Tympanic membrane perforation: size, site and hearing evaluation

Myringoplasty Using Human Birth Tissue Allografts to Repair Large Tympanic Membrane Perforations

OBJECTIVE

Examine outcomes among a series of pediatric patients who underwent myringoplasty using human birth tissue (BT) for repair of large tympanic membrane (TM) perforations.

STUDY DESIGN

Case series.

SETTING

Single-institution pediatric hospital.

METHODS

Retrospective chart review of patients treated with BT during a 4-year study period. Subjects who underwent myringoplasty for large (size 40% or greater) TM perforations were included for this study. Patients with a stable perforation of at least 1 month's duration preoperatively who then followed up for at least 3 months postoperatively met inclusion criteria.

RESULTS

Six subjects were included in this study. One subject underwent bilateral repair; thus, this series includes a total of 7 perforations. TM perforations ranged from 40% to 70% of the TM. At initial follow-up (median of 2 months), 5 of the 7 perforations had healed. One of these 5 had evidence of a 10% recurrent perforation at 5 months, which subsequently healed. Of the 2 patients not healed at initial follow-up, 1 had only a residual pinpoint perforation that subsequently healed; the other had a persistent 30% perforation that was possibly related to their postoperative recovery period, which was complicated by a respiratory viral illness.

CONCLUSION

For large TM perforations, myringoplasty with BT grafts may be a viable alternative to longer, more invasive procedures like tympanoplasty. Larger, randomized, prospective studies are needed.

Finite element analysis of repairing tympanic membrane perforation using autologous graft material and biodegradable bionic cobweb scaffold

BACKGROUND AND OBJECTIVE

As for repairing the perforated tympanic membranes (TM), temporalis fascia and tragal cartilage are popular in clinics as autologous graft materials. However, there is a significant hearing loss after repairing the TM with autologous graft materials, which needs to be addressed in biomechanical engineering.

METHODS

The finite element model of normal middle ear is improved from two aspects: the repair method of tympanic fibrous layer and the bionic spider web tympanic scaffold. By creating the solid-shell coupling condition and strong coupling boundary condition to simulate the repair, TM umbo and stapes footplate displacement-frequency response are explored in 200-8000 Hz.

RESULTS

The tympanic membrane perforation (TMP) causes a significant conductive hearing loss in high frequency region, which is positively correlated with perforation area. Both temporalis fascia and tragal cartilage still perform a certain degree of high-frequency hearing loss after repairing TMP. The TM attachment the magnesium alloy scaffold (MAS) prevents appropriately the high frequency hearing loss after autologous graft repair and makes the sound transmission closer to the normal condition. Significantly, the density of graft material has a negative effect on high-frequency sound transmission without the MAS. The modal-motion of TM repaired with temporalis fascia and tragal cartilage is improved significantly after attaching the MAS. In addition, the MAS restores effectively the configuration and vibration frequency of the repaired TM, which is similar to that of the native TM.

CONCLUSION

The area size of TMP is studied through the finite element method, which includes autologous graft materials, the MAS, parameter sensitivity analysis, modal analysis of graft material and the MAS in biological form on the effect of middle ear sound transmission. Relevant conclusions provide some references for clinical trial protocol and the follow-up repair ideas of TM of tympanoplasty.

Diagnostic accuracy of the video otoscope in tympanic membrane perforation

OBJECTIVE

The video otoscope has already proven to be useful for the diagnosis of several pathologies, so the objective of this study was to evaluate the diagnostic accuracy of the video otoscope in cases of tympanic membrane perforation.

METHODS

This is a diagnostic accuracy study performed at the hearing health division of a tertiary-level referral hospital. Patients older than 8 years of age who had any symptom that could be related to perforation (otalgia, otorrhea, tinnitus, and/or hypoacusis) were invited to participate in the study. Participants were evaluated by three different diagnostic methods (otomicroscope, conventional otoscope, and video otoscope) performed by three different evaluators in a blind fashion. The microscope was considered the reference standard.

RESULTS

176 patients were evaluated, totaling 352 tympanic membranes. Twenty-seven tympanic membrane perforations were diagnosed by the microscope, a prevalence of 7.7%. The video otoscope showed a sensitivity of 85.2% (95% CI 81.5%‒88.9%), specificity of 98.1% (95% CI 96.7%‒99.5%) and accuracy of 97.1% (95% CI 95.4 %-98.8 %). The conventional otoscope showed a sensitivity of 96.3% (95% CI 94.3-98.3), specificity of 98.8% (95% CI 97.7-99.9) and accuracy of 98.6% (95% CI 97.4-99.8). The Kappa value between the microscope and the video otoscope was 0.8 and between the microscope and the conventional otoscope was 0.9. Regarding the participants' perception, 53.4% (p< 0.001) considered the video otoscope as the best method for understanding the tympanic membrane condition presented by them.

