Myringoplasty and tympanoplasty--results related to training and experience

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.

Outcome of Temporalis Fascia Myringoplasty With and Without use of Platelet Rich Plasma: A Randomized Control Trial

To compare efficacy of temporalis fascia myringoplasty using platelet-rich plasma(PRP) {MP-PRP} and conventional emporalis fascia myringoplasty (MP-C) in treatment of moderate to large central tympanic-membrane(TM) perforation. Randomized-Control-Trial. We randomly assigned eighty-patients with COMmucosal-type with medium to large central TM-perforation and conductive hearing loss planned for primary myringoplasty to receive either MP-PRP orMP-C. Myringoplasty was performed through postauricular approach underlay graft using temporalis fascia. Primary-outcome was graft uptake (an intact TM) at 6 months postoperatively. Secondary-outcome was the postoperative hearing improvement measured by pure-tone-audiometry (PTA). Eighty-myringoplasties (MP-PRP group-40, MP-C group-40) done for 80 patients (male = 41; female = 39, age-group = 18-45-years) were included in analysis. At 6 months postoperatively graft uptake rate was 94.4% in MP-PRP and 92.1%% in MP-C group. There was no statistically significant difference in graft-uptake between the two groups (p = 0.358). Success in terms of hearing gain (≥ 10 dB) was achieved in 34 patients (89.5%) in MP-C and 37 patients (94.9%) in MP-PRP group. At 6 months follow-up; mean-PTA-average improved from 35.10 ± 5.401 dB to 27.74 ± 5.660 dB and mean ABG improved from 24.00 ± 5.204 dB to17.42 ± 5.559 dB in MP-C group. At 6 months followup; mean-PTA-average improved from 37.00 ± 6.144 dB to 26.65 dB and mean air bone gap (ABG) improved from 25.98 ± 5.736 dB to 16.21 ± 4.318 dB in MP-PRP group. No statistically significant differences in improvement in PTA-values were observed between both groups (p = 0.336).Postoperative complications were similar in both groups. Graft-uptake, hearing outcomes and complications of MP-PRP were similar to MP-C. MP-PRP offers no advantages over MP-C for treatment of TM perforation.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

An insight to tympanic membrane perforation pressure through morphometry: A cadaver study

INTRODUCTION

A cadaveric experimental investigation aimed to show the rupture pressure of the tympanic membrane (TM) for otologists to evaluate its tensile strength.

METHODS

Twenty adult ears in 10 fresh frozen whole cadaveric heads (four males, six females) mean age 72.8 (SD 13.8) years (range 40-86) were studied. The tensile strength of the TM was evaluated with bursting pressure of the membrane. The dimensions of the membranes and perforations were measured with digital imaging software.

RESULTS

The mean bursting pressure of the TM was 97.71 (SD 36.20) kPa. The mean area, vertical and horizontal diameters of the TM were 57.46 (16.23) mm², 9.54 (1.27) mm, 7.99 (1.08) mm respectively. The mean area, length and width of the perforations were 0.55 (0.25) mm², 1.37 (0.50) mm, and 0.52 (0.22) mm, respectively. Comparisons of TM dimension, bursting pressure, and perforation size by laterality and gender showed no significant differences. The bursting pressure did not correlate (positively or negatively) with the TM or perforation sizes.

CONCLUSIONS

The TM can rupture during activities such as freediving or scuba diving, potentially leading to serious problems including brain injuries. Studying such events via cadaveric studies and data from case studies is of fundamental importance. The minimum experimental bursting pressures might better be taken into consideration rather than average values as the danger threshold for prevention of TM damage (and complications thereof) by barotrauma.

Comparison of fetal and adult tympanic membrane sizes: a cadaveric study

OBJECTIVE

The work aimed to compare fetal and adult tympanic membrane (TM) sizes for understanding dimensional development from intrauterine life to adulthood.

METHODS

Fifty-six temporal bones (18 fetuses, 10 elderly adults, half male and half female in each group) were included in this study. Using a digital image software, the TM height, width and area were measured.

