Impact of Mastoidectomy on Simple Tympanic Membrane Perforation Repair

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.

Mastoidectomy in surgical procedures to treat retraction pockets: a single-center experience and review of the literature

PURPOSE

Retraction pocket (RP) is a common event affecting the middle ear when a negative pressure within it causes a retraction of a single part of the tympanic membrane (TM). Patients can be asymptomatic or can experience hearing loss, fullness feeling and/or ear discharge. RP can be stable or develop a cholesteatoma; aim of the study was to investigate if mastoidectomy may play a role in the surgical management of patients suffering from RP, both reporting our experience and discussing the existing literature.

METHODS

Fifty-one patients affected by RP were referred for surgery and randomly divided into two groups. Patients of G1 group underwent tympanoplasty with mastoidectomy, patients of G2 group underwent tympanoplasty only. A systematic review of the literature was then carried out by applying the PRISMA guidelines.

RESULTS

The mean follow-up lasted about 36 months. The G1 and G2 groups reached a postoperative mean air-bone gap (ABG) of 7.1 dB HL and 5.1 dB HL, respectively, with a mean ABG improvement of 13.2 dB HL and 12.4 dB HL. An ABG improvement was observed in the 59.7% of the G1 group and in the 63.2% of the G2 group, respectively (p > 0.5). Only one case of long-term complication was recognized in the G1 group. We combined, integrated and analyzed results of our prospective study with results of the literature review.

CONCLUSIONS

Based on the combined results of our study and literature review we may conclude that there is no evident benefit in performing mastoidectomy for the treatment of RP. In fact, no differences in ABG improvement or in RP recurrence were reported between the two groups.

Tympanoplasty With and Without Mastoidectomy for Chronic Otitis Media Without Cholesteatoma: A Systematic Review and Meta-analysis

OBJECTIVE

This study aimed to compare surgical and audiometric outcomes of tympanoplasty alone (T) to tympanoplasty and mastoidectomy (T&M) in patients without cholesteatoma.

DATABASES REVIEWED

According to PRISMA guidelines, English articles in PubMed, Scopus, CINAHL, and Cochrane Library databases from inception to 7/29/2021 were searched.

METHODS

Studies describing a comparison of patients who underwent T to patients who underwent T&M were included. Studies describing patients with cholesteatoma were excluded. Patient demographics, graft failure rates, and preoperative and postoperative audiological findings were collected. Mean differences (MD) and risk difference (RD) were calculated using RevMan 5.4. Heterogeneity was assessed using Q test and I2 statistic. Risk of bias was assessed using both version 2 of the Cochrane risk-of-bias tool for randomized trials and Risk of Bias in Non-randomized Studies of Interventions.

RESULTS

A total of 27 studies fulfilled eligibility with T (n = 1,711) and T&M (n = 1,186). When pooling the data, mean differences between T versus T&M for air bone gap (-0.3 dB: 95% CI = -1.9 to 1.3, p = 0.730) and pure tone average (1.9 dB: 95% CI = -0.3 to 4.2, p = 0.090) were not statistically significant. Graft failure was higher with T only (16.4% versus 14.2%) than T&M (RD = -0.04, 95% CI = -0.07 to -0.00, p = 0.030, I2 = 35%].

CONCLUSION

This study endorses clinically similar audiological outcomes and a reduced risk difference of graft failure with mastoidectomy. Although these data suggest that adding a mastoidectomy could decrease the risk of graft failure, the risk reduction is minimal. More research on the cost-effectiveness and the specific patient clinical characteristics and comorbidities that would benefit from adding a mastoidectomy is warranted.

Role of Mastoidectomy with Type 1 Tympanoplasty in Paediatric Patients with Poor Contralateral Ear Status

The aim of the study was to assess the role of mastoidectomy with type 1 tympanoplasty in the management of paediatric patients with poor contralateral ear status and to evaluate the prognostic factors that may influence the success outcome of type 1 tympanoplasty. A prospective study of 112 paediatric patients from 4 to 12 years of age. All patients in the study had bilateral ear perforations. They were randomly assigned to undergo either type 1 tympanoplasty (group 1, n = 56) or type 1 tympanoplasty with mastoidectomy (group 2, n = 56). The outcomes between the two groups were compared at 12 months postoperative period. The outcomes evaluated were: 1. anatomical condition of the tympanic membrane, 2. functional improvement in hearing (≥ 10 db), 3. air-filled middle ear space without atelectasis or otitis media with effusion, 4. overall outcome. The outcomes were also compared in both the surgical groups for patients who were ≤ 8 years (n = 51) and > 8 years (n = 61) of age. Prognostic factors for success outcome for type 1 tympanoplasty were evaluated. The prognostic factors considered were age at the time of surgery, age groups, duration of the disease prior to surgery, previous adenoidectomy, mechanism of perforation, location of perforation, size of the perforation, type of ear surgery performed (tympanoplasty with or without mastoidectomy). The success outcome in anatomical condition of the tympanic membrane was significantly higher in mastoidectomy group (p = 0.015) but was not significantly different in those ≤ 8 years and > 8 years (p = 0.112, p = 0.064 respectively).There was no difference in the functional improvement in hearing in both the surgical groups for all patients, ≤ 8 years and > 8 years (p = 0.188 p = 0.061, p = 0.865 respectively). Mastoidectomy group showed significantly higher success outcome for air-filled middle ear space without atelectasis or OME for all patients, ≤ 8 years and > 8 years (p < 0.001, p = 0.004, p = 0.041 respectively).Overall success was significantly higher in mastoidectomy group for all patients and ≤ 8 years (p = 0.040, p = 0.012 respectively),but not significantly different for > 8 years (p = 0.592).Out of the prognostic factors considered for success only the type of ear surgery performed showed as a better predictor for success (AUC = 0.606, p = 0.046). Cortical mastoidectomy done along with type 1 tympanoplasty in paediatric patients with poor contralateral ear showed statistically significant higher overall success outcome. Although mastoidectomy done with type 1 tympanoplasty showed better success outcome in patients above 8 years, it was not statistically significant. Except the type of ear surgery performed, none of the prognostic factors considered could influence the success outcome. Our study recommends mastoidectomy to be combined with type 1 tympanoplasty in paediatric patients aged ≤ 8 years with poor contralateral ear status to enhance the overall success outcome.

