Cortical mastoidectomy in surgery of tubotympanic disease. Are we overdoing it?

Postoperative Outcomes After Tympanoplasty for Active Versus Inactive Otitis Media Patients With Tympanic Membrane Perforation: A Systematic Review and Meta-Analysis

ABSTRACT

OBJECTIVES

To compare postoperative tympanoplasty outcomes between active versus inactive otitis media (OM) patients with tympanic membrane perforation.

DATABASES REVIEWED

Medline via PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials, and Google Scholar for studies published from inception to March 1, 2023.

METHODS

Studies of 15- to 60-year-old patients undergoing microscopic/endoscopic myringoplasty using underlay/overlay technique with reported postoperative mean hearing gain and graft uptake were included. Studies requiring simultaneous surgical procedures, reporting patients with comorbidities and with non-English full text articles were excluded. Articles were independently screened by two researchers with data extracted according to a predetermined proforma in Microsoft Excel. Cochrane risk-of-bias assessment was used for risk of bias evaluation of randomized studies and Risk of Bias in Nonrandomized Studies of Interventions for nonrandomized studies. Similar studies were pooled for meta-analysis using the inverse variance random effects model to calculate the mean difference and corresponding 95% confidence interval (CI) for mean hearing gain and DerSimonian and Laird random effects model for graft uptake.

RESULTS

Thirty-three studies comprising 2,373 patients met the inclusion/exclusion criteria, seven were pooled for meta-analysis. Included articles showed inactive OM patients have higher average postoperative mean hearing gain of 10.84 dB and graft uptake of 88.7% compared to active OM patients (9.15 dB and 84.2%). Meta-analysis of mean hearing gain (MD, -0.76 dB; 95% CI, -2.11 to 0.60; p = 0.27, moderate certainty) and graft uptake (OD, 0.61; 95% CI, 0.34-1.09; p = 0.10, moderate certainty) have an overall p value >0.05.

CONCLUSION

There were no statistically significant differences in postoperative mean hearing gain and graft uptake between active and inactive OM patients undergoing tympanoplasty. Hence, tympanoplasty procedures should not be postponed solely because of patients' preoperative ear discharge status.

Tympanoplasty With and Without Mastoidectomy for Chronic Otitis Media Without Cholesteatoma: A Systematic Review and Meta-analysis

OBJECTIVE

This study aimed to compare surgical and audiometric outcomes of tympanoplasty alone (T) to tympanoplasty and mastoidectomy (T&M) in patients without cholesteatoma.

DATABASES REVIEWED

According to PRISMA guidelines, English articles in PubMed, Scopus, CINAHL, and Cochrane Library databases from inception to 7/29/2021 were searched.

METHODS

Studies describing a comparison of patients who underwent T to patients who underwent T&M were included. Studies describing patients with cholesteatoma were excluded. Patient demographics, graft failure rates, and preoperative and postoperative audiological findings were collected. Mean differences (MD) and risk difference (RD) were calculated using RevMan 5.4. Heterogeneity was assessed using Q test and I2 statistic. Risk of bias was assessed using both version 2 of the Cochrane risk-of-bias tool for randomized trials and Risk of Bias in Non-randomized Studies of Interventions.

RESULTS

A total of 27 studies fulfilled eligibility with T (n = 1,711) and T&M (n = 1,186). When pooling the data, mean differences between T versus T&M for air bone gap (-0.3 dB: 95% CI = -1.9 to 1.3, p = 0.730) and pure tone average (1.9 dB: 95% CI = -0.3 to 4.2, p = 0.090) were not statistically significant. Graft failure was higher with T only (16.4% versus 14.2%) than T&M (RD = -0.04, 95% CI = -0.07 to -0.00, p = 0.030, I2 = 35%].

CONCLUSION

This study endorses clinically similar audiological outcomes and a reduced risk difference of graft failure with mastoidectomy. Although these data suggest that adding a mastoidectomy could decrease the risk of graft failure, the risk reduction is minimal. More research on the cost-effectiveness and the specific patient clinical characteristics and comorbidities that would benefit from adding a mastoidectomy is warranted.

Role of Mastoidectomy with Type 1 Tympanoplasty in Paediatric Patients with Poor Contralateral Ear Status

