Hyaluronic acid fat graft myringoplasty vs fat patch fat graft myringoplasty

3D printing technology and applied materials in eardrum regeneration

Tympanic membrane perforation is a common condition in clinical otolaryngology. Although some eardrum patients can self-heal, a long period of non-healing perforation leads to persistent otitis media, conductive deafness, and poor quality of life. Tympanic membrane repair with autologous materials requires a second incision, and the sampling site may get infected. It is challenging to repair tympanic membranes while maintaining high functionality, safety, affordability, and aesthetics. 3D bioprinting can be used to fabricate tissue patches with materials, factors, and cells in a design manner. This paper reviews 3D printing technology that is being used widely in recent years to construct eardrum stents and the utilized applied materials for tympanic membrane repair. The paper begins with an introduction of the physiological structure of the tympanic membrane, briefly reviews the current clinical method thereafter, highlights the recent 3D printing-related strategies in tympanic membrane repair, describes the materials and cells that might play an important role in 3D printing, and finally provides a perspective of this field.

Can Tissue Engineering Bring Hope to the Development of Human Tympanic Membrane?

The tympanic membrane (TM), more commonly known as the eardrum, consists of a thin layer of tissue in the human ear that receives sound vibrations from outside of the body and transmits them to the auditory ossicles. The TM perforations (TMPs) are a common ontological condition, which in some cases can result in permanent hearing loss. Despite the spontaneous healing capacity of the TM to regenerate in the majority of cases of acute perforation, chronic perforations require surgical interventions. However, the disadvantages of the surgical procedure include infection, anesthetic risks, and high failure of graft patency. The tissue engineering strategy, which includes the applications of a three-dimensional (3D) scaffold, cells, and biomolecules or a combination of them for the closure of chronic perforation, has been considered as an emerging treatment. Using this approach, emerging products are currently under development to regenerate the TM structure and its properties. This research aimed to highlight the problems with the current methods of TMP treatment, and critically evaluate the tissue engineering approaches, which may overcome these drawbacks. The focus of this review is on recent literature to critically discuss the emerging advanced materials used as a 3D scaffold in the development of a TM with cellular engineering, biomolecules, cells, and the fabrications of the TM and its pathway to the clinical application. In this review, we discuss the properties of TM and the advantages and disadvantages of the current clinical products for repair and replacement of the TM. Furthermore, we provide an overview of the in vitro and preclinical studies of emerging products over the past 5 years. The results of recent preclinical studies suggest that the tissue engineering field holds significant promise.

Comparative efficacy of platelet-rich plasma applied in myringoplasty: A systematic review and meta-analysis

BACKGROUND

Tympanic membrane (TM) perforation is quite common in the clinical setting. Chronic TM perforations require surgical treatments such as myringoplasty. Currently, platelet-rich plasma (PRP) is a novel, effective substance that is increasingly utilized for TM perforation repair. This study aims to evaluate the effectiveness of PRP in the application of TM perforation repair.

METHODS

A systematic search was conducted to screen the Medline, Embase, Cochrane, Scopus and Web of Science databases up to July 2020. Studies were identified in accordance with the selection criteria by two coauthors independently. Data regarding the healing and hearing outcomes were pooled and analyzed via Review Manager version 5.3 and STATA version 12.0 software. Odds ratio (OR) was utilized to compare the closure rate. Furthermore, the results of hearing improvements and incidence of complications were also compared to evaluate the effectiveness of PRP.

RESULTS

A total of eight studies with 455 participants were eligible according to the selection criteria. Compared to conventional surgery, the OR of closure was 2.70 (95% CI: 1.27 to 5.76, P = 0.01, I2 = 0%) in randomized controlled trial (RCT) subgroup and 6.18 (95% CI: 2.22 to 17.25, P = 0.0005, I2 = 0) in non-RCT subgroup. The overall OR of closure was 3.69 (95% CI: 2.02 to 6.74, P<0.0001, I2 = 0%), suggesting a significant effect on the healing of TM perforation. Between preoperative and postoperative hearing results, there is no statistical difference between the PRP and the control groups. Additionally, the use of PRP resulted in a lower incidence of complication than the use of conventional approaches.