Effect of pre-operative mastoid pneumatisation on tympanoplasty success

Objective

This study aimed to compare the effect of pneumatised and non-pneumatised mastoid on the success of tympanoplasty in terms of rate of graft uptake and air–bone gap improvement.

Method

A comprehensive electronic search of PubMed Medline, Scopus, Web of Science and Cochrane Library was conducted in August 2020 for articles from 1990 to 2020. Selected studies were published in the English language, were conducted on human patients, were concerned with evaluating pre-operative mastoid pneumatisation on tympanoplasty success, were not laboratory studies and were not opinion studies. Five studies were included with 178 patients in the pneumatised group and 97 patients were included in the non-pneumatised group. Comparison between both groups was performed in terms of graft uptake rate and air–bone gap improvement.

Results

Although the pneumatised group showed better graft uptake rate than the non-pneumatised group, there was no statistically significant difference between the two groups in the success rate of tympanoplasty.

Conclusion

Pneumatisation of the mastoid does not significantly affect the success rate of tympanoplasty.

Long-Term Health Utilization and Outcomes in Chronic Suppurative Otitis Media

OBJECTIVE

To report health utilization patterns and outcomes of medical and surgical management in patients with chronic suppurative otitis media (CSOM).

STUDY DESIGN

Retrospective cohort.

SETTING

Academic otology clinic.

METHODS

This study included 175 patients with CSOM with a first clinic visit at our institution between March 2011 and November 2016. All patients displayed a diagnosis of CSOM by International Classification of Diseases code, had at least 1 episode of active CSOM (defined as perforation with otorrhea), and had a documented history of chronic ear infections. The mean age was 49.5 ± 1.5 years, 53% were female, and mean follow-up time was 3.5 ± 0.3 years.

RESULTS

Patients had an average of 9.5 ± 0.5 otology visits, 4.7 ± 0.4 prescriptions, and 1.7 ± 0.1 surgeries, with estimated per patient cost ranging from $3927 to $20,776. Under medical management, 69% of patients displayed recurrence of disease, with a median time to recurrence of 4 months. For tympanoplasty and tympanomastoidectomy, median time to recurrence was similar at 5 and 7 years, respectively (P = .73). At the most recent visit, the prevalence of all patients with CSOM displaying moderate or worse sensorineural hearing loss (SNHL) was 41%.

CONCLUSIONS

CSOM represents a major public health issue with high health care utilization and associated costs. Surgery is superior to medical therapy for achieving short- to medium-term inactive disease. Patients with CSOM display a high SNHL burden.

Myringoplasty Outcomes From a 5-Year Single Surgeon's Experience and Important Surgical Technical Aspects

BACKGROUND AND OBJECTIVES

The United Kingdom (UK) national standard for the closure rate for myringoplasty is 89.5% (90.6% and 84.2% for primary and revision surgeries, respectively). The average hearing gains for primary and revision myringoplasty are 9.14 dB and 7.86 dB, respectively. This study compared the myringoplasty outcomes for a single surgeon over 5 years.

SUBJECTS AND PURPOSE

Data for 68 cases were analyzed retrospectively. The outcome measures were achievement of the tympanic membrane closure and the average hearing gain or loss.

RESULTS

The overall and primary closure rates were 97% and 98%, respectively and significantly higher than the UK national standard (p=0.0210 and p=0.0287, respectively). The revision closure rate was 93%; however, it was not significantly higher than the national standard (p=0.1872). The average hearing gain was 5.18 dB. The gains for primary and revision surgeries were 5.15 dB and 5.25 dB, respectively.

CONCLUSIONS

We propose that these outcomes are a result of our surgical technique, including the simultaneous use of cortical mastoidectomy in ears with discharge.

A Three Point Assessment Protocol for Tympanoplasty Outcomes: A Retrospective Analysis

Introduction  The surgical outcome of chronic otitis media (COM) of the mucosal type in the pediatric population with high rates of recurrent tympanic membrane perforation is indeed a concern for the attending surgeon. Objective  The present study was done to evaluate the outcome of tympanoplasty in children with chronic otitis media mucosal type. Methods  A retrospective analysis of the medical records of all children, aged < 16 years old, who underwent tympanoplasty for COM of the mucosal type was performed. These patients were addressed by a three-point assessment, for predicting outcome of tympanoplasty, which included the age of the patient, addressing the nasal/pharyngeal issues, and the status of the COM (discharging or dry). Surgical success was assessed in terms of graft uptake and improvement of hearing. Factors affecting the surgical outcome were also analyzed. Results  A total of 90 children underwent type 1 tympanoplasty; 7 were lost to follow-up and 10 had incomplete audiometric results. In the 73 tympanoplasties analyzed, graft uptake was seen in 91.7% of the patients. Children with longer duration of ear discharge (> 8 years) had greater hearing loss. Children aged > 8 years old showed statistically significant higher chance of graft uptake ( p  = 0.021). Five of the six children who had graft rejection had bilateral disease. Conclusion  A three-point assessment in the management of pediatric COM of the mucosal type offers good outcomes with post-tympanoplasty graft uptake rates > 90%.

Surgical Management of Retraction Pockets: Does Mastoidectomy have a Role?

Introduction  Retraction pocket is a condition in which the eardrum lies deeper within the middle ear. Its management has no consensus in literature.

Objective  To assess the role of mastoidectomy in the management of retraction pockets added to a tympanoplasty.

Methods  Prospective study of patients with retraction pocket and referred to surgery. The patients were randomly assigned to two groups: one managed with tympanoplasty and mastoidectomy and the other group with tympanoplasty only. The minimum follow-up considered was 12 months. The outcomes were: integrity of eardrum, recurrence, and hearing status.

