Transcanal endoscopic type 1 tympanoplasty in children: Cartilage butterfly and fascia temporalis graft

Comparison of cartilage and temporalis fascia grafts in type 1 tympanoplasty: A meta-analysis

OBJECTIVE

To systematically review the results of type 1 tympanoplasties with temporalis fascia (TF) vs cartilage grafts in patients with chronic otitis media.

METHODS

Eligible studies were identified from PubMed, Ovid, and EMBASE databases prior to November 2021. We analyzed the pure tone audiometry (PTA) and air-bone gap (ABG) data as continuous variables, and the success rate was analyzed as a dichotomous variable.

RESULTS

Forty-four studies, including 4582 patients, were eligible. The cartilage graft overall morphologic success rate was higher than that of the TF grafts (P < .001). In the palisade (P < .004) and island grafts (P < .001) subgroups, the analysis was significantly different. However, there was no significant difference in the inlay butterfly grafts subgroup. For hearing outcomes, the analysis revealed that TF grafts had a smaller mean post-operative ABG (P = .009). However, the subgroup analysis showed no significant difference in the mean post-operative ABG. For PTA, there was no significant difference in hearing improvement. However, the palisade cartilage graft subgroup resulted in a better hearing outcome than the TF graft subgroup in terms of the mean post-operative PTA (P = .007). There was no significant difference in the functional success rate or mean ABG gain.

CONCLUSION

Cartilage grafts have a better success rate than TF grafts in tympanoplasty. Both cartilage and TF tympanoplasty provided similar improvements in hearing outcome, while TF grafts generated a better outcome in post-operative ABG and palisade cartilage grafts in post-operative PTA. This may be related to the biological characteristics of the grafts. Further thorough studies need to be 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.

Janus membranes with asymmetric cellular adhesion behaviors for regenerating eardrum perforation

The tympanic membrane plays an important role in the human hearing system, which is easily perforated under unfavorable conditions, leading to loss of hearing and otitis media. Many autologous materials and artificial materials have been used to repair a perforated tympanic membrane, but these materials sometimes can cause severe hearing loss because of their adhesion to the ossicle during the healing process and the postoperative process. Herein, we report Janus membranes with asymmetric cellular adhesion behaviors for regenerating the eardrum. These Janus membranes are constructed by co-depositing a tannic acid (TA)/3-aminopropyltriethoxysilane (APTES) coating on one surface of the polypropylene microfiltration membrane. Cellular experiments indicate that the Janus membranes have good biocompatibility and asymmetric cellular adhesion properties. The repair of the tympanic membrane perforation experiment and laser Doppler vibrometer (LDV) measurements prove that the hydrophilic surface of Janus membranes repairs perforated eardrums, and meanwhile the hydrophobic surface can avoid adhering to the inner ear tissue for reducing hearing loss. The Janus membranes have good prospects in the treatment of tympanic membrane perforation.

Comparing two different techniques to repair pediatric anterior tympanic membrane perforations

OBJECTIVE

Compare outcomes between a microscopic and endoscopic technique for anterior tympanic membrane (TM) perforation.

METHODS

Results of microscopic overlay (MT) and endoscopic tympanoplasty (ET) for management of anterior TM perforations from a single surgeon.

RESULTS

There were 28 patients in the MT group and 35 in the ET group. The mean age was 7.1 years and 10.9 years (p < 0.001) MT and ET groups respectively. There was no statistical differences in perforation location (p = 0.1), etiology (p = 0.52) or size (p = 0.1) between both groups. Mean operating time was 119.0 min and 131.0 min in the MT and ET groups respectively (p = 0.23). Follow up was 30.9 months and 9.0 months (p = 0.001) MT and ET respectively. The perforation was successfully closed in 29 patients at 6 weeks in the ET (82.9%) and 25 in the MT (89.3%), p = 0.47. Adjusting for age revealed no significant difference between groups. Long term follow up, resulted in 10 failures (28.6%) and 7 patients (25.0%) in the ET and MT groups respectively, p = 0.75. Adjusting for the follow-up period or age, there was no significant difference between groups. The change in ABG and PTA measures were not statistically different between groups.

