Type I Tympanoplasty: surgical success and prognostic factors

The Prognostic Value of Active Otitis Media on Tympanoplasty Success Rate-A Systematic Review

OBJECTIVES

The aim is to investigate the influence of an active otitis media on the success rate of tympanoplasty in patients with a chronic otitis media (COM) and a tympanic membrane perforation.

DATABASES REVIEWED

PubMed, Embase and the Cochrane Library.

METHODS

The inclusion criteria were studies on closure rates of tympanoplasty performed in COM patients of any age with a tympanic membrane perforation caused by COM. The exclusion criteria were studies on patients undergoing concomitant mastoidectomy, ossicular chain reconstruction, tuboplasty, adenoidectomy, revision tympanoplasty, patients with perforations due to other conditions than COM, and letters to editors, commentaries, conference abstracts and case reports. The included articles were critically appraised using the QUIPS tool. Data on tympanic membrane closure rate were extracted, odds ratio (OR) and 95% confidence intervals (CI) of the closure rate with a wet versus a dry ear were calculated.

RESULTS

The search was performed on 1 February 2023. Of 4671 articles, 16 studies were included and critically appraised. Of these observational studies (nine prospective, seven retrospective), with a total of 1509 patients (dry ear group n = 1003; wet ear group n = 506), two studies stated a significant difference in success rate, one in favour of a dry ear and one in favour of a wet ear at time of surgery. All other studies did not show a statistically significant difference. Overall, the risk of bias was considered moderate to high.

CONCLUSIONS

We found no significant prognostic value of having an active otitis media during tympanoplasty on tympanic membrane closure rates. Because the overall risk of bias was considered moderate to high, no strong conclusions can be made. To be able to answer this question with higher levels of evidence, high-quality prospective or randomized studies are needed.

Prediction of Hearing Prognosis After Intact Canal Wall Mastoidectomy With Tympanoplasty Using Artificial Intelligence

OBJECTIVE

To evaluate the performance of a machine learning model and the effects of major prognostic factors on hearing outcomes following intact canal wall (ICW) mastoidectomy with tympanoplasty.

STUDY DESIGN

Retrospective cross-sectional study.

SETTING

Tertiary hospital.

METHODS

A total of 484 patients with chronic otitis media who underwent ICW tympanomastoidectomy between January 2007 and December 2020 were included in this study. Successful hearing outcomes were defined by a postoperative air-bone gap (ABG) of ≤20 dB and preoperative air conduction (AC)-postoperative AC value of ≥15 dB according to the Korean Otological Society guidelines for outcome reporting after chronic otitis media surgery. The light gradient boosting machine (LightGBM) and multilayer perceptron (MLP) models were tested as artificial intelligence models and compared using logistic regression. The main outcome assessed was the successful hearing outcome after surgery, measured using the area under the receiver operating characteristic curve (AUROC).

RESULTS

In the analysis using the postoperative ABG criterion, the LightGBM exhibited a significantly higher AUROC compared to those of the baseline model (mean, 0.811). According to the difference between preoperative and postoperative AC, the MLP showed a significantly higher AUROC than those of the baseline model (mean, 0.795).

CONCLUSION

This study analyzed multiple factors that could affect the hearing outcome using different artificial intelligence models and found that preoperative hearing status was the most important factor. Our findings provide additional information regarding postoperative hearing for clinicians.

Tympanoplasty in the Setting of Complex Middle Ear Pathology: A Systematic Review

OBJECTIVE

To assess the prognostic factors for anatomic and hearing success after tympanoplasty in the setting of complex middle ear pathology.

METHODS

A systematic review was performed in January 2022. English-language articles describing outcome data for tympanoplasty repair variables including underlying pathology, perforation location, smoking status, graft technique, reconstruction material, anatomic success, and hearing success were extracted. Articles were included when tympanosclerosis, retraction pockets, adhesions, cholesteatoma, chronic suppurative otitis media, anterior perforations, and smoking were included. Underlying pathology, perforation location, smoking status, graft technique, reconstruction material, anatomic success, and hearing success were extracted. Any factors analyzed as potential indicators of success were sought out.

RESULTS

Data sources included PubMed, OVID, Cochrane, Web of Science, Scopus, and manual search of bibliographies. Ninety-three articles met final criteria, which accounted for 6685 patients. Fifty articles presented data on both anatomic and hearing outcomes, 32 articles presented data on anatomic outcomes only, and 11 articles presented data on hearing outcomes only. This systematic review found that adhesions and tympanosclerosis were prognostic factors for poorer hearing. Additionally, smoking and tympanosclerosis may be predictive of anatomic failure; however, the significance of this finding was mixed in included studies. This analysis is significantly limited by both the heterogeneity within the patients and the lack of controls.

CONCLUSION

Adhesions and tympanosclerosis were prognostic factors for poorer hearing. Clearly documented methods and outcomes for the included pathologies could lead to more definitive conclusions regarding prognostic factors for success.

