Effectiveness of MeroGel hyaluronic acid on tympanic membrane perforations

The Effect of Using Ofloxacin Ear Drops in Traumatic Tympanic Membrane Healing: A Systematic Review and Meta-Analysis

Objectives: To evaluate the effectiveness of ofloxacin ear drops versus no intervention in the repair of traumatic tympanic membrane (TM) perforations from randomized controlled trials (RCTs). Data Sources: Medline/PubMed, CENTRAL, Clinical Trials.Gov, and Google Scholar. Study Selection: Inclusion criteria: (1) English language; (2) RCT studies; (3) reported the outcomes on the application of ofloxacin and outcomes of spontaneous healing. Exclusion criteria: (1) studies without a control group; (2) patient with severe otologic disease such as chronic suppurative otitis media or ossicular disruption or patients with craniocerebral injury; (3) studies with no pretreatment values or single-arm clinical studies. Data Extraction: Country, year of publication, number of participants in each arm, patient characteristics such as age, sex, intervention details, laterality, cause of TM perforation, position of perforation, follow-up time, hearing gain, rate of TM closure, and closure time. Results: A total of 6 RCTs studies were analyzed. A total of 502 participants were included; the relative risk for closure rate of ofloxacin treatment was 1.18 [95% confidence interval (CI), 1.08 to 1.28, P < .001] and the mean difference (MD) for healing time was -18.4 (95% CI, -19.96 to -16.82, P < .001), suggesting ofloxacin has a significant effect on closure of TM perforations. However, no clinically significant effect in hearing (SMD: 0.21, 95% CI, 0.02 to 0.40, P = .03) was seen in ofloxacin group. Also, patients in the ofloxacin group were associated with a 13% reduction in the risk of infections compared to their observation-assigned counterparts, but this estimate was not statistically significant. Conclusion: Ofloxacin use in patients with traumatic TM perforation is effective in reducing healing time and increasing rate of TM perforation closure. No evidence of increased risk of hearing loss or infection rates are encountered when ofloxacin is prescribed to patients with traumatic TM perforation.

Tissue engineering in otology: a review of achievements

Tissue engineering application in otology spans a distance from the pinna to auditory nerve covered with specialized tissues and functions such as sense of hearing and aesthetics. It holds the potential to address the barriers of lack of donor tissue, poor tissue match, and transplant rejection through provision of new and healthy tissues similar to the host and possesses the capacity to renew, to regenerate, and to repair in-vivo and was shown to be a bypasses for any need to immunosuppression. This review aims to investigate the application of tissue engineering in otology and to evaluate the achievements and challenges in external, middle and inner ear sections. Since gaining the recent knowledge and training on use of different scaffolds is essential for otology specialists and who look for the recovery of ear function and aesthetics of patients, it is shown in this review how utilizing tissue engineering and cell transplantation, regenerative medicine can provide advancements in hearing and ear aesthetics to fit different patients' needs.

Histopathological Evaluation of Platelet-Rich Plasma Effect in Acute Tympanic Membrane Perforation

Platelet-rich plasma (PRP) is a reliable and has low side-effect profile and has beneficial effects on wound healing. Its investigatory effects on wound-healing process were shown on various tissues. This study aims to investigate PRP's local application effects to perforated rat TM in terms of healing and histopatological outcomes. Twenty-two Wistar rats were used in the study. The rats' ears were examined with a pediatric endoscope (2.7 mm, 0°), and the TM posterior quadrant of their right ear was perforated with a 20-gauge needle. After this procedure, the rats were divided into two equal groups. A spongel with PRP was applied on the perforated TM in the first group, and spongel with standard saline solution was applied on the second group. Following the sacrifice, the middle air bullas were carefully dissected and removed for histopathological examination. Hematoxylin eosin (for fibroblasts, lymphocyte, collagen fibers) and immunohistochemical staining were done for epithelial growth factor receptor (EGFR), fibroblast growth factor receptor (FGFR1), and vascular endothelial growth factor (VEGF) staining for histopathologic examinations. There was not a significant difference between the two groups for lymphocyte. There was a significant difference between control and study groups for collagen and EGFR (P < 0.05). Although the mean value of FGF- and VEGF-positive cells was higher in the study group than in the control group, the difference was not significant (P > 0.05). PRP is an effective autologous material for the healing process of acute TM perforations in a rat model, as demonstrated in the present study. We think that the use of PRP for acute TM perforations can have a positive effect on the healing process by increasing the level of growth factors, especially EGFR. In addition, an increase in collagen can also have a positive effect on healing.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-021-02912-2.

The Effect of Platelet-Rich Fibrin and Hyaluronic Acid on Perforation of Nasal Septum

BACKGROUND

Conservative approaches and surgical methods have been tried for the treatment of nasal septum perforations (NSPs), but a satisfactory method has not yet been determined.