Results  This study included 43 patients. In 24 cases retraction occurred in the posterior half of the eardrum, and in 19 patients there was clinical evidence of ossicular interruption. The two groups of treatment were composed by: 21 patients that underwent tympanoplasty with mastoidectomy and 22 patients had only tympanoplasty. One case of the first group had a recurrence. In 32 cases patients follow up was longer than 48 months. The average air-bone gap changed from 22.1 dB to 5 dB. The percentage of air-bone gap improvement was assessed at 60% in those patients treated with mastoidectomy, and 64.3% in those without it ( p  > 0.5).

Conclusion  Tympanoplasty and ossiculoplasty should be considered to treat atelectatic middle ear and ossicular chain interruption. Mastoidectomy as a way to increase air volume in the ear seems to be a paradox; it does not add favorable prognostic factor to management of retraction pockets.

Prognostic roles of preoperative CT findings and air-bone gaps in type 1 tympanoplasty

BACKGROUND

Although CT has been used widely, the role of preoperative CT findings including other factors in tympanoplasty has not been elucidated comprehensively.

AIMS/OBJECTIVES

To evaluate relationship of CT findings with other factors and audiological results in type 1 tympanoplasty.

MATERIAL AND METHODS

A cohort of consecutive 175 patients with type 1 tympanoplasty was enrolled. Addition of mastoidectomy was based on the presence of soft tissue in antrum on CT. Postoperative air-bone gap (ABG) and reperforation rate were analyzed.

RESULTS

Positive soft tissue in antrum on CT was found in 52 (29.7%) patients and showed larger preoperative ABG than the negative group. Successful ABG closure (≤20 dB) was obtained in 97% when preoperative ABG ≤20 dB, but it decreased as the preoperative ABG increased (83% with preoperative ABG of 21-30 dB, and 0% with preoperative ABG >30 dB). Postoperative reperforation rate was positively related to the preoperative ABG, but not the presence of soft tissue in the antrum, the size, or locations of preoperative perforations.

CONCLUSIONS AND SIGNIFICANCE

Our findings showed that temporal bone CT was helpful in determining addition of mastoidectomy and the presence of soft tissue in the antrum was associated with large ABG.

Long-Term Outcomes after Performing Tympanoplasty without Mastoidectomy for Active and Inactive Noncholesteatomatous Chronic Otitis Media

OBJECTIVE

This study aimed to assess long-term outcomes after performing tympanoplasty without mastoidectomy (TWOM) for active and inactive noncholesteatomatous chronic otitis media (COM) and to estimate the optimal time for surgery.

METHODS

The patients were placed into an active ear group (group A) and an inactive ear group (group B). All patients were followed up for 5 years after TWOM.

RESULTS

Ninety-two cases among 113 achieved dry ears in half a month to 1 month. The tympanic pressure gradually improved 3-6 months after the operation. A total of 69/72 ears achieved dry ears in the active ear group, and 37 ears had effective hearing improvement. In all, 40/41 ears achieved dry ears in the inactive ear group, and 20 ears had effective hearing improvement. There was no difference in the recurrence rate or hearing improvement in the two groups.

CONCLUSION

With good quality control of the surgical treatment of TWOM, there are no differences in long-term outcomes in noncholesteatomatous COM in different chronic infection conditions.

Therapeutic Mastoidectomy Does Not Increase Postoperative Complications in the Management of the Chronic Ear

OBJECTIVE

Tympanoplasty with or without concurrent therapeutic mastoidectomy is a controversial topic in the management of chronic ear disease. We sought to describe whether there is a significant difference in postoperative complications.

STUDY DESIGN

Retrospective cohort study.

SETTING

American College of Surgeons National Surgical Quality Improvement Program public files.

PATIENTS

Current procedural terminology codes were used to identify patients with chronic ear disease undergoing tympanoplasty ± concurrent mastoidectomy in the 2011 to 14 American College of Surgeons National Surgical Quality Improvement Program files.

INTERVENTION

Therapeutic.

MAIN OUTCOME MEASURES

Variables were compared with χ, Fischer's exact, and Mann-Whitney U tests, as appropriate to analyze postoperative complications between tympanoplasty with or without concurrent mastoidectomy. To account for confounding factors, presence of a complication was analyzed in binary logistic regression. Analysis considered sex, hypertension, obesity, advanced age, diabetes, smoking status, American Society of Anesthesiologists Physical status, procedure.

RESULTS

There were 4,087 patients identified meeting criteria (tympanoplasty = 2,798, tympanomastoidectomy = 1,289). There was no statistical difference in postoperative complications (tympanoplasty n = 49 [1. 8%], tympanomastoidectomy n = 33 [2. 6%]; p = 0. 087) or return to the operating room (tympanoplasty = 4 [0. 1%], tympanomastoidectomy = 6 [0. 5%]; p = 0. 082). Binary logistic regression demonstrated smoking as a predictor of a postoperative complication (OR: 1. 758, 95% CI: 1. 084-2. 851; p = 0. 022), while concurrent mastoidectomy did not significantly increase the risk of complication (OR: 1. 440, 95% CI: 0. 915-2. 268; p = 0. 115). There was a significant difference in mean operative time between tympanoplasty and tympanomastoidectomy: 85.7 versus 154.23 min, p < 0. 001.

CONCLUSION

In the management of chronic ear disease, tympanoplasty with concurrent mastoidectomy increases time under anesthesia, but it is not associated with any increased postoperative complications compared with tympanoplasty alone.

Postoperative Mastoid Aeration Following Canal Wall Up Mastoidectomy according to Preoperative Middle Ear Disease: Analysis of Temporal Bone Computed Tomography Scans

Background and Objectives

The aim of our study was to evaluate postoperative mastoid aeration according to the preoperative middle ear disease and investigate the factors affecting it.

Subjects and Methods

We retrospectively reviewed the high-resolution computed tomography (CT) scans of temporal bones that were taken 1 year after surgery. The postoperative mastoid aeration was evaluated according to the preoperative diagnosis, and classified into three groups: grade 1 (complete mastoid aeration), an air-filled epitympanum and mastoid cavity; grade 2 (partial mastoid aeration), an air-filled epitympanum and partially aerated mastoid cavity; and grade 3 (absence of mastoid aeration), no air space in the mastoid cavity.