CONCLUSION

The application of PRP during the TM surgeries can enhance the closure rate, provide similar hearing improvements and decrease the incidence of postoperative complications. Given these advantages, PRP can be considered an effective treatment for TM regeneration.

Long-Term Follow-Up After Fat Graft Myringoplasty: Do Size and Location Matter?

OBJECTIVE

To assess clinical and functional outcomes of a fat graft myringoplasty under local in an office setting.

STUDY DESIGN

Prospective case series.

SETTING

Tertiary care facility.

PATIENTS

Patients with a tympanic membrane (TM) perforation presenting between December 2005 and June 2019. Inclusion criteria included perforation size >25% of the surface of the pars tensa of the TM, entire perforation margins visualized through a transcanal view, and lack of spontaneous closure at the 6-month follow-up. The exclusion criteria were the presence of cholesteatoma, wet appearance of the mucosa in the tympanic cavity, ear discharge in the 3 months before surgery, or signs of ossicular inconsistency.

INTERVENTION

In-office fat graft myringoplasty technique under local anesthesia.

MAIN OUTCOME MEASURES

Complete perforation closure rate and audiometric outcomes.

RESULTS

A total of 121 patients underwent the procedure, of whom 21 had bilateral sequential procedures (total 142 ears). Average age was 51.1 ± 18.4 years (range, 3-78 years). The size of perforation was <25% of TM in 39 (27.5%) ears, 25% to 50% of TM in 49 (34.55%) ears, 50% to 75% of TM in 34 (23.91%) ears, and 75% to 100% of TM in 20 (14.10%) ears. Complete perforation closure was evident in 130 (91.55%) of the 142 ears. Preoperative mean air conduction threshold was 59.3 dB (17-95 dB) and significantly improved into 35.6 dB (10-85 dB; P < .0004) after surgery. Preoperative air-bone gap was 30.2 dB (5-70 dB) and also significantly improved into 10.2 dB (5-65 dB; P < .0001) after surgery.

CONCLUSION

In office fat graft myringoplasty, in adult and pediatric patients with variable perforation sizes, is a well-tolerated procedure with very satisfactory clinical results.

What is the Role of Hyaluronic Acid Ester in Myringoplasty? Systematic Review and Meta-Analysis

OBJECTIVE

To reveal odds of tympanic membrane closure and postoperative hearing outcomes for myringoplasty utilizing hyaluronic acid ester via systematic review and meta-analysis.

DATA SOURCES

1) Search of English articles in PubMed/Medline, Embase, and Cochrane databases published between January 1, 1998 and March 31, 2018.

STUDY SELECTION

Inclusion criteria: 1) English language; 2) clinical studies; 3) reported posttreatment perforation status, hearing outcomes, or complications.

EXCLUSION CRITERIA

hyaluronic acid used for middle ear packing or topical application of hyaluronic acid solution.

DATA EXTRACTION

Number of patients, surgical technique, mean age, overall rate of tympanic membrane closure, success rate based on size of perforation, mean air-bone gap improvement, and postoperative speech scores and complications.

DATA SYNTHESIS

Ten studies encompassing 531 patients met criteria. Reported success rates for closure of chronic perforation ranged from 70.0 to 92.7% (mean, 85.21%). Smaller perforation predicted success in complete closure. Mean air-bone gap closure was 10.6 dB (4-24 dB). There were five complications reported. Meta-analysis was performed on five studies. No difference was noted in the success rates between hyaluronic acid ester myringoplasty and conventional tympanoplasty using fascia or perichondrium, with an overall closure rates of 89.8 and 89.4%, respectively (odds ratio [OR] 1.04, 95% confidence interval [CI] 0.59-1.82, p = 0.896). A higher closure rate was seen in hyaluronic acid ester myringoplasty (87.9%) when compared with fat graft myringoplasty (70.8%), (OR 3.01, 95% CI 1.42-6.35, p = 0.004).

