Bioprinted collagen-based cell-laden scaffold with growth factors for tympanic membrane regeneration in chronic perforation model

With the recent development of bioprinting technology, various attempts have been made to replace bioprinting technologies and regenerative medicine are more directed towards transplantation/reconstructive surgeries only with the implantation of scaffolds. The purpose of this study is to determine whether the growth factors, human umbilical cord serum (hUCS) and bFGF (basic fibroblast growth factor), have a synergistic effect on eardrum regeneration, when used with a cell-printed scaffold in a chronic tympanic membrane perforation (TMP) model. In this study, in vitro cellular activities for bioprinted cell-laden collagen scaffolds using human adipose stem cells (hASCs) and supplemented with 10 μg/mL hUCS and 10 ng/mL bFGF were performed. The mixture of the growth factors in the cell-laden structures effectively affects various in vitro cellular responses including the proliferation of hASCs and the migration of keratinocytes due to the synergistic effect of the growth factors and hASCs. For the in vivo evaluation, a rat TMP model was used, and the TMP regeneration was assessed by otoscopic examination, hearing threshold measurement, and histologic examination. Although the cell-laden structure containing hUCS was more enhancing effect compared to the structure with bFGF, more synergistic effect in the structure using hUCS/bFGF was observed. Based on the results, we believe that the cell-laden structure incorporating hUCS and bFGF can induce significant regeneration of chronic tympanic membrane perforation.

Necessities, opportunities, and challenges for tympanic membrane perforation scaffolding-based bioengineering

Tympanic membrane (TM) perforation is a global clinical dilemma. It occurs as a consequence of object penetration, blast trauma, barotrauma, and middle ear diseases. TM perforation may lead to otitis media, retraction pockets, cholesteatoma, and conductive deafness. Molecular therapies may not be suitable to treat perforation because there is no underlying tissue matrix to support epithelium bridging. Chronic perforations are usually reconstructed with autologous grafts via surgical myringoplasty. Surgical treatment is uncomfortable for the patients. The grafting materials are not perfect because they produce an opaque membrane, fail in up to 20% of cases, and are suboptimal to restore acoustic function. Millions of patients from developing parts of the world have not got access to surgical grafting due to operational complexities, lack of surgical resources, and high cost. These shortcomings emphasize bioengineering to improve placement options, healing rate, hearing outcomes, and minimize surgical procedures. This review highlights cellular, structural, pathophysiological, and perforation specific determinants that affect healing, acoustic and surgical outcomes; and integrates necessities relevant to bioengineered scaffolds. This study further summarizes scaffolding components, progress in scaffolding strategies and design, and engenders limitations and challenges for optimal bioengineering of chronic perforation.

[Spontaneous course of traumatic tympanic membrane perforations]

BACKGROUND

Traumatic eardrum perforation is a common presentation in otorhinolaryngologic practices and emergency clinics. A consistent management strategy (active intervention vs. watchful waiting) is, however, still lacking.

OBJECTIVE

In the following study, the outcome of watchful waiting is analyzed and presented.

MATERIALS AND METHODS

A collective of 272 patients presenting at two different specialist ENT practices within days of traumatic tympanic membrane perforation from June 2002 to March 2019 were analyzed. Treatment was non-surgical, with prospective monitoring. Whereas antibiotics were not given at all in one practice, they were given only upon signs of infection in the other practice. The outcome was evaluated retrospectively on the basis of patient files.

RESULTS

The collective consisted of 185 males and 87 females. Mean age was 30 years (range: 7 months to 82 years). The perforations were most commonly located in the upper anterior and lower posterior quadrants. According to Griffin grading, the size was grade I in 97%. The three most common causes were impact to the ear, barotrauma, and foreign bodies. Under a watchful waiting regimen, 95% of the patients presenting for follow-up checks showed complete closure.

CONCLUSION

Watchful waiting can be assessed as appropriate in traumatic eardrum perforation, provided otorhinolaryngologic follow-up is ensured. An exception is blast injury, which is now much less common in Central Europe, as this is associated with a risk of secondary cholesteatomas. In these rare cases, active treatment with surgical exploration of the middle ear including relining the perforation is indicated.

Topical platelet rich plasma versus hyaluronic acid during fat graft myringoplasty

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Repair of Tympanic Membrane Perforations with Customized Bioprinted Ear Grafts Using Chinchilla Models

The goal of this work is to develop an innovative method that combines bioprinting and endoscopic imaging to repair tympanic membrane perforations (TMPs). TMPs are a serious health issue because they can lead to both conductive hearing loss and repeated otitis media. TMPs occur in 3-5% of cases after ear tube placement, as well as in cases of acute otitis media (the second most common infection in pediatrics), chronic otitis media with or without cholesteatoma, or as a result of barotrauma to the ear. About 55,000 tympanoplasties, the surgery performed to reconstruct TMPs, are performed every year, and the commonly used cartilage grafting technique has a success rate between 43% and 100%. This wide variability in successful tympanoplasty indicates that the current approach relies heavily on the skill of the surgeon to carve the shield graft into the shape of the TMP, which can be extremely difficult because of the perforation's irregular shape. To this end, we hypothesized that patient specific acellular grafts can be bioprinted to repair TMPs. In vitro data demonstrated that our approach resulted in excellent wound healing responses (e.g., cell invasion and proliferations) using our bioprinted gelatin methacrylate constructs. Based on these results, we then bioprinted customized acellular grafts to treat TMP based on endoscopic imaging of the perforation and demonstrated improved TMP healing in a chinchilla study. These ear graft techniques could transform clinical practice by eliminating the need for hand-carved grafts. To our knowledge, this is the first proof of concept of using bioprinting and endoscopic imaging to fabricate customized grafts to treat tissue perforations. This technology could be transferred to other medical pathologies and be used to rapidly scan internal organs such as intestines for microperforations, brain covering (Dura mater) for determination of sites of potential cerebrospinal fluid leaks, and vascular systems to determine arterial wall damage before aneurysm rupture in strokes.

