologous graft, and postoperative closure rate were assessed.

RESULTS

The PRISMA approach yielded 61 articles, including 3,247 ears that met inclusion criteria. Studies evaluated nonautologous grafts including paper patch, gelatin sponge, growth factors, porcine small-intestinal submucosa, among others. Traumatic perforations (62.3%) were most commonly studied, whereas postinfectious perforations (31.9%) and other etiologies (5.8%) comprised a minority of cases. Acute perforations of <8 weeks duration constituted just over half of all treated ears. Overall closure rate was 82.1%, with significantly higher closure rates in acute (89.9%) versus chronic perforations (64.9%, P < .01), regardless of material. A median postoperative air-bone gap of 5.6 dB was found in the 23% of studies reporting this metric.

CONCLUSIONS

The majority of publications reviewing nonautologous materials in tympanoplasty evaluate acute or traumatic perforations, and few rigorously report hearing outcomes. Given available data, porcine submucosa and basic fibroblast growth factor may hold promise for chronic perforation closure. Future studies should report closure rates and hearing outcomes in perforations >8 weeks duration. Laryngoscope, 131:392-400, 2021.

The evaluation of prognostic factors in endoscopic cartilage tympanoplasty

PURPOSE

The aim of the present study was to evaluate the prognostic factors that may affect the success in endoscopic cartilage tympanoplasty and determine the outcomes of endoscopic cartilage tympanoplasty.

METHODS

This study included 312 patients who underwent transcanal endoscopic type I cartilage tympanoplasty. The effects of sex, the affected side, the size of the perforation, the location of the perforation, the absence of myringosclerosis, external ear canal protrusion, the condition of the contralateral ear, and surgical experience on the rate of graft success and hearing improvement were investigated.

RESULTS

The affected side, sex, location of the perforation, myringosclerosis, the condition of contralateral ear, and surgical experience did not significantly affect the surgical success (p > 0.05). However, the size of perforation and ear canal wall protrusion were significantly related to both functional and anatomical success (p < 0.05).

CONCLUSION

Endoscopic transcanal type I cartilage tympanoplasty can be performed with a high anatomical and functional success rate. However, surgeons should be more careful and design a case-specific operation strategy in patients with external ear canal anterior wall protrusion and large perforations.

Tympanoplasty: factors associated with anatomical and audiometric results

INTRODUCTION

Tympanoplasty is a frequent surgery in otolaryngology. Its main indication is tympanic perforation, followed by adhesive otopathy. Its main and (or) anatomic objective is to restore the tympanic membrane's integrity, preventing infections, and its secondary or audiometric objective is to preserve or improve hearing.

MATERIAL AND METHOD

Retrospective study of all patients submitted to tympanoplasty at our hospital. Biodemographic, ear pathology and surgery characteristics were registered, and anatomic and audiometric success rates were analyzed.

RESULTS

A total of 182 patients were included, most female (57.1%), with average age of 36.1 years. The main surgical indication was tympanic perforation (89.0%), followed by adhesive otopathy (7.1%). Most tympanoplasties were primary surgeries (84.1%), type I (62.6%), performed by endoaural approach (83.5%) using medial or Austin technique (90.1%). Compound cartilage-perichondrium grafts were most frequently used (87.9%). The anatomic success rate was 84.6%, and the audiometric success rate was 66.8%. Patients who underwent myringoplasty (without raising of tympanomeatal flap) presented a better audiometric result (p=.003). No factors associated with better anatomical results were identified.

CONCLUSIONS

Our anatomic and audiometric results are comparable to those previously published. Further prospective studies are required to define factors associated with improved anatomic and audiometric results.

Impact of perforation size and predictive factors for successful pediatric gelfoam myringoplasty

OBJECTIVES

Rates of success with pediatric myringoplasty range from 35 to 95%. The objective of this study is to evaluate the impact of perforation size on successful closure of the tympanic membrane (TM) after gelfoam myringoplasty. We also aim to identify variables that affect perforation closure rates and define predictive factors for successful TM closure.

METHODS

A retrospective chart review of all patients that underwent gelfoam myringoplasty by a single surgeon from August 2008 through January 2015 was performed.

