Surgical management of retraction pockets of the pars tensa with cartilage and perichondrial grafts

A deep learning approach to the diagnosis of atelectasis and attic retraction pocket in otitis media with effusion using otoscopic images

BACKGROUND

This study aimed to develop and validate a deep learning (DL) model to identify atelectasis and attic retraction pocket in cases of otitis media with effusion (OME) using multi-center otoscopic images.

METHOD

A total of 6393 OME otoscopic images from three centers were used to develop and validate a DL model for detecting atelectasis and attic retraction pocket. A threefold random cross-validation procedure was adopted to divide the dataset into training validation sets on a patient level. A team of otologists was assigned to diagnose and characterize atelectasis and attic retraction pocket in otoscopic images. Receiver operating characteristic (ROC) curves, including area under the ROC curve (AUC), accuracy, sensitivity, and specificity were used to assess the performance of the DL model. Class Activation Mapping (CAM) illustrated the discriminative regions in the otoscopic images.

RESULTS

Among all OME otoscopic images, 3564 (55.74%) were identified with attic retraction pocket, and 2460 (38.48%) with atelectasis. The diagnostic DL model of attic retraction pocket and atelectasis achieved a threefold cross-validation accuracy of 89% and 79%, AUC of 0.89 and 0.87, a sensitivity of 0.93 and 0.71, and a specificity of 0.62 and 0.84, respectively. Larger and deeper cases of atelectasis and attic retraction pocket showed greater weight, based on the red color depicted in the heat map of CAM.

CONCLUSION

The DL algorithm could be employed to identify atelectasis and attic retraction pocket in otoscopic images of OME, and as a tool to assist in the accurate diagnosis of OME.

The Role of Cartilage-perichondrium Tympanoplasty in the Treatment of Tympanic Membrane Retractions: Systematic Review of the Literature

Introduction  Tympanic retraction is a condition characterized by the displacement of the tympanic membrane toward the structures of the middle ear. Clinically, tympanic retractions can lead to hearing loss, ear discharge and/or ear pain. In most of the cases, however, tympanic retractions are asymptomatic and are found accidentally during an ear, nose, and throat (ENT) examination. This condition has created numerous debates regarding the optimal choice of treatment, especially in the asymptomatic forms. The main controversy is regarding the relationship between retraction and the development of cholesteatoma, which would justify a surgical intervention performed for preventive purposes.

Objectives  To study the effectiveness of cartilage tympanoplasty in the management of tympanic membrane retractions by analyzing the results of the studies conducted on the use of cartilage as a reconstruction material.

Data Synthesis  A literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses group (PRISMA). Study selection, data extraction, and quality assessment were conducted independently by two reviewers. Our initial literature search yielded 2,258 references. Applying the PRISMA flow chart, 1,415 duplicates were excluded, and the remaining 843 abstracts were examined. Afterwards, 794 articles were excluded based on the research protocol criteria. Only 8 papers were included in the review by applying the inclusion and exclusion criteria.

Conclusions  Despite the limitations of the studies taken into consideration, we can conclude that cartilage tympanoplasty may successfully rehabilitate the atelectatic ear especially in the more advanced stages of retraction, unlike the conservative strategies.

Long-term results of type I tympanoplasty with perichondrium reinforced cartilage palisade vs temporalis fascia for large perforations: A retrospective study

Objective

To compare the rate of graft uptake and postoperative hearing outcomes of Type I tympanoplasty with perichondrium reinforced cartilage palisade to temporalis fascia for large tympanic membrane (TM) perforations over 5 years follow-up period.

Materials and methods

This was a retrospective comparative study involving patients with chronic otitis media with large TM perforations. The patients underwent type I tympanoplasty using either perichondrium reinforced cartilage palisade (CP group) or temporalis fascia (TF group) as the graft via a transmeatal approach and under local anesthesia. Morphological and functional results were recorded at three- and five years follow-up. Demographic profiles including age and sex, surgery side, contralateral disease and graft uptake rate, as well as hearing outcomes, were compared between the two groups.

Results

At three years follow-up, graft uptake was 94.87% for perichondrium reinforced cartilage palisade and 80.7% for fascia, respectively, (p = 0.67). At five years follow-up, the uptake rate dropped to 87.17% in the CP group, but to 66.6% in the TF group (p=0.019). Hearing improved after surgery in both groups, and showed no significant difference between the two groups.