The aim of the study was to assess the role of mastoidectomy with type 1 tympanoplasty in the management of paediatric patients with poor contralateral ear status and to evaluate the prognostic factors that may influence the success outcome of type 1 tympanoplasty. A prospective study of 112 paediatric patients from 4 to 12 years of age. All patients in the study had bilateral ear perforations. They were randomly assigned to undergo either type 1 tympanoplasty (group 1, n = 56) or type 1 tympanoplasty with mastoidectomy (group 2, n = 56). The outcomes between the two groups were compared at 12 months postoperative period. The outcomes evaluated were: 1. anatomical condition of the tympanic membrane, 2. functional improvement in hearing (≥ 10 db), 3. air-filled middle ear space without atelectasis or otitis media with effusion, 4. overall outcome. The outcomes were also compared in both the surgical groups for patients who were ≤ 8 years (n = 51) and > 8 years (n = 61) of age. Prognostic factors for success outcome for type 1 tympanoplasty were evaluated. The prognostic factors considered were age at the time of surgery, age groups, duration of the disease prior to surgery, previous adenoidectomy, mechanism of perforation, location of perforation, size of the perforation, type of ear surgery performed (tympanoplasty with or without mastoidectomy). The success outcome in anatomical condition of the tympanic membrane was significantly higher in mastoidectomy group (p = 0.015) but was not significantly different in those ≤ 8 years and > 8 years (p = 0.112, p = 0.064 respectively).There was no difference in the functional improvement in hearing in both the surgical groups for all patients, ≤ 8 years and > 8 years (p = 0.188 p = 0.061, p = 0.865 respectively). Mastoidectomy group showed significantly higher success outcome for air-filled middle ear space without atelectasis or OME for all patients, ≤ 8 years and > 8 years (p < 0.001, p = 0.004, p = 0.041 respectively).Overall success was significantly higher in mastoidectomy group for all patients and ≤ 8 years (p = 0.040, p = 0.012 respectively),but not significantly different for > 8 years (p = 0.592).Out of the prognostic factors considered for success only the type of ear surgery performed showed as a better predictor for success (AUC = 0.606, p = 0.046). Cortical mastoidectomy done along with type 1 tympanoplasty in paediatric patients with poor contralateral ear showed statistically significant higher overall success outcome. Although mastoidectomy done with type 1 tympanoplasty showed better success outcome in patients above 8 years, it was not statistically significant. Except the type of ear surgery performed, none of the prognostic factors considered could influence the success outcome. Our study recommends mastoidectomy to be combined with type 1 tympanoplasty in paediatric patients aged ≤ 8 years with poor contralateral ear status to enhance the overall success outcome.

Endoscopic Tympanoplasty without Mastoidectomy for Active Mucosal Chronic Otitis Media with Mastoid and Tympanic Antrum Lesions: A Prospective Clinical Study

OBJECTIVE

This study aims to assess the effectiveness of endoscopic tympanoplasty without mastoidectomy in the management of active mucosal chronic otitis media (COM) patients with mastoid and tympanic antrum lesions.

METHODS

It is a prospective controlled study where 42 patients with active mucosal COM with mastoid and tympanic antrum lesions or normal aeration were recruited from the outpatient clinic of the otology department, Eye Ear Nose and Throat Hospital of Fudan University. All patients underwent endoscopic tympanoplasty without mastoidectomy by using the underlay technique with tragal cartilage graft with one side-perichondrium. The follow-up period was at least 3 months and results were evaluated in terms of graft uptake, ear dryness and hearing improvement.

RESULTS

Statistics showed no significant difference in graft uptake between the mastoid and tympanic antrum lesions group (90.5%) and the normal aeration group (95.2%). There was no significant difference in ear dryness between the mastoid and tympanic antrum lesions group (95.2%) and the normal aeration group (100%). Hearing improvement was comparable in the 2 groups.

CONCLUSION

Regardless of the occurrence of soft density shadows in temporal bone showed by high-resolution computerized tomography in the mastoid and tympanic antrum, mastoidectomy is an unnecessary procedure for dealing with active mucosal COM without cholesteatoma. Therefore, this study shows that endoscopic tympanoplasty without mastoidectomy may be applied to active mucosal COM without cholesteatoma.

Postoperative Mastoid Aeration Following Canal Wall Up Mastoidectomy according to Preoperative Middle Ear Disease: Analysis of Temporal Bone Computed Tomography Scans

Background and Objectives

The aim of our study was to evaluate postoperative mastoid aeration according to the preoperative middle ear disease and investigate the factors affecting it.

Subjects and Methods

We retrospectively reviewed the high-resolution computed tomography (CT) scans of temporal bones that were taken 1 year after surgery. The postoperative mastoid aeration was evaluated according to the preoperative diagnosis, and classified into three groups: grade 1 (complete mastoid aeration), an air-filled epitympanum and mastoid cavity; grade 2 (partial mastoid aeration), an air-filled epitympanum and partially aerated mastoid cavity; and grade 3 (absence of mastoid aeration), no air space in the mastoid cavity.

Results

The overall mastoid aeration rate was 55.8%, with adhesive otitis media accounting for 21.2%, attic cholesteatoma 53.8%, and chronic otitis media 75.4%. The rates of postoperative mastoid aeration were significantly higher in the chronic otitis media cases and attic cholesteatoma cases than in the adhesive otitis media cases. There were 14 cases requiring revision operations due to the development of a retraction pocket in the tympanic membrane. All of the revised cases had grade 3 postoperative mastoid aeration, and underwent canal wall down mastoidectomies.

Conclusions

The degree of postoperative mastoid aeration is associated with the preoperative middle ear disease. When planning a canal wall up mastoidectomy, the surgeon should contemplate the middle ear disease, because a canal wall down mastoidectomy or mastoid obliteration is recommended if the patient has adhesive otitis media.

