Myringoplasty: a comparison of bismuth iodoform paraffin paste gauze pack and tri-adcortyl ointment ear dressing

Graft Healing Process Following Cartilage Myringoplasty Without Trimming of the Perforation Margin

Objective: The objective of this study was to endoscopically evaluate the graft healing process and graft success rate following cartilage myringoplasty, without trimming of the perforation margin or external ear canal (EAC) packing. Material and Methods: Patients with chronic tympanic membrane (TM) perforation underwent endoscope cartilage underlay myringoplasty, without trimming perforation margin or EAC packing. The healing process of the cartilage graft and the graft success rate were evaluated at 6 months postoperatively. Results: Fifty-eight ears were included in this study. At 1 week postoperatively, clinical inosculation and neovascularization of the graft were observed in small- and medium-sized perforations, but not in large or subtotal perforations. At 2 weeks postoperatively, graft clinical inosculation and neovascularization were completed in the small- and medium-sized perforations; however, neovascularization of the graft had only just begun in the large perforations. At 3 weeks postoperatively, completion of the graft clinical inosculation was achieved in 57 of the 58 ears. At 4 weeks postoperatively, complete neovascularization was achieved in all perforations. Of the 58 ears, postoperative infection resulted in residual perforation in 1 ear, and an insufficient graft resulted in residual perforation in a large perforation without infection. Overall, the graft success rate was 96.6% (56/58). There was no correlation between the graft success rate and graft neovascularization score. Conclusions: The graft healing process experienced the dilation of the blood vessels of the remnant TM, graft clinical inosculation, and neovascularization following cartilage myringoplasty without trimming of the perforation margin and EAC packing; however, the graft success rate was not related to the endoscopic graft neovascularization scores.

Role of topical antibiotic ointment in the lateral graft following underlay myringoplasty: a prospective randomised study

OBJECTIVE

The objective of this study was to compare the graft outcome and postoperative infection of with and without the use of antibiotic ointment following myringoplasty for the treatment of chronic perforations.

STUDY DESIGN

Randomized controlled trial.

MATERIAL AND METHODS

135 chronic perforations were prospectively randomized to use of antibiotic ointment group (UAO, n = 68) or no use of antibiotic ointment group (NAO, n = 67) following myringoplasty. The graft outcomes and postoperative infection were compared among two groups at 6 months.

RESULTS

At postoperative 6 months, the graft infection rate was 4.4% in the UAO group and 10.4% in the NAO group, the difference was not significant (P = 0.312).The graft success rates were 92.6% in the UAO group and 91.0% in the NAO group, the difference was not significant (P = 0.979). In the UAO group, 3 patients with purulence ear discharge resulted in a residual perforation although they received ofloxacin ear drops and intravenous antibiotic therapy treatment. In the NAO group, 6 patients with purulence ear discharge resulted in a residual perforation, only one, with mild purulence discharge was successfully treated and closed. In addition, no significant between-group differences were observed pre- (P = 0.746) or post- (P = 0.521) operative air bone gap (ABG) values or mean ABG gain (P = 0.745). However, granular myringitis with minimal moistness but without infection has been noted in 3 (4.4%) patients in the UAO group and in 5 (7.5%) in the NAO group, the difference was not significant (P = 0.699).

CONCLUSIONS

Use and non-use of antibiotic ointments for lateral packing of graft are both comparable methods following myringoplasty for postoperative infection and graft outcomes.

Effect of Packing Versus No Packing in Transperforation Myringoplasty for Chronic Tympanic Membrane Perforations

OBJECTIVE

To compare the operation times, graft survival and success rates, audiometric outcomes, and complications of patients who underwent transperforation myringoplasty with and without packing but without perforation rimming.

STUDY DESIGN

A prospective, randomized controlled trial.

SETTING

A university-affiliated teaching hospital.

METHODS

We conducted a randomized controlled trial that enrolled patients who underwent underlay myringoplasty. No patient underwent perforation rimming. Patients underwent myringoplasty with or without graft lateral packing. The operation times, graft survival and success rates, audiometric outcomes, and complications were compared between the 2 groups.