LEVEL OF EVIDENCE

3B.

Endoscopic Versus Microscopic Type 1 Tympanoplasty (Myringoplasty) in a Rural Tertiary Care Hospital in India: A Retrospective Comparative Study

Background Chronic suppurative otitis media (CSOM) is described as middle ear cleft inflammation that results in long-term alterations to the tympanic membrane and/or the middle ear structures. In cases of CSOM, type 1 tympanoplasty, also known as myringoplasty, is a successful procedure for repairing the tympanic membrane and can even help restore hearing loss. This study aims to compare functional and clinical outcomes of type 1 tympanoplasty performed using transcanal endoscopic ear surgery (TEES) versus those performed via microscopic ear surgery (MES) for perforation in the tympanic membrane in the safe type of CSOM. Methodology Between January 2018 and January 2022, a retrospective analysis of 100 patients (47 men and 53 women) operated for the safe type of CSOM with a perforated tympanic membrane was conducted in our department. Based on the surgical methods, cases were randomly divided into two groups. There were 50 people in group 1 who underwent endoscopic tympanoplasty and 50 in group 2 who underwent microscopic tympanoplasty. The following factors were assessed: patient demographics; tympanic membrane perforation size at the time of surgery; operating room time; hearing outcomes, that is, closure of air-bone gap (ABG); graft uptake success rate; postoperative hospital stay; and medical resource usage. Patients were followed up for 12 weeks. Results Both groups shared similar epidemiological profiles, preoperative hearing status, and perforation sizes. In both groups, the rate of graft uptake was comparable. The average ABG closure was also quite comparable. In the case of endoscopic surgeries, the mean operative time was shorter; which was statistically significant, and complications were significantly lower in group 1. Conclusions Compared to its microscopic counterpart, endoscopic tympanoplasty has a similar graft uptake success rate and a comparable hearing outcome; however, it requires less operative time and hospital stay, has early recovery, and makes lesser use of medical resources, and it is cosmetically better.

Factors influencing successful reconstruction of tympanic membrane perforations: a systematic review and meta-analysis

PURPOSE

Based on a systematic review and meta-analysis, our study aimed to provide information about the factors that influence the success of tympanic membrane reconstruction.

METHODS

Our systematic search was conducted on November 24, 2021, using the CENTRAL, Embase, and MEDLINE databases. Observational studies with a minimum of 12 months of follow-up on type I tympanoplasty or myringoplasty were included, while non-English articles, patients with cholesteatoma or specific inflammatory diseases, and ossiculoplasty cases were excluded. The protocol was registered on PROSPERO (registration number: CRD42021289240) and PRISMA reporting guideline was used. Risk of bias was evaluated with the QUIPS tool. A random effect model was used in the analyses. Primary outcome was the rate of closed tympanic cavities.

RESULTS

After duplicate removal, 9454 articles were found, of which 39 cohort studies were included. Results of four analyses showed significant effects: age (OR: 0.62, CI 0.50; 0.78, p value: 0.0002), size of the perforation (OR: 0.52, CI 0.29; 0.94, p value: 0.033), opposite ear condition (OR: 0.32, CI 0.12; 0.85, p value: 0.028), and the surgeon's experience (OR: 0.42, CI 0.26; 0.67, p value: 0.005), while prior adenoid surgery, smoking, the site of the perforation, and discharge of the ear did not. Four factors: etiology, Eustachian tube function, concomitant allergic rhinitis, and duration of the ear discharge were analyzed qualitatively.

CONCLUSIONS

The age of the patient, the size of the perforation, the opposite ear status, and the surgeon's experience have a significant effect on the success of tympanic membrane reconstruction. Further comprehensive studies are needed to analyze the interactions between the factors.

LEVEL OF EVIDENCE

Not applicable.

Patient Factors Predicting Success in Lateral Graft Tympanoplasty

Objective

To compare the effects of preoperative medical comorbidities and operative findings on the success of lateral graft tympanoplasty.

Study Design

Retrospective chart review.

Setting

Tertiary medical center.

Patients

Ninety-six patients undergoing lateral graft tympanoplasty from December 2008 to November 2020 with at least 2 months follow-up were included. Patient demographics, comorbidities including smoking status, intraoperative findings, and healing, and hearing outcomes were recorded.

Interventions

Lateral graft tympanoplasty.

Main Outcome Measures

The primary outcome was perforation closure. Secondary outcomes were postoperative complications and change in air-bone gap (ABG).