CONCLUSIONS

Hyaluronic acid (HA) ester myringoplasty appears to be safe and effective at attaining complete closure of tympanic membrane perforation, although there exists significant selection bias and inconsistent reporting among existing papers.

Hyaluronic acid in otology: Its uses, advantages and drawbacks - A review

OBJECTIVES

Review of the literature for studies involving the use of hyaluronic acid (HA) in otology.

METHODS

Pubmed and OvidMedline were searched using a combination of the following words in different variations: hyaluronic acid, hyaluronate, otolaryngology, otology, ear, tympanic membrane, perforation, tympanostomy, tympanoplasty, myringoplasty, packing, middle ear, cochlea, gene delivery, gene therapy, cochlear implant, hearing loss, meniere, vertigo, otitis and cholesteatoma.

RESULTS

The papers relevant for this review were triaged based on abstracts and titles and were then categorized based on topic/disease entity/procedure. The papers were read and summarized in order to use their findings in this review.

CONCLUSIONS

HA is being recently used as adjuvant therapy for multiple inflammatory conditions and in tissue repair. These immunomodulatory properties and biocompatibility have interested researchers specially in the field of otology for repair, gene delivery, immunomodulation etc. Recent data in the field show optimistic results for the use of HA in several conditions especially tympanic membrane perforations and gene delivery. It also establishes the role of HA as ancillary treatment in many other otologic pathologies. This review presents the most recent findings on the use of HA in otology. The results could be used to guide clinical practice and incite further research based on the presented results of the literature.

Can Fat-plug Myringoplasty Be a Good Alternative to Formal Myringoplasty? A Systematic Review and Meta-analysis

OBJECTIVE

This study reviewed available literature to evaluate the success rate of fat myringoplasty compared with methods using other graft materials and suggests proper indications for this procedure.

DATA SOURCES

Studies reporting the success rate of fat myringoplasty were systematically reviewed by searching the MEDLINE, PubMed, and Embase databases for studies published from database inception to 2017.

STUDY SELECTION

The following terms were used for the literature search: ("Fat" OR "Adipose") and ("Myringoplasty" OR "Tympanoplasty").

DATA EXTRACTION

Eight case series reported the data of perforation size and audiologic results. The success rate varied according to the perforation size with a cutoff value of 3 to 5 mm in length or 30% of the total tympanic membrane area. The success rate in anterior perforation was lower than that in other sites, ranging from 76.7 and 85.2% to 84.5 and 91.7%, respectively. The meta-analysis was performed on 10 articles. The overall success rate in fat myringoplasty and paper patch technique was not significantly different, while the success rate of fat myringoplasty was lower than that for the conventional myringoplasty technique using fascia or perichondrium (OR 0.63, 95% CI 0.49-0.80). Hyaluronic acid showed a significantly higher success rate than fat myringoplasty (90.1% versus 69.9%) (OR 0.20, 95% CI 0.09-0.46).

CONCLUSIONS

The success rate of fat myringoplasty may be associated with the perforation site and size. The success rate of fat myringoplasty was equivalent to that of the paper patch but inferior to a conventional method using perichondrium or fascia.

Evaluating short and long term outcomes following pediatric Myringoplasty with Gelfoam graft for tympanic membrane perforation following ventilation tube insertion

Background

Myringotomy with ventilation tube (VT) insertion to treat recurrent acute otitis media and chronic secretory otitis media has become one of the most common surgical procedures performed in children. Although contemporary literature has detailed the various patient and perioperative factors that affect successful pediatric myringoplasty, there is still limited evidence surrounding the increasing number of graft material options. In particular, gelfoam patching has arisen as a simple and efficient modality for perforation closure, but has a paucity of evidence particularly in pediatric cohorts. Our study aims to evaluate the clinical and audiometric outcomes following gelfoam myringoplasty for TMP following prolonged VT insertion in an urban pediatric population.