RESULTS

Sixty patients with unilateral perforations were included. The mean neovascularization score at postoperative week 2 was significantly higher in the no-packing group than in the packing group (p < .01) but did not differ significantly at postoperative weeks 3 and 4, or postoperative month 3. Neither the graft healing rate (p = .313) nor the perforation closure rate (p = .640) significantly differed between the 2 groups. The mean air-bone gap improved by 8.91 ± 5.45 dB in the packing group and 8.17 ± 1.19 dB in the no-packing group (p = .758).

CONCLUSION

The long-term graft success and hearing improvements in transperforation myringoplasty with no rimming of the perforation and no-graft lateral packing were comparable to those in the graft lateral packing group with no rimming of the perforation, with a low incidence of complications. These results may change the traditional practice of packing the external auditory canal and rimming the perforation in underlay myringoplasty, even for all myringoplasty surgery.

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.

Review of endoscopic myringoplasty success: comparisons of intra-operative graft material and post-operative packing in terms of graft failure rate

Background

Myringoplasty success rate is estimated to be between 60 and 90 per cent. Factors predicting success include the choice of graft and use of auditory canal packing. This study aimed to determine the intra-operative factors associated with endoscopic myringoplasty success.

Methods

A retrospective review of all endoscopic myringoplasty cases between January 2017 and January 2020 was undertaken. Data were collected on: patient demographics, tympanic membrane perforation size, intra-operative details, audiology and post-operative outcomes.

Results

There was no significant difference in graft success rates between cases using bismuth iodoform paraffin paste and Spongostan packing (86.7 per cent vs 84.9 per cent, respectively). Conchal cartilage graft had a higher success rate (100.0 per cent) compared with Biodesign grafting biomaterial (66.7 per cent), but was not superior to tragal cartilage (84.6 per cent) or temporalis fat or fascia (80.0 per cent).

Conclusion

Spongostan packing is equivalent to bismuth iodoform paraffin paste in terms of endoscopic myringoplasty success rate. Although conchal cartilage graft had higher success rates, it was not statistically significantly different from tragal cartilage.

A safe and comparable alternative to BIPP packing following tympanoplasty for tympanic membrane perforation

PURPOSE

To compare two post-operative ear packing methods following tympanoplasty for tympanic membrane perforation.

METHODS

A prospective study of patients undergoing tympanoplasty for tympanic membrane perforation over a 2-year period was undertaken across two district general hospitals. Data, including demographics, pre-operative ear state, and graft type used for repair were recorded. Ears were packed using one of two distinct methods. Pack A: gelatin sponge, chloramphenicol ointment and an antibiotic-soaked ear wick. Pack B: antibiotic-soaked gelatin sponge, bismuth iodoform paraffin paste (BIPP) impregnated gauze dressing. The primary outcome measure was post-operative complications associated with each packing method RESULTS: One hundred and fifty-three tympanoplasties were performed during this period: 68 underwent Pack A and 85 underwent Pack B. Chi squared test showed no significant association between pack type and complication rate (p = 0.572). Univariate analysis suggested that age (p = 0.047) and concurrent bony canaloplasty (p = 0.006) significantly increased complication rates. Pre-operative ear status, indication, graft type and gender did not affect complication rate.

CONCLUSIONS

BIPP-impregnated ribbon gauze and chloramphenicol/wick are both comparable methods for packing an ear following tympanoplasty for tympanic membrane perforation. This is useful information both for surgeons who commonly use BIPP and have a patient with a known iodine allergy, or who is not known to be allergic to iodine but has been packed with BIPP previously, and for those who do not have access to BIPP and wish to use a pack with comparable success.

