Is office-based myringoplasty a suitable alternative to surgical tympanoplasty?

Tunable ciprofloxacin delivery through personalized electrospun patches for tympanic membrane perforations

Approximately 740 million symptomatic patients are affected by otitis media every year. Being an inflammatory disease affecting the middle ear, it is one of the primary causes of tympanic membrane (TM) perforations, often resulting in impaired hearing abilities. Antibiotic therapy using broad-spectrum fluoroquinolones, such as ciprofloxacin (CIP), is frequently employed and considered the optimal route to treat otitis media. However, patients often get exposed to high dosages to compensate for the low drug concentration reaching the affected site. Therefore, this study aims to integrate tissue engineering with drug delivery strategies to create biomimetic scaffolds promoting TM regeneration while facilitating a localized release of CIP. Distinct electrospinning (ES) modalities were designed in this regard either by blending CIP into the polymer ES solution or by incorporating nanoparticles-based co-ES/electrospraying. The combination of these modalities was investigated as well. A broad range of release kinetic profiles was achieved from the fabricated scaffolds, thereby offering a wide spectrum of antibiotic concentrations that could serve patients with diverse therapeutic needs. Furthermore, the incorporation of CIP into the TM patches demonstrated a favorable influence on their resultant mechanical properties. Biological studies performed with human mesenchymal stromal cells confirmed the absence of any cytotoxic or anti-proliferative effects from the released antibiotic. Finally, antibacterial assays validated the efficacy of CIP-loaded scaffolds in suppressing bacterial infections, highlighting their promising relevance for TM applications.

Local Anesthesia-Based Modified Cartilage "Inlay" Graft Myringoplasty for Repairing Large Perforation

OBJECTIVE

The objective of this study was to evaluate the graft success rate and hearing outcome of modified cartilage inlay graft technique for repairing large perforations under local anesthesia.

STUDY DESIGN

Prospective case series.

METHODS AND MATERIALS

We performed a prospective study in 31 patients with large perforations who underwent endoscopic local anesthesia-based modified cartilage inlay graft technique with no raising of the squamous epithelium and no rimming of the perforation margins. The graft outcomes and complications were evaluated at 6 and 24 months postoperatively.

RESULTS

Thirty-one patients (31 ears) were included in this study. The mean operation time was 42.3 ± 2.6 (ranged 36-51) minutes. The visual analog scale pain scores at intraoperative and 2 and 48 hours postoperatively were, respectively, 2.6 ± 0.6, 1.4 ± 0.2, and 0.6 ± 0.1. The graft success rate was 100.0% (31/31) at 6 months after surgery. However, only 25 (80.6%, 25/31) patients completed a 2-year follow-up and performed a temporal bone CT examination; re-perforation was seen in 2 patients, the graft success rate was 92.0% (23/25). CT revealed the well-developed pneumatization of the mastoids and middle ear in all the patients. Nevertheless, 1 (1/25, 8.0%) patient developed a graft epithelial inclusion cyst, which was removed by endoscope in the outpatient setting. The mean preoperative air bone gap (ABG) was 23.1 ± 4.3 dB, while the mean postoperative ABG after 6 months was 14.9 ± 2.6 dB; the difference between these values was significant (P < .05; Wilcoxon's signed-rank test), and the functional success rate was 93.5% (29/31).

CONCLUSION

Endoscopic modified cartilage "inlay" graft technique with no raising the squamous epithelium and no rimming the perforation is a minimally invasive technique with a short operative time and satisfying success rate for closure of large perforations under local anesthesia.

Perichondrium-Cartilage Inlay Butterfly Myringoplasty: An Office-Based Procedure for Closing Small- to Medium-Sized Tympanic Membrane Perforations

Objective: The objective of this study was to assess the graft and functional outcomes of inlay butterfly cartilage-perichondrium graft myringoplasty in an office setting. Material and Methods: Adult patients with chronic perforations underwent inlay butterfly cartilage-perichondrium graft myringoplasty under local and topical anesthesia. The graft and functional outcomes, intraoperative pain score, and complications were evaluated at 6 months postoperatively. Results: A total of 39 patients (39 ears) were included in this study. All patients completed 6 months of follow-up. The mean operation time was 26.5 ± 3.2 (ranged from 21 to 32) minutes. The intraoperative mean pain score was 0.61 ± 0.28. The graft success rate was 97.4% (38/39) at 6 months postoperatively. The mean preoperative air-bone gap (ABG) was 19.18 ± 4.01 dB, while the mean postoperative ABG at 6 months was 10.56 ± 2.27 dB (P < .05; Paired-Samples T Test). The functional success rate was 100.0% (38/38). Endoscopic examination showed that the transplanted perichondrium graft gradually atrophied, flattened, and became indistinguishable from the surrounding tympanic membrane 2 to 3 months following surgery, the superficial layer of perichondrium graft formed the crust and migrated into the external auditory canal at 3 to 6 months postoperatively. Conclusions: Perichondrium-cartilage inlay butterfly myringoplasty is a highly successful and minimally invasive procedure well tolerated by adults for closure of small- and medium-sized perforations in an office setting.