OBJECTIVE

Our study aimed to investigate the effect of platelet-rich fibrin (PRF) and hyaluronic acid (HA) in repairing NSPs, which were experimentally created in rabbit septum.

METHODS

A total of 36 white New Zealand rabbits were included in the study. Perforations measuring 0.7 × 0.7 cm were created in their nasal septa. No additional intervention was made to the control group, which was the first group. For the second, third, and fourth groups, respectively, HA, PRF, and HA + PRF were used in the NSP region. Macroscopic and histopathological evaluations were performed after 40 days.

RESULTS

In the first group, closure was observed in none of the rabbits' NSPs. In the second group, 6 rabbits (66.7%) had full closure in their NSPs. In the third group, the NSP of 6 rabbits (66.7%) was completely closed. In the fourth group, the NSP of 7 rabbits (77.8%) had full closure.

CONCLUSION

Statistically significant closure was achieved with PRF and/or HA in rabbits in which NSP was established. These materials can be used to increase the likelihood of perforations closing.

Past and Future Biologics for Otologic Disorders

Biologic therapies have the ability to fundamentally change the management of hearing loss; clinicians need to familiarize themselves with their prospective applications in practice. This article reviews the current application of 4 categories of biological therapeutics-growth factors, apoptosis inhibitors, monoclonal antibodies, and gene therapy-in otology and their potential future directions and applications.

What is the Role of Hyaluronic Acid Ester in Myringoplasty? Systematic Review and Meta-Analysis

OBJECTIVE

To reveal odds of tympanic membrane closure and postoperative hearing outcomes for myringoplasty utilizing hyaluronic acid ester via systematic review and meta-analysis.

DATA SOURCES

1) Search of English articles in PubMed/Medline, Embase, and Cochrane databases published between January 1, 1998 and March 31, 2018.

STUDY SELECTION

Inclusion criteria: 1) English language; 2) clinical studies; 3) reported posttreatment perforation status, hearing outcomes, or complications.

EXCLUSION CRITERIA

hyaluronic acid used for middle ear packing or topical application of hyaluronic acid solution.

DATA EXTRACTION

Number of patients, surgical technique, mean age, overall rate of tympanic membrane closure, success rate based on size of perforation, mean air-bone gap improvement, and postoperative speech scores and complications.

DATA SYNTHESIS

Ten studies encompassing 531 patients met criteria. Reported success rates for closure of chronic perforation ranged from 70.0 to 92.7% (mean, 85.21%). Smaller perforation predicted success in complete closure. Mean air-bone gap closure was 10.6 dB (4-24 dB). There were five complications reported. Meta-analysis was performed on five studies. No difference was noted in the success rates between hyaluronic acid ester myringoplasty and conventional tympanoplasty using fascia or perichondrium, with an overall closure rates of 89.8 and 89.4%, respectively (odds ratio [OR] 1.04, 95% confidence interval [CI] 0.59-1.82, p = 0.896). A higher closure rate was seen in hyaluronic acid ester myringoplasty (87.9%) when compared with fat graft myringoplasty (70.8%), (OR 3.01, 95% CI 1.42-6.35, p = 0.004).

CONCLUSIONS

Hyaluronic acid (HA) ester myringoplasty appears to be safe and effective at attaining complete closure of tympanic membrane perforation, although there exists significant selection bias and inconsistent reporting among existing papers.

Hyaluronic acid in otology: Its uses, advantages and drawbacks - A review

OBJECTIVES

Review of the literature for studies involving the use of hyaluronic acid (HA) in otology.

METHODS

Pubmed and OvidMedline were searched using a combination of the following words in different variations: hyaluronic acid, hyaluronate, otolaryngology, otology, ear, tympanic membrane, perforation, tympanostomy, tympanoplasty, myringoplasty, packing, middle ear, cochlea, gene delivery, gene therapy, cochlear implant, hearing loss, meniere, vertigo, otitis and cholesteatoma.

RESULTS

The papers relevant for this review were triaged based on abstracts and titles and were then categorized based on topic/disease entity/procedure. The papers were read and summarized in order to use their findings in this review.

CONCLUSIONS

HA is being recently used as adjuvant therapy for multiple inflammatory conditions and in tissue repair. These immunomodulatory properties and biocompatibility have interested researchers specially in the field of otology for repair, gene delivery, immunomodulation etc. Recent data in the field show optimistic results for the use of HA in several conditions especially tympanic membrane perforations and gene delivery. It also establishes the role of HA as ancillary treatment in many other otologic pathologies. This review presents the most recent findings on the use of HA in otology. The results could be used to guide clinical practice and incite further research based on the presented results of the literature.

Healing Human Moderate and Large Traumatic Tympanic Membrane Perforations Using Basic Fibroblast Growth Factor, 0.3% Ofloxacin Eardrops, and Gelfoam Patching

OBJECTIVE

The goal of this study was to evaluate the effects of basic fibroblast growth factor (bFGF), 0.3% ofloxacin eardrops (OFLX), and Gelfoam patching on the healing of human moderate and large traumatic tympanic membrane perforations (TMPs).