Application of Protocols Devised to Study Bi(III) Complex Formation by Voltammetry: The Bi(III)-Picolinic Acid System

Bi(III) coordination chemistry has been largely neglected due to the difficulties faced when studying these systems even though Bi(III) is used in various medicinal applications. This study of the Bi(III)-picolinic acid system by voltammetry applies the rigorous methodologies already developed to enable the study of Bi(III) systems starting in very acidic solutions to prevent precipitation. This includes calibrating the glass electrode accurately at these low pHs, compensating for the diffusion junction potential below pH 2 and determining the reduction potential of uncomplexed Bi(III) which cannot be directly measured. The importance of including nitrate from the background electrolyte as a competing species is highlighted, especially for data acquired below pH ∼ 2. From analysis of the voltammetric data, it was not clear whether a ML₃OH species formed in solution or whether it was a combination of ML₄ and ML₄OH. Information from crystal structures and electrospray ionization-mass spectrometry measurements was thus used to propose the most probable species model. The log β values determined were 7.77 ± 0.07 for ML, 13.89 ± 0.07 for ML₂, 18.61 ± 0.01 for ML₃, 22.7 ± 0.2 for ML₄, and 31.4 ± 0.2 for ML₄OH. Application of these methodologies thus opens the door to broaden our understanding of Bi(III) complexation.

Wound Healing Concepts in Clinical Practice of OMFS

BACKGROUND

Wound healing is a complex and dynamic process and a thorough knowledge of the basics of physiology of wound healing is a must to implement principles of chronic wound care. Understanding wound healing at multiple levels-biochemical, physiologic, cellular and molecular provides the surgeon with a framework for basing clinical decisions aimed at optimizing the healing response.

OBJECTIVE

This review article describes the classification of wounds and aims to highlight the fundamentals of wound repair, enumerating the dressings used commonly and also, the newer concepts of wound healing.

MATERIALS AND METHODS

Search engines and medical databases were tapped to gather information on the subject. Search words employed were "Wounds", "wounds in OSMF", "Wound healing", "Repair", "Dressings in OMFS".

RESULTS

The search resulted in total of 153 articles which we reviewed to add to the literature the concepts of wound healing and to throw some light on recent advances in wound care.

CONCLUSIONS

Wound healing remains a challenging clinical problem and correct, efficient wound management is essential to positively influence the wound healing course and reduce potential complications.

A pilot randomized controlled trial comparing bismuth iodine paraffin paste external ear pack and no ear pack after middle ear surgery

To pilot a substantive randomized control trial comparing post-operative external ear canal pack with no ear pack after middle ear surgery, 32 adults undergoing primary posterior bony canal wall preserving middle ear surgery were randomized to have either a bismuth iodoform paraffin paste pack or no ear pack post-operatively. Outcome measures included clinician- and patient-recorded visual analogue scale scores for ear signs and symptoms at 3 weeks and 3 months and audiometric findings at 3 months post-operatively. There was no statistically significant inter-group difference in 3-week clinician and patient cumulative scores for ear signs and symptoms. There was also no significant difference in graft take rate, appearance of ear canals and audiometric results in either group at 3 months. No difference in ear symptoms, clinician findings or hearing was demonstrated between patients with a post-operative pack compared to those without a pack following middle ear surgery in this pilot study.

How we do it: the absorbable gelatin sponge cube, an effective and economical approach to packing in ear surgery

Introduction:

There is currently a lack of robust evidence on the best form of packing for otological surgery. We describe the use of the absorbable gelatin sponge, a packing material that does not require removal and has the benefit of being considerably cheaper compared to other common forms of ear packing.

Methods:

A comparison was made of the financial cost of several forms of packing for common otological procedures. In addition, a retrospective audit of complications was undertaken of all patients in whom the absorbable gelatin sponge was used over the past three years.

Results:

The absorbable gelatin sponge was shown to be cheaper to purchase per unit and also more economical to use. It has been the exclusive form of packing used in 519 procedures over the past three years at the William Harvey Hospital in Ashford (UK), with very few complications noted at the follow-up review.

Conclusion:

We strongly advocate using the absorbable gelatin sponge, a packing material that is kinder to the patient, has similar efficacy to other forms of packing and is also much cheaper to use compared to other common forms of packing.