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.

The Long-Term Stability of Fat-Graft Myringoplasty in the Closure of Tympanic Membrane Perforations and Hearing Restoration

BACKGROUND/AIMS

This study was conducted to evaluate the long-term stability of fat-graft myringoplasty (FGM) for chronic tympanic membrane perforations, analyzing the perforation closure rate and re-gained hearing outcome with respect to the size and location of the perforations.

METHODS

Between August 2007 and June 2018, a total of 193 patients who underwent FGM due to chronic tympanic membrane perforation at a tertiary referral center were enrolled and analyzed.

RESULTS

The mean follow-up was 14.6 months (range 6-39). The complete perforation closure rate after FGM was 89.6%, with no statistical difference among the perforation size groups. The mean postoperative air-bone gap (ABG) was 11.0 dB and mean ABG improvement was 4.9 dB.

CONCLUSION

Our FGM technique had a favorable tympanic closure rate for small to large perforations, and yielded relatively good hearing improvement in the mid-size perforation cases over long-term follow-up periods. According to the topographic evaluation of FGM, this procedure resulted in a reliable perforation closure rate and audiological results regardless of the perforation site.

What is the Role of Hyaluronic Acid Ester in Myringoplasty? Systematic Review and Meta-Analysis

OBJECTIVE

To reveal odds of tympanic membrane closure and postoperative hearing outcomes for myringoplasty utilizing hyaluronic acid ester via systematic review and meta-analysis.

DATA SOURCES

1) Search of English articles in PubMed/Medline, Embase, and Cochrane databases published between January 1, 1998 and March 31, 2018.

STUDY SELECTION

Inclusion criteria: 1) English language; 2) clinical studies; 3) reported posttreatment perforation status, hearing outcomes, or complications.

EXCLUSION CRITERIA

hyaluronic acid used for middle ear packing or topical application of hyaluronic acid solution.

DATA EXTRACTION

Number of patients, surgical technique, mean age, overall rate of tympanic membrane closure, success rate based on size of perforation, mean air-bone gap improvement, and postoperative speech scores and complications.

DATA SYNTHESIS

Ten studies encompassing 531 patients met criteria. Reported success rates for closure of chronic perforation ranged from 70.0 to 92.7% (mean, 85.21%). Smaller perforation predicted success in complete closure. Mean air-bone gap closure was 10.6 dB (4-24 dB). There were five complications reported. Meta-analysis was performed on five studies. No difference was noted in the success rates between hyaluronic acid ester myringoplasty and conventional tympanoplasty using fascia or perichondrium, with an overall closure rates of 89.8 and 89.4%, respectively (odds ratio [OR] 1.04, 95% confidence interval [CI] 0.59-1.82, p = 0.896). A higher closure rate was seen in hyaluronic acid ester myringoplasty (87.9%) when compared with fat graft myringoplasty (70.8%), (OR 3.01, 95% CI 1.42-6.35, p = 0.004).

CONCLUSIONS

Hyaluronic acid (HA) ester myringoplasty appears to be safe and effective at attaining complete closure of tympanic membrane perforation, although there exists significant selection bias and inconsistent reporting among existing papers.

Clinical and economic evaluation of minimally invasive cartilaginous palisade myringoplasty

OBJECTIVES

To test the clinical and audiometric efficacy of a minimally invasive myringoplasty technique, combining cartilaginous palisades while avoiding flap elevation, for small and wide perforations.

METHODS

Over 4 years, this retrospective study included all patients over 6 years of age presenting an indication for myringoplasty. Several clinical and economic criteria were noted at 7 d, 2 months, 6 months and 2 years postoperative. The main outcome was the absence of perforation 2 years postoperative. The secondary outcomes were an audiometric gain at 6 months and the evaluation of the treatment cost.

RESULTS

Thirty patients underwent the minimally invasive technique and 28 patients the technique with an elevation of the tympanomeatal flap. The minimally invasive surgical procedure was shorter (p = .001). At 2 years, the tympanic closure rate was equivalent (95% versus 89.5%, p = .77). The audiometric gain was similar between the two techniques (p = .09). From a medico-economic point of view, the minimally invasive procedure was the most effective because it was three times less expensive than the conventional technique with no reduction in efficacy (p = .02).

CONCLUSION

This quick and easy technique could be developed in an ambulatory setting or even in conditions adapted to consultation.