CONCLUSIONS

An anteriorly based ET is a novel technique for management of anterior TM perforations. Results from this pilot study indicate that this ET approach may be an appropriate alternative to MT for difficult to repair anterior perforations. A longer follow-up will be necessary to determine its role in these perforations.

Myringoplasty for pediatric chronic otitis media: An uncritical closure of a natural middle ear drainage?

BACKGROUND

Performing tympanoplasty for tympanic perforations in children and adolescents is often considered to be less successful than in adults.

OBJECTIVES

The aim of our study was to evaluate the surgical outcome of tympanoplasty type I in patients under 15 years of age with chronic otitis media and to identify potential factors that influence the success rate.

MATERIALS UND METHODS

The present study was based on a retrospective analysis of the medical records of all patients under the age of 15 who were treated for chronic otitis media by means of type I tympanoplasty between 2005 and 2020. The minimum follow-up period was 6 months. The data were analyzed with regard to epidemiological parameters, tube-related pathologies in the contralateral ear, the local condition and the extent of the eardrum perforation as well as the extent of the surgical intervention (tympanoplasty type I with or without adenotomy).

RESULTS

83 cases were included in our study. The mean age at the time of the surgery was 8.9 years. The mean follow-up time was 46 months (6-182 months). The anatomical closure rate was 88.0%. Children with "dry" tympanic perforations tended to perform better (p = 0.052). The average improvement in the air bone gap was 2.0 dB.

CONCLUSION

Detailed preoperative counseling about the advantages and disadvantages as well as the expected success rate of an early myringoplasty in this age group is just as important as an individualized approach for a high level of patient satisfaction.

Butterfly Cartilage Tympanoplasty as an Alternative to Conventional Surgery for Tympanic Membrane Perforations: A Systematic Review and Meta-Analysis

OBJECTIVE

To compare the effectiveness of butterfly cartilage tympanoplasty (BCT) with that of conventional surgical approaches in the treatment of tympanic membrane perforations.

METHODS

A systematic search was performed by screening the PubMed, Embase, and Cochrane Library databases up to October 31, 2020. Two coauthors independently identified studies in accordance with the selection criteria. Data were pooled and analyzed via Review Manager version 5.3 and Stata version 12.0 software. The postoperative outcomes were measured and expressed as odds ratios (ORs) and standardized mean differences (SMDs). Additionally, heterogeneity was assessed through the I² statistic.

RESULTS

A total of 15 articles were eligible for final inclusion. The OR values for the graft uptake rate, compared to conventional tympanoplasty, were 1.12 (95%CI: 0.56-2.22, I² = 52%, P = .75) and 1.22 (95%CI: 0.58-2.59, I² = 0%, P = .60), and the OR compared to fat plug myringoplasty was 3.02 (95%CI: 1.04-8.77, I² = 0%, P = .04). The qualitative analysis of the hearing results reflected significant postoperative auditory gains with no significant differences between the BCT and control groups, indicating satisfactory and similar postoperative hearing improvement. Moreover, the operation time was shortened (SMD = -2.19, 95%CI: -2.79 to -1.59, I² = 82%, P < .05), and the postoperative pain was less with the BCT approach.

CONCLUSION

Butterfly cartilage tympanoplasty has satisfactory efficacy in terms of anatomical and functional results in small to medium perforations. It reduces operation time and postoperative pain. However, the effectiveness on large perforation requires further assessment by well-designed studies.

Endoscopic Transcanal Push-Trough Myringoplasty for Different Types of Tympanic Membrane Perforations

OBJECTIVE

This study aims to explore the feasibility of endoscopic transcanal push-trough myringoplasty (ETPM) for all types of tympanic membrane perforations (TMPs), and compare the outcomes with those of endoscopic type 1 tympanoplasty (ETT) with meatal flap elevation.