Results

The overall mastoid aeration rate was 55.8%, with adhesive otitis media accounting for 21.2%, attic cholesteatoma 53.8%, and chronic otitis media 75.4%. The rates of postoperative mastoid aeration were significantly higher in the chronic otitis media cases and attic cholesteatoma cases than in the adhesive otitis media cases. There were 14 cases requiring revision operations due to the development of a retraction pocket in the tympanic membrane. All of the revised cases had grade 3 postoperative mastoid aeration, and underwent canal wall down mastoidectomies.

Conclusions

The degree of postoperative mastoid aeration is associated with the preoperative middle ear disease. When planning a canal wall up mastoidectomy, the surgeon should contemplate the middle ear disease, because a canal wall down mastoidectomy or mastoid obliteration is recommended if the patient has adhesive otitis media.

Type I Tympanoplasty Meta-Analysis: A Single Variable Analysis

OBJECTIVE

To determine which independent variables influence the efficacy of type I tympanoplasty in adult and pediatric populations.

DATA SOURCES

A search of the PubMed database and Cochrane Database of Systematic Reviews using the key words "tympanoplasty OR myringoplasty" from January 1966 to July 2014 was performed.

STUDY SELECTION

Studies reporting outcomes of myringoplasty or Type I tympanoplasty in primary non-cholesteatomatous chronic tympanic membrane (TM) perforation were included.

DATA EXTRACTION

Of 4,698 abstracts reviewed, 214 studies involving 26,097 patients met our inclusion criteria and contributed to meta-analysis.

DATA SYNTHESIS

The primary outcome of success was defined as closure rate at 12 months. The independent variables analyzed were age, follow-up period, approach, graft material, perforation cause, size, location, ear dryness, and surgical technique. Only those studies providing data on a given parameter of interest could be included when comparing each variable.

CONCLUSION

The weighted average success rate of tympanic closure was 86.6%. Based on this meta-analysis, pediatric surgery has a 5.8% higher failure rate than adults and there is no correlation between follow-up period and success. Other variables associated with improved closure rates include perforation with a size less than 50% of total area (improved by 6.1%) and the use of cartilage as a graft (improved by 2.8% compared with fascia), while ears that were operated on while still discharging, those in different locations of the pars tensa, or using different surgical approaches or techniques did not have significantly different outcomes.

Comparative Evaluation of Tympanoplasty with or Without Mastoidectomy in Treatment of Chronic Suppurative Otitis Media Tubotympanic Type

To study the role of tympanoplasty alone and tympanoplasty done along with cortical mastoidectomy in CSOM in term of graft uptake, improvement of hearing and removal of disease. This is retrospective study of patient at tertiary referral centre, conducted in between October 2015 and October 2016, study was done on 40 patients of either sex in the age group 20-50 years. Tympanoplasty alone was done in 20 cases and tympanoplasty along with cortical mastoidectomy was done in rest 20 cases. Patient were reviewed post operatively on 2, 4, 8 and 16 weeks to inspect post operative graft uptake and PTA was done at fourth month to evaluate hearing improvement. Hearing improvement was compared in both the groups in tympanoplasty group was 9.41 and in tympanoplasty combined with cortical mastoidectomy was 12.05. Graft uptake was 80% in tympanoplasty group and 95% in tympanoplasty combined with cortical mastoidectomy. Recurrence of discharge was seen in 4 cases of tympanoplasty. Though tympanoplasty combined with cortical mastoidectomy is better in hearing improvement, graft uptake and clinical improvement but the difference in 2 groups is statistically insignificant. Results of tympanoplasty alone and tympanoplasty along with cortical mastoidectomy in terms of hearing gain and graft uptake were statistically insignificant.

Therapeutic Mastoidectomy in the Management of Noncholesteatomatous Chronic Otitis Media

Objective

Despite evidence that therapeutic mastoidectomy does not improve outcomes in noncholesteatomatous chronic otitis media, it remains widely performed. An up-to-date systematic review is undertaken and conclusions drawn regarding the best evidence-based practice of its management.

Data Sources

PubMed, Google Scholar, Medline Embase, Cochrane, and Web of Science.

Review Method

A combination of the following words was used: chronic otitis media, chronic suppurative otitis media, COM, CSOM, mastoidectomy, tympanoplasty, atelectasis, retraction, tympanic perforation, and therapeutic.

Results

From 1742 studies, 7 were selected for full analysis with respect to the benefit of mastoidectomy in the management of active and inactive mucosal chronic otitis media. Most were retrospective studies, with 1 prospective randomized controlled trial available. Overall, there was no evidence to support routine mastoidectomy in conjunction with tympanoplasty in chronic otitis media. For ears with sclerotic mastoids, the evidence suggested that there may be some benefit as a staged procedure. Two studies were analyzed for the benefit of mastoidectomy in addition to tympanoplasty for the management of the atelectatic ear (inactive squamous chronic otitis media). The conclusion was also that mastoidectomy added no benefit.

Conclusions

Examination of the available literature supports the notion that therapeutic mastoidectomy does not lend any additional benefit to the management of noncholesteatomatous chronic otitis media. This has implications for patient care, both clinically and financially. Further research, ideally in the form of a prospective, multi-institutional, geographically wide, ethnically diverse, randomized controlled trial, is needed to further support this notion.

Tympanoplasty in adhesive otitis media: A descriptive study

OBJECTIVES/HYPOTHESIS

There is no consensus among clinicians regarding the best treatment strategy for adhesive otitis media (AdOM). It is common practice to only intervene in the presence of recurrent infections or significant conductive hearing loss. In an attempt to provide evidence regarding the efficacy and safety of surgical intervention, we have analyzed the long-term outcome of tympanoplasty for AdOM .

STUDY DESIGN

Prospective study.

METHODS

From January 2013 to April 2014, 57 patients with AdOM (60 ears) who fit our criteria for tympanoplasty were recruited and underwent tympanoplasty using tragal cartilage combined with transtympanic ventilation tube and cortical mastoidectomy. Otorrhea control, graft uptake, hearing level changes, and complications were evaluated within a 3-year period of follow-up.