STUDY DESIGN

A prospective, quasi-randomized, controlled clinical study.

SETTING

A University-affiliated teaching hospital.

SUBJECTS AND METHODS

We performed a quasi-randomized prospective analysis between January 2010 and December 2014. All patients had traumatic TMPs covering areas >25% of the entire tympanic membrane. The closure rates, closure times, hearing gains, and rates of otorrhea in patients who underwent conservative observation, Gelfoam patching, topical bFGF application, and direct application of OFLX were compared.

RESULTS

We ultimately included 185 patients. Closure rates did not significantly differ among the four groups (p = 0.257). Post-hoc multiple comparisons also showed that the closure rates did not differ between any two groups (p > 0.083). The mean closure times were 25.6 ± 13.32, 12.3 ± 8.15, 14.3 ± 5.44, and 13.97 ± 8.82 days for the observation, bFGF, Gelfoam patch, and OFLX groups, respectively. The closure times of the four groups differed significantly (p < 0.001). Post-hoc multiple comparisons showed that the differences between the observation group and each of the other groups were significant (p < 0.001). No other between- or among-group differences were significant (p > 0.0083).

CONCLUSION

The findings of this study suggest that OFLX, bFGF, and Gelfoam patching accelerated the closure of human moderate and large traumatic TMPs. Hence, treatment of human traumatic TMPs should be revisited clinically. Topical application of OFLX may be recommended, because OFLX is more easily available and convenient than bFGF or Gelfoam patch for otology outpatients.

A comparative study to evaluate the efficacy of EGF, FGF-2, and 0.3% (w/v) ofloxacin drops on eardrum regeneration

BACKGROUND

Traumatic tympanic membrane perforations (TMPs) tend to spontaneous healing, however, large TMPs usually fail to healing. Clinical and experimental studies had demonstrated that growth factors accelerated the healing of large TMPs. The aim of this study was to compare the effects of growth factors and 0.3% (w/v) ofloxacin drops n the healing of human large TMPs.

METHODS

A total of 184 human large traumatic TMPs were randomly assigned to receive epidermal growth factor (EGF) treatment, fibroblast growth factor-2 (FGF-2) treatment, 0.3% (w/v) ofloxacin drops treatment, and conservative observation (only).

RESULTS

A total of 180 patients were analyzed in this study at the 6-month follow-up. The closure rates of the perforations in the EGF, FGF-2, 0.3% (w/v) ofloxacin drops, and conservative observation groups were 91.11%, 93.18%, 95.65%, and 82.22%, respectively, the closure rates did not significantly differ among the groups (P = .165). Similarly, pairwise comparisons did not reveal any significant between-group differences (P > .0083). However, the difference of the mean closure time was significant among the 4 groups (P < .001), pairwise comparisons showed that closure time was significantly longer in the observational group than in the other 3 groups (P < .001). Nevertheless, no significant difference in mean closure time was evident between any 2 treated groups (P > .0083). The mean hearing gain after 6 months was 11.49 ± 5.88 dB for the EGF group, 10.89 ± 5.16 dB for the FGF-2 group, 10.54 ± 5.56 dB for the ofloxacin group, and 9.29 ± 5.36 dB for the observation group. Differences in hearing improvement rates among the 4 groups were not statistically significant (P = .283).

CONCLUSION

Epidermal growth factor, FGF-2, and 0.3% (w/v) ofloxacin drops accelerated the closure of large TMPs compared with conservative treatment. Surprisingly, neither the closure rate nor closure time differed significantly among the 3 treated groups. Further experimental studies to demonstrate whether 0.3% (w/v) ofloxacin per se accelerates the healing of TMPs will be interesting in the future.

A moist edge environment aids the regeneration of traumatic tympanic membrane perforations

OBJECTIVE

To review the history of moist therapy used to regenerate traumatic tympanic membrane perforations.

STUDY DESIGN

Literature review.

METHODS

The literature on topical agents used to treat traumatic tympanic membrane perforations was reviewed, and the advantages and disadvantages of moist therapy were analysed.

RESULTS

A total of 76 studies were included in the analysis. Topical applications of certain agents (e.g. growth factors, Ofloxacin Otic Solution, and insulin solutions) to the moist edges of traumatic tympanic membrane perforations shortened closure times and improved closure rates.

CONCLUSION

Dry tympanic membrane perforation edges may be associated with crust formation and centrifugal migration, delaying perforation closure. On the contrary, moist edges inhibit necrosis at the perforation margins, stimulate proliferation of granulation tissue and aid eardrum healing. Thus, moist perforation margins upon topical application of solutions of appropriate agents aid the regeneration of traumatic tympanic membrane perforations.