RESULTS

The mean area, height and width of the TM in adults were found as 58.84 ± 22.01 mm², 9.06 ± 1.33 mm, and 8.10 ± 1.43 mm, respectively. Moreover, the mean area, height and width of the TM in fetuses were measured as 47.62 ± 12.57 mm², 8.22 ± 1.12 mm, and 7.25 ± 1.15 mm, respectively. The TM dimensions were increasing in fetuses between 20-32 weeks of gestation. However, the TM dimension was statistically similar at the 7th month, the 8th month and adult periods. The TM height was greater than its width in fetuses and adults.

CONCLUSION

The calculated regression equations of the TM parameters in fetuses may be used to estimate its size. The TM size did not change from the 7th gestational month, and thus the membrane reached adult diameter in fetal life. The TM height and width showed a very wide range; therefore, we thought that the 12 mm (the height) × 10 mm (the width) graft might be ideal dimension during the repair of the TM perforations.

Implementation and results of a surgical training programme for chronic suppurative otitis media in Cambodia

Background

Chronic suppurative otitis media is a massive public health problem in numerous low- and middle-income countries. Unfortunately, few low- and middle-income countries can offer surgical therapy.

Methods

A six-month long programme in Cambodia focused on training local surgeons in type I tympanoplasty was instigated. Qualitative educational and quantitative surgical outcomes were evaluated in the 12 months following programme completion. A four-month long training programme in mastoidectomy and homograft ossiculoplasty was subsequently implemented, and the preliminary surgical and educational outcomes were reported.

Results

A total of 124 patients underwent tympanoplasty by the locally trained surgeons. Tympanic membrane closure at six weeks post-operation was 88.5 per cent. Pure tone audiometry at three months showed that 80.9 per cent of patients had improved hearing, with a mean gain of 17.1 dB. The trained surgeons reported high confidence in performing tympanoplasty. Early outcomes suggest the local surgeons can perform mastoidectomy and ossiculoplasty as safely as overseas-trained surgeons, with reported surgeon confidence reflecting these positive outcomes.

Conclusion

The training programme has demonstrated success, as measured by surgeon confidence and operative outcomes. This approach can be emulated in other settings to help combat the global burden of chronic suppurative otitis media.

Use of porcine small intestinal submucosa for pediatric endoscopic tympanic membrane repair

Tympanic membrane perforationsoccur frequently in children, and can result in hearing loss, otorrhea, pain, and cholesteatoma. Due to the narrower ear canal in children, a postauricular incision is often needed to access the tympanic membrane for surgical repair. Endoscopic approaches are increasingly being used for tympanic membrane repair, reducing the need for postauricular incisions. As the need for a postauricular incision decreases, the demand for non-autologous grafting material has increased. Acellular porcine small intestinal submucosa (SIS) has been described in the literature as an alternative to commonly used autologous grafts, and is well suited for use with transcanal endoscopic ear surgery as a minimally invasive approach. This paper describes techniques for use of SIS in endoscopic tympanic membrane repair in children.

Study of Various Prognostic Factors Affecting Successful Myringoplasty in a Tertiary Care Centre

Introduction  Myringoplasty is a commonly performed otologic surgery.

Objectives  The objective of this study is to evaluate the effect of prognostic factors like - size, site of perforation, status of operating ear, approach, status of contralateral ear, experience of surgeon, primary or revision myringoplasty, and smoking in graft uptake, as well as to evaluate the hearing results after myringoplasty.

Methods  This is a prospective study. We included in our sample patients aged over 13 years with a Tubotympanic Chronic Otitis Media diagnosis. The patients underwent preoperative evaluation and Pure Tone Audiogram within one week prior to surgery. We performed myringoplasty using temporalis fascia graft with conventional underlay technique. We evaluated postoperative graft uptake and various factors related to the study and did a Pure Tone Audiogram at one year after surgery.