RESULTS

One hundred fifty-nine patients met inclusion criteria and underwent a total of 219 procedures. Overall, gelfoam myringoplasty had an 83.1% rate of successful closure. Average perforation size was 15.31%. Classification tree analysis separated our cohort into three groups based on perforation size: Group 1 (<16.25%) had a 91% closure rate, group 2 (16.25% to <31.25%) had a 66.0% closure rate and group 3 (≥31.25%) had a 30.0% closure rate. Smaller perforations (P ≤0.001) were associated with increased success rates. Other factors associated with successful closure of the TM included younger age at the time of myringoplasty (P ≤0.001), fewer number of prior tympanostomy tubes (P = 0.016), and lesser duration of tube retention (P = 0.003).

CONCLUSION

Gelfoam myringoplasty provides good overall TM closure rates and may be considered as a potential first-line option for repair of perforations, including those involving up to 40% of the TM. Younger patients with smaller perforations, fewer sets of tubes, shorter length of tube retention are more likely to have successful closure of the tympanic membrane.

Transcanal Endoscopic Type 1 Cartilage Tympanoplasty in Children

Objective

Transcanal endoscopic type 1 tympanoplasty is a minimally invasive procedure that enables better visualization of deep and narrow spaces compared to conventional microscopic methods. In our study, we aimed to evaluate air-bone gap difference, graft success, and hearing gain according to the perforation size and location in pediatric patients who underwent transcanal endoscopic type 1 cartilage tympanoplasty.

Methods

Fifty pediatric patients who underwent transcanal endoscopic type 1 cartilage tympanoplasty for chronic otitis media were included in the study. Tragal cartilage grafts were used in all patients. Air conduction pure tone audiometry hearing results (500, 1000, 2000, and 4000 Hz), mean air-bone gap levels, operating times, postoperative gap closure, and graft success rates were evaluated.

Results

Mean operating time was 43.34±8.56 minutes. Overall graft success was 94% (47/50). Mean hearing levels at all frequencies (500, 1000, 2000, and 4000 Hz) were found to have significantly improved after the operation (p<0.001). Mean preoperative air conduction pure tone threshold and mean air-bone gap had statistically significantly improved by the 6th postoperative month (p<0.001).

Conclusion

Transcanal endoscopic type 1 cartilage tympanoplasty was found to be a minimally traumatic, easy and safe method with a low complication rate. In pediatric patients, this method allows for high rates of anatomic and functional recovery with optimal surgery time regardless of the location and the size of the perforation.

The Effect of Nitrous Oxide on the Outcomes of Underlay Tympanoplasty: A Prospective Study

The main aims of tympanoplasty are eradication of chronic middle ear disease, repair of the tympanic membrane, and restoration of hearing. Nitrous oxide (N₂O) is not a commonly preferred anesthetic agent for tympanoplasty because this agent may increase middle ear pressure and displace the graft. In this study, we researched the surgical outcomes of the underlay tympanoplasty performed with N₂O anesthesia. Patients who underwent tympanoplasty were included in this prospective study. A type 1 tympanoplasty was performed in all patients using the underlay technique. Patients were randomized to groups that did and did not receive N₂O. Preoperative and postoperative hearing thresholds were evaluated, postoperative pain scores were recorded, and the differences between the groups were statistically evaluated. There were 44 patients who received N₂O and 44 who did not. The graft success rate was 93.2% in the N₂O-receiving group and 84.1% in the nonreceiving group (P > .05). Hearing levels improved significantly after surgery in each group (P < .05), but the difference between the groups was not significant (P > .05). The postoperative pain score was 3.72 ± 1.3 in the N₂O-receiving group and 4.45 ± 2.3 in the nonreceiving group (P > .05). Nitrous oxide is a cheap, safe, and readily available anesthetic agent that provides acceptable success rates in patients undergoing tympanoplasty.

Pars tensa and tympanicomalleal joint: proposal for a new anatomic classification

PURPOSE

The tympanic membrane (TM) belongs to the ear. Despite its place in the ear anatomy, can we give it also a different anatomic classification? The main objective is to clarify the nature of TM, tympanic bone and malleus to propose a new anatomic classification.

METHODS

This cadaveric study was performed in two human heads and six fresh temporal bones. A study of the temporomandibular joint, external acoustic meatus (EAM), TM and middle ear structures was conducted. A medical literature review englobing anatomy, embryology, histology and phylogeny of the ear was performed and the results were compared with the results of the dissection.

