Cortical mastoidectomy in quiescent, tubotympanic, chronic otitis media: is it routinely necessary?

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.

Topical Therapy Failure in Chronic Suppurative Otitis Media is Due to Persister Cells in Biofilms

OBJECTIVE

Chronic suppurative otitis media (CSOM) is characterized by a chronically draining middle ear. CSOM is typically treated with multiple courses of antibiotics or antiseptics which are successful in achieving quiescence; however, the disease is prone to relapse. Understanding why these treatment failures occur is essential.

STUDY DESIGN

The minimum inhibitory concentration (MIC), minimal biofilm eradication concentration, and the inhibitory zone were determined for ototopicals and ofloxacin for the laboratory strains and CSOM-derived isolates. The percentage of persister cells and bacterial biofilm formation were measured. Disease eradication was tested in a validated in-vivo model of CSOM after treatment with ofloxacin.

SETTING

Microbiology Laboratory.

METHODS

Basic science experiments were performed to measure the effectiveness of a number of compounds against CSOM bacteria in a number of distinct settings.

RESULTS

The minimal biofilm eradication concentration is higher than is physiologically achievable with commercial preparations, except for povo-iodine. Clincial isolates of CSOM have equivalent biofilm-forming ability but increased proportions of persister cells. Ofloxacin can convert to inactive disease temporarily but fails to eradicate disease in an in-vivo model.

CONCLUSIONS

Higher percentages of persister cells in clinical CSOM isolates are associated with resistance to ototopicals. Current ototopicals, except povo-iodine, have limited clinical effectiveness; however, it is unknown what the maximum achievable concentration is and there are ototoxicity concerns. Fluoroquinolones, while successful in producing inactive disease in the short term, have the potential to encourage antimicrobial resistance and disease recalcitrance and do not achieve a permanent remission. Given these limitations, clinicians should consider surgery earlier or use of clinically safe concentrations of povo-iodine earlier into the treatment algorithm.

Endoscopic epitympanic exploration in mucosal chronic otitis media: is canal wall up mastoidectomy really needed?

OBJECTIVE

To compare endoscopic epitympanic exploration with conventional canal wall up (cortical) mastoidectomy for mucosal chronic otitis media in terms of post-operative outcomes.

METHODS

Seventy-six patients diagnosed with chronic otitis media (mucosal variety) were randomly assigned to two treatment groups: endoscopic epitympanic exploration and conventional canal wall up (cortical) mastoidectomy. The groups were compared in terms of: post-operative anatomical outcomes (graft uptake), middle-ear physiological outcomes (post-operative tympanometry), audiological outcomes (air-bone gap), surgical time, post-operative pain, vertigo, and long-term complications such as retraction pocket and re-perforation.

RESULTS

There was a statistically significant difference between the groups in terms of mean air-bone gap at 12 months, surgical time, and median post-operative pain measured at 6 hours (p < 0.05). No statistically significant differences were noted in terms of: graft uptake at 1, 3 and 6 months, mean air-bone gap at 3 and 6 months, tympanometry at 3, 6 and 12 months, vertigo at 1 week, or long-term complications.

CONCLUSION

Endoscopic epitympanic exploration resulted in significantly better long-term audiological outcomes, shorter operating time and less pain compared with conventional canal wall up (cortical) mastoidectomy.

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.

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.

Doing Mastoidectomy Along with Tympanic Membrane Repair Reduces the Need for Revision Procedures: A Prospective Study

To determine the role of cortical mastoidectomy on the results of tympanoplsty in tubotympanic type of chronic suppurative otitis media. A prospective, observational, interventional study was conducted from a period of October 2006-October 2008. This included 40 patients of either sex in the age group of 15-45 years having tubotympanic type of CSOM. Tympanoplasty with mastoidectomy was done in all the patients and they were followed up for graft acceptance and hearing impairment for 5 years to see the long term results. Per-operatively, the antrum was involved in 17, aditus in 11 and middle ear in 8 patients. Incus was necrosed in 10 cases and malleus and incus were absent in a single case. Mucoid discharge was found in the middle ear in 12 out of 40 patients. Mucoid discharge ears had antral mucosal hypertrophy in 100%, blocked aditus in 75% and middle ear mucosal hypertrophy in 58% cases; ossicular necrosis in 75% cases. 90% of the cases had graft accepted. In dry ears, graft take up rate was 89% and in ears with mucoid discharge it was 92%. Average air-bone-gap reduced to 13.90 dB as compared to average air-bone-gap (Av. AB Gap1) preoperatively of 38.62 dB. After 5 years, 83.5% patients had >10 dB improvement in hearing. We recommend opening of the mastoid if on inspection of middle ear one finds mucoid type of discharge.

Comparative Evaluation of Tympanoplasty with or Without Mastoidectomy in Treatment of Chronic Suppurative Otitis Media Tubotympanic Type

To study the role of tympanoplasty alone and tympanoplasty done along with cortical mastoidectomy in CSOM in term of graft uptake, improvement of hearing and removal of disease. This is retrospective study of patient at tertiary referral centre, conducted in between October 2015 and October 2016, study was done on 40 patients of either sex in the age group 20-50 years. Tympanoplasty alone was done in 20 cases and tympanoplasty along with cortical mastoidectomy was done in rest 20 cases. Patient were reviewed post operatively on 2, 4, 8 and 16 weeks to inspect post operative graft uptake and PTA was done at fourth month to evaluate hearing improvement. Hearing improvement was compared in both the groups in tympanoplasty group was 9.41 and in tympanoplasty combined with cortical mastoidectomy was 12.05. Graft uptake was 80% in tympanoplasty group and 95% in tympanoplasty combined with cortical mastoidectomy. Recurrence of discharge was seen in 4 cases of tympanoplasty. Though tympanoplasty combined with cortical mastoidectomy is better in hearing improvement, graft uptake and clinical improvement but the difference in 2 groups is statistically insignificant. Results of tympanoplasty alone and tympanoplasty along with cortical mastoidectomy in terms of hearing gain and graft uptake were statistically insignificant.

