Fat graft myringoplasty using umbilical fat

Comparing Myringoplasty to Type I Tympanoplasty in Tympanic Membrane Repair: A Systematic Review and Meta-Analysis

OBJECTIVE

To compare the anatomic success rates of type I tympanoplasty (tympanoplasty) versus myringoplasty. By our definition, tympanoplasty involves entering the middle ear via elevation of a tympanomeatal flap, while myringoplasty involves surgery to the drumhead without middle ear exposure.

DATA SOURCES

PubMed, Scopus, CINAHL, Cochrane.

REVIEW METHODS

To be included, studies must have documented surgical technique, tympanic membrane (TM) perforation size (as % of TM), and success rate using tissue or alloplastic grafts. Exclusion criteria included series with more than 10% of patients with cholesteatoma or middle ear pathology. A meta-analysis of weighted summary proportions under the random effects model was performed, and proportion differences (PD) were calculated. A secondary analysis of hearing outcomes was performed.

RESULTS

Eighty-five studies met inclusion, with a tympanoplasty cohort of n = 7966 and n = 1759 for myringoplasty. For perforations, less than 50% of the TM, the success rate for tympanoplasty and myringoplasty was 90.2% and 91.4%, respectively (PD: 1.2%, p = .19). In perforations greater than 50%, tympanoplasty and myringoplasty success rates were 82.8% and 85.3%, respectively (PD: 2.5%, p = .29). For both procedures, perforations less than 50% of the TM had higher success rates than perforations greater than 50% of the TM (p < .01). Both techniques endorsed significant improvements to air-bone gap (ABG) metrics.

CONCLUSION

Our analysis suggests that the anatomic success rate is similar for tympanoplasty and myringoplasty, regardless of perforation size, and that smaller perforations experience higher success rates in both techniques. ABG outcomes were also similar between procedure techniques.

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.

Myringoplasty without tympanomeatal flap elevation in children: A systematic review

OBJECTIVES

Systematic review of the literature on myringoplasty techniques without tympanomeatal flap elevation in children.

MATERIAL AND METHODS

A systematic review following PRISMA guidelines reported papers on patients under 18years of age undergoing myringoplasty for chronic tympanic perforation on a transcanal approach without tympanomeatal flap elevation. Tympanic closure rates and audiometric results were analyzed.

RESULTS

Twenty studies were included. Nine reported the butterfly technique, using a microscope or endoscope, with closure rate of 82.3% (246/299), for perforations of various sizes. Ten reported the fat-plug technique, with closure rate of 86.8% (869/1001), mostly for perforations of less than one-third of the tympanum. Both techniques improved audiometric results. Morbidity was very low. The absence of chronic otitis or co-morbidities (contralateral otitis media with effusion, craniofacial malformations, Down's syndrome) implies that patient selection technique may be necessary to obtain the best results.

CONCLUSION

Fat-plug myringoplasty, for small perforations, and butterfly cartilage myringoplasty seem to be reliable procedures in selected patients, with low morbidity in children.

Retained Tympanostomy Tubes: Who, What, When, Why, and How to Treat?

BACKGROUND

Tympanostomy tube placement is one of the most common surgical procedures performed across the globe. Controversies exist regarding what to do when a tube is considered to be retained in the tympanic membrane for too long.

MATERIALS AND METHODS

Review of the PubMed medical literature starting in 1990, focusing on English language studies reporting on the definition, complications, and management of retained tympanostomy tubes.

RESULTS

The medical literature reporting on outcomes regarding retained tympanostomy tubes is relatively sparse. Most studies recommend prophylactic removal of tubes after a defined period of time, usually around 2 to 3 years after placement. A preferred method of myringoplasty after tympanostomy tube retrieval has not been established, but most studies recommend grafting the perforation at the time of tube removal.

CONCLUSIONS

Although a consensus as to the optimal management of retained tympanostomy tubes is not yet established in the medical literature, a preponderance of studies recommend prophylactic removal at defined period of time (>2-3 years) before the onset of complications such as otorrhea and granulation tissue formation. Due to a lack of best evidence, the surgeon's preference remains the guiding principle as to the best technique for myringoplasty at the time of removal.

Impact of perforation size and predictive factors for successful pediatric gelfoam myringoplasty

OBJECTIVES

Rates of success with pediatric myringoplasty range from 35 to 95%. The objective of this study is to evaluate the impact of perforation size on successful closure of the tympanic membrane (TM) after gelfoam myringoplasty. We also aim to identify variables that affect perforation closure rates and define predictive factors for successful TM closure.

METHODS

A retrospective chart review of all patients that underwent gelfoam myringoplasty by a single surgeon from August 2008 through January 2015 was performed.

RESULTS

One hundred fifty-nine patients met inclusion criteria and underwent a total of 219 procedures. Overall, gelfoam myringoplasty had an 83.1% rate of successful closure. Average perforation size was 15.31%. Classification tree analysis separated our cohort into three groups based on perforation size: Group 1 (<16.25%) had a 91% closure rate, group 2 (16.25% to <31.25%) had a 66.0% closure rate and group 3 (≥31.25%) had a 30.0% closure rate. Smaller perforations (P ≤0.001) were associated with increased success rates. Other factors associated with successful closure of the TM included younger age at the time of myringoplasty (P ≤0.001), fewer number of prior tympanostomy tubes (P = 0.016), and lesser duration of tube retention (P = 0.003).

CONCLUSION

Gelfoam myringoplasty provides good overall TM closure rates and may be considered as a potential first-line option for repair of perforations, including those involving up to 40% of the TM. Younger patients with smaller perforations, fewer sets of tubes, shorter length of tube retention are more likely to have successful closure of the tympanic membrane.

