Clinical Profile of Tubotympanic CSOM and Its Management With Special Reference to Site and Size of Tympanic Membrane Perforation, Eustachian Tube Function and Three Flap Tympanoplasty

Comparative Efficacy of Different Therapeutic Interventions in Eustachian Tube Dysfunctions: A Cross-Sectional Analysis

Eustachian tube dysfunction (ETD) affects a significant portion of the population, manifesting symptoms that impact the quality of life. Despite the prevalence of ETD, there remains a notable gap in comprehensive studies exploring the condition's dynamics within specific demographic contexts, particularly within Saudi Arabia. This study aimed to assess the prevalence and severity of ETD across different demographic groups, to evaluate the efficacy of various treatment modalities, and to identify key predictors of treatment response in a Saudi Arabian cohort. A cross-sectional study was conducted from June 2022 to May 2023 in tertiary care hospitals in the Aseer region, Saudi Arabia. Participants included adults diagnosed with ETD, assessed through clinical symptoms, otoscopic examinations, audiometric evaluations, tympanometry, and the ETDQ-7 questionnaire. The study incorporated advanced diagnostics such as nasopharyngoscopy and pressure equalization tube function tests and involved 154 participants, revealing significant variations in ETD severity, with the 46-60 age group exhibiting the highest mean ETDQ-7 score of 4.85, and urban residents displaying lower severity scores compared to rural counterparts. Pharmacological interventions were most effective, achieving the highest symptom relief and audiological improvement rates of 87.78%. Multivariate regression highlighted age, geographic location, and treatment modality as key predictors of treatment efficacy, with notable interaction effects between climate conditions and treatment types influencing outcomes. The findings underscore the heterogeneity in ETD presentation and the differential efficacy of treatment modalities.

Surgical Outcomes of Type 1 Tympanoplasty in Chronic Otitis Media in Paediatric Patients: A Prospective Study

Objectives: To observe the surgical outcome of type 1 tympanoplasty in paediatric patients in the form of graft uptake and audiological improvement. Materials and methods: A prospective study was done in which 40 paediatric patients in age group 6-16 years, diagnosed of chronic otitis media, were taken up for tympanoplasty under general anaesthesia. Patients were followed in post operative period at 4, 6 and 12 weeks for assessment of graft status and audiological evaluation. Results: In this study, we found surgical success rate in the form of graft uptake in 80% of the cases and audiological improvement in 75% of the cases. Conclusion: Tympanoplasty is safe and effective in children with adequate graft uptake and audiological outcome.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-03965-1.

Morphometric Comparison of Tympanic Membrane in Unilateral Mucosal Chronic Otitis Media

Previous studies of the middle ear in Chronic Otitis Media have focussed on radiological assessment of temporal bone; endoscopic studies were focussed on perforation size and location. The malleus handle (manubrium) is a constant ossicular feature visible on otoendoscopy. It's relative position may indicate the previously documented differences in ossicular chain and middle ear cleft development relative to the tympanic ring and inner ear capsule between affected ear and contralateral ear.

DESIGN

descriptive.

SETTING

hospital based.

SUBJECTS

84 patients with unilateral mucosal chronic otitis media.

METHODS

each patient underwent Otoendoscopy and the findings were recorded through a camera connected to a laptop. Using image j software these images were analysed. Participants were of mean age of 35 years with left preponderance, and no gender preponderance was found. In our study, majority of the perforations were small sized perforations. The malleus handle foreshortening was about 92.6% compared to unaffected ear which was statistically insignificant. There was a significant inter group difference in the distance between the tip of the manubrium and the inferior annulus-which was decreased in affected ears and in the distance from the lateral process to the anterior tympanic ring-which was increased in affected ears. There was no difference in the malleo scutal angles. These differences were not dependent on the site or size of the perforation. The differences we found between ears were unexpected. The significance of the differences in the shape of the tympanic membrane between affected and unaffected ears in unilateral mucosal COM need further study. We did not find a statistically significant difference in the malleo-scutal angles between ears.

A Prospective Randomised Comparative Study Between Cartilage and Fascia Tympanoplasty in a Tertiary Care Hospital to Look for Better Alternative in High Risk Cases

Introduction

CSOM patients are most commonly managed surgically by type I tympanoplasty using either cartilage shield technique or underlay grafting technique. In our study, we have compared the graft uptake and hearing results of type I tympanoplasty using temporalis fascia and cartilage shield, and also reviewed the literature regarding the results of these two methods.

