Endoscopic tympanoplasty with limited tympanomeatal flap elevation in pediatric cases: comparison of anatomic and audiological results of grafts

Effects of no perforation margin trimming and EAC packing in cartilage underlay myringoplasty for chronic large perforations in children

OBJECTIVE

Trimming of perforation margins and external auditory canal (EAC) packing are basic procedures in underlay myringoplasty for repairing chronic perforations. The objective of this study was to compare the operation time, graft outcome, hearing improvement, and complications of endoscopic cartilage underlay myringoplasty with and without trimming of perforation margins and EAC packing in children.

STUDY DESIGN

Prospective, randomized study.

SETTING

Tertiary referral center.

MATERIAL AND METHODS

Pediatric patients older than 12 years with chronic perforations were randomly divided into two groups: myringoplasty with trimming of perforation margin and EAC packing (TPME) group or no trimming of perforation margin and EAC packing (NTPME) group. The operation time, graft success rate, hearing improvement, and complications were compared between the two groups.

RESULTS

Fifty-two patients were ultimately included in the study. The mean operation time was 31.4 ± 4.2 min in the TPME group and 23.6 ± 1.7 min in the NTPME group; the difference was significant (P < 0.01). The rate of aural fullness significantly differed between the TPME and NTPME groups (P = 0.000). All participants were followed up for 12 months; the graft success rate did not significantly differ between the groups (88.5% vs. 96.2%; P = 0.603). No patients developed adhesive otitis media. Between the preoperative and postoperative measurements, the mean air-bone gap improved by 10.2 ± 2.8 dB in the TPME group and 11.6 ± 0.7 dB in the NTPME group; this was significant (P < 0.001) in both groups.

CONCLUSIONS

Endoscopic cartilage underlay myringoplasty NTPME shorted the operation time and avoided aural fullness and EAC discomfort compared with the TPME technique; however, graft success and hearing improvement were comparable between the two techniques for repairing large perforations in children.

Comparison of perichondrium-cartilage button technique and traditional over-underlay technique for repairing large perforations

OBJECTIVE

This study was performed to compare the operation time, graft outcomes and complications between the endoscopic cartilage-perichondrium button technique and over-under technique for repairing large perforations.

METHODS

A total of 52 chronic large perforations were randomly allocated to receive treatment using the endoscopic cartilage-perichondrium button technique (n = 26) or over-under technique (n = 26). The graft outcomes, mean operation time and post-operative complications were compared between the two groups at 12 months.

RESULTS

The study population consisted of 52 patients with unilateral chronic large perforations. All patients completed 12 months of follow up. The mean operation time was 32.3 ± 4.2 minutes in the button technique group and 51.6 ± 2.8 minutes in the over-underlay technique group (p < 0.01). The graft success rate at 12 months was 92.3 per cent (24 out of 26) in the button technique group and 96.2 per cent (25 out of 26) in the over-underlay group (p = 0.552).

CONCLUSION

The endoscopic cartilage-perichondrium button technique had similar graft success rates and hearing outcomes for large chronic perforations to the over-under technique, but significantly shortened the mean operation time.

[Chronic mesotympanic Otitis media - Part 2: Surgical Therapy]

Chronic mesotympanal otitis media (CMOM) is a well-developed clinical presentation that is established in diagnostics and therapy. On closer inspection, however, this principle cannot be confirmed in all its facets. Already the physiology and pathophysiology of the middle ear mucosa leave questions unanswered, starting with the distribution of the ciliated epithelium in the middle ear and mastoid to the function of gas exchange.In addition, there are new diagnostic and therapeutic approaches. In the future, optical coherence tomography could help to determine the status of the middle ear mucosa. In addition, there are new findings on the effectiveness of local and systemic antibiotics as well as antiseptics in chronic otorrhea. Other new developments include minimally invasive surgical procedures using endoscopic techniques. All this gives reason to provide an update on the topic of chronic mesotympanal otitis media, which should contribute in preparation for the specialist examination or refreshing.Basics of physiology and pathophysiology as well as new diagnostic approaches and medical treatment were covered in Part 1 of this paper. In Part 2, in addition to established methods, new developments in surgical therapy with minimally invasive surgical procedures are described in more detail.