CONCLUSIONS

The video otoscope showed relevant sensitivity and specificity for clinical practice in the diagnosis of tympanic membrane perforation. Moreover, this is an equipment that can facilitate the patient's understanding of the otologic pathology presented by him/her. In this regard, this method may be important for better patient compliance, requiring further studies to evaluate this hypothesis.

LEVEL OF EVIDENCE

Is this diagnostic or monitoring test accurate? (Diagnosis)-Level 2 (Individual cross-sectional studies with consistently applied reference standard and blinding).

Automated Segmentation of Optical Coherence Tomography Images of the Human Tympanic Membrane Using Deep Learning

Optical Coherence Tomography (OCT) is a light-based imaging modality that is used widely in the diagnosis and management of eye disease, and it is starting to become used to evaluate for ear disease. However, manual image analysis to interpret the anatomical and pathological findings in the images it provides is complicated and time-consuming. To streamline data analysis and image processing, we applied a machine learning algorithm to identify and segment the key anatomical structure of interest for medical diagnostics, the tympanic membrane. Using 3D volumes of the human tympanic membrane, we used thresholding and contour finding to locate a series of objects. We then applied TensorFlow deep learning algorithms to identify the tympanic membrane within the objects using a convolutional neural network. Finally, we reconstructed the 3D volume to selectively display the tympanic membrane. The algorithm was able to correctly identify the tympanic membrane properly with an accuracy of ~98% while removing most of the artifacts within the images, caused by reflections and signal saturations. Thus, the algorithm significantly improved visualization of the tympanic membrane, which was our primary objective. Machine learning approaches, such as this one, will be critical to allowing OCT medical imaging to become a convenient and viable diagnostic tool within the field of otolaryngology.

Analysis of cognitive framework and biomedical translation of tissue engineering in otolaryngology

Tissue engineering is a relatively recent research area aimed at developing artificial tissues that can restore, maintain, or even improve the anatomical and/or functional integrity of injured tissues. Otolaryngology, as a leading surgical specialty in head and neck surgery, is a candidate for the use of these advanced therapies and medicinal products developed. Nevertheless, a knowledge-based analysis of both areas together is still needed. The dataset was retrieved from the Web of Science database from 1900 to 2020. SciMAT software was used to perform the science mapping analysis and the data for the biomedical translation identification was obtained from the iCite platform. Regarding the analysis of the cognitive structure, we find consolidated research lines, such as the generation of cartilage for use as a graft in reconstructive surgery, reconstruction of microtia, or the closure of perforations of the tympanic membrane. This last research area occupies the most relevant clinical translation with the rest of the areas presenting a lower translational level. In conclusion, Tissue engineering is still in an early translational stage in otolaryngology, otology being the field where most advances have been achieved. Therefore, although otolaryngologists should play an active role in translational research in tissue engineering, greater multidisciplinary efforts are required to promote and encourage the translation of potential clinical applications of tissue engineering for routine clinical use.

Hearing loss increases with size but not site of tympanic membrane perforation in Aboriginal Australian children in remote locations

Objective

To investigate the effect of size, site, and activity of tympanic membrane (TM) perforation on hearing loss (HL) in Aboriginal and Torres Strait Islander (ATSI) children.

Design

Observational study.

Methodology

Children aged 5-18 years who identified as ATSI at seven Anangu community schools within the Anangu Pitjantjatjara Yankunytjatjara Lands and Maralinga Lands of South Australia underwent 4-frequency pure-tone audiometry (0.5, 1, 2, and 4 kHz) and video-otoscopy (VO). VO data was reviewed by surgeons for a middle ear diagnosis and VO files with TM perforations were then classified by perforation site (AS, AI, PS, PI, A, P, I) and size (<25%, 25%-50%, 50%-75%, or 75%-100%).

Results

Five hundred seventy-five VO files with matching audiological data were obtained. Active perforations (35 dBHL; 28-44 IQR) demonstrated greater HL than inactive perforations (31 dBHL; 29-39 IQR) p = .0029. For inactive perforations there was a significant difference between <25% and all larger perforations (p < .0001) whereas for active perforations the significance changed to between <25% (p < .0001) and 25%-50% (p < .05) when compared to larger perforations. When perforation site was compared within all size/activity groups, no statistically different findings were identified. In all analyses, findings did not change when individual frequencies were compared to 4-frequency pure-tone average dBHL.

