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Surgery for chronic suppurative otitis media performed in low- and middle-income countries creates specific challenges. This paper describes the equipment and a variety of techniques that we find best suited to these conditions. These have been used over many years in remote areas of Nepal.
Results and conclusion
Extensive chronic suppurative otitis media is frequently encountered, with limited pre-operative investigation or treatment possible. Techniques learnt in better-resourced settings with good follow up need to be modified. The paper describes surgical methods suitable for resource-poor conditions, with rationales. These include methods of tympanoplasty for subtotal wet perforations, hearing reconstruction in wet ears and open cavities, large aural polyps, and canal wall down mastoidectomy with cavity obliteration. Various types of autologous ossiculoplasty are described in detail for use in the absence of prostheses. The following topics are discussed: decision-making for surgery on wet or best hearing ears, children, bilateral surgery, working with local anaesthesia, and obtaining adequate consent in this environment.
Perforations of the tympanic membrane are treated with various surgical techniques and materials. This study aimed to determine the efficacy of platelet-rich plasma during underlay myringoplasty.
The study included 40 patients. Autologous platelet-rich plasma was applied in-between temporalis fascia graft and tympanic membrane remnant during underlay myringoplasty in group 1 (n = 20). The outcome was evaluated after three months and compared with group 2 (n = 20), a control group that underwent routine underlay tympanoplasty.
After three months’ follow up, graft uptake was 95 per cent in group 1 and 85 per cent in group 2 (p < 0.03). Mean hearing threshold gain was 18.62 dB in group 1 and 13.15 dB in group 2. This difference was statistically significant (p < 0.01).
Platelet-rich plasma, with its ease of preparation technique, availability, low cost, autologous nature and good graft uptake rate, justifies its use in tympanoplasty type I procedures.
To review the history of moist therapy used to regenerate traumatic tympanic membrane perforations.
The literature on topical agents used to treat traumatic tympanic membrane perforations was reviewed, and the advantages and disadvantages of moist therapy were analysed.
A total of 76 studies were included in the analysis. Topical applications of certain agents (e.g. growth factors, Ofloxacin Otic Solution, and insulin solutions) to the moist edges of traumatic tympanic membrane perforations shortened closure times and improved closure rates.
Dry tympanic membrane perforation edges may be associated with crust formation and centrifugal migration, delaying perforation closure. On the contrary, moist edges inhibit necrosis at the perforation margins, stimulate proliferation of granulation tissue and aid eardrum healing. Thus, moist perforation margins upon topical application of solutions of appropriate agents aid the regeneration of traumatic tympanic membrane perforations.
This study investigated the performance of a cartilage slicer device referred to as the ‘Hacettepe cartilage slicer’.
Forty-one cartilage pieces were harvested from eight fresh frozen human ears and measured in thickness with a digital micrometer. These pieces were randomly sliced using four different thickness settings and two different types of blades. The thicknesses of the slices and remaining pieces were measured also. Scanning electron microscopy was utilised to determine the surface smoothness of the slices.
Thickness results showed a proportional increase with the increasing thickness setting, with a ±0.1 mm margin of error. The measurements showed that over 95 per cent of the slices’ structural integrity was preserved. Although both blades provided satisfactory results, scanning electron microscopy revealed that the slices cut with a single bevel blade had superior surface smoothness.
To our knowledge, the current study is the first to evaluate the performance of a cartilage slicer device. Based on the thickness results, the Hacettepe cartilage slicer fulfilled its design goals: to consistently produce slices at the intended thickness with a ±0.1 mm tolerance, and to preserve over 95.3 per cent of cartilage thickness thereby ensuring undamaged, strong cartilage slices.
Temporalis fascia has become the most widely used graft for tympanoplasty, as it is strong, durable, and easy to procure and handle. However, the type of temporalis fascia graft to use (i.e. dry or wet) remains controversial. The present review aimed to evaluate the success rates of dry and wet temporalis fascia grafts in type I underlay tympanoplasty.
A literature search was performed, using PubMed up to August 2016, to identify all studies of dry and wet temporalis fascia grafts in type I underlay tympanoplasty. The initial search using the key words ‘temporalis fascia’ and ‘tympanoplasty’ identified 130 articles; these were screened by reviewing the titles or abstracts based on the inclusion and exclusion criteria. Ultimately, this review included seven articles.
Results and conclusion:
A dry or wet temporalis fascia graft did not affect the outcome of type I underlay tympanoplasty. However, using wet temporalis fascia could shorten the duration of surgery in type I underlay tympanoplasty. Concerns that the fibroblast count of temporalis fascia may beneficially affect success rate have not been substantiated in clinical reports thus far.
The middle ear and mastoid are complex three-dimensional structures and therefore tympanomastoid procedures require detailed documentation. Traditional written accounts can be inaccurate and difficult to interpret.
This audit of 95 patients compares the completion of essential operative details using: an all-electronic version of a standardised proforma with a diagrammatic template, a non-electronic version with a diagrammatic template, and a traditional handwritten template.
The electronic template resulted in 81 per cent of essential operative items being recorded, compared to 78 per cent (p = 0.3) with a previous non-electronic template and 50 per cent (p = 0.0004) when using simple handwritten recording.
