A randomised controlled trial comparing spontaneous healing, gelfoam patching and edge-approximation plus gelfoam patching in traumatic tympanic membrane perforation with inverted or everted edges

Tunable ciprofloxacin delivery through personalized electrospun patches for tympanic membrane perforations

Approximately 740 million symptomatic patients are affected by otitis media every year. Being an inflammatory disease affecting the middle ear, it is one of the primary causes of tympanic membrane (TM) perforations, often resulting in impaired hearing abilities. Antibiotic therapy using broad-spectrum fluoroquinolones, such as ciprofloxacin (CIP), is frequently employed and considered the optimal route to treat otitis media. However, patients often get exposed to high dosages to compensate for the low drug concentration reaching the affected site. Therefore, this study aims to integrate tissue engineering with drug delivery strategies to create biomimetic scaffolds promoting TM regeneration while facilitating a localized release of CIP. Distinct electrospinning (ES) modalities were designed in this regard either by blending CIP into the polymer ES solution or by incorporating nanoparticles-based co-ES/electrospraying. The combination of these modalities was investigated as well. A broad range of release kinetic profiles was achieved from the fabricated scaffolds, thereby offering a wide spectrum of antibiotic concentrations that could serve patients with diverse therapeutic needs. Furthermore, the incorporation of CIP into the TM patches demonstrated a favorable influence on their resultant mechanical properties. Biological studies performed with human mesenchymal stromal cells confirmed the absence of any cytotoxic or anti-proliferative effects from the released antibiotic. Finally, antibacterial assays validated the efficacy of CIP-loaded scaffolds in suppressing bacterial infections, highlighting their promising relevance for TM applications.

Collagen Matrix to Restore the Tympanic Membrane: Developing a Novel Platform to Treat Perforations

Modern otology faces challenges in treating tympanic membrane (TM) perforations. Instead of surgical intervention, alternative treatments using biomaterials are emerging. Recently, we developed a robust collagen membrane using semipermeable barrier-assisted electrophoretic deposition (SBA-EPD). In this study, a collagen graft shaped like a sponge through SBA-EPD was used to treat acute and chronic TM perforations in a chinchilla model. A total of 24 ears from 12 adult male chinchillas were used in the study. They were organized into four groups. The first two groups had acute TM perforations and the last two had chronic TM perforations. We used the first and third groups as controls, meaning they did not receive the implant treatment. The second and fourth groups, however, were treated with the collagen graft implant. Otoscopic assessments were conducted on days 14 and 35, with histological evaluations and TM vibrational studies performed on day 35. The groups treated with the collagen graft showed fewer inflammatory changes, improved structural recovery, and nearly normal TM vibrational properties compared to the controls. The porous collagen scaffold successfully enhanced TM regeneration, showing high biocompatibility and biodegradation potential. These findings could pave the way for clinical trials and present a new approach for treating TM perforations.

Chitin nanofibrils modulate mechanical response in tympanic membrane replacements

The tympanic membrane (TM), is a thin tissue lying at the intersection of the outer and the middle ear. TM perforations caused by traumas and infections often result in a conductive hearing loss. Tissue engineering has emerged as a promising approach for reconstructing the damaged TM by replicating the native material characteristics. In this regard, chitin nanofibrils (CN), a polysaccharide-derived nanomaterial, is known to exhibit excellent biocompatibility, immunomodulation and antimicrobial activity, thereby imparting essential qualities for an optimal TM regeneration. This work investigates the application of CN as a nanofiller for poly(ethylene oxide terephthalate)/poly(butylene terephthalate) (PEOT/PBT) copolymer to manufacture clinically suitable TM scaffolds using electrospinning and fused deposition modelling. The inclusion of CN within the PEOT/PBT matrix showed a three-fold reduction in the corresponding electrospun fiber diameters and demonstrated a significant improvement in the mechanical properties required for TM repair. Furthermore, in vitro biodegradation assay highlighted a favorable influence of CN in accelerating the scaffold degradation over a period of one year. Finally, the oto- and cytocompatibility response of the nanocomposite substrates corroborated their biological relevance for the reconstruction of perforated eardrums.

Decellularized tympanic membrane scaffold with bone marrow mesenchymal stem cells for repairing tympanic membrane perforation

BACKGROUND

Tympanic membrane perforation (TMP) is a common disease in otology, and few acellular techniques have been reported for repairing this condition. Decellularized extracellular matrix (ECM) scaffolds have been used in organ reconstruction.

OBJECTIVE

This study on tissue engineering aimed to develop a tympanic membrane (TM) scaffold prepared using detergent immersion and bone marrow mesenchymal stem cells (BMSCs) as repair materials to reconstruct the TM.

RESULTS

General structure was observed that the decellularized TM scaffold with BMSCs retained the original intact anatomical ECM structure, with no cell residue, as observed using scanning electron microscopy (SEM), and exhibited low immunogenicity. Therefore, we seeded the decellularized TM scaffold with BMSCs for recellularization. Histology and eosin staining, SEM and immunofluorescence in vivo showed that the recellularized TM patch had a natural ultrastructure and was suitable for the migration and proliferation of BMSCs. The auditory brainstem response (ABR) evaluated after recellularized TM patch repair was slightly higher than that of the normal TM, but the difference was not significant.

CONCLUSION

The synthetic ECM scaffold provides temporary physical support for the three-dimensional growth of cells during the tissue developmental stage. The scaffold stimulates cells to secrete their own ECM required for tissue regeneration. The recellularized TM patch shows potential as a natural, ultrastructure biological material for TM reconstruction.

3D printing technology and applied materials in eardrum regeneration

Tympanic membrane perforation is a common condition in clinical otolaryngology. Although some eardrum patients can self-heal, a long period of non-healing perforation leads to persistent otitis media, conductive deafness, and poor quality of life. Tympanic membrane repair with autologous materials requires a second incision, and the sampling site may get infected. It is challenging to repair tympanic membranes while maintaining high functionality, safety, affordability, and aesthetics. 3D bioprinting can be used to fabricate tissue patches with materials, factors, and cells in a design manner. This paper reviews 3D printing technology that is being used widely in recent years to construct eardrum stents and the utilized applied materials for tympanic membrane repair. The paper begins with an introduction of the physiological structure of the tympanic membrane, briefly reviews the current clinical method thereafter, highlights the recent 3D printing-related strategies in tympanic membrane repair, describes the materials and cells that might play an important role in 3D printing, and finally provides a perspective of this field.