The effects of fibroblast growth factor-2 delivered via a Gelfoam patch on the regeneration of myringosclerotic traumatic eardrum perforations lying close to the malleus

OBJECTIVE

We evaluated the effects of fibroblast growth factor-2 (FGF-2) delivered via a Gelfoam patch on the regeneration of myringosclerotic traumatic tympanic membrane perforations (TMPs) lying close to the malleus.

STUDY DESIGN

A prospective, randomized, controlled clinical study.

SETTING

A university-affiliated teaching hospital.

SUBJECTS AND METHODS

We prospectively analyzed, in a randomized manner, the outcomes of treatment for traumatic TMPs constituting >25% of the tympanic membrane. The closure rates, closure times, and otorrhea rates were compared among patients treated via FGF-2-containing Gelfoam patches, Gelfoam patches alone, and observation only.

RESULTS

We analyzed data from 138 patients. The perforation closure rates in the FGF-2 plus Gelfoam patch, Gelfoam patch, and observation alone groups were 97.9, 89.8, and 70.7%, respectively. Both the FGF-2 plus Gelfoam and Gelfoam alone groups exhibited significantly higher closure rates than the observational group (both p<0.05).The mean closure times were 15.7±5.1, 24.8±4.9, and 35.7±9.2days in the FGF-2 plus Gelfoam patch, Gelfoam patch alone, and observation alone groups, respectively. The FGF-2 plus Gelfoam patch group exhibited a significantly shorter closure time than the Gelfoam patch alone and observation alone groups (p<0.05). The incidences of purulent otorrhea were 14.6, 6.1, and 4.9% in the FGF-2 plus Gelfoam patch, Gelfoam patch alone, and observation alone groups, respectively. Surprisingly, 7 of 7 (100.0%) perforations associated with purulent otorrhea completely closed in the FGF-2 plus Gelfoam patch group; however, no such perforation healed in either the Gelfoam alone or observation alone group.

CONCLUSIONS

FGF-2 plus Gelfoam patching significantly shortened the closure time compared to observation and Gelfoam patching alone, and it significantly improved the closure rate (compared to observation alone) of myringosclerotic perforations lying close the malleus. FGF-2 plus Gelfoam patching is a valuable, minimally invasive alternative treatment that may be readily applied to outpatient settings.

Conditions of the external and middle ear: an overview of presentation, management and associated complications

Ear, nose and throat (ENT) presentations to primary care are common and frequently affect military patients. Many patients can be managed in primary care with appropriate treatment, but some presentations require appropriate, timely, and occasionally emergency onward referral for hospital management. This paper discusses the management of common otological presentations including otitis externa (OE), acute otitis media, chronic suppurative otitis media (including cholesteatoma), tympanic membrane (TM) perforations and pinna haematoma.

Acceleration of Healing of Traumatic Tympanic Membrane Perforation in Rats by Implanted Collagen Membrane Integrated with Collagen-Binding Basic Fibroblast Growth Factor

Traumatic tympanic membrane (TM) perforation is very common in clinical practice. Several biomaterials have been reported to play a role in TM reparation, whereas their functional recovery is limited when used alone. Meanwhile, the administration of biofactors could promote functional recovery, but rapid distribution and short half-time obstruct their application. To study the effect of traumatic TM regeneration, we prepared collagen membrane (CM) integrated with collagen-binding basic fibroblast growth factor (CBD-bFGF) and implanted into the injury site of perforated TM in Sprague-Dawley rats. The study on CBD-bFGF in vitro showed that CBD-bFGF accelerated the proliferation of human fibroblast cell HS-865 biologically and was released from CM gradually. In vivo study, through the gross anatomy, auditory brainstem responses assay, histological staining, and transmission electron microscopy observation at d7, d14, and d28 after the acute TM perforation, we found that CBD-bFGF-integrated CM promoted the healing rate at an early stage (∼7 days), reduced the healing time of perforated TM, and notably retrieved the structure and hearing of TM. These findings suggest that CM modified with CBD-bFGF could be therapeutically appropriate for the treatment of TM perforation.

Crosslinked hydrogels for tympanic membrane repair

PROBLEM: To provide a less expensive and more convenient protocol for the treatment of tympanic membrane perforations (TMPs).

METHODS: Several materials were prepared and compared for TMP repair including Carbylan-SX, Gelatin-DTPH-PEGDA (GX), Carbylan-S/Gelatin-DTPH (Carbylan-GSX) (injectable and sponge), Gelfoam, Epifilm, and crosslinked thiolated chondroitin sulfate (CS-DTPH-PEGDA [CS-SX]). Hartley pigmented guinea pigs (Elm Hill) underwent bilateral myringotomy with 1 ear left as a control and the other treated with one of the previously mentioned materials.

RESULTS: Carbylan-GSX (injectable and sponge), Gelfoam with saline, and CS-SX had the shortest time for TMP closure. Epifilm, Carbylan, and gelatin preparations resulted in closure rates similar to controls. CS-SX showed a marked inflammatory reaction compared with controls and other materials based on neutrophil, lymphocyte, epitheloid counts, and degree of fibrosis.

CONCLUSIONS: This study shows the validity of Carbylan-GSX compared with Gelfoam as a material to promote TMP closure in an acute TMP guinea pig model.