Acceleration of Healing of Traumatic Tympanic Membrane Perforation in Rats by Implanted Collagen Membrane Integrated with Collagen-Binding Basic Fibroblast Growth Factor

Traumatic tympanic membrane (TM) perforation is very common in clinical practice. Several biomaterials have been reported to play a role in TM reparation, whereas their functional recovery is limited when used alone. Meanwhile, the administration of biofactors could promote functional recovery, but rapid distribution and short half-time obstruct their application. To study the effect of traumatic TM regeneration, we prepared collagen membrane (CM) integrated with collagen-binding basic fibroblast growth factor (CBD-bFGF) and implanted into the injury site of perforated TM in Sprague-Dawley rats. The study on CBD-bFGF in vitro showed that CBD-bFGF accelerated the proliferation of human fibroblast cell HS-865 biologically and was released from CM gradually. In vivo study, through the gross anatomy, auditory brainstem responses assay, histological staining, and transmission electron microscopy observation at d7, d14, and d28 after the acute TM perforation, we found that CBD-bFGF-integrated CM promoted the healing rate at an early stage (∼7 days), reduced the healing time of perforated TM, and notably retrieved the structure and hearing of TM. These findings suggest that CM modified with CBD-bFGF could be therapeutically appropriate for the treatment of TM perforation.

The effect of ofloxacin otic drops on the regeneration of human traumatic tympanic membrane perforations

OBJECTIVE

To investigate the effects of direct application of ofloxacin otic drops on human traumatic tympanic membrane perforations (TMPs).

STUDY DESIGN

Prospective, sequential allocation, controlled clinical study.

SETTING

Tertiary university hospital.

PARTICIPANTS

In total, 149 patients with traumatic TMPs were recruited. They were allocated sequentially to two groups: a conservative observation group (n = 75) and a ofloxacin drops-treated group (n = 74).

MAIN OUTCOME MEASURES

The closure rate, closure time and rate of otorrhoea were compared between the groups at 6 months.

RESULTS

In total, 145 patients were analysed. The closure rates of medium perforations between the groups were not significantly different (P = 0.35); however, the ofloxacin drops-treated group had a significantly shorter closure time for medium perforations than the observation group (P < 0.01). Additionally, the ofloxacin drops-treated group showed improvement in the closure rate of large perforations (P = 0.02) and a significantly shorter mean closure time (P < 0.01) than the observation group. However, purulent otorrhoea was not significantly different between the groups (P = 0.37).

CONCLUSIONS

The present findings indicate that the moist eardrum environment resulting from topical application of ofloxacin drops shortened the closure time and improved the closure rate, but did not affect hearing improvement or increase the rate of middle ear infection of large traumatic TMPs. Thus, although traumatic TMPs tend to heal spontaneously, moist therapy can be considered for traumatic, large TMPs in the clinic.

Recent advances in local drug delivery to the inner ear

Inner ear diseases are not adequately treated by systemic drug administration mainly because of the blood-perilymph barrier that reduces exchanges between plasma and inner ear fluids. Local drug delivery methods including intratympanic and intracochlear administrations are currently developed to treat inner ear disorders more efficiently. Intratympanic administration is minimally invasive but relies on diffusion through middle ear barriers for drug entry into the cochlea, whereas intracochlear administration offers direct access to the colchlea but is rather invasive. A wide range of drug delivery systems or devices were evaluated in research and clinic over the last decade for inner ear applications. In this review, different strategies including medical devices, hydrogels and nanoparticulate systems for intratympanic administration, and cochlear implant coating or advanced medical devices for intracoclear administration were explored with special attention to in vivo studies. This review highlights the promising systems for future clinical applications as well as the current hurdles that remain to be overcome for efficient inner ear therapy.

Enhanced expression of hepatocyte growth factor in the healing of experimental acute tympanic membrane perforation

OBJECTIVES

The present study was performed to investigate the expression of hepatocyte (HGF), epidermal (EGF) and vascular endothelial (VEGF) growth factors in the course of healing of experimental tympanic membrane (TM) perforations in rats. The goal was to explain the role of these growth factors in the healing process of TM and to assess the possibility of their future application as healing promoters.

METHODS

Seventy rats were used, of which 10 served as controls and the others had their TM perforated. The experimental animals were divided into six subgroups on the basis of time points (01, 03, 05, 07, 09, 15 day after injury). Videootoscopy and histology were employed to assess the morphology of the healing process. The expressions of HGF, EGF and VEGF were evaluated using Western blot analysis. Tissue localization of HGF was determined by the immunofluorescence method.

RESULTS

HGF was hardly detectable in normal TM; however, a significant increase was noted in its expression starting from the third day after injury throughout the follow-up period, with the highest level on day 05. The analysis of HGF tissue localization with immunofluorescence revealed diffuse staining in the cytoplasm of proliferating epithelial cells. The expression of EGF was elevated on the first day after injury, not reaching statistical significance, and then returned to the level observed in the control TM. No significant differences were noted in the expression of VEGF.