RESULTS

Otorrhea was controlled in 94% of the ears. Tympanic membrane healing was achieved in all ears except one ear, which had myringitis. Overall there was significant improvement in hearing. Whereas the mean preoperative air-bone gap (ABG) was 30.4 ± 4.0 dB, postoperative mean ABG was 8.6 ± 6.9 dB at 1 year. Closure of ABG to within 20 dB was achieved in 46 ears (83.6%). One ear showed a drop in bone conduction level by 25 dB. No iatrogenic cholesteatoma was detected in any of the cases.

CONCLUSION

This study demonstrated that tympanoplasty has favorable outcomes in AdOM . Risks of iatrogenic sensorineural hearing loss or cholesteatoma formation are negligible.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:2804-2810, 2016.

Factors affecting myringoplasty success

Objective:

To identify factors that significantly influence myringoplasty success.

Methods:

A retrospective study was performed of all adults and children who underwent myringoplasty from January 2005 to January 2010 in a teaching hospital. Outcome measures were tympanic membrane perforation closure and air–bone gap closure to within 20 dB HL. The factors assessed were the surgeon grade, pre-operative condition of the ipsilateral and contralateral middle ears, perforation site, perforation size, graft material, and whether simultaneous cortical mastoidectomy was performed. Factors with statistically significant effects were determined by logistic regression analysis.

Results:

In the adult group, the perforation site significantly influenced tympanic membrane closure (p = 0.016): anterior (p = 0.008) and subtotal (p = 0.017) sites had the greatest influence. None of the factors proved to have a significant influence on tympanic membrane closure in the paediatric group.

Conclusion:

There was a significant association between perforation site and tympanic membrane perforation closure in adults. Anterior and subtotal perforations had a significantly reduced closure rate.

Myringoplasty with and without Cortical Mastoidectomy in Treatment of Non-cholesteatomatous Chronic Otitis Media: A Comparative Study

OBJECTIVE

To compare the outcome and success of repair of uncomplicated tympanic membrane perforations with myringoplasty alone and when combined with mastoidectomy.

METHODS

A prospective study where 40 patients with non-cholesteatomatous chronic suppurative otitis media (CSOM) were recruited during the period of June 2013 to December 2013 from the outpatient clinic of Otorhinolaryngology department, Faculty of medicine, Cairo University. Patients were managed medically and after dryness of their perforations they were operated upon. Twenty patients underwent simple myringoplasty alone and 20 patients underwent myringoplasty with cortical mastoidectomy. Underlay technique with temporalis fascia was done for all patients. Follow-up period was at least 3 months.

RESULTS

Hearing improvement was comparable in both groups. There was no significant difference in graft uptake between the myringoplasty alone group (70%) and cortical mastoidectomy group (80%) (P = 0.7). There was no significant difference in ear dryness between the myringoplasty alone group (75%) and cortical mastoidectomy group (90%) (P = 0.4).

CONCLUSION

Mastoidectomy performed in non-cholesteatomatous CSOM in this study gives no statistically significant benefit over simple myringoplasty as regards graft success rate and dryness of the middle ear with comparable hearing outcome.

A novel technique for reconstruction of the posterior wall of the external auditory canal and tympanum using pedicled temporalis myofascia

CONCLUSIONS

The procedure cleared the lesion completely and preserved the physiological function of the external auditory canal.

OBJECTIVE

To develop a novel surgical procedure to treat chronic suppurative otitis media (CSOM). To explore the merit of using pedicled temporalis myofascia (PTM) and reconstruction of the posterior wall of the external auditory canal with pedicled postauricular periosteal flap and intact skin of the external auditory canal.

METHODS

Forty-seven patients with CSOM were chosen. Open radical mastoidectomy was used to complete clean-up lesions; the fascia of PTM was used to repair the tympanic membrane. The PTM, pedicled postauricular periosteal flap, and intact skin of the external auditory canal were used in the reconstruction of the posterior wall of the external auditory canal. All subjects were followed up for over 2 years. Hearing thresholds, including air conduction (AC), bone conduction (BC), and air-bone gap (ABG) before and after surgery, and after follow-up, were compared.

RESULTS

The healing rate of postoperated tympanic membrane was 95.74% and the 2-year healing rate of tympanic membrane perforation was 95.65%. The 46 ears included in the 2-year follow-up showed significant improvement between preoperative and postoperative AC and ABG values.

Success of myringoplasty: our experience

The purpose of this study is to compare the efficacy of myringoplasty with or without cortical mastoidectomy in terms of freedom from discharge, graft take up and improvement in hearing. This is a Clinical prospective study of 120 patients from among a group of patients with chronic suppurative otitis media. A detailed history and examination was conducted including pure tone audiogram. Patients were randomly divided into two groups; group A would undergo myringoplasty only and group B would undergo cortical mastoidectomy with myringoplasty. Patients were reviewed after 3 weeks for inspection of the operated ear. Second post-operative review was at 3 months for clinicoaudiological assessment. Group B was found to have slightly more improvement as compared to the other group. No significant difference in the success rates of graft take-up in patients with unilateral or bilateral disease was found. Higher take up rates were seen in large (91.83 %) and medium perforations (90.69 %). In all our failed cases, post-operative ear discharge continued to be a persistent and troubling problem. The average audiological gain was 12.88 dB in group B, whereas it was 12.40 dB in group A. The reduction of air bone gap within each group was found to be significant. There is no statistical significant data indicating that tympanoplasty with mastoidectomy yields better results. When considering the addition of a mastoidectomy to a Tympanoplasty, the performing surgeon should consider not only the potential added benefit but also potential risks and costs to the patient.

Air space reduction tympanomastoidectomy repairs difficult perforations more reliably than tympanoplasty

OBJECTIVES/HYPOTHESIS

Air space reduction tympanomastoidectomy improves outcomes over tympanoplasty in repairing tympanic membrane perforations in the presence of unfavorable risk factors.