Large discrepancies in otomycosis treatment in private ear, nose, and throat clinics in Denmark

INTRODUCTION

Otomycosis is a fungal infection of the external ear canal that can involve the middle ear in case of tympanic membrane perforation and also extend to the auricle. Fungi cause 7-15% of external otitis. Diagnosing otomycosis is often based entirely on non-specific clinical signs and symptoms. A multitude of antifungal drugs are available. Some are ototoxic in animals, a few are proven safe, but the ototoxicity of many drugs remains unknown. The aim of this study was to describe how otomycosis was diagnosed and treated by private ear, nose, and throat (ENT) consultants in Denmark and to investigate if the patient's immune status and the presence of a tympanic membrane perforation affected the chosen treatment modality.

METHOD

A questionnaire on the treatment of otomycosis was sent to 147 private ENT consultants.

RESULTS

In total, 103 (70%) responded. 95% performed intensive aural cleaning using an otomicroscope. The initial diagnosis was based on symptoms as only 20% required to see fungal hypha. 42% sent material for culture and sensitivity (C + S) before starting treatment and 92% sent for C + S if treatment failed. 89% used a variety of topical antifungal drugs as the first line of medical treatment. Antiseptics were used in 5%. The presence of a tympanic membrane perforation did not alter the treatment modality. Only 13% treated immunocompromised patients differently.

CONCLUSION

The initial diagnosis was based on non-specific symptoms and there were large discrepancies in the chosen antifungal treatment. Topical antifungal drugs were preferred. Additional research is needed.

FUNDING

Department of Otorhinolaryngolgy and Maxillofacial Surgery, Zealand University Hospital, Køge, Denmark. The Danish Association of Research-interested Otorhinolaryngology Consultants: Kim Werther, Peter Tingsgaard, Mads Stougaard, Steen Telmer, Henrik Møller, Liviu Guldfred.

TRIAL REGISTRATION

No trial registration was necessary as the questionnaire was anonymous and contained no patient data.

Middle ear damages

Middle ear damages. The eardrum and middle ear are often exposed to blunt and penetrating trauma, blasts, thermal or caustic injuries. These injuries may result in tympanic membrane perforation, middle ear haemorrhage, dislocation and fracture of the ossicular chain, perilymphatic fistula and damage to the chorda tympani and/or facial nerve. In case of life-threatening injuries and/or mass casualty incidents, middle ear trauma obviously does not take highest priority. However, middle ear lesions should be suspected and recognized as early as possible. After meticulous history taking, physical examination consists of cranial nerve evaluation, thorough inspection of the outer ear, otoscopy and assessment of hearing and vestibular function. In the majority of cases, traumatic tympanic membrane perforations by penetrating and blunt injuries have a good prognosis with spontaneous resolution. Tympanic membrane perforations from blast trauma, thermal or caustic injuries are less likely to heal spontaneously. Perforations lasting six months after injury warrant surgery. A high resolution CT scan of the temporal bone is required in case of immediate complete facial nerve paralysis and when oval window pathology or perilymphatic fistula is suspected. Early surgical intervention is needed in case of early onset facial nerve paralysis, when there is suspicion of a perilymphatic fistula with persisting or increasing vestibular symptoms or neurosensory hearing loss and in case of vestibular dislocation of the stapes footplate. When ossicular chain damage is suspected, elective tympanoplasty is indicated. As any traumatic tympanic membrane perforation runs the risk of cholesteatoma formation, biannual follow-up during a minimum of two years is recommended.

OTOLOGIC FOREIGN BODY: AN UNDECLARED AND UNUSUAL IMPACTION

BACKGROUND

This study reports two cases of undeclared and unusual foreign body (FB) impaction in the ears of Nigerian adult patients that were accidentally discovered and successfully managed.

AIM

The report aims to create awareness, and encourage Otorhinolaryngologist to have proper otoscopy done for all patients with suspected ear FB and double check again following FBs removal. CONCLUSION It has recommended a need for an increased public enlightenment to raise awareness about the danger of cleaning the ears with cotton swab or other sharp materials.

To study the role of antibiotic+steroid irrigation of the middle ear in active chronic otitis media with small perforation and pulsatile discharge

OBJECTIVE

To evaluate the usefulness of antibiotic+steroid irrigation of the middle ear in patients with otitis media with small perforation and pulsatile discharge.

METHOD

A prospective, randomised, evaluator-blinded study was carried at a single tertiary care centre over eight years, looking at 100 patients with chronic suppurative otitis media involving small tympanic membrane perforations and pulsatile mucopurulent discharge. The patients were randomised and divided into two groups. In group A, the examination under microscope, with suction cleaning of the external canal, was followed by irrigation of the middle ear with antibiotic+steroid solution for up to one week, while group B was prescribed self-administration of the same drops with systemic antibiotics. The patients were followed up daily for 10 days to monitor otorrhoea relief and on a weekly basis subsequently to monitor the healing of the tympanic membrane.

RESULTS

Forty-nine patients in group A had a dry ear after 3-7 days of daily suction and the irrigation of middle ear with the antibiotic+steroid solution and 44 had a healed tympanic membrane after an average three months of follow-up. Five patients with dry ear but persistent perforation underwent tympanoplasty, while only one patient with a persistent ear discharge underwent mastoid exploration. In group B, eight patients on oral antibiotics and self-administration of the same drops had dry ear while 34 had dry ear after receiving intravenous antibiotics. Thirty perforations healed spontaneously and 12 required tympanoplasty. In 8 patients, the tympano-mastoid was explored and these patients had dry, hearing ears only after surgery.