Conclusion

In ATSI children from remote communities, HL is greater in ears with larger perforations and active middle ear disease but there was no relationship between perforation site and HL.Level of evidence: Level 4.

Tissue engineering and regenerative medicine strategies for the repair of tympanic membrane perforations

Despite the high success rate of autologous grafts in tympanic membrane repair, clinical alternatives are required for the closure of unresponsive chronic perforations that can lead to recurring infection and hearing loss. Tissue engineering and regenerative medicine approaches have emerged as another strategy to repair the eardrum, in addition to negating the need for donor tissue harvest and related surgical iatrogenicities. This review highlights the main approaches using biomaterials, growth factors, and cell therapies towards the healing of complex TM perforations. In addition, we discuss the challenges and advances for the development of reliable animal models, which will allow the optimisation and development of novel techniques. Finally, we indicate technologies that are currently used clinically and others that are closer to the market. The advances here discussed on tissue engineering and regenerative medicine strategies applied to the field of TM perforations will allow otologists, surgeons, and researchers to better bring novel technologies to the bedside as well as to develop new ones.

The application of a 70° endoscope in performing transcanal middle ear surgery

BACKGROUND

Endoscopes increase the expediency of transcanal middle ear surgery. However, the application of a 70° endoscope is limited and seldom discussed, mainly because of its large angle. We introduce our experiences with the 70° endoscope in transcanal middle ear surgery.

METHODS

This is a retrospective chart review of 127 patients with chronic otitis media who underwent middle ear surgery performed by the senior author in 2016 at a tertiary referral center. The types of eardrum perforation were classified as central, inferior, posterior, or anterior according to the main location of the hole. The demographics, surgical pictures, and operative records were reviewed.

RESULTS

In 15 ears of the 127 patients, the ossicles were recognized directly by a microscope. In another 112 ears, the ossicles could not be identified under a microscope. Without elevating the tympanomeatal flap, the ossicles could be recognized in 72 of these 112 ears with endoscopes, especially the 70° endoscope. In 35 of these 112 ears, an incision to extend the drum perforation or creation of a small tympanomeatal flap in the posterior-superior canal was made to observe the ossicles. However, 5 of these 112 ears were still noted to have a narrow and/or curved ear canal and preoperatively needed to undergo endaural incisions. Among the other 122 patients who first underwent attempted transcanal surgery, 15 ears changed to endaural incisions. The drum perforations were repaired directly through the perforation in 107 ears via the transcanal route. One year after surgery, the air-bone gap closure was 16.0 ± 11.8 dB, and the graft take rate was 91.3%.

CONCLUSION

With the help of a 70° endoscope, we can use the transcanal transperforation route to evaluate and reconstruct drum perforations and ossicular chains in appropriate patients. Hence, normal tissue injuries to the ear canal can be minimized.

A Study of Correlation Between Tympanic Membrane Perforation Size With Hearing Loss in Patients With Inactive Mucosal Chronic Otitis Media

PURPOSE

This study is directed towards establishing a correlation between the objective measurement of tympanic membrane (TM) perforation size with hearing loss in patients with inactive mucosal chronic otitis media (COM), and to compare the otoscopic findings of the TM perforation vis-a-vis the results obtained by image analysis of the endoscopic image of the perforation.

MATERIALS AND METHODS

An observational, prospective and hospital based study was performed on 107 ears (78 patients) with inactive mucosal chronic otitis media. Objective measurement of the TM perforation size was done by capturing the images of the perforation on ImageJ analysis software. A correlation was established between the hearing loss and the perforation with respect to its size and location. The accuracy of the otoscopic finding of the perforation was established with respect to the endoscopic image of the perforation.

RESULTS

The extent of the hearing loss was seen to increase with increasing size of the TM perforation (r = 0.435, p < 0.0001). Posterior perforations had a 12% greater hearing loss than anterior perforations but this was significant only at the frequency of 500 Hz (p = 0.02). There was a positive correlation between the otoscopic estimation of the size of the perforation with the endoscopically obtained image.

CONCLUSION

Hearing loss in chronic otitis media is directly proportional to the size of the TM perforation and posteriorly based perforations have worse audiometric thresholds at lower frequencies (500 Hz).

Regenerative treatment for tympanic membrane perforation using gelatin sponge with basic fibroblast growth factor

OBJECTIVE

The objective of this study was to evaluate safety and efficacy of regenerative treatment using gelatin sponge with basic fibroblast growth factor (bFGF) in patients with tympanic membrane perforation (TMP).

