A Myringoplasty Would Be The Repair Of What Anatomical Part?

Indian J Otolaryngol Head Cervix Surg. 2022 December; 65(4): 358–362.

Success of Myringoplasty: Our Experience

M. Panduranga Kamath

Department of ENT and Head & Neck Surgery, Kasturba Medical College, Manipal University, Mangalore, India

Suja Sreedharan

Department of ENT and Head & Cervix Surgery, Kasturba Medical College, Manipal University, Mangalore, India

A. Raghavendra Rao

Department of ENT and Head & Neck Surgery, Kasturba Medical College, Manipal University, Mangalore, India

Vinay Raj

Section of ENT and Head & Neck Surgery, Kasturba Medical College, Manipal University, Mangalore, Bharat

Krishnam Raju

Section of ENT and Head & Neck Surgery, Kasturba Medical College, Manipal Academy, Mangalore, Republic of india

Received 2022 February 23; Accepted 2022 Mar 26.

Abstract

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

Keywords: Cortical mastoidectomy, Myringoplasty, Temporalis fascia, Pure tone audiogram

Introduction

Chronic otitis media is an inflammatory process of the mucoperiosteal lining of the center ear space and mastoid. The mucus membrane may exist thickened by edema, sub mucosal fibrosis, and infiltration with chronic inflammatory cells. Infection of the eye ear has been a problem encountered in the human race, and is as erstwhile equally humanity itself. Chronic center ear disease is a major trouble in Republic of india peculiarly in the rural areas. It is estimated that half-dozen % of Indian population suffers from chronic ear disease [1]. This is significantly higher than the incidence reported in Western countries which is almost 1.8 %. To complicate matters, in India, there is general lack of sensation of the affliction per se and also regarding the complications of the illness. CSOM is a sequel of acute or unresolved otitis media, particularly in children with poor socioeconomic conditions, and usually presents within the first 5 years of life. In the presence of a preexisting perforation or ventilation tube dysfunction, infection may develop secondary to contamination from ear culvert organisms or with an upper respiratory tract infection.

The surgical treatment of chronic suppurative otitis media is still controversial. It is well accepted that the main purpose of functioning is to obtain a permanently dry ear and close the perforation. Traditionally, myringoplasty with mastoidectomy has been identified as an effective method of treatment of chronic ear infection resistant to antibiotic therapy. But the effect of mastoidectomy on patients without show of active infectious disease remains highly debated and unproven. The purpose of this written report is to compare the efficacy of myringoplasty with and without cortical mastoidectomy in terms of freedom from discharge, graft take upwardly and improvement in hearing.

Materials and Methods

This was a randomised, controlled study undertaken in a tertiary referral, teaching hospital. It comprised a prospective report of ii surgical procedures. The total study period was 4 years, from May 2008 to September 2022. One hundred and twenty patients who fulfilled the eligibility criteria were recruited into the report and randomly allocated into 2 groups. In group A, sixty ears underwent blazon one tympanoplasty only. In group B, threescore ears underwent cortical mastoidectomy together with type 1 tympanoplasty.

The inclusion criteria comprised (one) Patients of age grouping 10–60 years with chronic suppurative otitis media of the safe type; (two) Patients who had merely conductive hearing loss. The intactness of the ossicular chain was confirmed by otoendoscopy and pure tone audiometry.

The exclusion criteria comprised the presence of the following: (one) Active belch; (2) Patients with sensorineural hearing loss; (iii) Immunocompromised status; (four) Ossicular discontinuity; (5) Patient with long standing history of allergy; (6) Presence of Cholesteatoma.

A detailed proforma was filled for each patient with regard to history, consummate general concrete, systemic and ENT examination. In all the patients a routine claret examination, X-ray mastoid, examination under microscope and pure tone audiometry were done. Eustachian tube function was assessed clinically.

Those patients with a predisposing focus of infection in the Olfactory organ and Para Nasal Sinuses were subjected to septal correction, endoscopic sinus surgeries and tonsillectomy to eliminate the foci of infection. Preoperatively all the patients who had CSOM-TTD had a discharge free catamenia of 4 weeks.