CONCLUSION

Patients with chronic suppurative otitis media involving small perforations and pulsatile discharge can be managed conservatively with simple suction cleaning + middle ear irrigation with antibiotics + steroid drops.

[Tympanic membrane perforation ]

Tympanic membrane perforation may be caused by, e.g., trauma or acute or chronic middle ear infection. Perforation causes conductive hearing loss. Since it predisposes to infections, it is important to keep the ear dry. In most cases traumatic perforations heal spontaneously. Perforations caused by acute middle ear infections are treated with antibiotics. Chronic perforation due to chronic middle ear infection or cholesteatoma will usually not heal without surgery. Most perforation cases can be taken care of in primary care. ENT consultation is needed when alarming signs, such as continuous pain, vertigo or facial paralysis exist, or if the perforation persists.

Healing of laser-induced tympanic membrane perforations in rats: no contribution of granulocyte colony-stimulating factor or Gelfoam

OBJECTIVES

To study whether granulocyte colony-stimulating factor together with Gelfoam (absorbable gelatin sponge, USP) could enhance the healing of freshly perforated tympanic membranes. The frequency and occurrence of different immunocompetent cells and collagen types was noted.

METHODS

Laser perforations were made in the tympanic membrane of rats that were sacrificed at different time intervals post-myringotomy: Day 1, 3, 6, and 12. Tympanic membrane specimens were embedded and sections were stained with hematoxylin/eosin and an immunohistochemical technique was used, with antibodies against macrophages, B-cells, T-cells, and type I-IV collagens. Semi-quantification was performed after counting positive cells, mean values were calculated and analyzed statistically.

RESULTS

All perforations, except one, had closed by Day 12 and no difference was observed between experimental and control ears at the other time points. Gelfoam was still present in a high amount at Day 12. The sections were initially stained positive for type I and II collagen, but after Day 6, the regenerating tissue stained positive for mainly type III and IV collagens. Results showed that the recruitment of macrophages, B-cells, and T-cells could not be mapped with a statistical significance.

CONCLUSIONS

This study showed that at 6-12 days post-laser myringotomy, type III and IV collagen has replaced the collagen type II that normally constitutes the healthy tympanic membrane. There is a concern for excessive scarring involving adjacent structures. It was also seen that the combination of Gelfoam and granulocyte colony-stimulating factor or saline did not affect the healing times in perforated tympanic membranes. No significant results regarding the inflammatory cell recruitment could be obtained on the studied time points or between experimental and control ears, except for in the Gelfoam matrix.

[The reconstruction of the tympanic membrane with the use of fetal fibroblasts]

The first clinical experience with the successful application of fetal fibroblasts for the reconstruction of the tympanic membrane is presented.

Effect of treatment at different time intervals for traumatic tympanic membrane perforation on the closure

CONCLUSION

Treatment of traumatic tympanic membrane (TM) perforation with everted or involute edge flaps at different time intervals within 1 week after the injury did not affect the perforation closure rate and mean closure time.

OBJECTIVE

To retrospectively analyze the effect of treatment at different time intervals for traumatic tympanic membrane perforation with gelatin sponge patch and edge approximation plus gelfoam patching.

METHODS

Patients with traumatic TM perforation visited at different days since the injury for medical treatment (1, 2, 3, 4, and 5-7 days post trauma). These patients were treated with the following prominent methods of treatment: gelatin sponge patch treatment and edge approximation plus gelfoam patching. Measurement indicators were perforation closure rate and mean closure time at 3 months.

RESULTS

In the group treated with the gelatin sponge patch technique, the patients sought medical treatment at different time intervals since the injury. Accordingly, the outcome of the treatment varied in terms of the perforation closure rates achieved in different patients in this group. The respective perforation closure rates were 100%, 100%, 96%, 94%, and 89% in accordance with the time interval at which the patients were treated since the injury. The results were not significantly different when compared by statistical analysis (p > 0.05); the mean closure times in each of the different sets of cases in this group were calculated and the following values were reported: 7.1 ± 2.3, 8.2 ± 1.6, 8.7 ± 1.2, 9.2 ± 3.1, and 10.7 ± 3.9 days. On the other hand, in the edge approximation plus gelfoam patching group, the perforation closure rates were 100%, 97%, 96%, 97%, and 94%, respectively. This was in accordance with the time elapsed since the injury for the patients who visited the hospital on different days. Statistical analysis confirmed that the perforation closure rates for the different cases of this group did not have any significant difference (p > 0.05); the mean closure times were 7.6 ± 1.9, 7.9 ± 2.2, 9.2 ± 2.8, 8.5 ± 3.6, and 11.2 ± 4.1 days, respectively, indicating that differences were not significant even in terms of mean closure rates for the different cases of this group (p > 0.05).

Outcome of children with edge-everted traumatic tympanic membrane perforations following spontaneous healing versus fibroblast growth factor-containing gelfoam patching with or without edge repair

OBJECTIVES

To retrospectively analyze the outcome of children with edge-everted tympanic membrane (TM) perforations following spontaneous healing and fibroblast growth factor-containing gelfoam patching with or without repair of the edge flaps.

METHODS

Medical records of children with TM perforations who underwent spontaneous healing (n = 69) or received fibroblast growth factor (FGF)-containing gelfoam patching treatment (n = 67) were retrieved from the Records Department of the Wenzhou Medical College-Affiliated Yiwu Hospital in China. The demographic data and outcome measures were analyzed and compared between these two groups of patients.