Results  The graft uptake rate after myringoplasty was 83.1% at one year in 219 patients. Graft uptake with normal opposite ear was 88.2%, and with Tubotympanic Chronic Otitis Media was 75% (statistically significant). We found no statistically significant difference in graft uptake results with other factors. We calculated hearing results of 132 patients with normal ossicular status who underwent myringoplasty. The average Air Conduction Threshold improvement was 11.44dB ( p  < 0.001) and the average Air-Bone Gap closure was 8.89dB, highly statistically significant ( p  < 0.001).

Conclusion  Diseased contralateral ear was a statistically significant poor prognostic factor for graft uptake after myringoplasty. Other factors studied were not statistically significant determining factor for graft uptake. Hearing improves significantly after myringoplasty if the ossicles are normal.

Myringoplasty outcomes in the UK

OBJECTIVES

To determine the outcome of myringoplasty as undertaken by ENT surgeons in the UK, and to assess the current systems available for providing national outcome data.

METHODS

A prospective national multicentre audit was conducted involving multiple hospitals throughout the UK. Participants consisted of ENT surgeons practising in the UK.

RESULTS

Data were prospectively collected over a three-year period between 1 March 2006 and 1 March 2009 using the web-based Common Otology Database. In total, 33 surgeons provided valid and complete data for 495 procedures. The overall closure rate for myringoplasty was 89.5 per cent. The average hearing gain for successful primary myringoplasties was 9.14 dB (standard deviation = 10.62). The Common Otology Database provided an effective platform for capturing outcome data.

CONCLUSION

Myringoplasty is a safe and effective procedure in the UK. With the introduction of revalidation by the General Medical Council, participation in national audits will be mandatory in the future. This study demonstrates that a web-based audit tool would be suitable for performing such audits.

A review of simulation platforms in surgery of the temporal bone

BACKGROUND

Surgery of the temporal bone is a high-risk activity in an anatomically complex area. Simulation enables rehearsal of such surgery. The traditional simulation platform is the cadaveric temporal bone, but in recent years other simulation platforms have been created, including plastic and virtual reality platforms.

OBJECTIVE OF REVIEW

To undertake a review of simulation platforms for temporal bone surgery, specifically assessing their educational value in terms of validity and in enabling transition to surgery.

TYPE OF REVIEW

Systematic qualitative review.

SEARCH STRATEGY

Search of the Pubmed, CINAHL, BEI and ERIC databases.

EVALUATION METHOD

Assessment of reported outcomes in terms of educational value.

RESULTS

A total of 49 articles were included, covering cadaveric, animal, plastic and virtual simulation platforms. Cadaveric simulation is highly rated as an educational tool, but there may be a ceiling effect on educational outcomes after drilling 8-10 temporal bones. Animal models show significant anatomical variation from man. Plastic temporal bone models offer much potential, but at present lack sufficient anatomical or haptic validity. Similarly, virtual reality platforms lack sufficient anatomical or haptic validity, but with technological improvements they are advancing rapidly.

CONCLUSIONS

At present, cadaveric simulation remains the best platform for training in temporal bone surgery. Technological advances enabling improved materials or modelling mean that in the future plastic or virtual platforms may become comparable to cadaveric platforms, and also offer additional functionality including patient-specific simulation from CT data.

Clinical efficacy of fat-graft myringoplasty for perforations of different sizes and locations

CONCLUSION

Fat-graft myringoplasty (FGM) has a reliable tympanic closure rate for small to large perforations, but yields poor hearing improvement in the latter case. A topographic evaluation of FGM showed that the procedure resulted in a reliable perforation closure rate and audiologic outcome, regardless of perforation location.

OBJECTIVES

This study assessed the utility of FGM in treating perforations of different sizes and locations.

METHODS

This retrospective study involved 45 patients (46 ears) who underwent FGM at St Mary's Hospital (Seoul, Korea) between August 2007 and February 2010.