STUDY DESIGN

Retrospective review of 67 subjects' 87 operations.

METHODS

Interventions were tympanoplasty versus air space reduction tympanomastoidectomy. Risk factors were contracted mastoid air cells, previous failed operations, descent from the indigenous peoples of the Americas, and middle/ear mastoid volumes l<3 CC. Favorable outcomes were closure of the perforation, no decline in hearing, and creation of a self-cleaning mastoid bowl.

RESULTS

Five out of 46 air space reduction tympanomastoidectomies failed to close their perforations (11%). Pure-tone threshold (PTA) worsened in 13/46 ears (28%). Four of 46 required mastoid bowl cleaning (9%). In contrast, 21 of 41 tympanoplasties failed to close (51%). PTA worsened in 9/34 ears (26%). All four tympanoplasty failures treated with an air space reduction tympanomastoidectomy closed. Three of the seven tympanoplasty failures treated with a second tympanoplasty did not close. Statistical analysis found two risk factors more prevalent among the air space reduction tympanomastoidectomies: contracted mastoids (P = .019) and middle ear volumes <3 CC (P = .0001). Increased closure of perforations occurring after the air space reduction tympanomastoidectomy was also statistically significant (P = .0002). Descendants of indigenous peoples of the Americas trended toward better PTAs after their air space reduction tympanomastoidectomies than their tympanoplasties and showed statistically significant increases in closure of perforation (P = .0046).

CONCLUSIONS

Air space reduction tympanomastoidectomy is an effective and safe method for closing tympanic membrane perforations.

Cartilage graft or fascia in tympanoplasty in patients with low middle ear risk index (anatomical and audological results)

The aim of this study was to compare anatomic and audiological results of cartilage graft with temporal fascia graft in type 1 tympanoplasty patients with low middle ear risk index (MERI). In this retrospective study, 63 patients that underwent type 1 tympanoplasty with chondroperichondrial island graft between July 2009 and November 2010 were compared with 45 patients in whom temporal muscle fascia was used. Patients in both groups had low MERI values varying between 1 and 3. Five and nine patients underwent masteidectomy in cartilage and fascia group, respectively. Mean duration of follow-up was 11.9 ± 3.7 (5-17) months. Mean value was calculated at pre-operative and post-operative hearing threshold 0.5, 1, 2, 4 kHz, and air bone gap (ABG) gain was compared in both cartilage and fascia groups. when pre-operative and post-operative ABG gain were compared, significant decrease was seen in ABG levels (p < 0.001). However, no significant difference was seen in ABG gain values (p = 0.608), which was 10.1 ± 7.00 dB in cartilage group and 10.8 ± 5.38 dB in fascia group. In both groups, age, sex, and the addition of mastoidectomy procedure had no significant effect on ABG gain and success. Cartilage is a graft material that may be preferred without concern about the effects on hearing results, especially, in patients with low MERI values. The addition of mastoidectomy had no impact on the outcome of operation and audiological results. However, further studies with larger case series may be carried out to further clarify the issue.

Usefulness of cortical mastoidectomy in myringoplasty

OBJECTIVES

The usefulness of cortical mastoidectomy in myringoplasty remains an issue of controversy. We aimed to assess the effectiveness of mastoidectomy on outcomes of tympanoplasty performed in patients with persistent or intermittent discharging chronic suppurative otitis media without cholesteatoma.

STUDY DESIGN

Prospective, randomized, single-blinded study. Level of evidence-1B.

SETTING

Tertiary referral center.

PATIENTS

Three hundred twenty consecutive adult patients presenting persistent or intermittent otorrhea during the preceding 6 months scheduled for myringoplasty were included.

INTERVENTIONS

Patients were randomly assigned to undergo either myringoplasty with cortical mastoidectomy (Group A) or myringoplasty only (Group B).

MAIN OUTCOME MEASURES

Graft success rate and mean postoperative air-bone gap. Auditory outcomes were evaluated at one year postoperatively.

RESULTS

At the end of the follow-up period, there were 24 failures within Group A (success rate, 82.8%) and 34 within Group B (success rate, 76%), statistically not significant. In the univariate analysis, 3 factors were found to be significant in predicting success rate: healthy opposite ear, a long dry period preceding the operation and nonsmoker status. The only factor attaining significance in the multivariate analysis was a dry period longer than 3 months.

CONCLUSION

Cortical mastoidectomy offers no additional benefit in myringoplasty performed on patients with persistent or intermittent discharging CSOM and no evidence of cholesteatoma or mucosal blockage within the antrum.

Efficacy of a topical suspension of bacterial antigens for the management of chronic suppurative otitis media

The aim of this study was to compare the efficacy and safety of a topical suspension of bacterial antigens for the management of chronic suppurative otitis media (CSOM). Two-hundred ten patients with CSOM were enrolled in this study. The patients were divided into two numerically equal groups and randomized to receive a topical suspension of bacterial antigens, Lantigen B (group A), or placebo (group B), according to the following protocol: 5 drops thrice a day for 12 consecutive weeks in the external acoustic duct. The topical suspension of bacterial antigens and placebo were administered by identical, anonymous dispensers in order to maintain double-blind conditions. Before, at the end and 3 months, and after the end of the treatment, all patients who entered in the study underwent pure tone audiometry, microscopic examination of ears, microbiological examination of the ear swab, aural suctioning and subjective assessment of symptoms by visual analog scale. In group A, we saw a statistically significant improvement in the different items measured. A topical suspension of bacterial antigens was significantly more effective than placebo in the treatment of CSOM.

Results of revision tympanoplasty for chronic non-cholesteatomatous otitis media

OBJECTIVE

To evaluate the success rate for revision tympanoplasty using different graft materials, to compare results of primary and re-tympanoplasty using the same technique and to analyse the effect of potential influencing factors on closure of tympanic membrane (TM) and hearing outcome.