CONCLUSION

High expression of HGF during the healing process of acute TM perforations makes it a promising candidate for further studies oriented towards its possible use in augmentation of TM healing.

Outlook for Tissue Engineering of the Tympanic Membrane

Tympanic membrane perforation is a common problem leading to hearing loss. Despite the autoregenerative activity of the eardrum, chronic perforations require surgery using different materials, from autologous tissue - fascia, cartilage, fat or perichondrium - to paper patch. However, both, surgical procedures (myringoplasty or tympanoplasty) and the materials employed, have a number of limitations. Therefore, the advances in this field are incorporating the principles of tissue engineering, which includes the use of scaffolds, biomolecules and cells. This discipline allows the development of new biocompatible materials that reproduce the structure and mechanical properties of the native tympanic membrane, while it seeks to implement new therapeutic approaches that can be performed in an outpatient setting. Moreover, the creation of an artificial tympanic membrane commercially available would reduce the duration of the surgery and costs. The present review analyzes the current treatment of tympanic perforations and examines the techniques of tissue engineering, either to develop bioartificial constructs, or for tympanic regeneration by using different scaffold materials, bioactive molecules and cells. Finally, it considers the aspects regarding the design of scaffolds, release of biomolecules and use of cells that must be taken into account in the tissue engineering of the eardrum. The possibility of developing new biomaterials, as well as constructs commercially available, makes tissue engineering a discipline with great potential, capable of overcoming the drawbacks of current surgical procedures.

A Randomized, Multi-Center, Single Blind, Active-Controlled, Matched Pairs Clinical Study to Evaluate Prevention of Adhesion Formation and Safety of HyFence in Patients After Endoscopic Sinus Surgery

Objectives

Recurrent mucosal disease and anatomic obstruction are commonly cited causes of failed endoscopic sinus surgery (ESS). Hyaluronic acid (HA) has been reported to reduce scarring and to promote wound healing in sinonasal surgery. HyFence is HA stabilized by 1, 4-butandiol diglycidyl ether, which makes it less-water-soluble and highly viscoelastic. The purpose of this study is to examine the anti-adhesion effect of HyFence after ESS compared to that of HA-CMC (Guardix-Sol).

Methods

Seventy-four patients with chronic rhinosinusitis who underwent ESS were included in the study. After the ESS procedure, Merocel was placed in the ethmoidectomized areas of the both sides. Five milliliters of Guardix-Sol was then applied to the Merocel of one side and HyFence LV was applied to the other side. The effect of the agents was evaluated at one, two, and four weeks after surgery by endoscopic examination. The severity of adhesion, edema, infection and complications were evaluated.

Results

There was no significant difference in the incidence of postoperative adhesion between the HyFence group and the Guardix-Sol group (P>0.05). Mean postoperative grades of edema and infection showed no significant difference between groups (P>0.05). There was no significant postoperative complications associated with either anti-adhesion agent (P>0.05).

Conclusion

HyFence has equivalent anti-adhesion effect compared to Guardix-Sol following ESS.

Repair of tympanic membrane perforation using novel adjuvant therapies: a contemporary review of experimental and tissue engineering studies

OBJECTIVE

To perform a contemporary review of experimental studies to describe the effects of various novel adjuvant therapies in enhancing tympanic membrane (TM) perforation healing.

METHODS

A PubMed search for articles from January 2000 to June 2012 related to TM perforation, along with the references of those articles, was performed. Inclusion and exclusion criteria were applied to all experimental studies assessing adjuvant therapies to TM healing.

RESULTS

Many studies have assessed the efficacy of biomolecules or growth factors, such as epidermal growth factors and basic fibroblast growth factors, in TM regeneration with significant success. More recent strategies in TM tissue engineering have involved utilizing bioengineered scaffold materials, such as silk fibroin, chitosan, calcium alginate, and decellularized extracellular matrices. Most scaffold materials demonstrated biocompatibility and faster TM perforation healing rates.

CONCLUSION

Although several studies have demonstrated promising results, many questions still remain, such as the adequacy of animal models and long-term biocompatibility of adjuvant materials. As well, further studies comparing various adjuvant substances and bioscaffolds are required prior to clinical application.

Effects of middle ear packing with collagen polyvinylpyrrolidone and hyaluronic acid in guinea pigs

OBJECTIVE

The aim of this study was to evaluate otoscopic and microscopic changes produced on the healthy mucosa of the middle ear (ME) and tympanic membrane (TM) of guinea pigs after packing with a collagen polyvinylpyrrolidone (CPVP) sponge soaked in hyaluronic acid (HA).