STUDY DESIGN

A prospective, controlled study.

METHODS

In the present study, inpatients with TMPs were divided into two groups according to the manner of tympanic membrane repair: one group received ETPM without raising the meatal flap, and the other received ETT. The operation duration, postoperative healing rate, visual analogue scale (VAS) of pain, and complication rates were compared between these two groups.

RESULTS

Regardless of the size and location of the perforation, and its relationship with the malleus manubrium, myringoplasty can be completed using the ETPM method. The operation duration for different types of TMPs was shorter in the ETPM group than in the ETT group, and the difference was statistically significant (p<0.05). However, there was no statistical difference in the short-term healing rate (p>0.05) and pain VAS score (p>0.05) between these two groups. Furthermore, no intraoperative or postoperative complications occurred in both groups.

CONCLUSION

ETPM without raising the meatal flap can be applied for all types of TMPs, regardless of how large the perforation is, or where it is located. This can shorten the operation duration, and has a high healing rate comparable to ETT and mild postoperative pain. Mastering some essential surgical skills under the endoscope would be helpful to ensure the success of the surgery.

The Pretragal Superficial Musculoaponeurotic System Fascia: A New Graft Material for Transcanal Tympanoplasty

OBJECTIVE

To compare outcomes of transcanal endoscopic tympanoplasty reconstructed using pretragal superficial musculoaponeurotic system (SMAS) fascia versus temporalis fascia.

STUDY DESIGN

Retrospective patient review and posttreatment questionnaire survey.

SETTING

Tertiary referral center.

PATIENTS

Sixty adult patients with chronic dry tympanic membrane perforation.

INTERVENTIONS

Patients underwent transcanal endoscopic type I tympanoplasty reconstructed using the SMAS fascia between September 2017 and May 2018; outcomes were compared with a matched cohort of patients where the temporalis fascia was used.

MAIN OUTCOME MEASURES

Tympanic membrane closure rate, audiogram threshold, duration of procedure, and donor site scar satisfaction survey.

RESULTS

Sixty patients were included in this study and were evenly divided into the SMAS and temporalis fascia groups. These cohorts were matched for age, sex, side of lesion, perforation size, and preoperative hearing level. The closure rate was 96.7% (29/30) and 93.3% (28/30) (p = 1.0), mean hearing gain was 8.3 ± 6.4 dB versus 8.2 ± 7.1 dB for air-conduction (p = 0.970) and 7.6 ± 5.1 dB versus 8.2 ± 6.8 dB for air-bone gap (p = 0.716), and mean surgical duration was 137.3 ± 23.0 versus 132.2 ± 27.3 minutes (p = 0.432) for the SMAS and temporalis fascia groups, respectively; there were no statistically significant differences for all the parameters listed. The posttreatment questionnaire survey revealed significantly higher acceptance of the SMAS fascia method.

CONCLUSION

This preliminary outcome report of SMAS fascia grafting in transcanal endoscopic type I tympanoplasty showed equivalent surgical outcomes and better cosmetic satisfaction compared with the temporalis fascia. The SMAS fascia is a reasonable alternative to conventional techniques for transcanal tympanoplasty.

Endoscopic tympanoplasty type I for tympanic perforations: analysis of prognostic factors

PURPOSE

To assess the anatomical and functional outcomes of endoscopic transcanal tympanoplasty type I for tympanic membrane perforations.

METHODS

Eight hundred thirty-five patients who underwent tympanoplasty between January 2011 and January 2019 were selected. Patients with tympanic membrane perforation treated with a transcanal endoscopic tympanoplasty type 1 and a follow-up period longer than 6 months have been retrospectively reviewed. The presence of cholesteatoma or ossicular chain dysfunctions were considered exclusion criteria. Eighty-one patients were included in the present study population. The main outcome was the rate of overall graft success. Secondary outcomes included hearing results. Prognostic factors related to both the abovementioned outcomes were assessed.