Methods

A retrospective review of pediatric patients who underwent myringoplasty between 2013 and 2018 following ventilation tube insertion. Patient demographics, comorbidities, and graft material were correlated with audiometric and clinical outcomes on follow up examination.

Results

One hundred twenty patients underwent myringoplasty, with 61 (50.8%) males with a mean age of 8.9 years old. 101 (84.2%) of patients eventually underwent successful tympanic membrane (TM) closure, with 93 (77.5%) demonstrating closure at initial follow up. In the gelfoam cohort, 77 (90.6%) of patients demonstrated successful TM closure at initial follow up. Overall mean time to closure was 5.6 (standard error (SE) 0.9) months. A multivariate Cox proportional hazards model demonstrated none of the covariates including graft material significantly affected TM closure. Mean change in air conduction threshold were comparable between graft materials.

Conclusions

Pediatric myringoplasty with gelfoam graft material is a safe and viable alternative with favorable short and long term clinical and audiometric outcomes.

Factors affecting the treatment outcomes of myringoplasty in patients with small tympanic membrane perforations

PURPOSE

Factors affecting the outcomes of myringoplasty have been widely discussed but remain controversial. In this study, we retrospectively analyzed the factors associated with the outcomes of myringoplasty treating small tympanic membrane perforations (defined as those involving less than 30% of the whole eardrum area) in patients with a history of chronic otitis media.

METHODS

The clinical demographic data, preoperative pure tone audiometry, surgical procedures, and surgical outcomes of patients with small tympanic perforations were analyzed statistically. Overlay myringoplasty was performed in 24 ears (45.27%); Gelfoam^® plugs were placed in 29 ears (54.73%). Univariate and multivariate tests among demographic, surgical procedure-related, hearing test-related factors were performed.

RESULTS

A total of 53 patients (22 males and 31 females) were enrolled (mean age 54.84 ± 15.51 years). Fourteen patients (26.41%) had the habit of cigarette smoking, 8 (15.09%) had diabetes mellitus, 20 (37.73%) had a past history of chronic otitis media, 5 (9.43%) had a history of grommet insertion, 5 (9.43%) had received radiotherapy in the head and neck region, and 1 (1.88%) had microtia. The success rate for overlay myringoplasty using Silastic^® sheets was 54.16%; the success rate for Gelfoam^® plugs was 54.16%. On univariate analysis, smoking, older age, and the mean air conduction and bone conduction hearing levels significantly affected the surgical outcomes. Cigarette smoking was the only independent (negative) prognostic factor of surgical success on multivariate analysis (OR  = 0.1614, 95% CI: 0.0336-0.7762, p = 0.0228).

CONCLUSION

As for surgical repair for the small tympanic membrane perforations with a history of chronic otitis media, age, cigarette smoking, mean air conduction threshold, and mean bone conduction threshold were associated with surgical outcomes; cigarette smoking was the independent predictive prognostic factor for the surgical outcomes.

Auditory effects of autologous fat graft for TORP stabilization in the middle ear: a cadaveric study

Background

Total ossicular replacement prostheses (TORP) are often used to re-establish ossicular coupling of sound in an ear lacking a stapes supra-structure. The use of TORPs, however, is associated with a 2/3 five year failure rate due to their anatomic instability over time in the middle ear. The use of autologous fat to try and stabilize TORPs may improve long-term results with this challenging ossicular reconstruction technique.

Methods

A cadaveric temporal bone model was developed and laser Doppler vibrometry was used to measure and record round window membrane vibration in response to sound stimulation under the following conditions: normal middle ear, middle ear filled with fat, normal middle ear with TORP prosthesis, TORP prosthesis with fat around its distal end and TORP prosthesis with fat filling the middle ear. Fourteen temporal bones were used.

Results

There was a significant decrease in round window membrane velocity after filling the middle ear with fat in both the normal middle ear (− 8.6 dB; p < 0.0001) and prosthesis conditions (− 13.7 dB; p < 0.0001). However, there was no significant drop in round window membrane velocity associated with using fat around the distal end of the TORP prosthesis as compared to the prosthesis without fat condition (p > 0.05).