MATERIAL AND METHODS

In 24 guinea pigs, myringotomy on the right side was created and the ME was packed as follows: Group I (n = 6): Absorbable gelatin sponge (AGS) soaked in saline solution; Group II (n = 6): AGS sponge soaked in HA, Group III (n = 6): CPVP sponge soaked in saline solution, Group IV (n = 6): CPVP sponge soaked in HA. Four weeks after miringotomy, the ME and TM integrity and residual packing material were evaluated otoscopically. Histologically, we evaluated inflammatory changes on the ME mucosa.

RESULTS

All animals in Groups I and II showed residual packing material (p < .001 ANOVA, TUKEY). Histologically, more inflammation was observed in Groups I, II, and III than in Group IV (p < .001 ANOVA, TUKEY). Group IV showed greater fibroblastic reaction (p < .02, ANOVA, TUKEY) versus other groups.

CONCLUSION

The CPVP sponge soaked in HA used as ME packing material is biocompatible and nontoxic, because it produces minimal inflammatory changes on the healthy mucosa of the ME and TM of guinea pigs. However, more research with injured mucosa is needed to validate its usefulness in otosurgery.

Healing of laser-induced tympanic membrane perforations in rats: no contribution of granulocyte colony-stimulating factor or Gelfoam

OBJECTIVES

To study whether granulocyte colony-stimulating factor together with Gelfoam (absorbable gelatin sponge, USP) could enhance the healing of freshly perforated tympanic membranes. The frequency and occurrence of different immunocompetent cells and collagen types was noted.

METHODS

Laser perforations were made in the tympanic membrane of rats that were sacrificed at different time intervals post-myringotomy: Day 1, 3, 6, and 12. Tympanic membrane specimens were embedded and sections were stained with hematoxylin/eosin and an immunohistochemical technique was used, with antibodies against macrophages, B-cells, T-cells, and type I-IV collagens. Semi-quantification was performed after counting positive cells, mean values were calculated and analyzed statistically.

RESULTS

All perforations, except one, had closed by Day 12 and no difference was observed between experimental and control ears at the other time points. Gelfoam was still present in a high amount at Day 12. The sections were initially stained positive for type I and II collagen, but after Day 6, the regenerating tissue stained positive for mainly type III and IV collagens. Results showed that the recruitment of macrophages, B-cells, and T-cells could not be mapped with a statistical significance.

CONCLUSIONS

This study showed that at 6-12 days post-laser myringotomy, type III and IV collagen has replaced the collagen type II that normally constitutes the healthy tympanic membrane. There is a concern for excessive scarring involving adjacent structures. It was also seen that the combination of Gelfoam and granulocyte colony-stimulating factor or saline did not affect the healing times in perforated tympanic membranes. No significant results regarding the inflammatory cell recruitment could be obtained on the studied time points or between experimental and control ears, except for in the Gelfoam matrix.

The impact of platelet-derived growth factor on closure of chronic tympanic membrane perforations: a randomized, double-blind, placebo-controlled study

OBJECTIVE

Patients with tympanic membrane (TM) perforations often have infections, and repetitive topical treatment may be required. These infections can be prevented by permanent closure of the TM perforation. Different surgical treatment options have been described, but noninvasive techniques may be preferred as they carry less risk than surgery. One noninvasive approach is to induce wound healing by application of growth factors. The effect and clinical use of applying topical platelet-derived growth factor (PDGF) for decrease of size and closure of chronic TM perforations is evaluated.

STUDY DESIGN

Prospective, randomized, placebo-controlled, double-blind study.

SETTING

Tertiary referral center.

PATIENTS

Twenty patients with chronic suppurative otitis media without cholesteatoma for more than 3 months.

INTERVENTION

Topical treatment with PDGF or placebo applied weekly to the TM for 6 weeks.

MAIN OUTCOME MEASURES

Success rate, defined as a reduction of perforation size of 50% or more to determine relative changes of the perforation size; effect of initial size and location of TM perforation on success rate; and air and bone conduction thresholds to determine air-bone gap measured before treatment.

RESULTS

Randomization made matching pretreatment perforation size of the 2 study groups impossible, and the initial rate perforation/TM was significantly smaller in the PDGF group. No difference between the 2 groups was found for perforation/TM less than 10%. However, success rate did not differ significantly between the 2 groups (power = 0.8), and the effect of PDGF was found to be small (-2%; standard deviation, ±49%). Initial size and position of the TM perforation were not significant factors determining success. Mean air-bone gap for the frequencies of 0.5, 1, 2, and 4 kHz was 22.5 dB.

CONCLUSION

The topical application of PDGF as an office treatment for chronic otitis media is not a favorable alternative to surgery.

Effect of treatment at different time intervals for traumatic tympanic membrane perforation on the closure

CONCLUSION

Treatment of traumatic tympanic membrane (TM) perforation with everted or involute edge flaps at different time intervals within 1 week after the injury did not affect the perforation closure rate and mean closure time.

OBJECTIVE

To retrospectively analyze the effect of treatment at different time intervals for traumatic tympanic membrane perforation with gelatin sponge patch and edge approximation plus gelfoam patching.