No systemic exposure of transtympanic heparin-binding epidermal growth factor like growth factor

CONTEXT

Heparin-binding epidermal growth factor like growth factor (HB-EGF) is an emerging therapeutic for the regeneration of the tympanic membrane (TM).

OBJECTIVE

Our aim was to determine whether the doses of HB-EGF delivered in a sustained release hydrogel into a middle ear mouse model, would be measurable in the systemic circulation. We also aimed to observe, in the scenario that the intended dose was absorbed directly into the circulation, whether these levels could be measured above the background levels of HB-EGF in the circulation.

METHODS

A total of 12 mice had transtympanic injections of 5 μg/ml of HB-EGF contained within a previously described novel hydrogel vehicle, while another 12 mice had intravenous delivery of 10 μg/kg of HB-EGF. Intravenous blood samples were collected at 0-, 3-, 24-, 168-, 288- and 720-h post-injection. A double-antibody sandwich one-step process enzyme-linked immunosorbent assay (ELISA) was used to determine the level of HB-EGF in the serum.

RESULTS

No mice in the transtympanic administration group and no mice in the intravenous administration group were found to have blood level measured above that in the controls.

DISCUSSION

The inability of the positive control to measure levels above background, suggest the total dose used in our studies, even if 100% absorbed into the system circulation is insignificant.

CONCLUSIONS

HB-EGF at the doses and delivery method proposed for treatment of chronic TM perforation in a mouse model are likely to have no measurable systemic effect.

Heparin Binding Epidermal Growth Factor-Like Growth Factor Heals Chronic Tympanic Membrane Perforations With Advantage Over Fibroblast Growth Factor 2 and Epidermal Growth Factor in an Animal Model

HYPOTHESIS

That heparin binding epidermal growth factor-like growth factor (HB-EGF) heals chronic tympanic membrane (TM) perforations at higher rates than fibroblast growth factor 2 (FGF2) and epidermal growth factor (EGF) in an animal model.

BACKGROUND

A nonsurgical treatment for chronic TM perforation would benefit those unable to access surgery or those unable to have surgery, as well as reducing the cost of tympanoplasty. Growth factor (GF) treatments have been reported in the literature with variable success with the lack of a suitable animal providing a major obstacle.

METHODS

The GFs were tested in a validated mouse model of chronic TM perforation. A bioabsorbable hydrogel polymer was used to deliver the GF at a steady concentration as it dissolved over 4 weeks. A control (polymer only, n = 18) was compared to polymer loaded with HB-EGF (5 μg/ml, n = 18), FGF2 (100 μg/ml, n = 19), and EGF (250 μg/ml, n = 19). Perforations were inspected at 4 weeks.

RESULTS

The healing rates, as defined as 100% perforation closure, were control (5/18, 27.8%), HB-EGF (15/18, 83.3%), FGF2 (6/19, 31.6%), and EGF (3/19, 15.8%). There were no differences between FGF2 (p = 0.80) and EGF (p = 0.31) with control healing rates. HB-EGF (p = 0.000001) showed a significant difference for healing. The HB-EGF healed TMs showed layers similar to a normal TM, whereas the other groups showed a lack of epithelial migration.

CONCLUSION

This study confirms the advantage of HB-EGF over two other commonly used growth factors and is a promising nonsurgical treatment of chronic TM perforations.

Heparin binding-epidermal growth factor-like growth factor for the regeneration of chronic tympanic membrane perforations in mice

We aim to explore the role of epidermal growth factor (EGF) ligand shedding in tympanic membrane wound healing and to investigate the translation of its modulation in tissue engineering of chronic tympanic membrane perforations. Chronic suppurative otitis media (CSOM) is an infected chronic tympanic membrane perforation. Up to 200 million suffer from its associated hearing loss and it is the most common cause of pediatric hearing loss in developing countries. There is a need for nonsurgical treatment due to a worldwide lack of resources. In this study, we show that EGF ligand shedding is essential for tympanic membrane healing as it's inhibition, with KB-R7785, leads to chronic perforation in 87.9% (n=58) compared with 0% (n=20) of controls. We then show that heparin binding-EGF-like growth factor (5 μg/mL), which acts to shed EGF ligands, can regenerate chronic perforations in mouse models with 92% (22 of 24) compared with 38% (10 of 26), also with eustachian tube occlusion with 94% (18 of 19) compared with 9% (2 of 23) and with CSOM 100% (16 of 16) compared with 41% (7 of 17). We also show the nonototoxicity of this treatment and its hydrogel delivery vehicle. This provides preliminary data for a clinical trial where it could be delivered by nonspecialist trained healthcare workers and fulfill the clinical need for a nonsurgical treatment for chronic tympanic membrane perforation and CSOM.