RESULTS

Overall, 66 patients (81.5%) had a successful graft at the last follow-up evaluation. Mean follow-up was 22.1 (range 6-104) months. The anterior quadrants were entailed by the perforation in 62 (76.5%) cases. The overall success rate with cartilage (or cartilage and perichondrium) was 91.2% (p < 0.01). The median preoperative and postoperative ABG were 18.7 (13.4-25.6) and 7.5 (2.5-12.5), respectively, revealing a significant median improvement of 11.2 (p < 0.001). The type of graft and the postoperative tympanic membrane status were significantly associated with the audiologic outcome with p = 0.01 and p = 0.02, respectively.

CONCLUSIONS

Endoscopic tympanoplasty type I is a reliable technique with reasonable anatomic and audiologic results. Tympanic membrane grafting with cartilage (or cartilage and perichondrium) guarantees a higher rate of perforation closure and satisfactory hearing results. Anterior eardrum perforations can be successfully and safely managed with transcanal endoscopic approach avoiding postauricular approach and canalplasty.

Endoscopic full-thickness cartilage-perichondrium double graft myringoplasty in adhesive perforation: retrospective case series

BACKGROUND

The adhesive perforation could be the sequela of adhesive otitis media, that partial tympanic membrane remnant is bound completely to the medial wall of the middle ear by fibrous adhesions. However, few studies have reported on the repairing of adhesive perforation.

OBJECTIVES

To evaluate the long-term outcome of endoscopic full-thickness cartilage-perichondrium double graft myringoplasty for adhesive perforation.

MATERIALS AND METHODS

In total, 26 patients with unilateral adhesive perforation associated with chronic otitis media who underwent full-thickness cartilage-perichondrium double graft myringoplasty were included. Outcomes were evaluated in terms of the hearing gain and graft success rate at 12 and 24 months.

RESULTS

The graft success rate was 96.15% (25/26) at 12 months and 88.46% (23/26) at 24 months. The neovascularization and epithelium covering the lateral surface of the cartilage graft were seen at preoperative 4 weeks, the superficial cartilage graft got complete epithelialization within 4-6 months. CT revealed the well-pneumatized middle ear and mastoid cells at postoperative 24th months in all the patients, no middle ear cholesteatoma formation and keratin pearls were found during the period of follow up.

CONCLUSIONS

Endoscopic full-thickness cartilage-perichondrium double graft myringoplasty without the tympanomeatal flap elevation is a feasible method for repairing adhesive perforations, with a higher graft success rate and satisfactory hearing results.

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.

Endoscopic stapes surgery outcomes and complication rates: a systematic review

OBJECTIVE

These days, the gold standard procedure for otosclerosis treatment is stapes surgery. The endoscopic approach of the procedure is gaining popularity as endoscopic ear surgery develops across the globe. The main objective of this study is to gather and compile well-documented and reliable data regarding surgical outcomes for the endoscopic approach to stapes surgery up to this date.

MATERIALS AND METHODS

Publications in English were searched in the PUBMED/MEDLINE database and were systematically reviewed. A total of 16 articles were reviewed according to the inclusion criteria, obtaining a total of 573 patients managed surgically for otosclerosis, using an endoscopic approach. Data were systematically extracted and compared across variables.