METHODS

Patients with traumatic TM perforation visited at different days since the injury for medical treatment (1, 2, 3, 4, and 5-7 days post trauma). These patients were treated with the following prominent methods of treatment: gelatin sponge patch treatment and edge approximation plus gelfoam patching. Measurement indicators were perforation closure rate and mean closure time at 3 months.

RESULTS

In the group treated with the gelatin sponge patch technique, the patients sought medical treatment at different time intervals since the injury. Accordingly, the outcome of the treatment varied in terms of the perforation closure rates achieved in different patients in this group. The respective perforation closure rates were 100%, 100%, 96%, 94%, and 89% in accordance with the time interval at which the patients were treated since the injury. The results were not significantly different when compared by statistical analysis (p > 0.05); the mean closure times in each of the different sets of cases in this group were calculated and the following values were reported: 7.1 ± 2.3, 8.2 ± 1.6, 8.7 ± 1.2, 9.2 ± 3.1, and 10.7 ± 3.9 days. On the other hand, in the edge approximation plus gelfoam patching group, the perforation closure rates were 100%, 97%, 96%, 97%, and 94%, respectively. This was in accordance with the time elapsed since the injury for the patients who visited the hospital on different days. Statistical analysis confirmed that the perforation closure rates for the different cases of this group did not have any significant difference (p > 0.05); the mean closure times were 7.6 ± 1.9, 7.9 ± 2.2, 9.2 ± 2.8, 8.5 ± 3.6, and 11.2 ± 4.1 days, respectively, indicating that differences were not significant even in terms of mean closure rates for the different cases of this group (p > 0.05).

Effects of Merogel coverage on wound healing and ostial patency in endonasal endoscopic dacryocystorhinostomy for primary chronic dacryocystitis

PURPOSE

To investigate the effects of Merogel coverage on ostial patency in endonasal endoscopic dacryocystorhinostomy (EES-DCR) for primary chronic dacryocystitis (PCD).

METHODS

In all, 260 patients with unilateral PCD were randomized into two groups: the Merogel group and the control group. All patients underwent EES-DCR. The Merogel group received Merogel covering the wound 1-2 mm around the ostium and the control group received no treatment. Patients were followed up for 9 months. The mucosal epithelialization of the wound, the proliferation of fibrosis tissue, and the success rate of ostial patency were compared.

RESULTS

Our study included 112 patients in the Merogel group and 115 patients in the control group. At the 2-week review, intact mucosal epithelium lined the ostia in 96 Merogel patients compared with 80 control patients (ITT analysis: χ(2)=4.502, P=0.034). At the 9-month review, scars were present in 18 patients in the Merogel group compared with 39 patients in the control group (ITT analysis: χ(2)=9.909, P=0.002, ITT analysis). No differences were observed in the granulation formation between the two groups. The success rate of ostial patency reached 94.6% (106/112) in the Merogel group compared with 80% (92/115) in the control group (ITT analysis: χ(2)=4.151, P=0.042).

CONCLUSION

Merogel coverage may enhance the success rate of EES-DCR for PCD by promoting mucosal epithelial healing and preventing excessive scarring.

Basic fibroblast growth factor combined with atelocollagen for closing chronic tympanic membrane perforations in 87 patients

OBJECTIVE

To present the clinical results of closing chronic tympanic membrane (TM) perforations using basic fibroblast growth factor (bFGF) combined with an atelocollagen/silicone bilayer membrane patch.

STUDY DESIGN

Closure of TM perforations in 87 patients was attempted using bFGF, which is thought to promote the regeneration of TM tissues by facilitating the growth of fibroblasts and collagen fibers.

METHODS

Under an operating microscope, the margin of the perforation was trimmed, and a piece of an atelocollagen/silicone bilayer membrane was placed in the perforation with the silicon layer facing outward and then infiltrated with 0.1 ml of trafermin. Data obtained from patient records included patient age, perforation size, and duration of treatment, with a focus on hearing improvement and complete TM closure.

RESULTS

The mean perforation size before treatment was 14.4%. Complete closure of the TM perforation was achieved in 80 patients (92.0%), whereas pinholes remained in 5 patients (8.7%), and small perforations were observed in 2 patients (2.3%). In the patients with complete closure, the TM perforations closed after an average 1.8 treatments, and hearing improved by 13.6 dB.

CONCLUSION

This study demonstrated that bFGF combined with atelocollagen is effective for the conservative treatment of TM perforation.

Acute tympanic membrane perforations and the early immunological response in rats

CONCLUSIONS

This study showed that macrophages, B cells, and T cells occurred at different frequencies, localizations, and times after acute laser tympanic membrane perforation. Immunological cells were most prevalent in the proliferative mass adjacent to the annulus region. The cellular immunological response in freshly perforated eardrums was unexpectedly aggressive.