Janus membranes with asymmetric cellular adhesion behaviors for regenerating eardrum perforation

The tympanic membrane plays an important role in the human hearing system, which is easily perforated under unfavorable conditions, leading to loss of hearing and otitis media. Many autologous materials and artificial materials have been used to repair a perforated tympanic membrane, but these materials sometimes can cause severe hearing loss because of their adhesion to the ossicle during the healing process and the postoperative process. Herein, we report Janus membranes with asymmetric cellular adhesion behaviors for regenerating the eardrum. These Janus membranes are constructed by co-depositing a tannic acid (TA)/3-aminopropyltriethoxysilane (APTES) coating on one surface of the polypropylene microfiltration membrane. Cellular experiments indicate that the Janus membranes have good biocompatibility and asymmetric cellular adhesion properties. The repair of the tympanic membrane perforation experiment and laser Doppler vibrometer (LDV) measurements prove that the hydrophilic surface of Janus membranes repairs perforated eardrums, and meanwhile the hydrophobic surface can avoid adhering to the inner ear tissue for reducing hearing loss. The Janus membranes have good prospects in the treatment of tympanic membrane perforation.

The Dorsal Skinfold Chamber as a New Tympanic Membrane Wound Healing Model: Intravital Insights into the Pathophysiology of Epithelialized Wounds

BACKGROUND

Tympanic membrane perforations (TMPs) are a common complication of trauma and infection. Persisting perforations result from the unique location of the tympanic membrane. The wound is surrounded by air of the middle ear and the external auditory canal. The inadequate wound bed, growth factor, and blood supply lead to circular epithelialization of the perforation's edge and premature interruption of defect closure. Orthotopic animal models use mechanical or chemical tympanic membrane laceration to identify bioactive wound dressings and overcome premature epithelialization. However, all orthotopic models essentially lack repetitive visualization of the biomaterial-wound interface. Therefore, recent progress in 3D printing of customized wound dressings has not yet been transferred to the unique wound setup of the TMP. Here, we present a novel application for the mice dorsal skinfold chamber (DSC) with an epithelialized full-thickness defect as TMP model.

METHODS

A circular 2-mm defect was cut into the extended dorsal skinfold using a biopsy punch. The skinfold was either perforated through both skin layers without prior preparation or perforated on 1 side, following resection of the opposing skin layer. In both groups, the wound was sealed with a coverslip or left unclosed (n = 4). All animals were examined for epithelialization of the edge (histology), size of the perforation (planimetry), neovascularization (repetitive intravital fluorescence microscopy), and inflammation (immunohistology).

RESULTS

The edge of the perforation was overgrown by the cornified squamous epithelium in all pre-parations. Reduction in the perforation's size was enhanced by application of a coverslip. Microsurgical preparation before biopsy punch perforation and sealing with a coverslip enabled repetitive high-quality intravital fluorescence microscopy. However, spontaneous reduction of the perforation occurred frequently. Therefore, the direct biopsy punch perforation without microsurgical preparation was favorable: spontaneous reduction did not occur throughout 21 days. Moreover, the visualization of the neovascularization was sufficient in intravital microscopy.

CONCLUSIONS

The DSC full-thickness defect is a valuable supplement to orthotopic TMP models. Repetitive intravital microscopy of the epithelialized edge enables investigation of the underlying pathophysiology during the transition from the inflammation to the proliferation phase of wound healing. Using established analysis procedures, the present model provides an effective platform for the screening of bioactive materials and transferring progress in tissue engineering to the special conditions of tympanic membrane wound healing.

Endoscopic inlay cartilage and perichondrium myringoplasty for repairing large perforations in teenagers

OBJECTIVE

This study compared the long-term graft success rates and hearing outcomes of overlay-underlay and underly cartilage myringoplasty for repairing large perforations in Teenagers.

STUDY DESIGN

prospective, randomized study.

SETTING

Tertiary referral center.

METHODS

Pediatric patients older than 12 years with chronic perforations were randomly divided into two groups:intervention group (n = 39) and control group (n = 41). The graft success rate, hearing improvement, and complications were compared between the two groups.

RESULTS

A total of 80 patients were included in this study. The graft success rate was 100% in the intervention group and 95.1% in the control group at postoperative 3 months, the difference wasn't significant (P = 0.496). Also, the graft success rate was not significantly different between the two groups at 12 months postoperatively (100.0% vs 87.8%, p = 0.073). However, the difference of graft success rate was significant between the two groups at 24 months postoperatively (97.4% vs 75.6%, p = 0.012). CT examination revealed well-pneumatized middle ears 24 months after surgery in both group. However, epithelial pearls near the umbo were seen at 31 months postoperatively in one patient in the observation group.

CONCLUSIONS

Compared to the endoscopic cartilage with perichondrium composite graft underlay technique, endoscopic perichondrial graft overlay and cartilage underlay had a better long-term graft success rate and lower rate of long-term re-perforation in teenagers. However, the graft technique had no effect on hearing outcome.

Transcanal Endoscopic Cartilage and Perichondrium Graft Myringoplasty for Large Tympanic Membrane Perforations

OBJECTIVES

The objective of this study was to evaluate the outcomes following transcanal endoscopic cartilage and perichondrium double-layer myringoplasty for subtotal and total tympanic membrane (TM) perforations.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary referral center.

METHODS

Adult patients who underwent transcanal endoscopic double-layer myringoplasty for subtotal and total TM perforations between January 2015 and December 2017 were included. The graft success rate, hearing outcomes, and complications were evaluated postoperatively. Temporal bone computed tomography or magnetic resonance imaging was performed at 24 months postoperatively.

RESULTS

The mean follow-up period was 28.2 ± 6.1 (range, 24-36) months. The graft success rate was in 95.7% (45/47) at 6 months, 93.6% (44/47) at 12 months, and 87.2% (41/47) at 24 months, respectively. The mean ABG improved from 32.89 ± 5.31 dB preoperatively to 10.89 ± 4.78 dB postoperatively 12 months (p < 0.05) for subtotal perforations; from 33.41 ± 7.41 dB preoperatively to 11.45 ± 2.41 dB postoperatively 12 months (p < 0.05) for total perforations. No graft-related complications (e.g., graft lateralization, significant blunting, graft atelectasis, graft adhesions, or effusion) were encountered during the follow-up period. Postoperative temporal bone imaging revealed a pneumatized middle ear and mastoid in all cases with no evidence of cholesteatoma.