Conclusion

Over long-term, perichondrium reinforced palisade showed a statistically significant better outcome regarding graft uptake than temporalis fascia in type Itympanoplasty for large TM perforations with comparable audiometric results

Cartilage rim augmented fascia tympanoplasty: a more effective composite graft model than temporalis fascia tympanoplasty

OBJECTIVE

To validate a newly introduced cartilage rim augmented temporalis fascia tympanoplasty technique by statistically comparing it with the morphological and audiological outcomes of traditional temporalis fascia tympanoplasty.

METHODS

A retrospective comparative study was conducted on 115 patients who underwent tympanoplasty during 2013 and 2015. Fifty-eight patients underwent temporalis fascia tympanoplasty and 57 underwent cartilage rim augmented fascia tympanoplasty.

RESULTS

In the cartilage fascia group, graft healing was achieved in 94.7 per cent of cases; in the temporalis fascia group, the graft take-up rate was 70 per cent. In those with a normal ossicular chain, the post-operative air-bone gap was within 20 dB in 92.6 per cent of cartilage fascia group cases and in 69.7 per cent of the temporalis fascia group cases, which was a statistically significant difference. Among the defective ossicular chain cases, the post-operative air-bone gap was within 20 dB in 76.9 per cent in the cartilage fascia group, as against 57.1 per cent in the temporalis fascia group.

CONCLUSION

Cartilage rim augmented temporalis fascia tympanoplasty has a definite advantage over the temporalis fascia technique in terms of superior graft take up and statistically significant hearing gain in those with normal ossicular mobility.

Cartilage tympanoplasty: literature review

There has been renewed interest in the use of cartilage for middle-ear reconstructions. The aim of the present review is to examine the indications, techniques and surgical outcomes of cartilage tympanoplasties reported in the literature. There have been concerns regarding weakening of cartilage struts, from histological studies involving explants; as a result, cartilage struts for ossiculoplasty have not gained popularity. On the other hand, cartilage tympanoplasty is now an established procedure for tympanic membrane and attic reconstruction. The commonest techniques involve cartilage palisades and composite cartilage–perichondrial island grafts. There are many variations on the shape, size and thickness of the cartilage grafts. The perceived benefit of cartilage tympanoplasty is to prevent retraction pockets at the grafted site, even though many otologists accept that this technique may not deal with the causal factors involved in the retraction process. Concerns that the stiffness and mass of cartilage grafts may adversely affect hearing have not been substantiated in clinical reports thus far.

Tympanoplasty in adhesive otitis media: A descriptive study

OBJECTIVES/HYPOTHESIS

There is no consensus among clinicians regarding the best treatment strategy for adhesive otitis media (AdOM). It is common practice to only intervene in the presence of recurrent infections or significant conductive hearing loss. In an attempt to provide evidence regarding the efficacy and safety of surgical intervention, we have analyzed the long-term outcome of tympanoplasty for AdOM .

STUDY DESIGN

Prospective study.

METHODS

From January 2013 to April 2014, 57 patients with AdOM (60 ears) who fit our criteria for tympanoplasty were recruited and underwent tympanoplasty using tragal cartilage combined with transtympanic ventilation tube and cortical mastoidectomy. Otorrhea control, graft uptake, hearing level changes, and complications were evaluated within a 3-year period of follow-up.

RESULTS

Otorrhea was controlled in 94% of the ears. Tympanic membrane healing was achieved in all ears except one ear, which had myringitis. Overall there was significant improvement in hearing. Whereas the mean preoperative air-bone gap (ABG) was 30.4 ± 4.0 dB, postoperative mean ABG was 8.6 ± 6.9 dB at 1 year. Closure of ABG to within 20 dB was achieved in 46 ears (83.6%). One ear showed a drop in bone conduction level by 25 dB. No iatrogenic cholesteatoma was detected in any of the cases.

CONCLUSION

This study demonstrated that tympanoplasty has favorable outcomes in AdOM . Risks of iatrogenic sensorineural hearing loss or cholesteatoma formation are negligible.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:2804-2810, 2016.

Tympanic membrane retraction pocket staging: is it worthwhile?