Does glubran 2 improve the graft uptake in tympanoplasty? A retrospective study

Tympanoplasty is a common procedure in otolaryngology practice and several factors have been described to increase graft uptake. Independent of the technique and graft material, the revascularization process of the graft is related to patient factors as well as contact of the tympanic membrane remnant's edges with the graft material. A number of different tissue glue materials and other packing methods have been used for graft stabilization. Glubran 2, a cyanoacrylate containing surgical tissue adhesive, has highly effective anticoagulant and adhesive properties, and the present study aims to reveal the effectiveness of this glue on tympanoplasty surgery. The study is designed as retrospective chart review and it was set up at Etlik İhtisas Research and Training Hospital which is a tertiary care center. The study population consisted of 68 consecutive patients aged between 9 and 75 years who underwent over-underlay tympanoplasty. The patients were divided into two groups according to use of glubran 2 as a sealing material for graft fixation. The patients in whom glubran 2 was not used served as the control group. There were 20 women and 16 men in the glubran 2 group, 17 women and 15 men in the control group. These two groups were also subdivided into two groups for the graft type used (temporal muscle fascia or tragal cartilage). The overall graft take rate was 88.9 % in the tympanoplasty group sealed with glubran 2 and 84.4 % in the control group. A statistically significant decrease was seen in hearing thresholds in both groups postoperatively when compared to the preoperative values (p < 0.001 for both). There was no significant otorrhea in either group. Graft uptake and hearing recovery were similar in glubran 2 and control groups. These findings suggest that glubran 2 is an effective material for fixation of the graft in tympanoplasty, but it does not have a notable effect on the success of the surgery.

Early healing and hearing improvement following type one tympanoplasty using the 'drum sandwich' technique

BACKGROUND

The results of a number of tympanic membrane perforation closure techniques have been reported. However, relatively little has been published on the 'drum sandwich' technique.

METHOD

Retrospective chart review of 123 patients undergoing type one tympanoplasty, performed by one surgeon using the drum sandwich technique.

RESULTS

Ninety-two per cent of perforations were successfully closed, and 87 per cent of patients had healed ears and were free from aural discharge 6 weeks following surgery. Post-operative hearing data were only available for 81 ears. Of these, 58 per cent had closure of the air-bone gap to within 10 dB. The mean hearing gain for the group was 10.6 dB.

CONCLUSION

The drum sandwich technique produces rapid healing of the ear with acceptable hearing outcomes. Drum closure rates are comparable with those reported for other techniques.

Allergic Reaction to Bismuth-lodoform-Paraffin Paste (BIPP) Following Ear Surgery

Bismuth Iodoform Paraffin Paste (BIPP) impregnated ribbon gauze is one of the most commonly used packs after external and middle ear surgery. Allergic reaction to BIPP is rare. We report two cases of hypersensitive BIPP reaction following tympanoplasty surgery. To our knowledge no such cases have been reported previously in Qatar. We reviewed the literature and discuss the management and its prevention.

Ear packing after ear surgery: is it really necessary?

OBJECTIVE

We question the need for packing of the ear canal after ear surgery. For several years, it had not been the first author's standard practice to use post-operative ear packing. During this period, few problems or complications had been encountered.

SETTING

Tertiary referral, academic, paediatric hospital.

MATERIALS AND METHODS

A retrospective review of all children who had undergone major ear surgery in our unit over the last year was carried out. These cases represented a full range of otological procedures. Post-operative complications and infections in the first six post-operative weeks were recorded.

RESULTS

A total of 135 ears were operated upon in 107 patients ranging in age from 11 months to 19 years (mean 9.5 years). During this time period, eight children (7.5 per cent) developed a post-operative ear infection. No cases of tympanic or meatal granulations, problems with the tympanomeatal flap, or meatal stenosis were encountered. All infections were successfully managed with topical antibiotics.

DISCUSSION

We conclude that packing after ear surgery may be safely abandoned. This would not only save valuable operating time, but would also obviate the need for pack removal, always a source of discomfort and anxiety. This is especially important in children, who may subsequently require a further general anaesthesia in order to remove the pack.