CONCLUSIONS

Transcanal endoscopic myringoplasty for large TM perforations using a double-layer perichondrium and cartilage graft is feasible with comparable rates of closure to more invasive approaches.

Comparison of long-term outcome of two endoscopic transtympanic myringoplasty without tympanomeatal flap elevating for repairing large chronic perforations

OBJECTIVE

We compare the long-term efficacy of the cartilage-perichondrium modified over-underlay technique and transtympanic underlay alone technique using endoscopic myringoplasty without tympanomeatal flap elevating for repairing large chronic perforations.

MATERIAL AND METHODS

Nine chronic large perforations with mucosal chronic otitis media were recruited and randomly allocated to endoscopic cartilage-perichondrium modified over-underlay myringoplasty (MOUM, n = 55) and endoscopic cartilage-perichondrium transtympanic underlay alone myringoplasty (TUAM, n = 54). The graft success rate, hearing gain, mean operation time and postoperative complications were compared between the groups at 6 and 24 months.

RESULTS

In total, 99 patients were finally analysed. The graft success rates 6 months after surgery between MOUM and TUAM groups were not significantly different (100.0% vs 96.0%, p = 0.484). However, the MOUM group had a significantly higher success rate 24 months after surgery than the TUAM group (93.9% vs 76.0%, p = 0.028). In addition, postoperative ABG < 10 dB was 73.5% patients in the MOUM group and 76.0% in the TUAM group, the difference wasn't significant (p = 0.953). CT examination revealed well-pneumatised middle ears 24 months after surgery in both groups, and no middle ear cholesteatoma was observed.

CONCLUSION

Endoscopic modified cartilage-perichondrium over-underlay myringoplasty without tympanomeatal flap elevating is reliable and effective for repairing large perforations. It improves the long-term graft success rate compared to the endoscopic cartilage-perichondrium transtympanic underlay alone technique. The risk for iatrogenic cholesteatoma is minimal.

Can Tissue Engineering Bring Hope to the Development of Human Tympanic Membrane?

The tympanic membrane (TM), more commonly known as the eardrum, consists of a thin layer of tissue in the human ear that receives sound vibrations from outside of the body and transmits them to the auditory ossicles. The TM perforations (TMPs) are a common ontological condition, which in some cases can result in permanent hearing loss. Despite the spontaneous healing capacity of the TM to regenerate in the majority of cases of acute perforation, chronic perforations require surgical interventions. However, the disadvantages of the surgical procedure include infection, anesthetic risks, and high failure of graft patency. The tissue engineering strategy, which includes the applications of a three-dimensional (3D) scaffold, cells, and biomolecules or a combination of them for the closure of chronic perforation, has been considered as an emerging treatment. Using this approach, emerging products are currently under development to regenerate the TM structure and its properties. This research aimed to highlight the problems with the current methods of TMP treatment, and critically evaluate the tissue engineering approaches, which may overcome these drawbacks. The focus of this review is on recent literature to critically discuss the emerging advanced materials used as a 3D scaffold in the development of a TM with cellular engineering, biomolecules, cells, and the fabrications of the TM and its pathway to the clinical application. In this review, we discuss the properties of TM and the advantages and disadvantages of the current clinical products for repair and replacement of the TM. Furthermore, we provide an overview of the in vitro and preclinical studies of emerging products over the past 5 years. The results of recent preclinical studies suggest that the tissue engineering field holds significant promise.

A Systematic Review of Nonautologous Graft Materials Used in Human Tympanoplasty

OBJECTIVES

Nonautologous graft materials may solve several dilemmas in tympanoplasty by obviating the need for graft harvest, facilitating consistent wound healing, and permitting graft placement in the clinical setting. Prior studies of nonautologous grafts in humans have shown variable outcomes. In this systematic review, we aim to 1) summarize clinical outcomes and 2) discuss limitations in the literature regarding nonautologous grafts for tympanoplasty in humans.

METHODS

A literature review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. The study size, etiology and duration of perforation, type of nonautologous graft, and postoperative closure rate were assessed.

RESULTS

The PRISMA approach yielded 61 articles, including 3,247 ears that met inclusion criteria. Studies evaluated nonautologous grafts including paper patch, gelatin sponge, growth factors, porcine small-intestinal submucosa, among others. Traumatic perforations (62.3%) were most commonly studied, whereas postinfectious perforations (31.9%) and other etiologies (5.8%) comprised a minority of cases. Acute perforations of <8 weeks duration constituted just over half of all treated ears. Overall closure rate was 82.1%, with significantly higher closure rates in acute (89.9%) versus chronic perforations (64.9%, P < .01), regardless of material. A median postoperative air-bone gap of 5.6 dB was found in the 23% of studies reporting this metric.

CONCLUSIONS

The majority of publications reviewing nonautologous materials in tympanoplasty evaluate acute or traumatic perforations, and few rigorously report hearing outcomes. Given available data, porcine submucosa and basic fibroblast growth factor may hold promise for chronic perforation closure. Future studies should report closure rates and hearing outcomes in perforations >8 weeks duration. Laryngoscope, 131:392-400, 2021.

Fibroblast Growth Factor 2-A Review of Stabilisation Approaches for Clinical Applications

Basic fibroblast growth factor (FGF)-2 has been shown to regulate many cellular functions including cell proliferation, migration, and differentiation, as well as angiogenesis in a variety of tissues, including skin, blood vessel, muscle, adipose, tendon/ligament, cartilage, bone, tooth, and nerve. These multiple functions make FGF-2 an attractive component for wound healing and tissue engineering constructs; however, the stability of FGF-2 is widely accepted to be a major concern for the development of useful medicinal products. Many approaches have been reported in the literature for preserving the biological activity of FGF-2 in aqueous solutions. Most of these efforts were directed at sustaining FGF-2 activity for cell culture research, with a smaller number of studies seeking to develop sustained release formulations of FGF-2 for tissue engineering applications. The stabilisation approaches may be classified into the broad classes of ionic interaction modification with excipients, chemical modification, and physical adsorption and encapsulation with carrier materials. This review discusses the underlying causes of FGF-2 instability and provides an overview of the approaches reported in the literature for stabilising FGF-2 that may be relevant for clinical applications. Although efforts have been made to stabilise FGF-2 for both in vitro and in vivo applications with varying degrees of success, the lack of comprehensive published stability data for the final FGF-2 products represents a substantial gap in the current knowledge, which has to be addressed before viable products for wider tissue engineering applications can be developed to meet regulatory authorisation.