RESULTS

Patching with FGF-containing gelfoams significantly improved the healing rate (P < 0.01) and the average perforation closure time (P<0.01), as compared with spontaneous healing. Repair of the perforation edge flaps did not significantly affect the outcome of gelfoam patching (P>0.05), despite a slightly reduced healing rate (96.4% versus 100%) and a slightly shorter closure time (10.2 ± 2.6 d versus 10.9 ± 3.3 d) observed as compared with no edge repair. The everted perforation edge flaps formed scabs during the process of spontaneous healing whereas they underwent retraction and eventually dissolved during the process of gelfoam patching-facilitated healing.

CONCLUSIONS

As compared with spontaneous healing, FGF-containing gelfoam patching had an improved outcome in children with edge-everted traumatic eardrum perforation. Repair of everted edge flaps did not affect the healing outcome. Our results suggest that growth factor-containing gelfoam patching without eardrum flap repair would offer a feasible option to manage traumatic tympanic membrane perforations in children.

[Evaluation of influencing factors and different repair mechanism of tympanic membrane perforations]

OBJECTIVE

Evaluation of different repair mechanism and influencing factors for Prognosis of tympanic membrane perforations.

METHOD

One hundred and twelve female patients of tympanic membrane perforations were randomly divided into two groups: control group (natural repair group) and treatment group (gelatin sponge patch bonded repair group). The perforation healing were dynamically observed in two groups by endoscope.

RESULT

The result show that low, medium and high perforations healing rates were 100.00%, 90.48%, 93.33%. The healing time of low, medium and high was (9.0 +/- 2.8) d, (13.0 +/- 2.6) d, (22.0 +/- 4.7) d, the epithelial layer reverse growth in 5 cases. The result show that low, medium and high perforations healing rates were 91.67%, 95.24%, 84.62%. The healing time of low, medium and high was (11.0 +/- 3.7) d, (24.0 +/- 3.8) d, (36.0 +/- 2.1) d, 2 cases were undergone surgeries.

CONCLUSION

There are differences in repair mechanism between natural repair and patch bonded repair patch bonded repair can promote granulation hyperplasia, it can help recovering and lessening the patient's conductive hearing loss and occasional tinnitus. granulation hyperplasia and the healing time is closely related. The epithelial layer reverse growth may affect the healing of tympanic membrane perforation.

[How to raise efficacy of myringoplasty in extensive defects]

A comparative trial of miringoplasty efficacy with or without application of biosynthetic wound cover Biocom-1 was performed in 82 patients with sub- and total chronic defects or acute traumatic rupture of the tympanic membrane (58 and 24 patients, respectively). Better clinico-morphological and functional results were achieved in patients treated with application of Biocom-1 (p<0.05). Their stay in hospital was also shorter. Biocom-1 not only provides stable position of the neotympanic membrane but also protects against secondary infection.

Chronic tympanic membrane perforation: a better animal model is needed

Developments in the treatment of chronic tympanic membrane perforation have been hindered by the lack of an ideal animal model. It is not appropriate to test such treatments on acute perforations as the majority of these heal spontaneously. An ideal animal model would be one that most closely resembles the human clinical situation. It should be inexpensive, readily available, and easy to create. There have been a number of attempts to create a chronic tympanic membrane perforation model with limited success. All published attempts at chronic tympanic membrane perforations have been reviewed and the limitations of each model are discussed. A number of areas for research exist for further developing a chronic tympanic membrane perforation model. These areas include a perforation model in the presence of bacteria and eustachian tube dysfunction. Understanding the molecular and genetic mechanisms of chronic otitis media and potential treatments will also be useful.

Healing time, long-term result and effects of stem cell treatment in acute tympanic membrane perforation

OBJECTIVE

The incidence of otitis media in children between the age of 2 and 6 years is well documented. Repeated attacks may cause acute and chronic perforations. The surgical treatment for repairing chronic perforation is quite uncomfortable for the patients of this age group because of the invasiveness of this treatment. The aim of this study was to determine the long-term influence of embryonic stem cells on acute perforations and the effect of gelatin as a vehicle for applied stem cells. The possibility of teratogenic effects of the stem cells was also observed.

METHODS

Bilateral laser myringotomy was performed in 17 adult Sprague-Dawley rats, divided into two groups. Gelatin, a substance suitable as vehicle for bioactive material was used bilaterally around the perforation in group A, to serve as a scaffold for repairing tissue. The stem cells were used in the right tympanic membrane perforation leaving the left tympanic membrane as a control. The animals in group B received the same treatment except for the use of gelatin and in addition received an immuno-suppressive agent. After half a year of observation the mechanical stiffness of the tympanic membrane was measured by moiré interferometry for group B and the morphological study was performed by light microscopy for both groups A and B and electron microscopy for group A.

RESULTS

Stem cell treated ears did not show any enhanced healing of the perforation although a marked thickening of the lamina propria was observed compared with control group. After half a year the strength and the stiffness of the tympanic membrane was almost the same for both treated and untreated ears. No evidence of teratoma was found after half a year.

CONCLUSION

This study suggests that the stem cells stimulate the proliferation of connective tissue and fibers in the lamina propria, possibly mediated by secreted substances, although the stiffness properties do not seem to be altered. The use of gelatin does not seem to enhance the healing process of the tympanic membrane perforation.