Endoscopic Versus Microscopic Pediatric Tympanoplasty: Is There a Difference Between Closure Rates and Hearing Outcomes?

OBJECTIVE

To compare closure rates and hearing outcomes of microscopic and endoscopic tympanoplasty in pediatric patients.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary university medical center.

PATIENTS

Pediatric patients who underwent tympanoplasty surgery by a fellowship-trained neurotologist between 2010 and 2019 with a minimum of 2 months of follow-up, a tympanic membrane perforation, and no preoperative cholesteatoma.

INTERVENTIONS

Transcanal endoscopic tympanoplasty or microscopic tympanoplasty (MT) surgery.

MAIN OUTCOME MEASURES

The primary outcome is postoperative closure of the tympanic membrane perforation, assessed using otomicroscopy at the last follow-up appointment. Secondary outcomes include operative time and changes in the air-bone gap (ABG) and pure-tone average (PTA).

RESULTS

Two hundred eleven tympanoplasty operations were analyzed: 121 in the transcanal endoscopic ear surgery (TEES) group and 90 in the MT group. Tympanic membrane closure rates were no different between the two groups (TEES, 82.6%; MT, 88.9%; p = 0.24), and no significant association was found on multivariable analysis (TEES: odds ratio, 0.8; p = 0.61). Both groups showed improvements in the 4-month PTA and ABG and the 12-month PTA, but the 12-month ABG only improved in the TEES group ( p < 0.01). The TEES group had a shorter average operative time (109.8 versus 123.5 min; p = 0.03) and less need for a postauricular incision (2.5% versus 93.3%; p < 0.01).

CONCLUSION

In pediatric tympanoplasty, TEES gives similar membrane closure and hearing outcomes as the microscopic technique, with less operative time and less need for a postauricular incision.

Canalplasty using underwater bone drilling in transcanal endoscopic myringoplasty for patients with a narrow external auditory canal

BACKGROUND

Canalplasty is important in microscopic ear surgery, but it has rarely been studied in otoendoscopic surgery.

OBJECTIVES

The aim of this study was to investigate the application of canalplasty due to external auditory canal stenosis caused by bony bulges in endoscopic myringoplasty.

MATERIALS AND METHODS

The procedures and effects of canalplasties and myringoplasties were analysed. During the canalplasties, depending on the location of the bulges, the meatal skin flaps were elevated in different manners, and the underwater bone drilling technique was adopted to remove the bulges to enlarge the osseous canals.

RESULTS

Canalplasties were performed in 18.5% (33/178) of myringoplasties. All surgeries were completed exclusively via the transcanal endoscopic approach. No iatrogenic injuries were found. Most of the canalplasties required drilling off bulges on multiple walls. The mean total duration of the canalplasties and myringoplasties was 76.6 ± 4.5 min, and the proportion of time required for the canalplasties was 47.3 ± 2.4%.

CONCLUSION

Only approximately one in five endoscopic myringoplasties require antecedent canalplasties due to concurrent canal stenosis. With the underwater bone drilling technique, transcanal endoscopic canalplasty can be safely and efficiently conducted.

Endoscopic perichondrium-cartilage button technique for repairing chronic large perforations in teenagers

OBJECTIVE

The objective of this study was to evaluate the graft outcome and complications of endoscopic perichondrium-cartilage button technique for repairing chronic large perforations in teenagers.

STUDY DESIGN

Prospective case series.

MATERIALS AND METHODS

56 patients with chronic large perforations more than 50% of the TM who underwent endoscopic perichondrium-cartilage button technique. The graft success rate, hearing outcome, and complications were evaluated at postoperative 3, 6 and 12 months.

RESULTS

Of the 56 ears, 3 (5.4%) patients lost follow-up, 53 (94.6%) patients were finally included in this study. The mean operation time was 37.2 ± 5.4 min. The retrograde tympanomeatal flap elevation was performed in 16 (30.2%) patients. The graft success rate was 96.2% (51/53) at postoperative 3 months and 94.3% (50/53) at postoperative 12 months. The mean preoperative ABG was 25.0 ± 3.7 dB, while the mean postoperative ABG postoperatively 6 months was 12.8 ± 3.1 dB; the difference between these values was significant. No graft-related complications (e.g., graft lateralization, significant blunting, and graft medialization) were encountered during the follow-up period. However, graft keratin pearl was noticed in 5.7% (3/53) patients, which occurred in the handle of malleus in 2 and antero-inferior margin in one. All the graft pearls were endoscopically removed in the outpatient setting.