Novel Use of Platelet Rich Fibrin Membrane in Transcanal Myringoplasty: A Prospective Study

Being rich in growth factors platelet rich fibrin (PRF) has been used for decades for its healing properties in cosmetic surgeries but its use in transcanal myringoplasty is a novel approach that remains unexplored. In todays era of minimally invasive surgery not only does it provide as a great alternative to conventional myringoplasty but also outshines it. It reduces post operative pain, hospital stay and unlike the conventional technique that uses termporalis fascia as a graft material, PRF myringoplasty if required can be reperformed on the same patient multiple times with minimal risk. This procedure comes as a boon for patients with recurrent graft defects because after multiple revision surgeries, temporalis fascia can be deficient and other graft materials like cartilage/perichondrium or fascia lata etc. have to be harvested surgically for myringoplasty. In PRF myringoplasty there is no upper limit in the number of times the PRF membrane can be made and also it does not entail any surgical incision for graft harvest. A prospective study involving 41 patients was conducted at Netaji Subhash Chandra Bose Medical College, Jabalpur where in the tympanic membrane perforations were repaired using PRF membrane with a successful outcome in 85.4% of the patients included in this study.

Repair of large traumatic tympanic membrane perforation using ofloxacin otic solution and gelatin sponge

Introduction

Traumatic large tympanic membrane perforations usually fail to heal and require longer healing times. Few studies have compared the healing and hearing outcomes between gelatin sponge patching and ofloxacin otic solution.

Objectives

To compare the healing outcomes of large traumatic tympanic membrane perforations treated with gelatin sponge, ofloxacin otic solution, and spontaneous healing.

Methods

Traumatic tympanic membrane perforations >50% of the entire eardrum were randomly divided into three groups: ofloxacin otic solution, gelatin sponge patch and spontaneous healing groups. The healing outcome and hearing gain were compared between the three groups at 6 months.

Results

A total of 136 patients with large traumatic tympanic membrane perforations were included in analyses. The closure rates were 97.6% (40/41), 87.2% (41/47), and 79.2% (38/48) in the ofloxacin otic solution, gelatin sponge patch, and spontaneous healing groups, respectively (p = 0.041). The mean times to closure were 13.12 ± 4.61, 16.47 ± 6.24, and 49.51 ± 18.22 days in these groups, respectively (p < 0.001).

Conclusions

Gelatin sponge patch and ofloxacin otic solution may serve as effective and inexpensive treatment strategies for traumatic large tympanic membrane perforations. However, ofloxacin otic solution must be self-applied daily to keep the perforation edge moist, while gelatin sponge patching requires periodic removal and re-patching.

Evaluating short and long term outcomes following pediatric Myringoplasty with Gelfoam graft for tympanic membrane perforation following ventilation tube insertion

Background

Myringotomy with ventilation tube (VT) insertion to treat recurrent acute otitis media and chronic secretory otitis media has become one of the most common surgical procedures performed in children. Although contemporary literature has detailed the various patient and perioperative factors that affect successful pediatric myringoplasty, there is still limited evidence surrounding the increasing number of graft material options. In particular, gelfoam patching has arisen as a simple and efficient modality for perforation closure, but has a paucity of evidence particularly in pediatric cohorts. Our study aims to evaluate the clinical and audiometric outcomes following gelfoam myringoplasty for TMP following prolonged VT insertion in an urban pediatric population.

Methods

A retrospective review of pediatric patients who underwent myringoplasty between 2013 and 2018 following ventilation tube insertion. Patient demographics, comorbidities, and graft material were correlated with audiometric and clinical outcomes on follow up examination.

Results

One hundred twenty patients underwent myringoplasty, with 61 (50.8%) males with a mean age of 8.9 years old. 101 (84.2%) of patients eventually underwent successful tympanic membrane (TM) closure, with 93 (77.5%) demonstrating closure at initial follow up. In the gelfoam cohort, 77 (90.6%) of patients demonstrated successful TM closure at initial follow up. Overall mean time to closure was 5.6 (standard error (SE) 0.9) months. A multivariate Cox proportional hazards model demonstrated none of the covariates including graft material significantly affected TM closure. Mean change in air conduction threshold were comparable between graft materials.

Conclusions

Pediatric myringoplasty with gelfoam graft material is a safe and viable alternative with favorable short and long term clinical and audiometric outcomes.

Comparison of the medical costs and effects of large traumatic eardrum perforations treatment

OBJECTIVE

We investigated the medical costs and effects of ofloxacin drops (OFLX), gelatin sponge patches, spontaneous healing, and endoscopic myringoplasty on healing in large tympanic membrane perforations (TMPs).

METHODS

In total, 100 patients with large traumatic TMPs involving >50% of the eardrum were randomly assigned to OFLX, gelatin sponge, spontaneous healing, or endoscopic myringoplasty treatment groups. Medical costs, closure times, and closure rates were compared among groups at 6 months.

RESULTS

The closure rates in the OFLX, gelatin sponge, spontaneous healing, and endoscopic myringoplasty groups were 95.7%, 82.6%, 58.3%, and 91.7%, respectively (P = 0.05). The mean closure time was 13.73 ± 6.14 days in the OFLX group, 15.89 ± 4.95 days in the gelatin sponge group, 48.36 ± 10.37 days in the spontaneous healing group, and 12 days in the endoscopic myringoplasty group (P < 0.001). The mean medical costs in US dollars were $15.53 ± 3.15, $103.64 ± 111.58, $11.17 ± 1.33, and $715.90 in the OFLX, gelatin sponge, spontaneous healing, and endoscopic myringoplasty groups, respectively (P < 0.001).

CONCLUSION

Although the gelatin sponge and myringoplasty treatments significantly shortened the closure time compared with spontaneous healing, the gelatin sponge patch did not significantly improve the closure rate, and the medical cost of myringoplasty was significantly higher than that of the other treatments. In contrast, OFLX significantly shortened closure time and had a higher closure rate than spontaneous healing, and the medical costs were lower than those of the gelatin sponge and myringoplasty procedures.

Pretreatment factors affecting traumatic tympanic membrane regeneration therapy using epidermal growth factor

OBJECTIVE

The use of epidermal growth factor (EGF) to achieve closure of human traumatic tympanic membrane perforations (TMPs) was recently reported. However, pretreatment factors affecting healing outcomes have seldom been discussed. This study was performed to evaluate pretreatment factors contributing to the success or failure of TMP healing using EGF.

DESIGN AND PARTICIPANTS

This was a retrospective cohort study of 95 TMPs who were observed for at least 6 months after EGF treatment. Eleven factors considered likely to affect healing outcome were evaluated by univariate and multivariate logistic regression analyses.