Our objectives were to review all reported staging systems of tympanic membrane (TM) retraction pockets (RP) and to report their reliability and utility to our daily clinical practice in terms of follow-up and decision making in the management of RP. We aim to propose a new management algorithm of TMRPs. We conducted a thorough research on Ovid Medline, Pubmed and Cochrane databases for English and French languages studies published between 1963 and 2012 on the retraction pocket. Studies were excluded if it were a short comments, photo clinical cases, experimental studies or round table articles. Cholesteatoma was not included in keywords, since it is considered as an advanced pathological entity with different staging and management approaches. We included 60 of 756 articles that met our inclusion criteria. Sadé and Berco proposed the first staging system of RP in 1976, while the last one was described by Borgstein et al. in 2007. From 1976 to 2007, 12 different staging systems have been described for tympanic membrane retractions. There are three broad categories of TMRPs: localized retractions of the pars tensa, generalized retractions of the pars tensa (atelectasis) and retraction of the pars flaccida. Most of the described staging systems are useful for following up the evolution of retractions over time. However, no consensus was found concerning the decision making in its management. In conclusion, proper management of TMRPs requires a reproducible, easily applicable staging system with low inter- and intra-observer variability. We propose a management algorithm that considers the functional handicap of the patient rather than the topographic description of the TM.

Type I tympanoplasty with island chondro-perichondral tragal graft: the preferred technique?

OBJECTIVE

This retrospective, comparative study aimed to assess anatomical and functional results in a group of adults undergoing type I tympanoplasty for subtotal tympanic membrane perforation, using two different types of graft.

SUBJECTS AND METHODS

The study included 106 patients affected by chronic otitis media, who underwent underlay type I tympanoplasty, 53 using an autologous chondro-perichondral tragal graft and 53 using temporalis fascia. Anatomical and functional outcomes were evaluated over time.

RESULTS

Audiometric results comparing the cartilage and fascia groups at six months and one year after surgery showed no statistically significant differences. Assessment of anatomical outcomes indicated a greater number of complications in the fascia group.

CONCLUSION

Functional results indicate the validity of the cartilage tympanoplasty, while anatomical results indicate a slightly better outcome in terms of graft re-perforation and retraction, compared with temporalis fascia at one-year follow up. These results suggest that the cartilage technique is preferable for type I tympanoplasty.

Ring versus 'Mercedes-Benz' cartilage-perichondrium graft tympanoplasty in management of pars tensa cholesteatoma

OBJECTIVE

To compare anatomical and audiological outcomes of ring versus 'Mercedes-Benz' cartilage-perichondrium graft tympanoplasty in patients with pars tensa cholesteatoma.

STUDY DESIGN

Prospective clinical study.

SETTING

Otolaryngology department, Tanta University Hospital, Egypt.

PATIENTS AND METHODS

Over three years, 60 ears in 60 patients underwent surgery for either sinus or tensa retraction cholesteatoma, reconstructed using either a ring-shaped (30 ears) or Mercedes-Benz symbol shaped (30 ears) cartilage-perichondrium graft, with at least two years' follow up. Post-operative drum perforation and retraction, cholesteatoma residue and recurrence, middle-ear effusion, and hearing acuity were monitored.

RESULTS

Anatomical outcomes were equivalent in both groups, but slightly better in the Mercedes group. Hearing improved significantly in both groups (pre- vs post-operative results), but significantly more so in the ring group. Within-group hearing outcomes were unaffected by cholesteatoma type or tympanoplasty type.

CONCLUSION

The Mercedes-Benz technique may be superior to the ring technique in preventing neodrum retraction. However, the ring graft technique had better hearing outcomes, perhaps due to its more physiological design.

Retraction pockets of pars tensa in pediatric patients: clinical evolution and treatment

OBJECTIVE

To assess outcome in pediatric patients after treatment for retraction pockets of pars tensa in relation to retraction grade, site, occurrence of complications, and patient age.

METHODS

Outcomes in 45 ears of 37 children medically or surgically treated for retraction pockets were compared to a control group of 40 untreated children over a follow-up period of at least 24 months. Grade I and II retractions were treated with medical therapy or ventilation tube insertion; in III or IV grade retractions, excision and tympanic reinforcement with cartilage grafting and in some cases ossiculoplasty were performed.

RESULTS

Medical treatment or ventilation tube insertion resolved grade I and II retractions in 94% of cases. In grade III or IV retractions the anatomic success rate was 75.8%. Normal hearing (air-bone gap <10 dB) was restored in 31 (68.8%) cases. Surgical failures and complications (recurrence, tympanic membrane perforation, progression to cholesteatoma) were higher in posterior retractions. In the control group, only 35% of retractions healed spontaneously; in the remaining cases the condition progressed to more serious retractions or complications.

CONCLUSION

A wait and see approach or conservative therapy is indicated only in mild-to-moderate retraction pockets owing to their benign prognosis. Pocket excision and tympanic reinforcement are absolutely indicated in advanced retractions with complications and/or bilateral conductive hearing loss to avert progression to more serious pathologies.