CONCLUSIONS

Endoscopic perichondrium-cartilage button technique can be achieved in every teenager patient with chronic large perforation without cholesteatoma, and, is a safe and efficient procedure.

Endoscopic inlay cartilage and perichondrium myringoplasty for repairing large perforations in teenagers

OBJECTIVE

This study compared the long-term graft success rates and hearing outcomes of overlay-underlay and underly cartilage myringoplasty for repairing large perforations in Teenagers.

STUDY DESIGN

prospective, randomized study.

SETTING

Tertiary referral center.

METHODS

Pediatric patients older than 12 years with chronic perforations were randomly divided into two groups:intervention group (n = 39) and control group (n = 41). The graft success rate, hearing improvement, and complications were compared between the two groups.

RESULTS

A total of 80 patients were included in this study. The graft success rate was 100% in the intervention group and 95.1% in the control group at postoperative 3 months, the difference wasn't significant (P = 0.496). Also, the graft success rate was not significantly different between the two groups at 12 months postoperatively (100.0% vs 87.8%, p = 0.073). However, the difference of graft success rate was significant between the two groups at 24 months postoperatively (97.4% vs 75.6%, p = 0.012). CT examination revealed well-pneumatized middle ears 24 months after surgery in both group. However, epithelial pearls near the umbo were seen at 31 months postoperatively in one patient in the observation group.

CONCLUSIONS

Compared to the endoscopic cartilage with perichondrium composite graft underlay technique, endoscopic perichondrial graft overlay and cartilage underlay had a better long-term graft success rate and lower rate of long-term re-perforation in teenagers. However, the graft technique had no effect on hearing outcome.

Excising or preserving perforation margins in endoscopic transtympanic cartilage myringoplasty does not affect surgical success

OBJECTIVE

To compare the outcome of endoscopic transtympanic cartilage myringoplasty with and without removal of perforation edges for repairing chronic perforations with mucosal chronic otitis media (COM).

STUDY DESIGN

Quasi-randomised clinical trial.

SETTING

Tertiary referral centre.

MATERIALS AND METHODS

Patients with chronic perforations and mucosal COM undergoing endoscopic transtympanic cartilage myringoplasty were allocated to a control group for whom the perforation edges were preserved (n = 40) and an intervention group for whom the edges were removed (n = 39). Mean operation time, graft success rate, mean scores of graft neovascularisation and epithelialisation, and hearing were compared between the groups at 4 weeks and/or 6 months postoperatively.

RESULTS

Graft success rate was 95% (38/40) in the control group and 97% (38/39) in the intervention group at 6 months postoperatively; the difference was not significant. Mean graft neovascularisation scores 4 weeks postoperatively were 2.52 ± 0.59 in the control group and 2.58 ± 0.55 in the intervention group; the difference was not significant. Mean graft epithelisation scores 4 weeks postoperatively were 1.48 ± 0.57 in the control group and 1.68 ± 0.51 in the intervention group; the difference was not significant and remained nonsignificant 6 months postoperatively (2.5 ± 0.55 vs. 2.76 ± 0.36). Audiological outcomes at 6 months did not differ between the groups.

CONCLUSION

Endoscopic, transtympanic cartilage underlay myringoplasty with preservation of the perforation margins did not affect graft neovascularisation, epithelialisation or success. Longer-term outcomes and risk of cholesteatoma require further study.

Prospective Comparison of Pediatric Endoscopic Lateral Graft and Interlay Tympanoplasty

OBJECTIVE

To compare outcomes and complications of endoscopic lateral graft (LGT) and interlay (IT) tympanoplasty.

STUDY DESIGN

Prospective observational cohort study of totally endoscopic ear surgery (TEES) tympanoplasty.

SETTING

Pediatric tertiary referral center.

PATIENTS

One hundred fourteen surgeries for children with tympanic membrane perforation without cholesteatoma.