INTERVENTIONS

Each traumatic TMP was treated by daily topical application of EGF. The main outcome measures were complete closure versus failure to close and mean closure time.

RESULTS

A total of 95 patients were included in the analyses. The total closure rate was 92.6% at 6 months, and the mean closure time was 10.5 ± 4.8 days. The closure rate was not significantly different according to the duration of perforation ≤3 days and >3 days (P = 0.816). However, the mean closure time was significantly different according to the duration of perforation (P < 0.001). The perforation size did not affect the closure rate (P = 0.442). The mean closure time in the low-dose EGF group was significantly shorter than that in the high-dose EGF group (P = 0.001). Logistic regression analyses showed that perforations with preexisting myringosclerosis were more likely to fail to close compared to those without preexisting myringosclerosis (P = 0.001). Multivariate logistic regression analyses showed that the duration of perforation (P = 0.011), size of perforation (P < 0.001), and involvement of the malleus in perforation (P = 0.005) were factors independently correlated with closure time.

CONCLUSIONS

Daily application of EGF can be used to treat all traumatic TMPs. The size of the perforation and inverted edges did not affect the closure rate, and the most beneficial dosage was sufficient to keep the eardrum moist. Multivariate logistic regression analyses revealed a significant correlation between preexisting myringosclerosis and failure to heal. Nevertheless, the size of perforation, starting time of application, and malleus injury were independent prognostic factors for prolonged healing time.

Endoscopic observation of different repair patterns in human traumatic tympanic membrane perforations

Introduction

In the last decade, there has been an increasing use of biomaterial patches in the regeneration of traumatic tympanic membrane perforations. The major advantages of biomaterial patches are to provisionally restore the physiological function of the middle ear, thereby immediately improving ear symptoms, and act as a scaffold for epithelium migration. However, whether there are additional biological effects on eardrum regeneration is unclear for biological material patching in the clinic.

Objective

This study evaluated the healing response for different repair patterns in human traumatic tympanic membrane perforations by endoscopic observation.

Methods

In total, 114 patients with traumatic tympanic membrane perforations were allocated sequentially to two groups: the spontaneous healing group (n = 57) and Gelfoam patch-treated group (n = 57). The closure rate, closure time, and rate of otorrhea were compared between the groups at 3 months.

Results

Ultimately, 107 patients were analyzed in the two groups (52 patients in the spontaneous healing group vs. 55 patients in the Gelfoam patch-treated group). The overall closure rate at the end of the 3 month follow-up period was 90.4% in the spontaneous healing group and 94.5% in the Gelfoam patch-treated group; the difference was not statistically significant (p > 0.05). However, the total average closure time was significantly different between the two groups (26.8 ± 9.1 days in the spontaneous healing group vs. 14.7 ± 9.1 days in the Gelfoam patch-treated group, p < 0.01). In addition, the closure rate was not significantly different between the spontaneous healing group and Gelfoam patch-treated group regardless of the perforation size. The closure time in the Gelfoam patch-treated group was significantly shorter than that in the spontaneous healing group regardless of the perforation size (small perforations: 7.1 ± 1.6 days vs. 12.6 ± 3.9, medium-sized perforations: 13.3 ± 2.2 days vs. 21.8 ± 4.2 days, and large perforations: 21.2 ± 4.7 days vs. 38.4 ± 5.7 days; p < 0.01).

Conclusion

In the regeneration of traumatic tympanic membrane perforations, Gelfoam patching not only plays a scaffolding role for epithelial migration, it also promotes edema and hyperplasia of granulation tissue at the edges of the perforation and accelerates eardrum healing.

Efficacy of EGF and Gelatin Sponge for Traumatic Tympanic Membrane Perforations: A Randomized Controlled Study

OBJECTIVE

To compare the outcomes of epidermal growth factor (EGF) and gelatin sponge patch treatments for traumatic tympanic membrane perforations.

STUDY DESIGN

Prospective, randomized, controlled.

SETTING

University-affiliated teaching hospital.

SUBJECTS AND METHODS

In total, 141 perforations encompassing >50% of the eardrum were randomly divided into 3 groups: EGF (n = 47), gelatin sponge patch (n = 47), and observation (n = 47). The edges of the perforations were not approximated. The closure rate, mean closure time, and infection rate were evaluated at 6 months and the related factors analyzed.

RESULTS

A total of 135 perforations were analyzed. At 6 months, the closure rates were 97.8%, 86.7%, and 82.2% in the EGF, gelatin sponge patch, and spontaneous healing groups, respectively (P = .054). The mean ± SD closure time was 11.12 ± 4.60, 13.67 ± 5.37, and 25.65 ± 13.32 days in the EGF, gelatin sponge patch, and spontaneous healing groups, respectively (P < .001). In addition, the presence of infection was not significantly associated with rate of closure in any group.

CONCLUSIONS

As compared with spontaneous healing, daily application of EGF and gelatin sponge patching reduced the closure time of traumatic tympanic membrane perforations. EGF treatment had a higher closure rate and shorter closure time but resulted in otorrhea. By contrast, gelatin sponge patches did not improve the closure rate or cause otorrhea but required repeated patch removal and reapplication. Thus, the appropriate treatment should be selected according to patient need.

Chitosan/PEI patch releasing EGF and the EGFR gene for the regeneration of the tympanic membrane after perforation

EGF and EGFR gene-releasing PEI/chitosan patch (EErP-CPs) was developed to increase the regeneration of tympanic membrane perforations.

Application of Platelet Rich Fibrin Matrix to Repair Traumatic Tympanic Membrane Perforations: A Pilot Study

Trauma in the form of instrumentation, slap, blast, accident, and sporting injury can result in tympanic membrane (TM) perforations which spontaneously recover in 53-94%. The closure rates of TM perforation due to above causes do not vary greatly; however, some otolaryngologists prefer to perform immediate microsurgical procedures to accelerate the recovery process. Our aim is to study the efficacy of Trichloroacetic acid (TCA) Chemical Cauterization (50%) and Platelet rich fibrin (PRF) Plug Myringoplasty technique in healing traumatic tympanic membrane perforations. To evaluate the preoperative and postoperative hearing outcome from the procedure and compare them. Study design is prospective study. A pilot study was carried out amongst selected 25 patients with central perforations in the Department of ENT, for duration of 2 years from July 13 to July 15. All 25 patients underwent PTA assessment & TCA (50%) and Autologous PRF Plug Myringoplasty technique done and follow up to 6 months postoperatively. The success rate traumatic tympanic membrane closure was found to be 92%. Pre- and post-operative hearing assessments of each patient were done & showed statistically significant air-bone gap closure with success rate of 88% (p < 0.05). From this study, the closure rate in traumatic tympanic membrane perforation by TCA (50%) and PRF Plug Myringoplasty technique was 92% with statistically significant hearing improvement (88%). This technique can be recommended as a time and cost effective office based procedure for treatment of traumatic tympanic membrane perforations.