Traumatic perforations of the tympanic membrane: immediate clinical recovery with the use of bacterial cellulose film

Introduction

Perforation of the tympanic membrane is a reasonably frequent diagnosis in otorhinolaryngologists’ offices. The expectant management is to wait for spontaneous healing, which usually occurs in almost all cases in a few weeks. However, while waiting for healing to be completed, the patients may experience uncomfortable symptoms. Although some research suggests the use of various materials to aid in the recovery of the tympanic membrane, none presented robust evidence of improvement in the cicatricial process. Nevertheless, the occlusion of the perforation with some material of specific texture and resistance can alleviate the patients’ symptoms and accelerate the healing process.

Objective

To evaluate the clinical (symptomatic and functional) improvement after the placement of bacterial cellulose film (Bionext®) on tympanic membrane perforations (traumatic).

Methods

We evaluated 24 patients, victims of traumatic perforations of the tympanic membrane, who were evaluated in the Otorhinolaryngology Emergency Room. Following otoscopy and audiometric examination was performed, before and after the use of cellulose film occluding the tympanic membrane perforation.

Results

Twenty-four patients were included, whose degree of overall discomfort caused by the tympanic membrane perforation and the presence of symptoms of autophonia, ear fullness and tinnitus were investigated. The mean score attributed to the overall annoyance caused by tympanic membrane perforation was 7.79, decreasing to a mean value of 2.25 after the film application. Symptom evaluation also showed improvement after using the film: autophonia decreased from a mean value of 6.25 to 2.08, tinnitus from 7 to 1.92 and ear fullness from 7.29 to 1.96. The auditory analysis showed mean threshold values still within the normal range at low and medium frequencies, with slight hearing loss at acute frequencies, but with significant improvement at all frequencies, with the exception of 8000 Hz, after film use.

Conclusion

The use of bacterial cellulose film fragment on traumatic perforations of the tympanic membrane promoted immediate functional and symptomatic recovery in the assessed patients.

Clinical and audiological short-term and long-term outcomes of fat graft myringoplasty

INTRODUCTION

Results of fat graft myringoplasty are often reported with only short-term follow-up. Audiological results are less commonly reported, as well as long-term follow-up results.

MATERIALS AND METHODS

One hundred consecutive patients scheduled for fat graft myringoplasty were included in a prospective cohort study. Clinical and audiological outcomes were assessed at six weeks and one year postoperatively.

RESULTS

Perforation sizes ranged from 0.5 to 4 mm. The six-week follow-up showed a total perforation closure rate of 72.9% with a statistically significant (p = .03) higher rate for the pediatric age group (83.0%). 64.4% of all patients were healed at one-year follow-up. Statistical analyses for background factors did not reveal any significant difference in healing rates with regard to patient sex or location or cause of the perforation. The mean preoperative air-conduction (AC) threshold was 25 dB with an air-bone gap of 12 dB. At the one-year follow-up the mean air conduction threshold for healed ears was improved to 16.6 dB, still 54.2% of them had a type B tympanogram.

CONCLUSIONS

Children had a higher perforation closure rate at six-week follow-up than adult patients. Recurrent tympanic membrane perforations were common after initially successful fat graft myringoplasties. Long-term hearing was improved after successful fat graft myringoplasty, resulting in a mean AC threshold of 16.6 dB.

Outlook for Tissue Engineering of the Tympanic Membrane

Tympanic membrane perforation is a common problem leading to hearing loss. Despite the autoregenerative activity of the eardrum, chronic perforations require surgery using different materials, from autologous tissue - fascia, cartilage, fat or perichondrium - to paper patch. However, both, surgical procedures (myringoplasty or tympanoplasty) and the materials employed, have a number of limitations. Therefore, the advances in this field are incorporating the principles of tissue engineering, which includes the use of scaffolds, biomolecules and cells. This discipline allows the development of new biocompatible materials that reproduce the structure and mechanical properties of the native tympanic membrane, while it seeks to implement new therapeutic approaches that can be performed in an outpatient setting. Moreover, the creation of an artificial tympanic membrane commercially available would reduce the duration of the surgery and costs. The present review analyzes the current treatment of tympanic perforations and examines the techniques of tissue engineering, either to develop bioartificial constructs, or for tympanic regeneration by using different scaffold materials, bioactive molecules and cells. Finally, it considers the aspects regarding the design of scaffolds, release of biomolecules and use of cells that must be taken into account in the tissue engineering of the eardrum. The possibility of developing new biomaterials, as well as constructs commercially available, makes tissue engineering a discipline with great potential, capable of overcoming the drawbacks of current surgical procedures.

Fat-plug myringoplasty of ear lobule vs abdominal donor sites

The purpose of this study is to compare the success rates of fat-graft myringoplasties harvesting adipose grafts from different donor sites (ear lobule vs abdomen). The clinical records of 61 patients (24 males and 37 females) who underwent fat-plug myringoplasty (FPM) were reviewed retrospectively. Fat from ear lobule (FEL) and abdominal fat were used as graft materials. The impact of age, gender, systemic diseases, topography of the perforation, utilization of fat graft materials of different origin on the tympanic membrane closure rate and the effect of FPM on hearing gain was analyzed. Our tympanic membrane (TM) closure rate was 82 %. No statistical significant difference was observed regarding age, gender, comorbidities (septal deviation, hypertension and diabetes mellitus) or habits (smoking). Posterior TM perforations had significantly lower healing rate. The change in TM closure rate considering different adipose tissue donor sites was not statistically significant. The hearing gain of the patients was mostly below 20 dB. Fat-plug myringoplasty (FPM) is a safe, cost-effective and easy operation for selected patients. Abdominal fat graft is as effective as ear lobe fat graft on tympanic membrane healing, has cosmetic advantages and should be taken into consideration when planning fat as the graft source.