RESULTS

The external ear is constituted by the auricle and the EAM. This last segment is made by a cartilaginous and an osseous portion. The osseous portion of the EAM is constituted mainly by tympanic bone. The external ear is separated from the middle ear by the TM. Inside the middle ear, there are three ossicles: malleus, incus and stapes, which allow the conduction of sound to the cochlea. Based on the anatomic dissection and medical literature review of the tympanic bone, malleus and TM, we propose that these structures are interconnected like a joint, and named it "Tympanicomalleal joint".

CONCLUSIONS

It seems that the TM can be part of a joint that evolved to improve sound transmission and middle ear protection. Thinking TM has part of a joint may help in the development of more efficient reconstructive surgical techniques.

Preventative and medical treatment of ear disease in remote or resource-constrained environments

BACKGROUND

Important ear problems can affect the outer ear, the middle ear and the inner ear. Globally, the greatest burden of disease is due to ear conditions that are associated with otorrhoea and hearing loss.

METHODS

This study reviewed the literature on the prevention and treatment of common ear conditions that are most relevant to settings with high rates of ear disease and limited resources. The grading of recommendations assessment, development and evaluation ('GRADE') approach was utilised to assess interventions.

RESULTS

Accurate diagnosis of ear disease is challenging. Much of the preventable burden of ear disease is associated with otitis media. Nine otitis media interventions for which there is moderate to high certainty of effect were identified. While most interventions only provide modest benefit, the impact of treatment is more substantial in children with acute otitis media with perforation and chronic suppurative otitis media.

CONCLUSION

Disease prevention through good hygiene practices, breastfeeding, reducing smoke exposure, immunisation and limiting noise exposure is recommended. Children with acute otitis media with perforation, chronic suppurative otitis media, complications of otitis media, and significant hearing loss should be prioritised for medical treatment.

Can Endoscopic Tympanoplasty Be a Good Alternative to Microscopic Tympanoplasty? A Systematic Review and Meta-Analysis

Although efficacies and proportions of tympanoplasty performed via endoscopic ear surgery (EES) have gradually introduced, it remains unclear whether total EES is a good alternative to microscopic ear surgery (MES). Herein, we aimed to compare therapeutic effects of EES and MES in patients receiving tympanoplasty or myringoplasty. A search of MEDLINE, PubMed, and Embase databases was conducted to compare the efficacies of EES and MES. Two investigators independently reviewed all studies and extracted data with a standardized form. We assessed risk of bias and calculated pooled odds ratio (OR) estimates with a 95% confidence interval (CI). Thirteen studies (607 EES patients and 678 MES patients) met inclusion criteria for quantitative meta-analysis. In pooled analysis, those who undergo EES have 0.99 times the OR of graft success compared to those with MES (95% CI, 0.84 to 1.16; P=0.894). In qualitative analysis, comparable hearing improvement was observed between the two groups, despite inconsistent audiometric evaluation. The air-bone gaps (ABGs) improved 2.02 dB less in EES than in MES (mean difference of improvements of ABGs, 2.02; 95% CI, –3.84 to –0.20; P=0.029); however, substantial heterogeneity and publication bias limited the integrity of this analysis. Further, EES significantly decreased canalplasty rate, wound complications, and operation time, compared to MES. Moreover, patients receiving EES reported higher cosmetic satisfaction than patients receiving MES. EES can be a good alternative to MES in terms of comparable graft success rate and hearing outcomes in patients receiving tympanoplasty or myringoplasty. Moreover, EES was less invasive, resulting in higher cosmetic satisfaction, reduced morbidity, and shorter operation time. Our results may affect decision-making and outcome prediction in cases of EES; however, confirmation is needed to clarify potential bias.

Topical platelet rich plasma versus hyaluronic acid during fat graft myringoplasty

OBJECTIVES

To evaluate the effect of adding platelet rich plasma (PRP) or Hyaluronic acid (HA) to fat graft myringoplasty (FGM) for medium sized central tympanic membrane (TM) perforations.

METHODS

This is a retrospective study conducted on 69 patients with medium sized central TM perforations. In 21 patients, PRP was used with the FGM; and in 23 patients, HA was used with the FGM; while in 25 patients, pure FGM was performed without adding an enhancing material.