All the cases were operated by senior consultants. 120 sequent cases of chronic suppurative otitis media meeting the inclusion criteria were taken for the study, and the patients were randomly divided into each group. Group-A patients were treated with myringoplasty lonely, whereas those in group-B were treated by cortical mastoidectomy with myringoplasty (Fig.1). A mastoid dressing was applied and was kept for 1 week post operatively. Local antibiotic drops and antihistaminics were advised in all cases. Patients were reviewed after 15 days and one month, for inspection of the operated ear. Third post-operative review was done at iii months for a clinico-audiological cess of the operated ear to evaluate the graft condition (Fig.2) and hearing improvement. Post-operative audiogram was recorded on third visit.

Mail operative graft in place

Results

Only uncomplicated chronic suppurative otitis media with safe central perforation were included in our report. 120 patients completed this study. A full of 60 ears were considered in each group for the study. In grouping A (myringoplasty without mastoidectomy) at that place were 29 males and 31 females where as in grouping B (myringoplasty with mastoidectomy) there were thirty males and xxx females. Both the groups thus matched for the sex activity. About of the patients were in the age group of 20–29 years. The youngest patient was establish to exist 12 years quondam and the oldest lx years.

The event of unilateral or bilateral CSOM on graft take up rate was evaluated. A full of 72 unilateral cases and 48 bilateral cases were included in the study. The number of cases in each group are summarized in Tableane. The success rate for unilateral disease was plant to exist 84.72 %, whereas for bilateral disease it was 83.33 %. However, in that location was no statistically significant difference for the success charge per unit based on laterality. Presence of bilateral ear illness at the fourth dimension of myringoplasty did not seem to have an influence on the graft have up. The issue of perforation size on graft uptake was also evaluated. Patients with chronic suppurative otitis media tubotympanic disease, with large and medium perforations had ameliorate graft uptake, when compared with the remaining, as seen in Table2. However there was no statistically meaning departure in the graft have up rate.

Table 1

Comparision of features between group A (myringoplasty) and group B (cortical mastoidectomy with myringoplasty)

Characteristics	Group A	Group B
Involved side (unilateral/bilateral)	35/25	37/23
Graft have upwardly (%)	80	88.33

Tabular array 2

Relationship between perforation size and graft take up

Size of perforation	No. of cases	Graft take upward	Failures	Take up charge per unit (%)
Small	7	v	2	71.4
Medium	43	39	four	90.69
Large	49	45	4	91.83
Subtotal	twenty	12	8	60
Total	i	0	1	0

Graft success rates were 80 % in group A and 88.33 % in grouping B. In that location was no statistically pregnant difference betwixt grouping A and group B. There were totally nineteen cases of graft failure, nigh of which presented after the second visit with complaints of ear belch.

There was a mean reduction of air conduction threshold from 34.69 ± eleven.half dozen to 23.82 ± x.39 dB in grouping A and from 36.019 ± 11.87 to 24.06 ± 11.02 dB in group B. The reduction of air conduction thresholds in each group was meaning. (P < 0.001). However, there was no pregnant difference in the air conduction thresholds accomplished post-operatively between the two groups as seen in Tabular array3.

Table 3

Audiological benefits seen in the ii groups

Audiological assessment	Myringoplasty	Cortical mastoidectomy with myringoplasty
Pre op hearing loss	34.69 ± xi.6	36.019 ± 11.87
Pure tone threshold 3rd calendar month	23.82 ± 10.39	24.06 ± eleven.02
Benefits in decibel	eleven.45 ± 5.53	11.83 ± 5.93
P value for comparing inside the group	<0.001	<0.001

Discussion

Myringoplasty or type I tympanoplasty is an operative procedure, in which the reconstructive procedure is limited to repair of tympanic membrane perforation. Implicit in the definition is that the ossicular chain is intact and mobile, and the middle ear is disease free. There are a number of studies in the literature highlighting the advantages and disadvantages of performing mastoidectomy in the surgical treatment of mucosal type of chronic otitis media. The master statement in favor of mastoidectomy has been an improvement in the eye ear and mastoid environment through clearance of diseased secretory mucosa, and the ventilator mechanisms of an open mastoid system. The mastoid air jail cell organisation is thought to function, at least in role, as a buffer to changes in pressure within the middle ear. According to Boyle's law, an increment in the book bachelor to heart ear infinite through a surgically opened mastoid would be protective for the tympanic membrane in response to middle ear pressure changes. Thus failure to create a pneumatized air cell system in a patient with non cholesteatomatous chronic otitis media may very well increase the chance of surgical failure.