METHODS

Study included all patients, who underwent tympanoplasty (n=617) and re-tympanoplasty (n=94) for chronic otitis media without cholesteatoma in the period between September 1998 and 2007. The data of all patients on preoperative disease, perforation size and localization, middle ear status, surgical approach, graft material, adjunctive procedures, pre- and postoperative morphological (otomicroscopy) and functional (hearing examination evaluating pure-tone audiogram) results were analyzed. All operations were performed using an underlay technique and either the retroauricular or transcanal approach. The temporal fascia, perichondrium or cartilage-perichondrium composite grafts were used for the reconstruction of TM. Ossiculoplasty was performed as needed. The interrelation between multiple pre-operative parameters and post-operative morphological (closure of the perforation) and functional (hearing level) outcomes was analysed.

RESULTS

Successful closure rates of the TM perforation were 93.6% and 90.2% of the patients in the primary and revision tympanoplasty groups, respectively. Graft take rate and hearing results did not depend on graft material. Structural changes were found more frequently in the re-tympanoplasty group (63.4% comparing to 29.5% of primary cases). Ossiculoplasty was performed more often in revision cases (24.4% comparing to 11.4% of primary cases). Successful hearing (ABG within 20dB) for primary tympanoplasties was achieved in 81.1%, and for retympanoplasty - in 69.5% of the cases. (p<0.01). There were no interrelation between any estimated parameters and the graft take rate for either primary or revision tympanoplasty.

CONCLUSIONS

There is no evidence of increased risk of graft failure in re-tympanoplasty cases when compared to primary tympanoplasty operations. Hearing results depend on structural changes in the middle ear (ossicular abnormalities and tympanoscerosis) which in revision cases are found more often. No differences were found between fascia, perichondrum or cartilage-perichondrium grafts in terms of graft healing and hearing results.

Do patients with sclerotic mastoids require aeration to improve success of tympanoplasty?

CONCLUSION

We could not find any significant difference in the results for graft success rate and functional hearing results between the myringoplasty and tympano-mastoidectomy groups. So mastoidectomy may not be necessary for successful tympanic membrane reconstruction and hearing improvement.

OBJECTIVE

To investigate the effect of aerating mastoidectomy on the surgical success rate of myringoplasty.

METHODS

This was a retrospective study. Data were analyzed from 92 patients who underwent surgical repair of tympanic membrane perforations due to chronic suppurative otitis media (CSOM) without cholesteatoma. Tympano-mastoidectomy was performed in 46 patients with a small sclerotic mastoid. The other 46 patients underwent myringoplasty without mastoidectomy. Patients were evaluated for success in tympanic membrane reconstruction and hearing levels after a minimum follow-up duration of 1 year.

RESULTS

Tympanic membrane perforation closure was successful in 76.1% (n = 35) of the 46 patients undergoing myringoplasty and in 78.3% (n = 36) of the 46 patients undergoing myringoplasty with mastoidectomy. The difference between the closure rates of the two groups was not statistically significant (p > 0.05). The difference between the two groups for hearing gain was also not statistically significant (p > 0.05).

Humanitarian otologic missions: long-term surgical results

OBJECTIVE

The purpose of this study was to determine the efficacy of treating chronic ear disease by performing a single surgical intervention in the austere environment of a developing nation.

SUBJECTS AND METHODS

Data were collected from retrospective chart reviews on 121 patients who underwent surgical treatment of chronic ear disease during humanitarian surgical missions in South and Central America. Surgical outcomes and clinical course were assessed at 10 to 12 months after the initial surgery.

RESULTS

A total of 117 patients were included in the study. Follow-up records were available for 75 patients (64%). A total of 20 surgeries were performed for dry perforations (group 1), 30 for chronically draining ears (group 2), and 25 for cholesteatomas (group 3). Surgical success was determined as 60 percent, 74 percent, and 92 percent for groups 1, 2, and 3, respectively.

CONCLUSIONS

Surgical results during international otologic outreach missions to developing nations fall within the results expected in developed nations.

Cortical mastoidectomy in quiescent, tubotympanic, chronic otitis media: is it routinely necessary?

Objective:

This study aimed to compare outcomes for mastoidotympanoplasty and for tympanoplasty alone in cases of quiescent, tubotympanic, chronic, suppurative otitis media.

Study design:

Single-blinded, randomised, controlled study within a tertiary referral hospital.

Methods:

Sixty-eight cases were randomly allocated into two groups. In group one, 35 ears underwent type one tympanoplasty along with cortical mastoidectomy. In group two, 33 ears underwent type one tympanoplasty alone. Outcome measures were as follows: perforation closure and graft uptake, hearing improvement, disease eradication, and post-operative complications.

Results:

There were no statistically significant differences in hearing improvement, tympanic perforation closure, graft uptake or disease eradication, comparing the two groups at three and six months post-operatively.

Conclusion:

Mastoidotympanoplasty was not found to be superior to tympanoplasty alone over a short term follow-up period. Hence, it may not be necessary to undertake routine mastoid exploration at this stage of disease.

Otologic surgery following ear trauma

OBJECTIVES

To investigate common presentations and expected outcomes in patients with traumatically induced otologic dysfunction.

STUDY DESIGN

Retrospective case review of patients who underwent otologic surgery for sequelae of otologic trauma over a 28-year period. Patients were stratified into major and minor trauma cohorts. Major trauma was designated as closed head injury with or without temporal bone fracture; lower-energy insults comprised the minor trauma group. Preoperative and postoperative audiograms were obtained and correlated with extent of injury.

SETTING

Tertiary referral center.

RESULTS

Major trauma accounted for 44.9 percent of all patients. The remaining 55.1 percent suffered minor trauma, of which simple traumatic tympanic membrane perforation was the most common insult (33.6%). Two hundred twenty-seven cases were performed on 214 patients. Pure tone averages improved a significant 20.8 dB to essentially normal levels postoperatively.

CONCLUSION

Regardless of injury extent, surgical rehabilitation of conductive losses attains excellent hearing results that surpass those historically reported for the chronic ear population.