RESULTS

Successful TM perforation repair was achieved in 18 ears (85.7) with using PRP with FGM and in 20 ears (87%) with using HA with FGM and in 15 ears (60%) with pure FGM.

CONCLUSION

FGM with adding PRP or HA is more successful in closure of TM perforation than pure FGM in case of medium sized central TM perforation.

Platelet-Rich Plasma Fat Graft versus Cartilage Perichondrium for Repair of Medium-Size Tympanic Membrane Perforations

OBJECTIVES

To compare clinical and audiologic outcomes among patients who underwent myringoplasty with fat graft enriched with platelet-rich plasma and cartilage perichondrium graft.

STUDY DESIGN

Prospective randomized controlled study.

SETTING

Department of Otolaryngology-Head and Neck Surgery, Tanta University, Egypt.

SUBJECTS AND METHODS

The study comprised 50 patients who had tympanic membrane perforation of medium size (25%-50% of its surface area) without evidence of active otitis media or ossicular abnormalities and who had surgery between December 2016 and December 2017. Patients randomly underwent myringoplasty with fat graft enriched with platelet-rich plasma (group 1) or cartilage perichondrium graft (group 2).

RESULTS

Twenty-five patients were included in each group. Rates of successful closure at 3-month follow-up were 88% (group 1) and 92% (group 2). The mean overall improvement in pure tone average was 18.08 dB (95% CI, 16.9-19.25) for group 1 and 18.24 dB (95% CI, 16.94-19.53) for group 2.

CONCLUSION

Fat graft enriched with platelet-rich plasma can be recommended as an alternative choice for first-line treatment of medium-size central perforations of the tympanic membrane, with healing and hearing results comparable to those of conventional cartilage perichondrium myringoplasty.

Butterfly cartilage tympanoplasty outcomes: A single-institution experience and literature review

PURPOSE

In 1998, Dr. Eavey described the trans-canal inlay butterfly cartilage tympanoplasty technique, also known as cartilage button tympanoplasty. Many retrospective studies have since demonstrated its efficacy and decreased operative time when compared to underlay and overlay tympanoplasty techniques. The butterfly cartilage tympanoplasty approach uses only a cartilage graft to repair tympanic membrane perforations. The aim of this study was to review the literature for studies that examined butterfly cartilage tympanoplasty success rates and outcomes and compare them to outcomes from our cohort.

MATERIALS AND METHODS

Butterfly cartilage tympanoplasties were performed in 23 pediatric patients and 7 adult patients. We evaluated the tympanic membrane perforation closure rate and hearing results measured by closure of the air-bone gap.

RESULTS

The reviewed studies evaluating butterfly cartilage tympanoplasties demonstrated perforation closure rates between 71%-100%. The hearing outcomes in the reviewed literature varied, although the majority reported improved hearing. In our cohort, 21 of the 32 repaired tympanic membrane perforations demonstrated complete perforation closure. The mean follow-up length was 13.4 months. The mean air-bone gap decreased from 13.4 dB to 6.9 dB.

CONCLUSIONS

The butterfly cartilage/cartilage button technique is effective in closing tympanic membrane perforations and decreasing the air-bone gap in both adults and children.

Otopathologic evaluation of temporalis fascia grafts following successful tympanoplasty in humans

OBJECTIVE

Temporalis fascia is a commonly used graft material in tympanoplasty; however, little is known about how the histological structure of fascia remodels postimplantation. Herein, we aim to quantify the pre- and postoperative microstructure of temporalis fascia and compare histological findings to the native tympanic membrane (TM).

METHODS

Temporal bone specimens having undergone successful subtotal or total drum replacement using temporalis fascia were identified (n = 3). Surgically prepared preimplantation temporalis fascia (PreTF, n = 4) and normal TMs (n = 5) were used as controls. Multiple measurements of thickness of PreTF and of normal and fascia reconstructed TMs at the mesotympanum and hypotympanum were obtained. Collagen fiber patterns of normal and reconstructed TMs were histologically described.