The effect of topical insulin application on the healing of acute tympanic membrane perforations: a histopathologic study

The aim of the present study was to investigate the effects of insulin on the healing of acute traumatic tympanic membrane (TM) perforations by observing the duration of perforation closure clinically and by examining the TM thickness, fibroblastic reaction, neovascularization and collagenization histologically. In all, 24 adult healthy guinea pigs were used. TM perforations, about 2 mm in diameter were made in the pars tensa of each ear. The perforations in the right ears of the guinea pigs (study group) were treated with 1 IU of regular insulin (Humulin-R 100 IU/ml, Lilly) daily topically. The left ears of the guinea pigs (control group) were treated with saline solution daily. The treatments were continued until the each perforation closed. The animals were examined with otomicroscopy at first, third, fifth and seventh days. TM specimens were obtained after the animals were decapitated under deep anesthesia by an intraperitoneal injection of sodium pentobarbital (0.5 ml/100 g) 3 and 7 days after wounding. Histologically, the epithelial and mucosal layers were examined. Finger-like projections, the edema of the LP, neovascularization of LP, fibroblastic activity of LP, inflammatory cell presence of LP, collagenization ratios of LP were evaluated. In the study group; LP fibroblastic reaction positivity and LP collagenization positivity was significantly higher than the control group (P < 0.001 and P < 0.05). Topical insulin treatment may be more beneficial in the treatment of atrophic membrane, which is a sequel of perforation, when tried in various dosages and time intervals.

Modern cell technologies in the treatment of patients with tympanic membrane injury inflicted by mine explosion

We evaluated the efficiency of transplantation of cultured human allofibroblasts onto tympanic membrane damaged by mine explosion in combination with Tampograss dressing (Paul Hartman). Transplantation of cultured human allofibroblasts was effective in 100% cases. Application of the film with fibroblasts onto perforation occupying from 1/4 to 1/2 of the tympanic membrane was more effective by 15% (by 59% in subtotal perforation) than tympanoplasty with amnion membrane. The mean duration of tympanic membrane restoration after spontaneous healing and amnionoplasty is virtually the same, while transplantation of allofibroblasts accelerated the process in comparison with other groups in perforation of any size; in subtotal defect the duration of tympanic membrane restoration was shorter by 14 +/- 1 days.

Myringoplasty: a comparison of bismuth iodoform paraffin paste gauze pack and tri-adcortyl ointment ear dressing

OBJECTIVES

To assess the myringoplasty graft take rate, comparing two methods of post-operative ear packing: bismuth iodoform paraffin paste (BIPP) gauze versus tri-adcortyl ointment (TAO).

METHODS

A retrospective study of patients who had undergone myringoplasty at our department within a three-year period was undertaken. Data, including age, site and size of perforation, grade of surgeon, surgical approach, use of post-operative ear dressings, complications, and audiometric outcome, were collected from the patient notes and analysed. The overall success rate of the operation (with success being defined as an intact tympanic membrane at six months) was noted.

RESULTS

One hundred and seventy myringoplasties were performed over the study period, but data were complete on 154 patients and these constituted the study population. Age ranged from nine to 71 years (mean age 34 years) and the mean follow-up period was seven months. Consultants performed 62 per cent of the operations, with an 85 per cent success rate, whereas trainees performed the remaining 38 per cent, with a success rate of 73 per cent (p=0.059). The overall success rate was 80 per cent; 79 per cent for BIPP and 83 per cent for TAO (p=0.55), and 87 per cent for small perforations and 75 per cent for subtotal perforations (p=0.22). There was audiometric improvement in 74 per cent of cases.

CONCLUSION

We found no significant difference in outcome between patients packed with TAO and BIPP. Packing with TAO is therefore a suitable alternative to BIPP gauze ear dressing following myringoplasty.

[Clinical management of terrorist bomb explosions]

At 07:39 on 11 March 2004 terrorist bomb explosions ocurred in 4 trains in Madrid killing 177 people instantly and 14 more later in the hospital. This report describes the organization, clinical management and patterns of injuries in casualties who were taken to our chil-patients were taken to the Gregorio Marañon hospital and 12 to the children's one. The mean age was 16 years (14-21), Two of them were critically ill and needed intensive care (ITP 5). Tympanic perforations occurred in 81% victims with moderate to severe trauma, shrapnel wounds in 36% and eye lesions in 27%. Among critically ill patients blast lung injury, cranial and abdominal trauma were the most important lesions. Training in AITP courses and hospital logistics were essential in clinical management of these casualties.

Outcomes in children with perforated tympanic membranes after tympanostomy tube placement: results using a pilot treatment algorithm

PURPOSE

The objective of this study was to examine the success of a pilot treatment algorithm for tympanic membrane perforations in children after tympanostomy tube placement.

MATERIALS AND METHODS

A retrospective chart review of children with diagnosed tympanic membrane perforations after tympanostomy tube placement from 1998 to 2003 at a tertiary care children's hospital was performed. The patients had been treated according to an algorithm used by 2 pediatric otolaryngologists for management of tympanic membrane perforations: observation vs myringoplasty. Success rates were examined.

RESULTS

Ninety-five children were identified, 27% of whom had nonhealing perforations after tube extrusion; 73% of the perforations were caused by a retained tube. The median duration of tube retention was 48 months, ranging from 13 to 120 months. After the treatment protocol, 76% of the patients underwent gelatin film or paper patch myringoplasty, 23% had adipose myringoplasty, and 1% were observed. Overall, 91% had healed perforations after the first intervention. Among those requiring a second intervention, the sizes of initial perforations were between 15% and 40%, with postrepair perforation sizes between 5% and 40%. In addition, 75% of those requiring a second intervention underwent tympanoplasty repair and 25% had fat patch myringoplasty. None required a third intervention.

CONCLUSIONS

Our treatment algorithm for children with tympanic membrane perforations after tympanostomy tube placement appears to be successful and is an excellent model for other clinicians.

Repair of subtotal tympanic membrane perforations with Seprafilm®

Objectives: We studied the experimental use of Seprafilm, a sheet-like filmform of hyaluronic acid, in the repair of subtotal perforations of the tympanic membrane (TM), and the durability of such repairs.