Conclusions

Autologous fat around the distal end of a TORP prosthesis may not be associated with any additional hearing loss, as demonstrated in this cadaveric model. The additional hearing loss potentially caused by using fat to completely surround the prosthesis and fill the middle ear is probably not clinically acceptable at this time, especially given the unknown way in which the fat will atrophy over time in this context.

Hyaluronic Acid Fat Graft Myringoplasty Versus Autologous Platelet Rich Plasma

BACKGROUND

Hyaluronic acid fat graft myringoplasty (HAFGM) is an office-based technique for tympanic membrane perforation (TMP) treatment. It is simple, inexpensive, and performed under local anesthesia at the outpatient office department. We aimed to compare HAFGM technique to a recently described topical use of autologous platelet rich plasma myringoplasty (PRPM) in the repair of TMP. We also aimed to assess the hearing level improvement postoperatively.

METHODS

We conducted a prospective study in an adult tertiary care center between January 2015 and January 2016. Adult patients presenting with simple TMP were operated randomly using either HAFGM or PRPM under local anesthesia in an office-based setting. Perforations were classified into four grades. Success was considered when complete closure is achieved. Audiometric parameters were evaluated pre- and postoperatively.

RESULTS

We included 27 patients, of whom 16 were operated with HAFGM and 11 were operated with PRPM. Complete closure was achieved in 81.2% and 18.1%, respectively. Postoperatively, no worsening of bone conduction threshold was noted. The study was abandoned due to the low success rate in patients with PRPM. The pure tone audiometry was improved postoperatively in patients with closed tympanic membrane.

CONCLUSIONS

The study was aborted because of the unsatisfactory obtained results using PRPM. It confirms once again the beneficial effect of hyaluronic acid in the healing process when added to fat graft myringoplasty. Furthermore, it requires no hospitalization.

Effects of Cell-Based Therapy for Treating Tympanic Membrane Perforations in Mice

OBJECTIVE

To investigate the effectiveness of scaffold-embedded mesenchymal stem cells (MSCs) as a topical treatment for healing tympanic membrane perforations (TMPs) in a mouse model.

STUDY DESIGN

Prospective animal study.

SETTING

Experimental.

SUBJECTS AND METHODS

In vitro: under sterile conditions, porcine-derived (Gelita-Spon [GS]), hyaluronate-derived (EpiDisc [ED]), and polyvinyl alcohol (PVA) scaffolds were cut into small pieces and cocultured with murine bone marrow-derived MSCs (BM-MSCs) expressing green fluorescent protein (GFP) for 72 hours. The cultures were either analyzed by confocal microscopy or used for subsequent in vivo experiments. In vivo: 26 mice were divided into 3 groups (ie, control [n = 9], GS [n = 8], ED [n = 9]). Under general anesthesia, TMPs of equal sizes were performed bilaterally using a sterile 27-gauge needle under a surgical microscope. The BM-MSCs embedded within GS or ED scaffolds were soaked in phosphate-buffered saline and then topically applied on right TMPs, and scaffolds alone were applied on left TMPs 6 to 8 hours after injury. Control mice did not receive treatment. On day 7, animals were euthanized and bullae were harvested for histological analysis.

RESULTS

In vitro: BM-MSCs grew well on both GS (P = .0012) and ED (P = .0001) scaffolds compared with PVA. In vivo: 100% of untreated (control) TMPs remained open after 7 days. Animals treated with MSC-embedded ED scaffolds had a higher percentage of TMP closure (P = .016) and a thicker neotympanum (P = .0033) than control animals. The experimentally applied BM-MSCs engrafted and differentiated into epithelial cells suggested by the colocalized expression of cytokeratin-19 and GFP.

CONCLUSIONS

The topical application of bone marrow-derived MSCs enhances the healing of TMPs in this animal model and is a promising alternative to tympanoplasty.