RESULTS

In cases of fascia tympanoplasty, the mean time of surgery to death was 16 years (range 8-28 years). All cases contained an aerated middle ear without residual perforation. There was no significant difference between the thickness of PreTF and fascia of reconstructed TMs (234.9 ± 144.9 μm vs. 162.9 ± 71.9 μm, P = 0.1). The lamina propria and total thicknesses of controls (59.8 ± 39.3 μm and 83.7 ± 42.4 μm, respectively) were thinner than the PreTF and fascia-reconstructed TMs, respectively, in all cases (P ≤ 0.001, P ≤ 0.001). Reconstructed TMs contained a thick, longitudinal fiber structure that was qualitatively similar to PreTF.

CONCLUSION

Based on human temporal bone specimens, temporalis fascia does not significantly remodel, change thickness, or change fibrous structure following successful tympanoplasty. Results have implications for selection and surgical preparation of graft materials in TM reconstruction.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:E351-E358, 2018.

A moist edge environment aids the regeneration of traumatic tympanic membrane perforations

OBJECTIVE

To review the history of moist therapy used to regenerate traumatic tympanic membrane perforations.

STUDY DESIGN

Literature review.

METHODS

The literature on topical agents used to treat traumatic tympanic membrane perforations was reviewed, and the advantages and disadvantages of moist therapy were analysed.

RESULTS

A total of 76 studies were included in the analysis. Topical applications of certain agents (e.g. growth factors, Ofloxacin Otic Solution, and insulin solutions) to the moist edges of traumatic tympanic membrane perforations shortened closure times and improved closure rates.

CONCLUSION

Dry tympanic membrane perforation edges may be associated with crust formation and centrifugal migration, delaying perforation closure. On the contrary, moist edges inhibit necrosis at the perforation margins, stimulate proliferation of granulation tissue and aid eardrum healing. Thus, moist perforation margins upon topical application of solutions of appropriate agents aid the regeneration of traumatic tympanic membrane perforations.

Outcomes of type I tympanoplasty using a cartilage shield graft in patients with poor prognostic factors

OBJECTIVE

Although fascia is widely used as the grafting material in tympanoplasty (TP), unsatisfactory outcomes can result in patients with poor prognostic factors. Recently, cartilage has emerged as a graft material in TP. This study examined the operative outcomes of type I TP using a cartilage shield graft (CSG) in patients with poor prognostic factors.

METHODS

This study reviewed the medical records of patients who underwent type I TP using CSG performed by the same surgeon, with over 24 months of follow-up.

RESULTS

There were 94 patients (mean age 46 years). Preoperatively, 39 patients had near-total perforation, 29 had a previous TP or myringoplasty, 14 had adhesive otitis media, and 12 had a marginal perforation covering ≥50% of the tympanic membrane area. The mean postoperative air-bone gap was significantly (p<0.0001) reduced compared to preoperative measurements. Postoperatively, tympanic membrane perforation occurred in 2.1% and otorrhea in 6.4%. There were no cases of retraction, adhesion, or lateralization. One subject complained of autophonia and ear fullness.

CONCLUSION

Type I TP using CSG has excellent surgical results and minimal complications, even in patients with poor prognostic factors, and should thus be considered in those patients.

Comparative acoustic performance and mechanical properties of silk membranes for the repair of chronic tympanic membrane perforations

The acoustic and mechanical properties of silk membranes of different thicknesses were tested to determine their suitability as a repair material for tympanic membrane perforations. Membranes of different thickness (10-100μm) were tested to determine their frequency response and their resistance to pressure loads in a simulated ear canal model. Their mechanical rigidity to pressure loads was confirmed by tensile testing. These membranes were tested alongside animal cartilage, currently the strongest available myringoplasty graft as well as paper, which is commonly used for simpler procedures. Silk membranes showed resonant frequencies within the human hearing range and a higher vibrational amplitude than cartilage, suggesting that silk may offer good acoustic energy transfer characteristics. Silk membranes were also highly resistant to simulated pressure changes in the middle ear, suggesting they can resist retraction, a common cause of graft failure resulting from chronic negative pressures in the middle ear. Part of this strength can be explained by the substantially higher modulus of silk films compared with cartilage. This allows for the production of films that are much thinner than cartilage, with superior acoustic properties, but that still provide the same level of mechanical support as thicker cartilage. Together, these in vitro results suggest that silk membranes may provide good hearing outcomes while offering similar levels of mechanical support to the reconstructed middle ear.