Identification and management of inverted or everted edges of traumatic tympanic membrane perforations

Introduction

Most of traumatic tympanic membrane perforations have inverted or everted edges, however, the effects of inverted and everted edges on the spontaneous healing of the eardrum remain controversial.

Objective

We investigated the influence of inverted or everted edges on the spontaneous healing of traumatic tympanic membrane perforations.

Methods

The clinical records of patients with a traumatic tympanic membrane perforations who met the study criteria were retrieved and categorized into two groups, based on whether the eardrum was inverted or everted. The features along the edge of each inverted or everted eardrum were described using 30° and 70° endoscopes.

Results

In total, 196 patients (196 ears) met the inclusion criteria; of these, 148 had inverted or everted eardrums while 48 did not. Of the 148 patients with inverted or everted eardrums, the perforation edges were everted in 77 patients, inverted in 44 patients, drooping in 17 patients, and both inverted and everted in 10 patients. The perforation shape was triangular in 18.9% of patients, sector-shaped in 11.5%, kidney-shaped in 14.2%, ovoid in 20.3%, and irregularly shaped in 35.1% of patients. The difference was not significant between the with and without inverted/everted eardrum edges groups in terms of the closure rate or closure time. Similarly, the difference was not significant between the with and without edge approximation groups in terms of the closure rate or closure time at the end of the 12-month follow-up period.

Conclusion

This study suggests that endoscopic inspection can clearly identify inverted/everted eardrum edges using 30° and 70° endoscopes. The edge is glossy in inverted/everted eardrums, whereas the edge is rough and irregular in non-inverted/everted cases. The inverted/everted eardrums gradually became necrotic, but this did not affect the healing process. Additionally, edge approximation did not improve the healing outcome of traumatic tympanic membrane perforations.

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.

The effects of fibroblast growth factor-2 delivered via a Gelfoam patch on the regeneration of myringosclerotic traumatic eardrum perforations lying close to the malleus

OBJECTIVE

We evaluated the effects of fibroblast growth factor-2 (FGF-2) delivered via a Gelfoam patch on the regeneration of myringosclerotic traumatic tympanic membrane perforations (TMPs) lying close to the malleus.

STUDY DESIGN

A prospective, randomized, controlled clinical study.

SETTING

A university-affiliated teaching hospital.

SUBJECTS AND METHODS

We prospectively analyzed, in a randomized manner, the outcomes of treatment for traumatic TMPs constituting >25% of the tympanic membrane. The closure rates, closure times, and otorrhea rates were compared among patients treated via FGF-2-containing Gelfoam patches, Gelfoam patches alone, and observation only.

RESULTS

We analyzed data from 138 patients. The perforation closure rates in the FGF-2 plus Gelfoam patch, Gelfoam patch, and observation alone groups were 97.9, 89.8, and 70.7%, respectively. Both the FGF-2 plus Gelfoam and Gelfoam alone groups exhibited significantly higher closure rates than the observational group (both p<0.05).The mean closure times were 15.7±5.1, 24.8±4.9, and 35.7±9.2days in the FGF-2 plus Gelfoam patch, Gelfoam patch alone, and observation alone groups, respectively. The FGF-2 plus Gelfoam patch group exhibited a significantly shorter closure time than the Gelfoam patch alone and observation alone groups (p<0.05). The incidences of purulent otorrhea were 14.6, 6.1, and 4.9% in the FGF-2 plus Gelfoam patch, Gelfoam patch alone, and observation alone groups, respectively. Surprisingly, 7 of 7 (100.0%) perforations associated with purulent otorrhea completely closed in the FGF-2 plus Gelfoam patch group; however, no such perforation healed in either the Gelfoam alone or observation alone group.

CONCLUSIONS

FGF-2 plus Gelfoam patching significantly shortened the closure time compared to observation and Gelfoam patching alone, and it significantly improved the closure rate (compared to observation alone) of myringosclerotic perforations lying close the malleus. FGF-2 plus Gelfoam patching is a valuable, minimally invasive alternative treatment that may be readily applied to outpatient settings.

Assessment and spontaneous healing outcomes of traumatic eardrum perforation with bleeding

OBJECTIVE

This study investigated the influence of the degree of bleeding from the remnant eardrum on the spontaneous healing of human traumatic tympanic membrane perforations (TMPs).

STUDY DESIGN

A case series with chart review.

SETTING

A tertiary university hospital.

MATERIALS AND METHODS

The clinical records of traumatic TMP patients who met the case selection criteria were retrieved and categorized into two groups based on the documented degree of bleeding from the remnant eardrum: with and without bleeding. The demographic data and spontaneous healing outcomes (i.e., healing rate and duration) of these two TMP types were analyzed using the chi-squared test or t-test.

RESULTS

One-hundred and eighty-eight cases met the inclusion criteria and were analyzed. Of these, 58.5% had perforations without bleeding and the remaining 41.5% had perforations with bleeding. The overall closure rate at the end of the 3-month follow-up period was 90.9% for perforations without bleeding and 96.2% for perforations with bleeding; the difference was not statistically significant (P>0.05). However, the average closure time differed significantly between the two groups (P<0.05): 29.4±3.7days for perforations without bleeding and 20.6±9.2days for perforations with bleeding. The closure rate was significantly different between the groups (62 vs. 15.6%, P<0.01) within 2weeks for medium-sized perforations. In total, 11 (39.3%) large-sized perforations achieved complete closure in the group with bleeding, while none of the large-sized perforations closed in the group without bleeding within 2weeks. The closure rate of medium-sized perforations was not significantly different (79.2 vs. 92%, P>0.05) between the groups without and with bleeding within 4weeks, while the closure rate of large-sized perforations was significantly different between the groups without and with bleeding (27.2 vs. 75%, P=0.0).

CONCLUSION

This study shows that traumatic TMPs with bleeding significantly shortened the closure time compared to TMPs without bleeding. This finding indicates a significant correlation between the prognosis of traumatic TMPs and the degree of eardrum bleeding: severe bleeding from and a hematoma in the remnant eardrum appear to be good signs.