Wehrs and Tulsa [2] in 1981 observed that, in order to achieve a good hearing result post-obit tympanoplasty, information technology is necessary to maintain an aerated middle ear space. Poor Eustachian tube function is most commonly blamed in cases of failure to obtain an aerated heart ear following tympanoplasty. Although this may be true in some cases, middle ear adhesions, loss of support of the posterior canal wall and inadvertent blockage of the Eustachian tube orifice past graft material may be contributing factors. Aeration of the mastoidectomy cavity is also important to prevent collapse of the posterior canal wall, retraction pockets and ensure an adequate air reserve.

Jackler and Schindler [3] in 1984 studied 48 patients with chronic otitis media with tympanic perforations who underwent myringoplasty with mastoidectomy. In their study it was found that, simple mastoidectomy was institute to be an constructive means of re-pneumatizing the sclerotic mastoid and eradicating mastoid sources of infection. The study concluded that uncomplicated mastoidectomy is a rubber and useful adjunct to myringoplasty, in selected cases.

Literature is also replete with studies in favour of tympanoplasty without mastoidectomy. In 1997, Balyan et al. [4] did a retrospective written report of 323 patients to evaluate part of mastoidectomy in non cholesteatomatous chronic suppurative otitis media. They observed no statistically significant departure in terms of graft success rates, or hearing upshot when mastoidectomy was done. They also concluded that success rates were similar for both dry and discharging ears. They ended that mastoidectomy does non give a ameliorate chance for graft success rate and functional hearing results, but it adds extra endeavor and risk.

Mishiro et al. [v] in 2001 reviewed 251 cases of non-cholesteatomatous chronic otitis media, to make up one's mind whether mastoidectomy is helpful when combined with tympanoplasty for these conditions. 147 patients were treated by tympanoplasty with mastoidectomy and 104 were operated on without mastoidectomy. At that place was no statistically significant difference betwixt the two groups. There was no statistically significant difference between graft success rate in discharging ears and dry out ears. They concluded that mastoidectomy is not helpful in tympanoplasty for not-cholesteatomatous CSOM, even if the ear is discharging.

Pignataro et al. [6] in 2001 conducted a retrospective report to assess the results of myringoplasty in children, and determine the factors influencing post-operative results. 41 myringoplasty in children was performed, considering but the cases of uncomplicated perforation that did non require ossiculoplasty or mastoidectomy. At that place was a significant statistical association between the presence of a dry ear at the fourth dimension of surgery and proficient surgical results. Surgical outcome was not affected by the patient's age, the site and size of the perforation, previous adenoidectomy, surgical technique (overlay vs. underlay), or the status of the contralateral ear. They concluded that myringoplasty is a valid process in the pediatric population that gives good anatomical and functional results. Also it was establish that the status of the middle ear, significantly improves surgical consequence.

McGrew et al. [7] in 2004 conducted a retrospective study of patients at a tertiary referral centre, where 4 hundred and eighty-four patients who underwent surgical repair of elementary tympanic membrane perforations were identified and reviewed. Surgical issue and clinical course were assessed to compare results of tympanic membrane perforation repair, with and without canal wall up mastoidectomy. They constitute that tympanic membrane repair was equally effective in both groups at 91 %. Hearing results were comparable. Development of persistent ipsilateral otological disease requiring a subsequent ipsilateral procedure was approximately twice as common in the tympanoplasty group. They ended that mastoidectomy was not necessary for successful repair of simple tympanic membrane perforations. Nevertheless, mastoidectomy impacted the clinical course in patients by reducing the number of patients requiring time to come procedures and past decreasing disease progression. This suggests that combining mastoidectomy with tympanoplasty during repair of simple perforations in patients with no active evidence of infection remains an appropriate option, and may exist valuable in reducing the need for future surgery.

A single-blinded, randomized, controlled study within a tertiary referral hospital was conducted by Bhat et al. [8] in 2008, to compare outcomes for mastoidotympanoplasty and for tympanoplasty alone in cases of quiescent, tubotympanic, chronic, suppurative otitis media. There were no statistically meaning differences in hearing improvement, tympanic perforation closure, graft uptake or disease eradication, comparing the ii groups at 3 and six months post-operatively. Mastoidotympanoplasty was not found to exist superior to tympanoplasty solitary over a brusk-term follow-up menstruum.