METHODS

The current study was a prospective, multicenter, open-label, single-arm, and exploratory clinical trial to evaluate the safety and efficacy of the TM regeneration procedure (TMRP). Myringotomy was used to mechanically disrupt the edge of the TMP, and a gelatin sponge immersed in bFGF was then placed over the perforation. Fibrin glue was dripped over the sponge as a sealant. TMP closure was examined 4 weeks later and, if insufficient, TMRP was repeated a maximum of three more times. TMP closure and hearing improvement 12 weeks after the final TMRP as well as safety were evaluated.

RESULTS

Of the 11 patients with TMP who participated in this study, one who fulfilled the exclusion criteria and did not undergo TMRP and one with cholesteatoma were excluded from the efficacy analysis. TMP closure and hearing improvement 12 weeks after the final TMRP were achieved in eight out of nine patients (88.9%). Mean bone conduction threshold significantly improved 12 weeks after the TMRP compared with baseline (35.7±20.3 vs 29.4±21.0dB, P=0.015). Six out of ten patients receiving TMRP experienced temporary adverse events: appendicitis (serious, severe), otorrhea (mild), otitis media (mild), and sudden hearing loss (mild). However, none were related to the protocol treatment.

CONCLUSION

TMP closure and hearing improvement were frequently confirmed following the TMRPs which were safely performed. These favorable outcomes were accompanied with significant improvement of the bone conduction threshold. These promising outcomes would encourage a large-scaled, randomized and pivotal clinical trial in the future. This trial is registered at http://www.umin.ac.jp/ctr/index.htm (identifier: UMIN000006585).

High-speed video analysis of acoustically oscillated guinea pig stapes

Objective:

We investigated the ossicular movement in the near-intact middle ear in response to acoustic stimulation using a high-speed video camera and video analysis software program.

Design:

We have designed a good visual access to the middle ear of the guinea pig by opening the ventral wall of the otic capsule, without injuring the sound-conducting structures, from the external auditory canal to the oval window. The high-speed video camera could record analysable ossicular motion up to 4000 frames per second.

Results:

The stapes showed reciprocal movement in the same frequency as the stimulating tone, and with an amplitude proportional to the stimulating sound intensity. Injury to the tympanic membrane attenuated the stapedial motion, which was recovered to that of the control level by patch repair of the perforation.

Conclusion:

Our experimental set-up was capable of evaluating the conductive hearing, regardless of the status of the animal's sensorineural hearing or even life. Such a video analysis may provide a powerful tool to investigate the physiology of the middle ear.

[The results of myringoplasty using underlay technique]

INTRODUCTION

The method of tympanic membrane repairing is called myringoplasty.

AIM OF THE STUDY

We analysed the reasons of failure of this procedure.

MATERIAL AND METHODS

The structural results were observed among 36 patients under restricted criteria with diagnosed chronic otitis media. The unsuccessful procedure was one with reperforation. We studied Eustachian tube function and also localisation and size of the perforation.

RESULTS

The failure rate was 25%, which was mainly observed among individuals with incorrect Eustachian tube function - 70% and margin perforations - 50%. The localisation and the size of the perforation did not matter.

CONCLUSIONS

The main reasons of myringoplasty failure were incorrect Eustachian tube function and margin perforations of tympanic membrane.

Mechanisms of hearing loss after blast injury to the ear

Given the frequent use of improvised explosive devices (IEDs) around the world, the study of traumatic blast injuries is of increasing interest. The ear is the most common organ affected by blast injury because it is the body's most sensitive pressure transducer. We fabricated a blast chamber to re-create blast profiles similar to that of IEDs and used it to develop a reproducible mouse model to study blast-induced hearing loss. The tympanic membrane was perforated in all mice after blast exposure and found to heal spontaneously. Micro-computed tomography demonstrated no evidence for middle ear or otic capsule injuries; however, the healed tympanic membrane was thickened. Auditory brainstem response and distortion product otoacoustic emission threshold shifts were found to be correlated with blast intensity. As well, these threshold shifts were larger than those found in control mice that underwent surgical perforation of their tympanic membranes, indicating cochlear trauma. Histological studies one week and three months after the blast demonstrated no disruption or damage to the intra-cochlear membranes. However, there was loss of outer hair cells (OHCs) within the basal turn of the cochlea and decreased spiral ganglion neurons (SGNs) and afferent nerve synapses. Using our mouse model that recapitulates human IED exposure, our results identify that the mechanisms underlying blast-induced hearing loss does not include gross membranous rupture as is commonly believed. Instead, there is both OHC and SGN loss that produce auditory dysfunction.