INTERVENTION

Porcine-derived collagen graft tympanoplasty using either LGT or IT.

MAIN OUTCOME MEASURES

Closure rates of perforation, hearing outcomes (four-tone average air conduction [AC] and air bone gap), and complications that required further surgery were assessed 12 months postoperatively.

RESULTS

Perforation closure rates did not differ between LGT (52/59 (88%)) and IT (45/51 (88%)), (Fisher's exact p = 1.00) (four ears lost to follow-up). AC thresholds (p = 0.32) and air bone gap (p = 0.88) improved similarly after surgery with LGT (median 8.8 dB) and IT (median 7.5 dB). The proportion of ears with serviceably normal hearing (AC ≤ 30 dB HL) postoperatively was similar (LGT 40/49 (82%), IT 36/46 (78%), Fisher's exact p = 0.80). Following IT, three (6%) ears developed inclusion cholesteatoma requiring revision surgery. One (2%) LGT ear developed blunting after myringitis.

CONCLUSIONS

IT and LGT provide similar perforation closure rates and hearing outcomes. When choosing between these two techniques to repair pediatric tympanic membrane perforations, LGT would seem to be preferable than IT due to the risk of inclusion cholesteatoma after IT. There is a small risk of anterior blunting after LGT.

Endoscopic myringoplasty in pediatric patients: a comparison of cartilage graft push-through and underlay fascia graft techniques

BACKGROUND

Although myringoplasty is performed in pediatric patients, there is still no consensus on the graft material and surgerical procedure.

OBJECTIVE

To compare the short-and long- term graft take rates of the cartilage push-through and fascia graft techniques employed during pediatric myringoplasty.

MATERIALS AND METHODS

93 pediatric patients with perforation who underwent myringoplasty were randomized into the cartilage push-through and underlay fascia graft group. The outcomes evaluated were hearing gains, and graft success rates at 12 and 24 months.

RESULTS

The graft success rate was similar between two groups (95.7% vs 91.3%, p = .653) at postoperative 12th months, however, the graft success rate was significantly higher 91.5% for the cartilage graft group compared with 73.9% for the fascia group at postoperative 24th months. No significant between-group differences were observed pre- (p = .694) or post- (p = .812) operative ABG values or mean ABG gain (p = .745).The re-perforation rate in fascia group was significantly higher than that in push through group (19.05 vs. 4.44%). No middle ear cholesteatoma formation was found in either group.

CONCLUSION

Endoscopic cartilage push-through and underlay fascia graft myringoplasty afforded comparable hearing results in pediatric patients; however, the push-through technique without the elevation of a tympanomeatal flap exhibited better long-term graft success rate compared to underlay fascia graft.

A Three Point Assessment Protocol for Tympanoplasty Outcomes: A Retrospective Analysis

Introduction  The surgical outcome of chronic otitis media (COM) of the mucosal type in the pediatric population with high rates of recurrent tympanic membrane perforation is indeed a concern for the attending surgeon. Objective  The present study was done to evaluate the outcome of tympanoplasty in children with chronic otitis media mucosal type. Methods  A retrospective analysis of the medical records of all children, aged < 16 years old, who underwent tympanoplasty for COM of the mucosal type was performed. These patients were addressed by a three-point assessment, for predicting outcome of tympanoplasty, which included the age of the patient, addressing the nasal/pharyngeal issues, and the status of the COM (discharging or dry). Surgical success was assessed in terms of graft uptake and improvement of hearing. Factors affecting the surgical outcome were also analyzed. Results  A total of 90 children underwent type 1 tympanoplasty; 7 were lost to follow-up and 10 had incomplete audiometric results. In the 73 tympanoplasties analyzed, graft uptake was seen in 91.7% of the patients. Children with longer duration of ear discharge (> 8 years) had greater hearing loss. Children aged > 8 years old showed statistically significant higher chance of graft uptake ( p  = 0.021). Five of the six children who had graft rejection had bilateral disease. Conclusion  A three-point assessment in the management of pediatric COM of the mucosal type offers good outcomes with post-tympanoplasty graft uptake rates > 90%.