Materials and Methods

160 patients aged between 15 and 60 years were randomized into two groups of 80 patients each, with odd numbers subjected to conchal or tragal cartilage shield grafting in group I, while in group II with even numbers, the patients underwent temporalis fascia grafting by underlay technique.

Results

Three months post-surgery, the graft uptake was seen in 76 patients (95%) in the cartilage shield group as compared to 58 patients (72.5%) in the temporalis fascia group, which was statistically significant between the two groups [Fisher's exact value = 0.000]. The uptake rate was much higher in cartilage shield graft as compared to fascia graft even in complicated cases like revision tympanoplasty (TP), discharging ear, subtotal perforation and retracted/adhered TP. Also, the hearing improvement in fascia and cartilage shield group was not statistically significant comparing pre- and post-operative patients, indicating that there was not much difference in audiological outcomes between the two groups.

Conclusion

We advocate the use of cartilage shield graft as a substitute for fascia graft in all feasible cases as well as in complicated situations to improve the success rate of type I tympanoplasty, without compromising on the hearing improvement, as seen in our study.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-022-03175-1.

A Study to Assess the Effect of Size & Site of Tympanic Membrane Perforation on Hearing Loss

The objective of the study was to assess the effect of size & site of tympanic membrane perforation on hearing loss. The study was carried out in ENT department of a tertiary health care hospital, between October 2018 and March 2020 (a total of 18 months). Patients aged 15-50 years having chronic otitis media with dry central perforation were included in the study after taking informed written consent and were evaluated with detailed history, clinical examination including otomicroscopy, tuning fork tests and pure tone audiometry. The patients were then posted for Tympanoplasty and just prior to the procedure, the tympanic membrane perforation size was measured using the Castroviejo caliper and site was noted using otomicroscopy. The status of the middle ear mucosa and ossicles were also analyzed to ensure normal middle ear mucosa and normal ossicular mobility and continuity and only then were these patients included in the study. All the patients in the study were evaluated for hearing loss using air conduction measurements in pure tone audiometry done at 250 Hz, 500 Hz, 1000 Hz, 2000 Hz, 3000 Hz and 4000 Hz. Hearing loss was found to be directly proportional to the size of perforation in our study. The site of the perforation has a significant association with the degree of hearing loss. Those perforations with posterior quadrant involvement and multiple quadrant involvement had a higher hearing loss. From our study, we concluded that there is a significant relationship between size and site of the perforation and the amount of hearing loss.

Relationship of Hearing Loss and Tympanic Membrane Perforation Characteristics in Chronic Suppurative Otitis Media Patients

Objective The objective of this study is to assess the relationship between the site of tympanic membrane (TM) perforation and the type and degree of hearing impairment. The secondary objective was to compare the duration of the disease and the degree of hearing loss. Study design This is a prospective observational study. Place and duration of the study This study was carried out in the Department of Otolaryngology/Head and Neck Surgery at the Pakistan Institute of Medical Sciences, Islamabad, from May 2021 to April 2022. Patients and methods Of all the screened patients, 77 fulfilled the inclusion criteria. Patients aged 10-40 years with inactive mucosal chronic otitis media and unilateral perforation in one quadrant were included. The site of TM rupture was observed, and audiometric analysis was performed. Results The mean age of participants was 25 ± 8.61 years, with a preponderance of the female gender (57.1%). A total of 32 (41.6%), 19 (24.7%), 19 (24.7%), and seven (9.1%) perforations involved posterosuperior, anterosuperior, anteroinferior, and posteroinferior quadrants respectively. Conductive, mixed, and sensorineural hearing loss was found in 52 (67.5%), 18 (23.4%), and seven (9.1%) cases, respectively. Of all the subjects, 13 (16.9%) had the disease for < one year, 39 (50.6%) for one to five years, 17 (22.1%) for five to 10 years, and eight (10.4%) for > 10 years. There was a statistically significant association between the degree of hearing loss and the site of perforation. No significant association was found between the site of perforation and the type of hearing loss. Duration of disease and degree of hearing loss also had no significant association. Conclusion The extent of hearing loss was found to be directly influenced by the anatomical site of perforation, with the posterosuperior quadrant perforation producing the greatest degree of impairment.

Quantitative Measurements in Otological Surgery: Use of an Endoscopic Integrated Multipoint Laser System

OBJECTIVES

Assess the clinical utility of an Endoscopic Integrated Multipoint Laser System (EMLS) to otology. This is an emerging technology from automotive engineering that may offer the ability to accurately measure anatomy and pathology using an endoscope while undertaking ear surgery.