Method: The research was conducted on 42 Sprague–Dawley rats. Right TMs of all rats were subtotally and thermally perforated in the same fashion. Seprafilm was applied to the perforated TMs of the 21 rats comprising the experiment group. The perforated TMs of the remaining 21rats, the control group, were left to heal spontaneously.

Results: The mean healing times were recorded as 7.8 ± 0.6 days for the Seprafilm group and 14.9 ± 1.1 days for the control group (p < 0.001).

Conclusions: These results suggest that Seprafilm may be a possible first choice (before thedecision to operate) in subtotal perforations, considering its easy application and patient follow-up.

Otorrinolaringología

The terrorist attack on 11 March caused a high percentage of patients with ear injuries. Shock waves provoke alterations to the external ear as well as to the middle and inner ear. The most frequent lesion is tympanic membrane perforation. Initial evaluation with otoscopy, acoumetry, tonal audiometry and vestibular examination was performed and was repeated after 2 and 3 months. In most patients there was a correlation between the grade of middle ear lesion and auditory damage. In most patients with tympanic rupture, the perforation was total or subtotal. Spontaneous closure can occur in some patients but is usually related to the size of the initial lesion. Thus in tympanic perforations of more than 50%, spontaneous closure is unlikely.

Management of the draining ear in children

There are a variety of causes of otorrhea in children. The most important factor in reaching the proper diagnosis and providing relief of the problem is aural toilet. Once adequate debridement has been performed, the diagnosis is usually clearer, and treatment with ototopicals is significantly more effective. Most cases of otorrhea are due to infection or granulation tissue and can be managed initially with appropriately selected ototopical medication, thereby avoiding the risks and side effects of systemic therapy and the need for referral to a specialist. However, otorrhea in children that is refractory to medical therapy may be due to retained tympanostomy tubes or insidious pathology such as cholesteatoma or malignancy. In such cases, prompt referral to the otolaryngologist can facilitate accurate diagnosis and successful management.

Progressive calvarial and upper cervical pneumatization associated with habitual valsalva maneuver in a 70-year-old man

A 70-year old man with a 15-year-history of chronic daily Valsalva maneuvers for left ear congestion presented with worsening vertigo and calvarial (occipitoparietal) and upper cervical hyperpneumatization. With continued frequent Valsalva maneuvers, subsequent studies demonstrated increased pneumatization with extension of air into the epidural space, causing mass effect on the left parietal lobe. Four months after discontinuing the habitual Valsalva maneuvers, CT demonstrated resorption of the epidural air and partial regression of the calvarial pneumatization.

A new method for closing tympanic membrane perforations using basic fibroblast growth factor

OBJECTIVE

To present a new method for closing tympanic membrane perforations using basic fibroblast growth factor (bFGF) combined with an atelocollagen/silicone bilayer membrane as a patch material.

STUDY DESIGN

Closure of tympanic membrane perforations was attempted using bFGF, which is thought to facilitate the growth of fibroblasts and collagen fibers at the margin of the perforation.

METHODS

Under an operating microscope, the margin of the perforation was trimmed, and a piece of an atelocollagen/silicone bilayer membrane infiltrated with 0.2 mL Trafermin (0.1% solution) (bFGF group) or saline (control group) was then placed in the perforation with the silicon layer facing outward. Nine patients were treated with bFGF, and five were treated with saline. Data obtained from patient records included patient age, perforation size, and duration of treatment, with a focus on hearing improvement and complete tympanic membrane closure.

RESULTS

The mean perforation size before treatment was 16.5% in the bFGF group and 9.6% in the control group. Closure of the tympanic membrane perforation was achieved in all cases in the bFGF group, whereas it was achieved in only two of five cases in the control group. With bFGF treatment, the tympanic membrane perforations closed completely within 3.7 weeks, and hearing improved by 13.3 dB in the bFGF group.

CONCLUSION

The study demonstrated that bFGF combined with an atelocollagen/silicone bilayer membrane is effective for the conservative treatment of tympanic membrane perforation.

Paper Patching for Chronic Tympanic Membrane Perforations

OBJECTIVE: This study was designed to evaluate the results of paper-patch myringoplasty in patients with chronic perforations of the tympanic membrane of different sizes.

STUDY DESIGN AND SETTING: A retrospective survey of paper-patch myringoplasties performed in a tertiary referral academic medical center on 77 patients with chronic perforations of the eardrum was carried out. Data consisted of the causes of the perforations, time the perforations had been present, their size, number of patch applications, duration of application, and number of successfully closed perforations.

RESULTS: Closure rate was 63.2%, 43.5%, and 12.5% for small, medium, and large perforations, respectively. Small perforations needed the least number of repeated applications and the least time for closure.

CONCLUSIONS AND SIGNIFICANCE: Paper patching is technically simple, time saving, safe to perform, cost effective, and suitable as an outpatient procedure and has a good success rate, It should be tried in perforations smaller than 5 mm before a patient is referred for surgery.

Embryonic stem cells enhance the healing of tympanic membrane perforations

OBJECTIVE

Tympanic membrane perforations may cause hearing impairment and otorhea. It is a common indication for ear surgery. The aim of the study was to test whether stem cells may enhance the healing of fresh tympanic membrane perforations.

METHODS

In a first assay, the status of the tympanic membrane at 5 days after myringotomy was tested in five Mongolian gerbils that were treated on one side with embryonic stem cells and on the other side with control substance. In a second assay, nine gerbils were treated in the same way, except that fluorescent-labeled embryonic stem cells were used. The integration of the stem cells into the surface layer of the healing tympanic membrane was assessed with fluorescence microscopy, as well as the differentiation of these cells.