Use of Endoscopic Cartilage Graft Myringoplasty Without Tympanomeatal Flap Elevation to Repair Posterior Marginal Perforations

OBJECTIVE

We evaluated the graft success rate and hearing outcomes of endoscopic cartilage graft myringoplasty without tympanomeatal flap elevation used to repair posterior marginal perforations.

STUDY DESIGN

A prospective case series.

MATERIALS AND METHODS

A total of 31 patients with posterior marginal perforations who underwent endoscopic cartilage graft myringoplasty were included. The outcomes were the hearing gain and graft success rate at 6 and 24 months.

RESULTS

The graft success rate was 96.7% (30/31) at 6 months and 90.3% (28/31) at 24 months; 1 patient exhibited composite graft extrusion and lateralization in the region of the anterior annulus; a residual perforation was apparent. Reperforation occurred in 2 patients. The mean preoperative air-bone gap (ABG; 28.61 ± 3.14 dB) was significantly greater than the mean postoperative ABG (12.15 ± 3.98 dB; P < .05) at 6 months; however, there was no statistically significant difference between the post-6 months and post-24 months with regard to ABG values (P = .871), ABG gain (P = 0.648), or functional success rate (P = .472). No significant graft blunting or atelectasis was noted during follow-up. The free perichondrium became fully integrated with the skin of the external auditory canal; the perichondrium could not be clearly distinguished endoscopically 4 to 8 weeks postoperatively. Computed tomography revealed well-pneumatized middle ear and mastoid cavity at postoperative 24 months.

CONCLUSION

Endoscopic cartilage graft myringoplasty without tympanomeatal flap elevation reliably repairs posterior marginal perforations. The short- and long-term graft success rate is high, and the hearing results are satisfactory; the technique is minimally invasive.

Endoscopic cartilage myringoplasty with the removal of a small rim of the external auditory canal to repair marginal perforations

Objective

To evaluate the graft success rate and postoperative hearing gain for marginal perforations using endoscopic cartilage myringoplasty with the removal of a small rim of the external auditory canal (EAC).

Study design

Prospective case series.

Materials and methods

We performed a prospective study in 41 patients with marginal perforations who underwent endoscopic cartilage myringoplasty with the removal of a small rim of EAC. Patients were followed up for 6 months.

Results

Of the 41 patients with unilateral marginal perforation included in this study, the graft success rate was 100% (41/41). The mean ABG improved from 11.31 ± 9.71 dB preoperatively to 7.31 ± 2.32 dB postoperatively for small-and medium-sized perforations (P = 0.13); the mean ABG improved from 21.46 ± 8.39 dB preoperatively to 9.84 ± 2.41 dB postoperatively for large perforations (P < 0.05); the mean ABG improved from 28.79 ± 6.74 dB preoperatively to 10.13 ± 3.56 dB postoperatively for subtotal and total perforations (P < 0.05). There were no cases of graft lateralization or significant blunting or atelectasis or graft adhesions. Three patients developed postoperative otorrhoea and five patients had mild myringitis.

Conclusions

Endoscopic cartilage myringoplasty with the removal of a small rim of the EAC is simple and feasible, showing a high graft success rate and minimal complications for repairing marginal perforations.

Bilateral same-day endoscopic tympanoplasty

PURPOSE

Although bilateral same-day tympanoplasty is a faster and more comfortable procedure for patients, it is rarely performed due to its theoretical risks. The present study aims to evaluate the results of patients who underwent bilateral same-day endoscopic tympanoplasty.

MATERIALS AND METHODS

In this study, 26 patients and 52 ears were evaluated. Postoperative anatomic success rate, pre- and postoperative hearing test results, hearing gains and postoperative complications were recorded.

RESULTS

Postoperative anatomic success rate was 92.3% (48/52). Audiological tests revealed the preoperative air-bone gap (ABG) as 19.1 ± 8.8 (7-35) dB and postoperative ABG as 9.8 ± 5.7 (5-25) dB. Postoperative ABG decreased significantly (p: <0.001) and 9.2 ± 4.6 (2-23) dB hearing gain was obtained. We did not observe any significant complications.

CONCLUSION

Bilateral same-day endoscopic tympanoplasty is a feasible surgical procedure with good anatomic and functional outcomes, low complication rate and good postoperative patient comfort.