PATIENTS

Simulated otology patients were used incorporating the Phacon Temporal Bone synthetic models and Kyoto Kagaku Ear Examination Simulator models to allow assessment of the EMLS technology in evaluating external ear and middle ear pathology, e.g., perforation or prosthesis sizing.

INTERVENTION

Eight otolaryngology resident and fellows at a tertiary university teaching hospital were given training in EMLS and reviewed simulated anatomy and pathology within the models including tympanic membrane perforation, ossicular discontinuity, and a cochleostomy.

MAIN OUTCOME MEASURE

Variance in measurement was assessed in relation to those made manually by an independent surgeon using surgical calipers (0.1 mm).

RESULTS

The 8 participants produced 47 mean measurements. The mean difference from independently made manual measurement was 0.294 mm (standard error of the mean 0.033). Maximum variance was 0.98 mm and minimum 0.01 mm.

CONCLUSION

Use of an integrated endoscopic laser measurement tool allows reliable, easy-to-obtain measurements to be obtained within a simulated otological surgical environment. Translation of the technology to a thinner delivery system through a rigid endoscope offers further promise for routine use in a clinical setting.

Impact of Site, Size and Duration of Tympanic Membrane Perforation on Hearing Loss and Postsurgical Outcome

This paper aims to assess correlation of site, size and duration of tympanic membrane perforation with hearing loss using pure tone audiogram and surgical outcome in terms of above parameters. The present study was conducted on 100 patients in Department of ENT and HNS, SMGS Hospital, Government Medical College Jammu during a time period of November 2018 to October 2019. All the patients with age 15-60 years who presented with tympanic membrane (pars tensa) perforation were included in the study. According to the size of perforation, mean pure tone threshold in group I was 20.87 ± 3.86 dB, in group II was 26.45 ± 6.08 dB and in group III was 32.6 ± 5.56 dB. The difference in hearing threshold between all the three groups was significant statistically. In terms of site, group E had maximum hearing threshold (34.67 ± 4.20 dB), followed by group B (32.71 ± 5.88 dB). Group A had the lowest hearing threshold of 24.99 ± 6.21 dB. The difference between hearing thresholds of group B perforations and group A perforations was statistically significant (p < 0.05). However, the difference between group E and group B was insignificant. This study has shown significant correlation between the size and the site of the perforation to the degree of hearing loss. The bigger the perforation, the greater the hearing loss. The central perforations were associated with more hearing loss than posterior perforations, thus refuting the hypothesis that site and size of a tympanic membrane perforation does not affect the degree of conductive hearing loss. This study did not show any correlation between duration of disease and degree of hearing loss. Surgical and audiometric results obtained in this study can be accepted as satisfactory and as expected by the literature.

Correlation of Tympanic Membrane Perforation with Hearing Loss and Its Parameters in Chronic Otitis Media: An Analytical Study

Chronic otitis media is one of the commonest illnesses in otorhinolaryngological practice which requires medical attention. Intact tympanic membrane acts as a shield for round window niche to create a phase difference in sound wave conduction. 700 patients of age 10-70 years with inactive mucosal chronic otitis media were included in the study. Condition of tympanic membrane and site of tympanic membrane perforation was noted and audiometric analysis was performed. 338 (48.28%) were males and 362 (51.71%) were females. In 1400 membranes examined, 769 (54.85%) presented with perforation. 631 (82.03%) had unilateral perforation and 69 (17.97%) had bilateral perforations. In unilateral cases, 289 (37.50%) had right ear perforation and 342 (44.53%) left ear perforation. Single quadrant perforations were present in 168 (21.74%) membranes and 419 (54.55%) involved two quadrants. Three quadrant perforations were seen in 62 (8.09%) and 120 (15.63%) perforations involved all four quadrants. In 171 (22.26%) ears, perforation was present anterior to handle of malleus and in 243 (31.53%) it was present only posterior to handle. In 355 (46.21%) perforations, handle of malleus was involved. Perforations involving posterior half of tympanic membranes showed greater loss than those involving anterior or inferior half of membrane statistically. Maximum loss (51.56 ± 5.1 dB) was seen in perforation involving all four quadrants. In 631 unilateral cases, conductive loss was seen in 424 (67.10%), 101 (16.10%) showed sensorineural and 74 (11.80%) showed mixed loss. Out of 769 perforated ears having hearing loss, 251 (37.69%) had complaints for 5-10 years with mean loss of 51.15 ± 7.8 dB, 172 (25.68%) had COM for 1-5 years with loss of 39.26 ± 5.1 dB. A mean hearing loss of 52.18 ± 4.2 dB was seen in 110 (16.52%) patients suffering from COM for more than 10 years. 134 (20.12%) patients having disease less than 1 year reported hearing loss of 36.46 ± 8.2 dB. The effects of perforation of tympanic membranes on transmission of sound and its dynamics are not easy to correlate because of additional pathological changes in middle ear.