Efeito da timpanoplastia no zumbido de pacientes com hipoacusia condutiva: seguimento de seis meses

O timpanoplastia tem como objetivos erradicar a doença da orelha média e restaurar os mecanismos de condução sonora. Contudo, alguns pacientes apresentam incômodo com o zumbido e muitas vezes questionam o médico sobre os resultados da cirurgia em relação ao zumbido. OBJETIVO: Avaliar a evolução do zumbido em pacientes com hipoacusia condutiva após timpanoplastia. Forma de Estudo: Coorte prospectiva. CASUÍSTICA E MÉTODO: Foram avaliados 23 pacientes com queixa de zumbido e diagnóstico de otite média crônica simples com indicação cirúrgica. Os pacientes foram submetidos a um protocolo de investigação médica e audiológica do zumbido antes, 30 e 180 dias após a timpanoplastia. RESULTADOS: 82,6% dos pacientes apresentaram melhora ou abolição do zumbido. Melhora significante do incômodo do zumbido no pré-operatório (5,26) em relação ao pós-operatório (1,91 com 30 e 180 dias), assim como entre o incômodo da perda auditiva pré-operatória (6,56) e pós-operatória (3,65 e 2,91). A audiometria revelou melhora do limiar tonal em todas as freqüências, com exceção de 8KHz, havendo fechamento ou gap máximo de 10dB NA em 61% dos casos. Pega total do enxerto em 78% dos casos. CONCLUSÃO: Além da melhora da perda auditiva, a timpanoplastia também proporciona bons resultados sobre o controle do zumbido.

The effect of timpanoplasty on tinnitus in patients with conductive hearing loss: a six month follow-up

Tympanoplasty is done to eradicate ear pathology and to restore the conductive hearing mechanism (eardrum and ossicles). Some patients, however, do not tolerate tinnitus and question physicians about the results of surgery when tinnitus persists.

AIM

to evaluate the progression of tinnitus in patients with conductive hearing loss after tympanoplasty.

STUDY DESIGN

a prospective cohort study.

MATERIAL AND METHODS

23 consecutive patients with tinnitus due to chronic otitis media underwent tympanoplasty. The patients underwent a medical and audiological protocol for tinnitus before and after tympanoplasty.

RESULTS

82.6% of patients had improvement or elimination of tinnitus after tympanoplasty The mean score of postoperative intolerance to tinnitus (1.91 for 30 and 180 days) was significantly different from preoperative scores (5.26). As to hearing loss, patients improved medically 30 and 180 days after surgery (3.65 and 2.91) compared to the preoperative condition (6.56). Audiometry revealed improvement at all frequencies from 0.25 to 6KHz, except at 8KHz. The air-bone gap was closed or was within 10dB in 14 cases (61%). An intact tympanic membrane was achieved in 78% of the cases.

CONCLUSION

Aside from the classical improvement of hearing loss, tympanoplasty also offers good control of tinnitus.

Tympanometric volume: a predictor of success of tympanoplasty in children

OBJECTIVES

To determine if preoperative tympanometric volumes have any predictive value in the success of pediatric tympanoplasty.

STUDY DESIGN AND SETTING

Retrospective chart review in a tertiary referral center.

MAIN OUTCOME MEASURES

Success was defined as no evidence of tympanic membrane perforation via otoscopic examination and normal aeration of the middle ear.

METHODS

Fifty-eight pediatric patients who underwent tympanoplasty between 1996 and 2004 were studied; reviewed factors included recent discharge from the ear, perforation size, disease of the contralateral ear, age, gender, middle ear findings, and location of perforation.

RESULTS

The overall success rate was 59 percent. The success rate was 89 percent for patients with a large preoperative tympanometric volume compared with 34 percent for patients with a small volume. Multivariate analysis demonstrated that disease of the contralateral ear and a large tympanometric volume were statistically significant.

CONCLUSION AND SIGNIFICANCE

A large tympanometric volume may be an important factor when considering tympanoplasty in children. In addition, disease of the contralateral ear may be a prognostic indicator.

Efficacy of mastoidectomy on MRSA-infected chronic otitis media with tympanic membrane perforation

OBJECTIVES

To retrospectively evaluate the efficacy of mastoidectomy on methicillin-resistant Staphylococcus aureus (MRSA)-infected chronic otitis media in comparison with methicillin-susceptible Staphylococcus aureus (MSSA)-infected otitis media.

METHODS

Between January 1998 and October 2003, 18 ears underwent surgery for MRSA-infected chronic otitis media with tympanic membrane perforation at the Department of Otolaryngology, Hyogo College of Medicine. Another 33 ears underwent surgery for MSSA-infected chronic otitis media with tympanic membrane perforation during the same period. The postoperative results of graft success rate, hearing results and other complications were compared between MRSA-infected and MSSA-infected ears with or without mastoidectomy, and discharging or dry ears.

RESULTS

In MRSA, the mastoidectomy group tended to have a better graft success rate than the non-mastoidectomy group. In MSSA, there were almost the same graft success rate and hearing results between the mastoidectomy and non-mastoidectomy groups regardless of the presence of discharge. In MRSA-infected discharging ears, the rate of postoperative complications (ear drum perforation, persistent otorrhea, and dehiscence of skin incision) were significantly lower in the mastoidectomy group than in the non-mastoidectomy group (p=0.046).

CONCLUSION

Mastoidectomy had significantly better results concerning postoperative complications in discharging ears with MRSA-infected chronic otitis media. We recommend performing tympanoplasty with mastoidectomy in MRSA-infected chronic otitis media.

Congenital cholesteatoma: theories, facts, and 53 patients

Congenital cholesteatoma has a different pathophysiology than acquired cholesteatoma in that these patients rarely have eustachian tube dysfunction. This likely accounts for their reasonable preoperative hearing and their lack of complications or recurrences postoperatively. The most important factor is early detection. Treatment remains surgical removal.

Indications and Technique in Mastoidectomy

The goal of any chronic ear surgery is to create a dry, safe ear and to preserve or restore hearing as much as possible. Multiple different mastoid procedures exist, each with their own indications, advantages, and disadvantages. A keen understanding of all mastoid procedures allows the surgeon to individualize which procedure is appropriate for each patient. A thorough understanding of the anatomy and dissection techniques allows each of these procedures to be done safely.