RESULTS

In the first assay, all perforations in the treated ears were closed, whereas only two of the untreated ears were closed. The strength of the healed perforation was greater in the stem cell treated tympanic membranes (mean rupture pressure 120 daPa in three treated ears compared to 60 daPa in the one control ear). Two stem cell-treated tympanic membranes remained intact throughout the whole sequence of pressures, whereas only one control tympanic membrane remained intact. In three tympanic membranes in the second assay, a group of fluorescence-doped cells was detected in the region of the perforation.

CONCLUSION

These findings indicate that stem cells enhance the healing of tympanic membrane perforations, possibly by differentiation and integration into the tympanic membrane tissue.

Feline immunodeficiency virus-mediated gene therapy of middle ear mucosa cells

HYPOTHESIS

To investigate the feasibility of gene therapy of the middle ear mucosa using a novel vector.

BACKGROUND

Given present medications are unable to affect chronic otitis media, cholesteatoma, or tympanic membrane perforation, newer methods of treatment like gene therapy for these diseases must be explored. These genes can then be used to alter cytokines in the middle ear, slow or stop cholesteatoma growth, or improve tympanic membrane perforation healing. Feline immunodeficiency virus (FIV), a new lentiviral vector has been found to have greater than 90% efficiency in transfecting epithelial cells. Therefore, in vivo gene therapy of middle ear mucosa cells was attempted.

METHODS

Twenty microliter of 5x10(5) vectors per ml FIV carrying the gene for green fluorescence protein (GFP) was introduced into the middle ears of Sprague-Dawley rats via a bulla approach.

RESULTS

Expression of the GFP gene was observed in the middle ear mucosa cells at 1 week post-inoculation indicating transfection.

CONCLUSION

Gene therapy of the middle ear is feasible with a FIV-based vector.

An observational study of the management of traumatic tympanic membrane perforations

Controversies of how best to treat fresh tympanic membrane perforations have always existed. While some otolaryngologists prefer the paper patch method, others prefer modified myringoplasty. A prospective study is needed to investigate the most effective and least expensive management of this common ear trauma. This study examined prospectively, in three sections, a group of patients with a cellophane patch (n = 6), another group with a gentamicin ointment seal (n = 15) and a control group (n = 9) with a gentamicin plug placed at the distal end of the external auditory cavity. Successful healing of the traumatic tympanic membrane perforations was achieved in 50 per cent of the cellophane seal group, 86.7 per cent of the gentamicin ointment seal group and 77.8 per cent of the control group. This study shows that the management of a fresh tympanic membrane perforation should be limited to cleaning the traumatized ear and preventing infection.

Tympanic membrane perforation in adults. How to manage, when to refer

Tympanic membrane perforation is a common and potentially serious condition. One of the most important aspects of primary care for perforations is deciding which patients need to be seen by an otolaryngologist and how urgently they need to be referred. There are several indications for surgical repair, but most cases can be managed with conservative care and require no referral.

Current trends in managing chronic middle ear disease

Major advances in reconstruction continue to be made in the treatment of chronic middle ear disease, while little prophylaxis is available and indications for intervention remain in many cases controversial. This reflects our lack of knowledge of the true causes of these diseases.

Topical ascorbic acid reduces myringosclerosis in perforated tympanic membranes. A study in the rat

Myringosclerosis, a common finding after myringotomy, has been recently associated with an increased production of oxygen free radicals. Ascorbic acid's proposed actions include collagen synthesis, antioxidation, and free radical scavenging. The effects of topical ascorbic acid on healing tympanic membranes were studied. Particular attention was given to detecting the presence of myringosclerosis. Twelve Sprague-Dawley rats were bilaterally myringotomized. Their ears were randomized into group A, which received topical ascorbic acid in Gelfoam, group B, which received topical saline solution in Gelfoam, and group C, which received no treatment. The tympanic membranes were harvested on day 13, after routine otomicroscopy. Under light microscopy, the connective tissue layer of the untouched side of the pars tensa was distinctly thicker in group A than in group B or group C. At this level, the extent of sclerotic lesions was significantly less in the ascorbic acid-treated group. It is inferred that topical ascorbic acid reduces the occurrence of myringosclerosis following tympanic membrane perforations in the rat.

Traumatic perforation of the tympanic membrane

Traumatic perforations of the ear drum are often encountered in the emergency room and in the primary care setting. We review mechanisms of injury to the tympanic membrane and elucidate the appropriate evaluation and treatment of this injury.

Creating a stable tympanic membrane perforation using mitomycin C

OBJECTIVE

To determine the ability of topically applied mitomycin C to create a stable tympanic membrane perforation.

STUDY DESIGN AND SETTING

Twenty-four rats underwent subtotal removal of the tympanic membranes bilaterally. Forty ears received 0.2 mg/ml of mitomycin C. The remaining 8 received phosphate-buffered saline solution (control). Photographs taken every 3 to 5 days for 44 days were digitally scanned and computer analyzed to calculate the percentage of residual perforation. Application of solutions, photography, and data analysis were performed in a blinded fashion.

RESULTS

The mitomycin C treated ears had delayed closure time and healing rate (from day 0 to 25) compared to the control group. All controls healed by day 14. By day 44, 92.5% of the mitomycin C treated ears healed.

CONCLUSION

Mitomycin C prolongs the closure and healing rate of myringotomies in rat tympanic membranes.

SIGNIFICANCE

Myringotomy with concurrent mitomycin C application may be useful for creating an animal model for chronic tympanic membrane perforation and should be tested in human beings as a method to maintain myringotomy patency for long-term ventilation.