To Study the Association of the Size and Site of Tympanic Membrane Perforation with the Degree of Hearing Loss

Chronic suppurative otitis media is a serious health problem worldwide. It has been a general view that the hearing loss increases with the size of the perforation, more so if it is in the postero- inferior quadrant. The present study is an effort to test the validity of above concepts. With Institutional ethical committee clearance, an observational study was carried at SMS medical college, Jaipur. A total of 90 cases were studied. All cases between the age group 15-50 years with dry tympanic membrane perforations were divided into 3 groups Group I (0-9 mm²), Group II (9-30 mm²), Group III (>30 mm²) with 30 in each group based on size of perforation. Hearing loss was calculated as average of hearing loss at 500, 1000, 2000 Hz. Similarly the site of perforation was grouped as perforation involving anterior quadrant, posterior quadrant and multiple quadrant as Group A, Group B, Group C respectively. At the end of study, data was compiled systematically and analyzed using Post Hoc test. The age group ranges between 15 and 50 years with mean age of 25.6 years. Hearing loss was found to be directly proportional to the size of perforation in our study. (p = 0.000, highly significant). We also observed that hearing loss was more in posterior and multiple perforations than in anterior perforations. (p = 0.000, highly significant). Overall this study has shown significant correlation between the size and the site of the perforation to the degree of hearing loss.

Ossiculoplasty: A Prospective Study on 50 Patients Using Various Graft Materials

With large number of grafts available for ossiculoplasty, choice becomes difficult. An ideal graft should be safe, easily available, cost efficient, with good hearing results, uptake and low extrusion rates. The ear nose and throat surgeon is still facing the indecision over type of graft to be selected. A prospective study was conducted in Department of Otorhinolaryngology, Rajindra Hospital, Patiala (August 2012-2014) on 50 patients 15-60 years, of either sex with ABG > 40 dB. Operative procedure planned and type of graft decided intraoperatively. Autografts included remodelled malleus, remodelled incus and tragal cartilage grafts. Synthetic (Teflon) grafts were PORP and TORP. Graft uptake/failure was noted at 1 and 3 months. PTA done at 3 months postoperatively. Net hearing gain (change in ABG) was calculated for various grafts used and analysed. Mean age was 35.26 ± 13 yrs, male and female 1:1. Most common involved ossicle was incus (100%) followed by stapes (36%) and malleus (34%). Autografts, 23, uptake in 20 (86.95%), failure 3 (13.04%) cases. Synthetic grafts, 27, uptake 18 (66.66%) and failure 9 (33.33%). 'p'value 0.09 (non significant). Mean hearing gain, autografts 14.47 ± 6.54 dB and synthetic grafts 14.57 ± 13.12 dB. 'p' value 0.976 (non significant). No significant difference seen in mean hearing gain and uptake/failure of autografts and synthetic grafts. Autografts being cost effective are preferred choice.

Study of outcome of tympanoplasties in relation to size and site of tympanic membrane perforation

There are not many studies on the effect of the site and size of the perforation on the hearing loss. This study is set to investigate the relationship between the size and site of perforation and hearing loss. This study was carried out between September 2011 to September 2013, at a tertiary care centre during which 100 cases of chronic otitis media tubotympanic type having central perforation were selected. All patients underwent, tympanoplasty using temporalis fascia/cartilage graft, underlay technique with or without simple mastoidectomy/modified radical mastoidectomy and followed up for 3 months and evaluated for graft uptake and hearing improvement with respect to size and site of TM perforation. To measure the size of perforation intra-operatively, thin transparency sheet was used, on which a graph paper of 1 × 1 mm(2) size was printed. Significant relationship was observed between size and site of tympanic membrane perforation with hearing loss. Perforations which were involving all four quadrants (AS + AI + PS + PI) are having maximum residual perforations after the surgery. In relation with size, subtotal perforation were having more residual perforations postoperatively, followed by medium sized perforations. An inherent relationship noted between ossicular involvement and hearing loss, maximum average hearing loss was observed in those cases, where all three ossicles (malleus, incus & stapes) were involved, also more hearing loss was noted in posterior perforations.