An electronic proforma with a diagrammatic template improves the documentation and interpretation of tympanomastoid procedures compared to traditional handwritten records.
Does revision myringoplasty have worse outcomes than primary surgery?
The International Otology Database has been used to record data on surgery for middle-ear disease in Norfolk, UK, over nine years. The data show the results of all myringoplasty cases and the results of revision cases. Outcome measures are perforation and hearing change. Comparison is made with benchmark centres of excellence.
A total of 611 operations included myringoplasty; 356 (58 per cent) of cases had a recorded follow up at 3 months. Twenty-nine patients (8.1 per cent) had a post-operative perforation. Benchmark centres performed 2319 operations; 1284 (55 per cent) of these had a follow up at 3 months, and 82 patients (6.4 per cent) had a perforation at follow up. Sixty-nine of the Norfolk patients were revision cases. Six of the 69 patients (8.7 per cent) had a perforation at follow up. The average hearing gain in the revision myringoplasty patients in Norfolk was 7 dB.
The results of the revision myringoplasty cases are the same as those for the primary myringoplasty cases in this series.
Bilateral tympanic membrane perforation closure is usually performed by otosurgeons in two sittings. However, in this study, transperforation myringoplasty was performed alongside contralateral tympanoplasty in a single sitting. The effectiveness of transperforation myringoplasty procedure and the benefits of single sitting bilateral surgery were evaluated.
A prospective study of 50 selected patients with mucosal-type bilateral chronic otitis media was conducted. All patients underwent transperforation myringoplasty on the side that met the inclusion criteria and tympanoplasty on the contralateral side. Graft uptake and hearing improvement were evaluated after 6 months.
At the 6-month follow up, the graft uptake rate was 82 per cent, the hearing gain was 11.5 dB and the air–bone gap gain was 11.6 dB.
This procedure offers perforation closure in a single sitting to patients with bilateral chronic otitis media who meet the inclusion criteria.
This paper presents our 10 years’ experience with Felix tympanoplasty. This surgical procedure is designed to repair large perforations of unhealthy tympanic membranes, providing good graft stability without blunting of the anterior tympanomeatal angle.
From January 2001 to December 2011, 64 Felix tympanoplasties were performed, conducted as the only surgical procedure. This paper describes the surgical technique and analyses the functional results.
Graft take was achieved in 61 ears (95.31 per cent). There was air–bone gap improvement in 84.6 per cent of cases.
Felix tympanoplasty was effective in repairing unhealthy tympanic membranes with large perforations; the avoidance of blunting at the anterior tympanomeatal angle achieved good functional results.
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.
A prospective national multicentre audit was conducted involving multiple hospitals throughout the UK. Participants consisted of ENT surgeons practising in the UK.
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.
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.
There are many reports of operations performed to successfully close ear drum perforations. Hearing deterioration after myringoplasty is not a widely published topic. This paper presents an audit of this complication.
A six-year retrospective analysis of a series of myringoplasty operations was performed using electronic patient records. Patients with post-operative hearing loss were identified and those with hearing loss greater than 10 dB were further scrutinised.
Out of 187 patients who underwent myringoplasty procedures, 44 (23.53 per cent) experienced a reduction in hearing thresholds. In seven cases (3.74 per cent), the hearing loss was greater than 10 dB. A case note review revealed no obvious predictive factors, although posterior perforations and the possibility of ossicular chain manipulation were considered.
Hearing loss following myringoplasty is not rare, and this may alter the consent process for this procedure.
We used an artificial dermis (Terdermis®), which is an atero-collagen sponge covered with a sheet of silicon.
Nineteen ears of 17 patients with perforation of the tympanic membrane under various conditions, including large and wet perforations, underwent operation using this collagen sponge.
The success rate of closure after the initial surgery was 8/19. The overall success rate of closure after initial and re-operation was 14/19. The success rate of closure was 12/14 for small-sized perforations, 1/4 for middle-sized perforations and 1/1 for a large-sized perforation. Middle- and large-sized perforations required multiple surgeries. The success rate of closure was 11/11 for dry perforations, 3/4 for perforations with light otorrhoea and 0/4 for perforations with extensive otorrhoea.
This surgery is a low-cost and minimally invasive surgery and has a high closure rate. This surgery is effective on small-sized, dry perforations although it can also close middle- and large-sized dry perforations.
To identify factors that significantly influence myringoplasty success.
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.
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.
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.
The results of a number of tympanic membrane perforation closure techniques have been reported. However, relatively little has been published on the ‘drum sandwich’ technique.
Retrospective chart review of 123 patients undergoing type one tympanoplasty, performed by one surgeon using the drum sandwich technique.
Ninety-two per cent of perforations were successfully closed, and 87 per cent of patients had healed ears and were free from aural discharge 6 weeks following surgery. Post-operative hearing data were only available for 81 ears. Of these, 58 per cent had closure of the air–bone gap to within 10 dB. The mean hearing gain for the group was 10.6 dB.
The drum sandwich technique produces rapid healing of the ear with acceptable hearing outcomes. Drum closure rates are comparable with those reported for other techniques.