RESULTS

The total perforation closure rate after FGM was 87% (40 cases), with no statistical difference among perforation size groups, even though the mean closure rates of the 10-20% and >30% perforation groups were lower than other groups. The difference in the closure rates of patients with anteriorly located perforations and those with perforations in other sites was not significant. The mean postoperative air-bone gap (ABG) was 14.3 (±7.5) dB. Mean postoperative ABG improved significantly after FGM; however, on a per-group basis, the >30% perforation group had the poorest results and the difference was statistically significant. The difference in mean postoperative ABGs of the two groups depending on the location of the perforation (anterior and other) was not significant.

Myringoplasty: impact of perforation size on closure and audiological improvement

Objectives:

To investigate the impact of perforation size and other variables on the success of myringoplasty, and also to determine audiological gain following successful closure of tympanic membrane perforations of various sizes.

Study design:

Retrospective analysis of 130 case notes.

Main outcome measures:

(1) Successful closure of tympanic membrane following myringoplasty, in relation to recorded variables (i.e. perforation size, grade of surgeon, surgical technique, graft material, previous myringoplasty and smoking history). (2) Mean, four-frequency, air conduction audiometric gain following successful myringoplasty for various, pre-operatively categorised tympanic membrane perforation sizes.

Results and Conclusion:

The collective myringoplasty success rate was 80.8 per cent (105/130); for successful patients, the mean air conduction audiometric gain was −6.8 dB (t = 5.29, p < 0.0001). Neither perforation size nor any other assessed variable was a statistically significant determinant factor for successful myringoplasty. Air conduction audiometric gains following successful myringoplasty were directly correlated with pre-operative perforation size (−4.0 dB for 0–20 per cent perforations, −5.0 dB for 21–40 per cent, −9.1 dB for 41–60 per cent, −10.8 dB for 61–80 per cent and −13.3 dB for 81–100 per cent).

Success is a matter of experience: type 1 tympanoplasty : influencing factors on type 1 tympanoplasty

Our objective was to identify the factors that could influence the success rate of type 1 tympanoplasty in a tertiary care centre where both residents and senior surgeons perform this operation. Six hundred and seven patients who had been performed type 1 tympanoplasty as a primary otologic surgery between January 1997 and December 2004 were retrospectively chart reviewed. The patients had intact and mobile ossicular chain peroperatively. Patients with any other macroscopic otologic pathology like cholesteatoma, granulation in the middle ear and osteitis in mastoid cells were excluded from the study. Dry ear, intact and mobile tympanic membrane, improvement of the hearing by at least 10 dB and air-bone gap less than 25 dB were accepted as success criteria after 12 months of follow-up period. Chi-square test was used for statistical comparison of the different influencing factors. The male gender, younger age, smaller-sized perforations and experience of the surgeon were stated as good prognostic factors due to statistical evaluation. Afterwards the data of the study group was reanalysed in order to decide the cases for the residents. Finally, it was observed that seniors had better results in cases with perforations greater than 50%, dry ears and patients older than 16 years. In training and research clinics where both residents and senior surgeons perform type 1 tympanoplasty, the rate of success can be enhanced if patients with perforations greater than 50%, dry ears and patients older than 16 years are operated by the senior surgeons. The reason for this is that these groups have the overall worse results and should by argument be done by senior surgeons.

A multivariate analysis of otological, surgical and patient-related factors in determining success in myringoplasty

OBJECTIVES

The aim of this study was to evaluate the effects of smoking and other prognostic factors on long-term surgical outcome and hearing results in myringoplasty.

DESIGN

Retrospective cohort.

SETTING

Tertiary medical centre.

PARTICIPANTS

Eighty myringoplasty operations were analysed retrospectively from the charts of 74 patients who underwent myringoplasty between January 2000 and November 2002 at the First ENT Clinic of Ataturk Training and Research Hospital, using the chi-squared test, Fisher's exact test, t-test and multiple logistic regression statistical analysis.