Results

Ninety-nine ears (mean age 40.94 ± 18.44 years) were included. Tympanic membrane perforation closure was achieved in 92 (92.9%) ears. Perforation closure was not associated with diabetes (P > 0.99), smoking (P > 0.99), or the presence of cholesteatoma at the time of lateral graft tympanoplasty (P = 0.10). Increased age (odds ratio [OR] = 1.04, P = 0.31) was also not correlated with tympanic membrane closure rate. An absent malleus resulted in a higher rate of lateralization (31.3% versus 2.1%; OR = 18.41, 95% confidence interval [CI] = 3.09-95.95, P = 0.001) but not blunting (12.5% versus 4.8%; OR = 0.24, 95% CI = 0.49-12.93, P = 0.24). The mean ABG improved 6.82 ± 11.33 dB (P < 0.01). History of prior tympanoplasty was associated with smaller ABG improvement following surgery (ß = 4.038, R2 = 0.262, P = 0.04) but not perforation closure (OR = 3.25, 95% CI = 0.63-16.81, P = 0.24).

Conclusions

Diabetes, active smoking, and advancing age were not associated with adverse healing in patients undergoing lateral graft tympanoplasty. Lateralization was more common with an absent malleus.

Endoscopic type 1 tympanoplasty: comparison of the effects of three different thicknesses grafts

BACKGROUND

The effects of graft thickness on tympanoplasty is uncertain.

OBJECTIVE

To compare the results of endoscopic tympanoplasty using different thicknesses of autologous tissues.

METHODS

This retrospective analysis included 186 patients who received type I tympanoplasty, divided into three main groups based of grafting material: perichondrium (A), cartilage-perichondrium (B), or cartilage-perichondrium plus additional perichondrium (C). Group A was subdivided based on whether the placement was inside (A1) or outside (A2) of the malleus. The hearing improvement, graft success rate, and surgery duration were analysed.

RESULTS

Statistical analysis showed significant hearing improvement in the three main groups (p < .001); recovery in group A occurred the earliest. Six months postoperatively, group A1 showed significantly greater hearing recovery compared with groups B and C (p < .05). There were no statistical differences the other groups (p > .05) or in the graft success rate among the three main groups (p = .235). The surgery duration of group A was significantly longer than that of groups B and C (p < .001).

CONCLUSION AND SIGNIFICANCE

Our results suggest that graft thickness affects hearing recovery; however, graft thickness does not affect the rate of grafting success. Endoscopic transplantation of the perichondrium is more difficult and requires more time.

Comparison of endoscopic and microscopic tympanoplasty in patients with chronic otitis media

BACKGROUND

To compare the results between type I tympanoplasty performed with transcanal endoscopic ear surgery (TEES) and microscopic ear surgery (MES) for treatment of chronic otitis media in a homogenous group of patients.

METHODS

A retrospective study was performed in our department between January 2011 and January 2016 to review primary type I tympanoplasty cases with a subtotal perforation, an intact ossicular chain, a dry ear for at least 1 month, normal middle ear mucosa, and a follow-up period of at least 6 months post surgery. The adoption of TEES or MES was divided temporally (before and since 2013). TEES was undertaken in 224 patients (224 ears) and MES in 121 patients (121 ears).

RESULTS

The successful graft take rate was 94.64% (212/224) in the TEES group and 90.91% (110/121) in the MES group (P = 0.239). The improvements in the air conduction levels between the 2 groups were not statistically different at 1, 3, or 6 (> 6) months (P > 0.05) after surgery. The improvements in the air-bone gaps were not significantly different between the 2 groups (P > 0.05). The average hearing gains in the TEES group 6 (and > 6) months post surgery were 11.85 ± 5.47 dB, which was better than 10.48 ± 5.18 dB in the MES group (P = 0.031). The use of medical resources was lower in the TEES group than in the MES group regarding the average operating time (49.22 ± 8.24 min vs 81.22 ± 14.73 min, respectively; P < 0.0001). Patients receiving MES had a significant higher incidence of the wound problems (ear pain, numbness around the ears, and wet ear; P < 0.05).

CONCLUSION

TEES for type I tympanoplasty seems to achieve a shorter operative time and ideal tympanic membrane healing rate and hearing results in patients with chronic otitis media.

Myringoplasty Outcomes From a 5-Year Single Surgeon's Experience and Important Surgical Technical Aspects

BACKGROUND AND OBJECTIVES

The United Kingdom (UK) national standard for the closure rate for myringoplasty is 89.5% (90.6% and 84.2% for primary and revision surgeries, respectively). The average hearing gains for primary and revision myringoplasty are 9.14 dB and 7.86 dB, respectively. This study compared the myringoplasty outcomes for a single surgeon over 5 years.

SUBJECTS AND PURPOSE

Data for 68 cases were analyzed retrospectively. The outcome measures were achievement of the tympanic membrane closure and the average hearing gain or loss.

RESULTS

The overall and primary closure rates were 97% and 98%, respectively and significantly higher than the UK national standard (p=0.0210 and p=0.0287, respectively). The revision closure rate was 93%; however, it was not significantly higher than the national standard (p=0.1872). The average hearing gain was 5.18 dB. The gains for primary and revision surgeries were 5.15 dB and 5.25 dB, respectively.

CONCLUSIONS

We propose that these outcomes are a result of our surgical technique, including the simultaneous use of cortical mastoidectomy in ears with discharge.