'Umbrella' graft tympanoplasty

OBJECTIVES

Tympanoplasty continues to pose a challenge in developing countries, where treatment cost and lack of compliance with second stage surgery are often important factors in determining the surgical strategy. This study aimed to determine the effectiveness of the newly developed, 'umbrella' autograft.

MATERIALS AND METHODS

In 22 patients suffering chronic suppurative otitis media, in whom the incus and stapes suprastructure were found to be absent during surgery, reconstruction was achieved using cartilage-malleus umbrella graft assembly. Six-month post-operative results were evaluated on the basis of average hearing gain, measured at 0.5, 1, 2 and 3 kHz.

RESULTS

At six months post-operatively, 77.3 per cent of patients showed hearing improvement. Audiography at this time indicated significant improvement (p < 0.001), suggesting that this hearing gain may stand the test of time.

CONCLUSION

Umbrella graft tympanoplasty appears to be a promising technique in terms of cost-effectiveness and the autologous nature of implant materials.

Audiologic results of surgery for cholesteatoma: short- and long-term follow-up of influential factors

OBJECTIVE

To review the audiologic results in a cohort of patients surgically treated for cholesteatoma.

STUDY DESIGN

Retrospective review of patient records.

SETTING

Tertiary referral center.

PATIENTS

A retrospective study of patients operated on for acquired middle ear cholesteatoma during the period 1990 to 2002 was performed. A total of 758 patients were followed during a short-term period, and 611 patients were followed during a long-term period. The patients were divided into 3 age groups: children, adolescents, and adults. The localization of cholesteatoma was classified as attic, sinus, or tensa.

INTERVENTIONS

Closed tympanoplasty was always performed as the single procedure of choice on all the children, and reoperation or conversion to open tympanoplasty was made later if needed. Adult patients were treated with single classic canal wall up, or wall down (CWD), according to the propagation of disease and condition of middle ear.

MAIN OUTCOME MEASURES

Preoperative and postoperative air-bone gap (ABG) and pure-tone average were compared after short-term and long-term follow-up.

RESULTS

Average hearing improvement (reduction of ABG) amounted 20.0 dB for short-term and deteriorated to 18.0 dB during long-term analysis for all the patients. Preoperative hearing level was significantly worse for CWD than for intact canal wall technique. The ABG closure was much better in the group with attic cholesteatoma. Both preoperative and postoperative hearing levels were worse for children than for adolescents or adults. Revision operations and bilateral cholesteatoma gave worse total postoperative hearing. The long-term results of primary operations, when recurrent cholesteatoma did not occur, were stable. Damage to auditory ossicles correlated well with total preoperative and postoperative results. The most hearing improvement was verified for the frequencies between 500 and 3,000 Hz, and there was no sensorineural hearing loss.

CONCLUSION

The audiologic results of cholesteatoma surgery are preserved during long-term follow-up. We found that recurrent cholesteatoma was associated with diminished postoperative hearing. Poorer preoperative hearing level, CWD tympanoplasty, younger age, bilateral cholesteatoma, and ossicular damage, as well as revision surgery, were associated with reduced gains in hearing with surgical management. Surgical experience was important for ICW technique and for advanced damage of auditory ossicles. Recurrent cholesteatoma resulted in significantly worse hearing results for each analyzed parameter.

Cartilage Tympanoplasty Methods: Proposal of a Classification

The 23 known cartilage tympanoplasty methods to reconstruct the eardrum are classified in six main groups. Each method is briefly defined, described, and illustrated:

Group A: Cartilage tympanoplasty with palisades, stripes, and slices. The eardrum is reconstructed by several, various, full-thickness pieces of cartilage with attached perichondrium on the ear canal side. In this group six different methods are described.

Group B: Cartilage tympanoplasty with foils, thin plates, and thick plates, not covered with the perichondrium. In this group four methods are included.

Group C: Tympanoplasty with cartilage-perichondrium composite island grafts. The perichondrium flap suspends or fixates the cartilage. In this group four methods are included.

Group D: Tympanoplasty with special total pars tensa cartilage-perichondrium composite grafts. All three methods are used to close a total perforation, but differ from each. Three special methods are included in this group.

Group E: Cartilage-perichondrium composite island grafts tympanoplasty for anterior, inferior, and subtotal perforations. Two on-lay and two underlay methods are included.

Group F: Special cartilage tympanoplasty methods: The cartilage disc is placed under the perforation, the perichondrium onto the denuded eardrum remnant.