OBJECTIVES

To study the occurrence of immunocompetent cells during the healing process of fresh perforated tympanic membranes. The information could be used to develop alternative outpatient procedures in the cure of chronic perforations, replacing conventional surgery.

MATERIALS AND METHODS

A laser myringotomy was carried out in Sprague-Dawley rats, which were sacrificed at 3 and 6 days after the myringotomy. Tympanic membrane sections were stained immunohistochemically according to the avidin-biotin method, targeting macrophages, B cells, and T cells. Semi-quantification was performed; positive cells were counted and mean values were calculated.

RESULTS

Macrophages and B cells were most frequent at day 6 and T cells at day 3 after laser myringotomy. B cells were the most prevalent studied cell type. T cells peaked at day 3, after which they decreased in number. Most immunocompetent cells were observed in the proliferative mass at the edge of the perforation.

Platelet-rich plasma improves healing of tympanic membrane perforations: experimental study

Objective:

The aim of this study was to investigate the effect of local application of platelet-rich plasma to perforated rat tympanic membranes, in terms of healing time and histopathological outcome.

Methods:

Eighty-eight tympanic membranes of 44 rats were given a standard 3 mm perforation, and platelet-rich plasma was applied to the right tympanic membrane perforations. The left tympanic membranes were left to heal spontaneously, as controls. The 44 rats were divided into two groups. In group one, comprising 20 rats, daily otomicroscopic examination of the tympanic membrane perforations was performed. The 24 rats in group two were subdivided into four subgroups of six rats each; these subgroups were sacrificed sequentially on days three, seven, 14 and 28 for histopathological examination, regardless of tympanic membrane healing stage.

Results:

In group one, the mean tympanic membrane healing times for tympanic membrane perforations receiving platelet-rich plasma and controls were respectively 10.2 ± 2.1 and 13.0 ± 2.9 days (mean ± standard deviation). This difference was statistically significant (p < 0.001). In group two, histopathological evaluation of tympanic membrane perforation healing at days three, seven, 14 and 28 did not reveal any statistically significant difference, individually or within the four groups as a whole.

Conclusion:

These findings suggest that earlier healing of tympanic membrane perforations occurred in the platelet-rich plasma group compared with the control group. These findings suggest that platelet-rich plasma is effective in accelerating tympanic membrane perforation healing, and that it may be effective in human subjects, particularly as it is an autologous material.

Stem cells and enhanced healing of chronic tympanic membrane perforation

CONCLUSIONS

Important information about the basic reparative process of tympanic membrane (TM) healing is shown, which can be incorporated for further clinical understanding. This provides a basis for the exploration of stem cell treatment for TM perforations and holds promise for future improvements.

OBJECTIVES

This study aimed to analyse the healing of TM perforation by using stem cells and the stiffness of the membrane was tested in an acute and long-term study.

MATERIALS AND METHODS

Sprague-Dawley rats were used in a model of TM perforation. The perforation was performed with a laser system. Stem cells were applied and the healing time and morphological analysis were performed with light and transmission electron microscope. Stiffness was examined by moiré interferometry.

RESULTS

The stiffness of the perforated and healed TM was restored after just 2 weeks. In the chronic perforation model, mesenchymal stem cells enhanced the healing.

Healing time, long-term result and effects of stem cell treatment in acute tympanic membrane perforation

OBJECTIVE

The incidence of otitis media in children between the age of 2 and 6 years is well documented. Repeated attacks may cause acute and chronic perforations. The surgical treatment for repairing chronic perforation is quite uncomfortable for the patients of this age group because of the invasiveness of this treatment. The aim of this study was to determine the long-term influence of embryonic stem cells on acute perforations and the effect of gelatin as a vehicle for applied stem cells. The possibility of teratogenic effects of the stem cells was also observed.

METHODS

Bilateral laser myringotomy was performed in 17 adult Sprague-Dawley rats, divided into two groups. Gelatin, a substance suitable as vehicle for bioactive material was used bilaterally around the perforation in group A, to serve as a scaffold for repairing tissue. The stem cells were used in the right tympanic membrane perforation leaving the left tympanic membrane as a control. The animals in group B received the same treatment except for the use of gelatin and in addition received an immuno-suppressive agent. After half a year of observation the mechanical stiffness of the tympanic membrane was measured by moiré interferometry for group B and the morphological study was performed by light microscopy for both groups A and B and electron microscopy for group A.

RESULTS

Stem cell treated ears did not show any enhanced healing of the perforation although a marked thickening of the lamina propria was observed compared with control group. After half a year the strength and the stiffness of the tympanic membrane was almost the same for both treated and untreated ears. No evidence of teratoma was found after half a year.

CONCLUSION

This study suggests that the stem cells stimulate the proliferation of connective tissue and fibers in the lamina propria, possibly mediated by secreted substances, although the stiffness properties do not seem to be altered. The use of gelatin does not seem to enhance the healing process of the tympanic membrane perforation.