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.

Analysis of Effect of Eggshell Membrane Patching for Moderate-to-Large Traumatic Tympanic Membrane Perforation

Background and Objectives

To evaluate the effect of eggshell membrane (ESM) patching for tympanic membrane (TM) perforation, and to investigate correlations between healing time and age, gender, patching time, perforation size, and perforation location.

Subjects and Methods

One hundred and seventy-five patients diagnosed with traumatic TM perforation at the Department of Otorhinolaryngology-Head and Neck Surgery, Korea University Ansan Hospital, between January 2008 and October 2013. Patients were divided into two groups, according to perforation edge approximation or ESM patching treatment. Healing time was compared between the group that received perforation edge approximation and the group that received ESM patching. Perforation grade, age, onset, and location were also compared between the two groups.

Results

ESM patching significantly improved healing time compared to spontaneous healing, especially in patients with moderate or large traumatic TM perforations (≥grade II). However, patient age, gender, perforation location, and especially timing of procedure, did not significantly affect healing time.

Conclusions

ESM patching can be a good treatment choice to promote tympanic membrane healing in large traumatic TM perforations.

Fibrinogen-Based Collagen Fleece Graft Myringoplasty for Traumatic Tympanic Membrane Perforation

Background and Objectives

The aim of this study was to investigate how fibrinogen-based collagen fleece (Tachocomb®) graft myringoplasty (FCGM), performed under microscopic guidance, improves both hearing and tympanic membrane tissue repair in patients with traumatic tympanic membrane perforation (TMP).

Subjects and Methods

Between August 2009 and March 2015, a total of 52 patients with traumatic TMP visited the department of otorhinolaryngology at a secondary medical center. Twenty-nine of these underwent FCGM under microscopic guidance in our outpatient clinic. For each patient, we recorded the location and size of the perforation, the time elapsed from the onset of TMP until the myringoplasty, and the hearing level both before and after myringoplasty.

Results

The TMP closed completely in all cases (29 of 29 patients). After myringoplasty, the postoperative air-bone gap (ABG) differed significantly from the preoperative ABG. Three of the 29 patients (10.3%) experienced complications. Specifically, 2 presented with otorrhea after FCGM, but conservative management led to improvement without recurrence of perforation. One patient showed delayed facial palsy 1 week after the procedure. The condition of this patient also improved and the palsy was not permanent.

Conclusions

FCGM may be an effective treatment option in case of traumatic TMP. The procedure requires no hospitalization, and can be used to avoid traditional tympanoplasty.

Use of a platelet-rich fibrin membrane to repair traumatic tympanic membrane perforations: a comparative study

OBJECTIVES

(1) To evaluate the effects of a platelet-rich fibrin (PRF) membrane in the repair of traumatic tympanic membrane (TM) perforations; and (2) to compare the use of a PRF membrane with the paper patch technique with regard to recovery rates, healing time, and correction of the mean air-bone gap.

METHODS

A randomized, prospective analysis was performed for 60 patients who were treated for traumatic TM perforations using one of the two methods. Closure rate, speed of healing, and hearing gain were compared between the PRF (Group 1) and paper patch (Group 2) groups.

RESULTS

Closure was obtained in 28 (93%) perforations in Group 1 and 25 (83%) perforations in Group 2 (p > 0.05). On day 10, full closure of the TM was observed in 24 (80%) patients in Group 1 and 16 (53%) patients in Group 2 (p < 0.05). The improvement in the mean air-bone gap was 14.1 dB in Group 1 and 12.4 dB in Group 2 on post-operative day 45 (p < 0.05).

CONCLUSIONS

In comparison with the paper patch method, PRF, a new method, provided more rapid healing with more successful audiological results, and with no requirement for a second procedure.

Comparative study on the effects of EGF and bFGF on the healing of human large traumatic perforations of the tympanic membrane

OBJECTIVES/HYPOTHESIS

We evaluated the effects of epidermal growth factor (EGF) and basic fibroblast growth factor (bFGF) on the healing of large traumatic tympanic membrane perforations (TMPs).

STUDY DESIGN

Prospective clinical study.

SETTING

Tertiary university hospital.

METHODS

A randomized, prospective analysis was performed between June 2013 and August 2014 on the treatment of traumatic TMPs larger than 25% of the TM. Closure rate, closure time, hearing gain, and rate of otorrhea were compared between EGF and bFGF groups, as well as to an observation-only group.

RESULTS

Final analysis was performed on 86 patients at 3 months. The closure rates of perforation in the EGF, bFGF, and observation groups were 86.2%, 89.3%, and 72.4%, respectively. The closure rates in the EGF and bFGF groups were 14% to 17% higher than in the observation group, although the difference was not statistically significant for the total closure rate among the three groups (P = 0.200). The average closure time was significantly longer (P < 0.01) in the observation group than in the EGF and bFGF groups. However, the closure times in the EGF and bFGF groups were not significantly different (P = 0.92). In addition, differences in purulent otorrhea rates among the groups were not statistically significant (P = 0.82).

CONCLUSIONS

Both EGF and bFGF can accelerate the closure of human large traumatic TMPs. The healing outcomes among the two growth factors were not significantly different.

Evaluation of the optimum time for direct application of fibroblast growth factor to human traumatic tympanic membrane perforations

OBJECTIVE

The aim of this study was to determine the optimum time for direct application of basic fibroblast growth factor (bFGF) on large traumatic tympanic membrane perforations (TMPs).

STUDY DESIGN

Prospective clinical study.

SETTING

Tertiary University Hospital.

METHODS

Ninety-three patients, with traumatic TMPs greater in extent than 25% of the entire tympanic membrane, were randomized into observation and bFGF-treated groups (~0.2-0.25 mL of bFGF solution was applied directly onto the TM once daily and continued until the perforation closed). Initial visit times were subcategorized into perforation durations of ≤3 and >3 days, thereby rendering two subgroups, as follows: A and B in the observation group; and C and D in the bFGF-treated group. The closure rate and mean closure time were evaluated after 6 months.

RESULTS

Eighty-six patients were finally analyzed. After 6 months, the bFGF-treated group exhibited a significantly higher total closure rate (97.8 versus 82.5%, p < 0.05) and a shorter mean closure time (12.5 ± 3.4 versus 34.0 ± 5.9 days, p < 0.05) compared with the spontaneous healing group. In addition, in the observation group, visiting time was not associated with differences in closure rate (p > 0.05) and mean closure time (p > 0.05), between the A and B subgroups. Similarly, in the bFGF-treated group, visiting time was not associated with differences in closure rate (p > 0.05) between the C and D subgroups. However, the D subgroup was characterized by significantly shortened mean closure time compared with the C subgroup (p < 0.05).