Indian Perspectives on Graft Materials Used for Repair of Tympanic Membrane

INTRODUCTION

Repair of Tympanic Membrane (TM) is one of the most common surgeries performed by the otologists. Literature reveals that Indian surgeons have contributed substantially in the research on techniques and graft materials used for the repair of tympanic membrane, though no review has been written so far highlighting their contributions.

AIM

To summarize and analyse the contributions of Indian authors who have used different graft materials for repair of TM and their studies listed in Medline search.

MATERIALS AND METHODS

A literature review was conducted using a Medline search using keywords of 'myringoplasty' and 'tympanoplasty' with 'India' on 30th June 2016. A total of 243 articles were found listed onwards from year 1998. Out of these 50 articles in which type 1 tympanoplasty or myringoplasty was performed using different graft materials were selected. The content of each abstract was studied in order to identify studies related to topic.

RESULTS

Authors have experimented with a variety of tissues as graft materials. Temporalis Fascia (TF) has been most widely used in 58.6% studies as graft material. The next popular graft is tragal perichondrium. The graft take up rates varied from 68.5% to 100%, while method of reporting of hearing gain in most studies was inconsistent amongst studies, though most studies have reported achievement of serviceable hearing of < 25 dB in most patients.

CONCLUSION

TF was the most prefered material due to anatomic proximity, light material and strength. It was followed in popularity by tragal perichondrium and tragal cartilage. All graft materials have given satisfactory hearing results.

Panel 7: Treatment and comparative effectiveness research

BACKGROUND AND OBJECTIVES

Otitis media (OM) is one of the most common reasons for antibiotic treatment in children. Controversies regarding antibiotic treatment for OM have accumulated in the past decade, and there seem to be more dilemmas than certainties. The objectives of this article are to provide the state-of-the art review on achievements in treatment of all different stages of OM, including acute otitis media (AOM), otitis media with effusion (OME), and chronic suppurative otitis media, and to outline the future research areas.

DATA SOURCES

PubMed, Ovid Medline, the Cochrane Database, and Clinical Evidence (BMJ Publishing).

REVIEW METHODS

All types of articles related to OM treatment published in English between January 2007 and June 2011 were identified. A total of 286 articles related to OM treatment were reviewed by the panel members; 114 relevant quality articles were identified and summarized.

RESULTS

New evidence emerged on beneficial results of antibiotic treatment, compared with observation of AOM in young children who were diagnosed based on stringent criteria. In OME, the main results were related to a nonsignificant benefit of adenoidectomy versus tympanostomy tube placement alone in the treatment of chronic OME in younger children. Other modalities of OM treatment were studied and described herein.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Significant progress has been made in advancing the knowledge on the treatment of OM. Areas of potential future research have been identified and outlined.

Factors affecting hearing improvement following successful repair of the tympanic membrane

BACKGROUND

The main aim of tympanic membrane repair is the elimination of chronic or intermittent aural discharge. Hearing improvement may or may not occur following a technically successful operation.

METHOD

This study entailed a retrospective analysis of prospectively collected data from 203 operations that resulted in an intact tympanic membrane 6 months after surgery.

RESULTS

Complete hearing data were available for 169 operations on 160 patients. Of these, 53 per cent resulted in closure of the air-bone gap to within 10 dB, and 54 per cent of cases had post-operative hearing thresholds of at least 30 dB. The mean hearing change after surgery was +8.3 dB. Multiple regression analysis indicated that hearing improvement was more likely in large compared with small perforations. Smaller hearing gains occurred in ears with erosion of the stapes arch and/or fixation of the stapes, as well as in those with active discharge at the time of surgery and in revision cases.

CONCLUSION

Greater hearing improvement can be expected following successful repair of perforations involving more than 50 per cent of the drum area. Poorer results are likely to occur in ears with additional middle-ear pathology and in revision cases.

Postmastoidectomy effusion measurement using a delay-line ultrasound transducer: cadaver experiments

Mastoidectomy is a surgical procedure for removing mastoid air cells and has been used widely to establish drainage and cleaning infections from the mastoid bone. Computed tomography (CT) and magnetic resonance imaging (MRI) are the primary instruments used to clinically detect mastoid effusion following surgery. This study examines the feasibility of ultrasonography to detect postsurgical mastoid effusion. In vitro ultrasound measurements were conducted on 10 cadavers. For each sample, mastoidectomy was performed, and saline and whole blood samples were injected into the surgical mastoid cavity to simulate different effusion properties. A 2.25-MHz delay-line ultrasound transducer was used to obtain ultrasound backscattered data from the mastoid. The data were used to analyze echo intensity and the backscattered statistics by estimating the scaling and Nakagami parameters of the Nakagami distribution model. The results show that the scaling and Nakagami parameters can successfully detect mastoid effusion. Specifically, the Nakagami parameter is capable of characterizing the mastoid effusion properties. This indicates that ultrasound measurement based on a combination of delay-line transducer and Nakagami parameter estimation is a potential real-time diagnostic tool for evaluating mastoid effusion following mastoidectomy without radiation exposure.