RESULTS

Data were obtained as follows: mean age of 43 years; female proportion of 60%; 3 mm endoscope diameter of 51%, 4 mm of 39%; titanium piston-type prostheses of 52% and Teflon of 48%; length of the prosthesis (mode) was 4.5 mm; 0.6 mm diameter of the piston of 81% and 0.4 mm of 19%; mean surgical time was 55 min. Hearing results, mean preoperative air-bone gap (ABG) 31 dB; mean postoperative ABG 9 dB; ABG improvement of 22 dB; an ABG closure rate to 20 dB or less of 92% and an ABG closure rate to 10 dB or less of 77%. Complication rates: intraoperative tympanic membrane perforation of 5%; postoperative vertigo of 11%; postoperative dysgeusia of 10%; reported a postoperative neurosensorial hearing loss of 0.2%; reported gusher phenomenon of one case (0.2%).

CONCLUSION

Endoscopic stapes surgery is completely achievable using 0º angle and 4-mm-diameter sinus surgery endoscope. Instrument availability should not be an obstacle to the development of this type of surgery in any otolaryngology department. Audiological outcomes are comparable to microscopic approaches.

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.

Endoscopic type 1 cartilage tympanoplasty in children

OBJECTIVES

Endoscopic type 1 tympanoplasty using cartilage grafts for repair of chronic tympanic membrane perforation is increasing. The aim of this study was to evaluate the results of endoscopic type 1 cartilage tympanoplasty in children.

MATERIALS AND METHODS

Patients under 18 years of age who underwent type 1 cartilage tympanoplasty between January 2013 and February 2019 were retrospectively evaluated. Anatomic success rate was calculated according to the intact status of the graft. Air conduction (AC), bone conduction (BC), air-bone gap (ABG) and hearing gain were calculated using pure tone audiometry tests at pre-operative, and 6th month postoperative period. Patients with postoperative ABG ≤20 dB were considered as functionally successful.

RESULTS

The study included 56 patients (6 bilateral) and 62 ears. The anatomic success rate of our study was 91.9% (57/62). Preoperative AC was 36.4 ± 6.5 (21-50) dB, BC was 7.8 ± 3.7 (5-25) dB, and ABG was 28.6 ± 6.9 (10-41) dB. Postoperative AC was 24.5 ± 8.8 (7-45) dB, BC was 7.6 ± 3.4 (5-19) dB, and ABG was 16.9 ± 7.4 (2-32) dB. There was no change in postoperative BC (p: 0.683), whereas AC, and ABG significantly decreased (p < 0.001). Mean hearing gain was 12.1 ± 6.2 (3-26) dB and the functional success rate was 72.5% (45/62).

CONCLUSION

Endoscopic type 1 cartilage tympanoplasty, a minimally invasive surgical procedure, provided successful functional and anatomical results at the pediatric population.

Transcanal Endoscopic Type 1 Cartilage Tympanoplasty in Children

Objective

Transcanal endoscopic type 1 tympanoplasty is a minimally invasive procedure that enables better visualization of deep and narrow spaces compared to conventional microscopic methods. In our study, we aimed to evaluate air-bone gap difference, graft success, and hearing gain according to the perforation size and location in pediatric patients who underwent transcanal endoscopic type 1 cartilage tympanoplasty.

Methods

Fifty pediatric patients who underwent transcanal endoscopic type 1 cartilage tympanoplasty for chronic otitis media were included in the study. Tragal cartilage grafts were used in all patients. Air conduction pure tone audiometry hearing results (500, 1000, 2000, and 4000 Hz), mean air-bone gap levels, operating times, postoperative gap closure, and graft success rates were evaluated.

Results

Mean operating time was 43.34±8.56 minutes. Overall graft success was 94% (47/50). Mean hearing levels at all frequencies (500, 1000, 2000, and 4000 Hz) were found to have significantly improved after the operation (p<0.001). Mean preoperative air conduction pure tone threshold and mean air-bone gap had statistically significantly improved by the 6th postoperative month (p<0.001).

Conclusion

Transcanal endoscopic type 1 cartilage tympanoplasty was found to be a minimally traumatic, easy and safe method with a low complication rate. In pediatric patients, this method allows for high rates of anatomic and functional recovery with optimal surgery time regardless of the location and the size of the perforation.