CONCLUSIONS

This study shows the beneficial effect of bFGF on human traumatic large TMPs when applied after the 3rd day post-injury had passed (i.e. during the proliferative stage of wound healing). The procedure can not only significantly shorten closure time but can also reduce both the clinical administration duration and occurrence of side-effects associated with bFGF.

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.

Risk factors affecting human traumatic tympanic membrane perforation regeneration therapy using fibroblast growth factor-2

OBJECTIVE

The use of growth factors to achieve closure of human traumatic tympanic membrane perforations (TMPs) has recently been demonstrated. However, pretreatment factors affecting healing outcomes have seldom been discussed. The objective of this study was to evaluate pretreatment factors contributing to the success or failure of healing of TMPs using fibroblast growth factor-2 (FGF-2).

DESIGN AND PARTICIPANTS

A retrospective cohort study of 99 patients (43 males, 56 females) with traumatic TMPs who were observed for at least 6 months after FGF-2 treatment between March 2011 and December 2012. Eleven factors considered likely to affect the outcome of perforation closure were evaluated statistically using univariate and multivariate logistic regression analysis.

INTERVENTIONS

Each traumatic TMP was treated by direct application of FGF-2.

MAIN OUTCOME MEASURES

Complete closure versus failure to close.

RESULTS

In total, 99 patients were analyzed. The total closure rate was 92/99 (92.9%) at 6 months; the mean closure time was 10.59 ±  6.81 days. The closure rate did not significantly differ between perforations with or without inverted edges (100.0% vs. 91.4%, p = 0.087), among different size groups (p = 0.768), or among different periods of exposure to injury (p = 0.051). However, the closure rate was significantly different between the high- and low-dose FGF-2 groups (85.0% vs. 98.3%, p = 0.010) and between perforations where the umbo or malleus was or was not involved in perforation (85.4% vs. 98.3%, p = 0.012). Additionally, univariate logistic regression analysis tests showed that it was difficult to achieve healing of these perforations with a history of chronic otitis media or residual TM calcification (p = 0.006), the umbo or malleus was involved in perforation (p = 0.038), and with a high dose of FGF-2 (p = 0.035) compared with control groups. Multivariate logistic regression analysis showed that only a history of chronic otitis media and residual TM calcification and perforation close to the umbo or malleus were associated with non-healing of the TM perforation (p = 0.03 and p = 0.017, respectively) with relative risk factors.

CONCLUSIONS

Direct application of FGF-2 can be used in all traumatic TMPs, the size of the perforation and inverted edges did not affect the closure rate, and the most beneficial dose was sufficient to keep the residual eardrum environment moist, but without adding liquid. Additionally, multivariate logistic regression analysis revealed that a large perforation was not a major risk factor for nonhealing of TM perforations. However, a history of chronic otitis media, residual TM calcification and involvement of the umbo or malleus in perforation were significant risk factors.

Effects of basic fibroblast growth factor dose on traumatic tympanic membrane perforation

OBJECTIVE

To compare the healing outcomes of higher and lower doses of basic fibroblast growth factor (bFGF) on human traumatic tympanic membrane perforation (TMP).

STUDY DESIGN

Prospective clinical study.

METHODS

All patients with traumatic TMP were treated by direct application of bFGF, and were sequentially allocated into one of two groups: lower-dose group (2-3 drops of bFGF solution daily, approximately 0.1-0.15 mL) and higher-dose group (5-6 drops of bFGF solution daily, approximately 0.25-0.3 mL). The results of closure rate, closure time, and rate of otorrhea between the higher- and lower-dose groups were compared at 3 months.

RESULTS

In total, 126 patients were included in this study. The higher-dose group showed significantly improved purulent otorrhea rate compared with the lower-dose group (p < 0.01) for perforations of the same size, although the closure rate of the middle-sized perforations did not differ significantly between higher- and lower-dose groups (p > 0.05). However, the lower-dose group had a significantly shorter closure time of 5 d compared with the higher-dose group (p < 0.05). In addition, although the lower-dose group showed shorter healing times (about 3 d) compared to the higher-dose group for large-sized perforations, the dosage of bFGF did not significantly affect the large-sized perforation closure rate (p > 0.05) or closure time (p > 0.05). Nine large-sized perforations with secondary purulent otorrhea achieved complete closure, with closure times of 7-25 (14.2 ± 5.8) d.

CONCLUSION

This study suggested that continued daily application of a lower dose of bFGF not only shortens the closure time of human traumatic TMP but also avoids secondary purulent otorrhea.

Healing outcomes of large (>50%) traumatic membrane perforations with inverted edges following no intervention, edge approximation and fibroblast growth factor application; a sequential allocation, three-armed trial

OBJECTIVE

The goal of this study was to evaluate the effects of perforation edge approximation and direct application of basic fibroblast growth factor (bFGF) each alone on the healing of large traumatic tympanic membrane perforations with inverted edges in humans.

STUDY DESIGN

Prospective, sequential allocation, three-armed, controlled clinical study.

SETTING

University-affiliated teaching hospital.

PARTICIPANTS

Fifty-eight patients with large traumatic tympanic membrane perforations (i.e. affecting >50% of the surface area) with inverted edges were recruited. They were sequentially allocated to three groups: no intervention (n = 18), edge approximation alone (n = 20) and direct application of bFGF (n = 20). Otoscopy were performed before the treatment and at follow-up visits.

MAIN OUTCOME MEASURES

The closure rate, closure time and rate of otorrhoea.

RESULTS

Application of bFGF yielded a significantly higher average rate of perforation closure (100%) than edge approximation (60%) and no intervention (56%) (P < 0.05). It also significantly shortened the average closure time (12.4 ± 3.6 days) as compared to edge approximation (46.3 ± 8.7 days) and no intervention control (48.2 ± 5.3 days) (P < 0.05). Purulent otorrhoea was observed in none of the three groups.

CONCLUSION

Edge approximation of inverted edges has little benefit in improving the healing outcome of large traumatic tympanic membrane perforations and thus is not an ideal treatment option for large traumatic tympanic membrane perforations. Application of bFGF materially improves the closure rate of large traumatic tympanic membrane perforations and significantly shortens the closure time.