In 2022 Albu et al. [9] presented a paper of iii hundred xx consecutive adult patients treated past either myringoplasty with cortical mastoidectomy or myringoplasty only. He plant that three factors were significant in predicting success rate i.eastward. good for you opposite ear, a long dry catamenia preceding the operation and nonsmoker status. The only factor attaining significance in the multivariate analysis was a dry menses longer than 3 months. They ended that, cortical mastoidectomy offers no boosted benefit in myringoplasty performed on patients with persistent or intermittent discharging CSOM and no testify of cholesteatoma or mucosal blockage within the antrum.

At that place has been niggling controversy over the importance of non mastoid factors similar eustachian tube dysfunction, general debility, in tympanic membrane reconstruction. Merely the role of mastoidectomy in the repair of tympanic membrane perforation has long been debated. Mastoidectomy was regarded every bit a ways of surgically creating an air reservoir and eradicating sequestered mastoid disease. Yet, in that location is no scientific data indicating that tympanoplasty with mastoidectomy yields better results. Our written report emphasizes the fact that overall satisfactory hearing upshot with adequate air-bone closure can be accomplished irrespective of cortical mastoidectomy in the surgical treatment of tubotympanic disease. When considering the addition of a mastoidectomy to a tympanoplasty, the performing surgeon should consider not only the potential added benefit only besides potential risks and costs to the patient. This report gives show that mastoidectomy performed in noncholesteatomatous CSOM does non give a better risk for graft success rate and functional hearing results, and is beneficial merely in instance of subconscious mastoid infection.

References

1. Smyth GD. Tympanic reconstruction. 15 year report on tympanoplasty. Part II. J Laryngol Otol. 1976;90(8):713–741. doi: x.1017/S0022215100082633. [PubMed] [CrossRef] [Google Scholar]

two. Wehrs RE, Tulsa OK. Aeration of the centre ear and mastoid in tympanoplasty. Laryngoscope. 1981;91:1463–1467. doi: x.1288/00005537-198109000-00008. [PubMed] [CrossRef] [Google Scholar]

3. Jackler RK, Schindler RA. Part of the mastoid in tympanic membrane reconstruction. Laryngoscope. 1984;94(4):495–500. doi: x.1288/00005537-198404000-00013. [PubMed] [CrossRef] [Google Scholar]

4. Balyan FR, Celikkanat S, Aslan A, Taibah A, Russo A, Sanna Chiliad. Mastoidectomy in not cholesteatomatous chronic suppurative otitis media: is it necessary? Otolaryngol Caput Neck Surg. 1997;117:592–595. doi: ten.1016/S0194-5998(97)70038-Ten. [PubMed] [CrossRef] [Google Scholar]

v. Mishiro Y, Sakagami M, Takahashi Y, Kitahara T. Tympanoplasty with and without mastoidectomy in non cholesteatomatous chronic otitis media. Eur Arch Otorhinolaryngol. 2001;258:13–15. doi: ten.1007/PL00007516. [PubMed] [CrossRef] [Google Scholar]

6. Pignataro L, Grillo Della Berta 50, Capaccio P, Zaghis A. Myringoplasty in children: anatomical and functional results. J Laryngol Otol. 2001;115(five):369–373. doi: 10.1258/0022215011907893. [PubMed] [CrossRef] [Google Scholar]

vii. McGrew BM, Jackson 1000. Bear upon of mastoidectomy on simple tympanic membrane perforation repairs. Laryngoscope. 2004;114:506–511. doi: 10.1097/00005537-200403000-00023. [PubMed] [CrossRef] [Google Scholar]

8. Bhat KV, Naseeruddin K, Nagalotimath Us, Kumar PR, Hegde JS. Cortical mastoidectomy in quiescent, tubotympanic, chronic otitis media: is information technology routinely necessary? J Laryngol Otol. 2008;x:1–eight. [PubMed] [Google Scholar]

9. Albu S, Trabalzini F, Amadori M. Usefulness of cortical mastoidectomy in myringoplasty. Otol Neurotol. 2012;33(4):604–609. doi: 10.1097/MAO.0b013e31825368f2. [PubMed] [CrossRef] [Google Scholar]

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3851513/

Posted by: hurstonessor.blogspot.com

Share this post