MAIN OUTCOME MEASURES

The effects of prognostic factors and smoking on myringoplasty were investigated by variables noted from patients' files such as smoking status, operation type, duration of dry period of the diseased ear, peroperative otorrhoea, status of the opposite ear, presence of perforation at admission, place of perforation, size of perforation, status of middle ear mucosa, presence of cholesteatoma and tympanosclerosis, ossicular status, previous and related surgery, experience of the surgeon, presence of anterior overhang, presence of valsalva manoeuvre, postoperative antiobiotic cover and income per day.

RESULTS

The overall take rate of the myringoplasty graft was 71%. Based on the univariate analysis, smoking status of the patients (P = 0.008), status of the opposite ear (P = 0.01), size of perforation (P = 0.009) and the experience of the surgeon (P = 0.002) were found to be statistically significant (P < 0.01) prognostic factors influencing the success rate of the operations. Multiple logistic regression analysis was subsequently carried out on these prognostic factors and yielded the following classification (95% CI): senior surgeon (OR = 14.3), non-smoking patient (OR = 11.4), longer duration of dry period of the diseased ear (OR = 5.3), normal opposite ear (OR = 5.0) and small perforation (OR = 4.8).

CONCLUSIONS

A non-smoking patient, a longer dry ear, a healthy opposite ear, a relatively smaller perforation and a senior surgeon were found to be significant prognostic factors positively influencing the success rate of myringoplasty.

Myringoplasty using a subcutaneous soft tissue graft

A retrospective study was performed on patients who underwent myringoplasty using an autologous subcutaneous soft tissue graft over a 5-year period. Details including age, site and size of perforation, grade of surgeon, surgical approach, postoperative dressings, overnight stay, complications and outcome were recorded and analysed. Fifty-two patients underwent myringoplasty using a subcutaneous soft tissue graft. Their ages ranged from 4 to 78 years (median = 36 years). The mean follow-up period was 19 months. Successful closure to give an intact tympanic membrane was obtained in 82.7% of patients. Thresholds improved on pure tone audiometry in 57.1% and deteriorated in only one patient. There was no case of dead ear as a result of surgery. Subcutaneous tissue graft has comparable outcomes with temporalis fascia graft with additional advantages of a smaller incision, minimum dissection and a lower risk of bleeding.

Anterosuperior anchoring myringoplasty technique for anterior and subtotal perforations

Anterior and subtotal tympanic perforations are difficult perforations to repair. We used the anterosuperior anchoring technique to repair 105 of those perforations. Our technique utilizes a large temporalis fascia graft using an underlay technique with due emphasis on anterosuperior anchorage. The success rates in paediatric myringoplasty for consultant solo (J.R.K.) and trainees under supervision were 100% and 85.7%, respectively. The overall success rates in adult myringoplasty for consultant solo and trainees under supervision were 93.8% and 82.4%, respectively. Analysis of the 82 successful cases showed statistically significant improvement in air conduction thresholds after myringoplasty at 500 Hz (P < 0.01), 1 kHz (P < 0.05), 2 kHz (P < 0.01) and 4 kHz (P < 0.01). Our study showed that the anterosuperior anchoring technique produced excellent results in the repair of challenging anterior and subtotal perforations in both adults and children.

Temporalis fascia grafts shrink

Temporalis fascia, placed as an underlay graft, is commonly used to repair tympanic membrane perforations. Graft failure, however, is a well recognized complication. Grafts are often allowed to dry out during the procedure and, therefore, are often positioned in a dry or partially dehydrated state and only become fully rehydrated after placement. This study looked at how the size of the temporalis fascia alters with its state of hydration. The size of 20 temporalis fascia grafts was measured when fresh, after flattening and allowing them to dry, and finally after rehydrating the grafts with 0.9 per cent saline solution. Significant shrinkage was demonstrated. It is therefore proposed that a cause of increased failure rates, particularly in anterior myringoplasties, is loss of underlay due to graft rehydration and shrinkage. Thus graft shrinkage should be considered when positioning the graft.