Chronic otitis media surgery and re-operation risk factor analysis: A nationwide retrospective cohort study of 18 895 patients

CONCLUSION

Patients with risk factors including younger age, mastoiditis, external ear disease, treatment by older surgeons, and concomitant mastoidectomy should receive detailed management to minimize the probability of re-operation for chronic otitis media (COM).

OBJECTIVES

Although COM remains a common ear disease requiring surgical intervention, its re-operation risks are less well-documented. This study aimed to compare patients with COM who underwent re-operation and those patients with no re-operation, and identify the risks of re-operation.

METHOD

This retrospective cohort study analyzed the trend of COM surgery from 1999-2009, and identified the re-operation risks of 18 895 patients with COM who underwent surgery from 2002-2006 using the National Health Insurance Research Database in Taiwan.

RESULTS

Among the study population, 129 patients underwent revision surgery during a 5.5 ± 1.5 year follow-up period. A univariate logistic regression analysis showed that the re-operation rate was significantly higher in patients under 18 years of age, those with mastoiditis, disorders of external ear, treatment by surgeons of 50-64 years of age, use of a very high volume surgeon, and combined surgery with mastoidectomy. A multivariate analysis further limited the re-operation risk factors to younger patients, those with mastoiditis, external ear disorders, treatment by older surgeons, and concomitant mastoidectomy.

Evidence-based management of otitis media: a 5S model approach

Objective:

The 5S model proposes five hierarchical levels (systems, summaries, synopses, syntheses and studies) of pre-appraised evidence to guide evidence-based practice. This review aimed to identify and summarise pre-appraised evidence at the highest available 5S level for the management of different subsets of otitis media: acute otitis media, otitis media with effusion, chronic suppurative otitis media and cholesteatoma in both adults and children.

Method:

Data sources were pre-appraised evidence resources. Evidence freely available from sources at the highest available level of the 5S model were summarised for this review.

Results:

System level evidence exists for acute otitis media and otitis media with effusion. Summary level evidence exists for recurrent acute otitis media and medical management of chronic suppurative otitis media. There is an absence of randomised controlled trials to prove the efficacy of surgical management of chronic suppurative otitis media and cholesteatoma.

Conclusion:

Until randomised controlled trial data are generated, consensus publications on the surgical management of chronic suppurative otitis media and cholesteatoma should be used to guide best practice.

Myringoplasty with and without Cortical Mastoidectomy in Treatment of Non-cholesteatomatous Chronic Otitis Media: A Comparative Study

OBJECTIVE

To compare the outcome and success of repair of uncomplicated tympanic membrane perforations with myringoplasty alone and when combined with mastoidectomy.

METHODS

A prospective study where 40 patients with non-cholesteatomatous chronic suppurative otitis media (CSOM) were recruited during the period of June 2013 to December 2013 from the outpatient clinic of Otorhinolaryngology department, Faculty of medicine, Cairo University. Patients were managed medically and after dryness of their perforations they were operated upon. Twenty patients underwent simple myringoplasty alone and 20 patients underwent myringoplasty with cortical mastoidectomy. Underlay technique with temporalis fascia was done for all patients. Follow-up period was at least 3 months.

RESULTS

Hearing improvement was comparable in both groups. There was no significant difference in graft uptake between the myringoplasty alone group (70%) and cortical mastoidectomy group (80%) (P = 0.7). There was no significant difference in ear dryness between the myringoplasty alone group (75%) and cortical mastoidectomy group (90%) (P = 0.4).

CONCLUSION

Mastoidectomy performed in non-cholesteatomatous CSOM in this study gives no statistically significant benefit over simple myringoplasty as regards graft success rate and dryness of the middle ear with comparable hearing outcome.

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.

Success of myringoplasty: our experience

The purpose of this study is to compare the efficacy of myringoplasty with or without cortical mastoidectomy in terms of freedom from discharge, graft take up and improvement in hearing. This is a Clinical prospective study of 120 patients from among a group of patients with chronic suppurative otitis media. A detailed history and examination was conducted including pure tone audiogram. Patients were randomly divided into two groups; group A would undergo myringoplasty only and group B would undergo cortical mastoidectomy with myringoplasty. Patients were reviewed after 3 weeks for inspection of the operated ear. Second post-operative review was at 3 months for clinicoaudiological assessment. Group B was found to have slightly more improvement as compared to the other group. No significant difference in the success rates of graft take-up in patients with unilateral or bilateral disease was found. Higher take up rates were seen in large (91.83 %) and medium perforations (90.69 %). In all our failed cases, post-operative ear discharge continued to be a persistent and troubling problem. The average audiological gain was 12.88 dB in group B, whereas it was 12.40 dB in group A. The reduction of air bone gap within each group was found to be significant. There is no statistical significant data indicating that tympanoplasty with mastoidectomy yields better results. When considering the addition of a mastoidectomy to a Tympanoplasty, the performing surgeon should consider not only the potential added benefit but also potential risks and costs to the patient.

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.