This study aimed to evaluate the feasibility and efficacy of the recently described chondroperichondrial clip myringoplasty technique, and make comparisons with conventional myringoplasty techniques.
The study comprised a select group of patients with chronic otitis media (mucosal disease only), with central tympanic membrane perforations affecting less than 50 per cent of the pars tensa, and an air–bone gap below 35 dB. A modified custom-made cartilage perichondrial graft was placed using the recently described ‘clip’ technique.
The graft success rate was 91.3 per cent. Post-operatively, the air–bone gap was within 10 dB in 52 per cent of cases and within 10–20 dB in 48 per cent of cases. There were few minor complications.
Chondroperichondrial clip myringoplasty can be considered as an alternative minimally invasive technique for the repair of select cases of tympanic membrane perforations. This technique, which showed impressive results, was associated with minimum morbidity and reduced operative time.
The main aim of tympanic membrane repair is the elimination of chronic or intermittent aural discharge. Hearing improvement may or may not occur following a technically successful operation.
This study entailed a retrospective analysis of prospectively collected data from 203 operations that resulted in an intact tympanic membrane 6 months after surgery.
Complete hearing data were available for 169 operations on 160 patients. Of these, 53 per cent resulted in closure of the air–bone gap to within 10 dB, and 54 per cent of cases had post-operative hearing thresholds of at least 30 dB. The mean hearing change after surgery was +8.3 dB. Multiple regression analysis indicated that hearing improvement was more likely in large compared with small perforations. Smaller hearing gains occurred in ears with erosion of the stapes arch and/or fixation of the stapes, as well as in those with active discharge at the time of surgery and in revision cases.
Greater hearing improvement can be expected following successful repair of perforations involving more than 50 per cent of the drum area. Poorer results are likely to occur in ears with additional middle-ear pathology and in revision cases.
We report lateral sinus thrombosis occurring as a rare complication following a routine and uneventful otological procedure.
Lateral sinus thrombosis is a rare but known complication of otitis media. It has not been documented as a complication of routine otological surgery. We present a case of this rare complication following a myringoplasty. We also discuss the presentation, investigation and treatment of lateral sinus thrombosis. It is essential to be able to recognise and treat this rare complication early, due to its high mortality rate.
Lateral sinus thrombosis is a rare but potentially life-threatening complication. It is therefore essential for clinicians to be able to recognise and treat this condition early.
Chronic tympanic membrane perforations can cause significant morbidity. The term myringoplasty describes the operation used to close such perforations. A variety of graft materials are available for use in myringoplasty, but all have limitations and few studies report post-operative hearing outcomes. Recently, the biomedical applications of silk fibroin protein have been studied. This material's biocompatibility, biodegradability and ability to act as a scaffold to support cell growth prompted an investigation of its interaction with human tympanic membrane keratinocytes.
Methods and materials:
Silk fibroin membranes were prepared and human tympanic membrane keratinocytes cultured. Keratinocytes were seeded onto the membranes and immunostained for a number of relevant protein markers relating to cell proliferation, adhesion and specific epithelial differentiation.
The silk fibroin scaffolds successfully supported the growth and adhesion of keratinocytes, whilst also maintaining their cell lineage.
The properties of silk fibroin make it an attractive option for further research, as a potential alternative graft in myringoplasty.
We report a unique case of traumatic tympanic membrane perforation caused by a needlefish beak. We describe the mechanism of injury, the clinical findings and the treatment.
An 11-year-old boy presented with otorrhoea and hearing loss secondary to a traumatic tympanic membrane perforation by a needlefish. The perforation was repaired by performing a myringoplasty, with satisfactory post-operative audiological results.
To our knowledge, this is the first reported case of its kind. It is recommended that careful examination of the middle-ear space should always be carried out prior to and during myringoplasty if there is a possibility of a foreign body.
To investigate the possible clinical relationship between gastroesophageal reflux disease and the type one tympanoplasty surgical outcomes of adults with chronic otitis media, by using a simple, cost-effective, reliable questionnaire and physical findings.
Fifty-two of 147 patients undergoing type one tympanoplasty were studied. Gastroesophageal reflux disease symptoms were evaluated using the Frequency Scale for the Symptoms of Gastroesophageal Reflux Disease questionnaire. Laryngoscopic physical findings of laryngopharyngeal reflux were evaluated using the Reflux Finding Score. A successful outcome was defined as an intact tympanic membrane. Correlations between the two assessment tool results and the patient's surgical success were calculated.
The gastroesophageal reflux disease questionnaire score was significantly higher in patients with unsuccessful tympanic membrane closure (group one) than in patients with successful closure (group two) (p < 0.05). The Reflux Finding Score was also significantly higher in group one than group two (p < 0.05). There was a significant positive relationship between the gastroesophageal reflux disease questionnaire score and the Reflux Finding Score (p < 0.01).
Gastroesophageal reflux disease may be a significant prognostic factor for tympanoplasty failure. Therefore, reflux investigation may be important during the treatment of chronic otitis media, and positive cases may need reflux treatment as well as ear disease treatment.