Natural History of Tympanic Membrane Retraction in Children with Cleft Palate

Cephalometric analysis in adults with tympanic membrane atelectasis

OBJECTIVE

This study aims to examine craniofacial morphology (CFM) with cephalometric radiographs in adults with tympanic membrane atelectasis (TMA).

METHODS

A total of 50 patients (study group) were included and standardized lateral and anteroposterior cephalograms were performed. The control group consisted of 50 patients. Anteroposterior cephalograms were compared with the normative data.

RESULTS

A significant increase in vertical and decrease in horizontal linear measurements were observed in lateral and anteroposterior cephalograms respectively. Except for the facial axis, the angular measurements were not statistically significant.

CONCLUSION

Cephalometric data indicate a narrow and elongated but nearly proportional CFM for patients with TMA.

Relevance of cleft palatal width in short-term otologic outcomes

OBJECTIVE

Children with cleft palate are at increased risk for Eustachian tube dysfunction (ETD) and conductive hearing loss from chronic otitis media. While it has been proposed that the severity of ETD is related to the severity of cleft palate, data are lacking to support this hypothesis. An improved understanding of the relevance of cleft width may have prognostic value that could inform decisions on the timing of tympanostomy tube placement and choice of tympanostomy tube design. The objective of this study was to assess severity of ETD in children with narrow, moderate, and wide cleft palate, with examination of hearing outcomes, number of tympanostomy procedures, and incidence of otologic complications.

METHODS

Retrospective chart review was conducted on 58 patients with primary palatoplasty performed at a single academic medical center from January 1, 2016-December 31, 2019. The primary outcome was the number of otologic procedures performed after the initial palatoplasty. Secondary outcomes included audiometric findings, number of tympanostomy tube placements, presence of effusion at the time of myringotomy, and occurrence of any postoperative otologic complication. Outcomes were compared for patients with narrow (<10 mm), moderate (10-15 mm), and wide (>15 mm) cleft palate. Analysis included consideration of cleft palatal morphology (Veau I - IV), presence of Robin sequence or syndromes, and risk factors for otitis media.

RESULTS

Patients with moderate and wide cleft palate underwent higher mean numbers of otologic procedures [narrow: 1.3 (95% confidence interval [CI] 0.9, 1.7); moderate: 1.6 (95% CI 1.1, 2.1); wide: 1.8 (95% CI 1.2, 2.4)]. Moderate and wide cleft palate were less likely to have normal hearing after their first tympanostomy (narrow: 50%, 10/20; moderate: 25%, 6/24; wide: 36%, 5/14). Patients with a wide cleft palate had a shorter median time between first and second tympanostomy procedures (median, IQR; narrow: 27.0, 20.8-35.7; moderate 20.4, 16.3-25.9; wide 17.3, 11.5-23.4).

CONCLUSION

Our findings suggest that patients with wider cleft palate may be more susceptible to severe ETD. Further large-scale study may help to allow for more informed and personalized clinical decision making for management of cleft palate, incorporating cleft width for prognosis of risks for persistent middle ear dysfunction.

Radiological and audiological predictors of stapes destruction in adherent pars tensa

PURPOSE

Progressive adherent pars tensa occasionally induces ossicular erosion. Specifically, stapes discontinuity adversely affects postoperative hearing. However, this irretrievable sequela is challenging to prove preoperatively, partly because perimatrix inflammation on the pars tensa can obscure the visibility of the ossicles or the partial volume effect of computed tomography (CT) imaging can hamper detailed ossicular visualization. Therefore, there is no consensus regarding the ideal timing for switching from a wait-and-see approach to a surgical one. Herein, we aimed to explore the potential predictors of stapes superstructure destruction in adherent pars tensa.

METHODS

This retrospective cohort study enrolled consecutive patients who underwent primary tympanoplasty for adherent pars tensa categorized as grade IV on Sadé's grading scale between April 2016 and September 2021. The impact of features on otoscopy and CT and air-bone gap (ABG) on stapes superstructure destruction was assessed using uni- and multivariable logistic regression analyses.

RESULTS

Sixty-four ears were included. Multivariate analysis revealed the presence of debris on the adherent pars tensa (odds ratio [OR] [95% confidence interval {CI}]): 4.799 [1.063-21.668], p = 0.0415), presence of soft-tissue density occupying the oval window (OR [95% CI]: 13.876 [3.084-62.437], p = 0.0006), and a ≥ 20-dB preoperative ABG at 3 kHz (OR [95% CI]: 7.595 [1.596-36.132], p = 0.0108) as independent predictors for stapes superstructure destruction.

CONCLUSION

High preoperative awareness of the possibility of destruction of the stapes superstructure would enable the surgeon to make a timely decision to provide surgical intervention before progression to severe stapes destruction, thereby maintaining long-term satisfactory hearing.

Management of tympanic membrane retractions: a systematic review

Importance

Tympanic membrane retraction (TMR) is a relatively common otological finding. However, no consensus on its management exists. We are looking especially for a treatment strategy in the military population who are unable to attend frequent follow-up visits, and who experience relatively more barotrauma at great heights and depths and easily suffer from otitis externa from less hygienic circumstances.

Objective

To assess and summarize the available evidence for the effectiveness of surgical interventions and watchful waiting policy in patients with a tympanic membrane retraction.

Evidence review

The protocol for this systematic review was published at Prospero (207859). PubMed, Embase, and the Cochrane Database of Systematic Reviews were systematically searched from inception up to September 2020 for published and unpublished studies. We included randomized trials and observational studies that investigated surgical interventions (tympanoplasty, ventilation tube insertion) and wait-and-see policy. The primary outcomes of this study were clinical remission of the tympanic membrane retraction, tympanic membrane perforations and cholesteatoma development.

Findings

In total, 27 studies were included, consisting of 1566 patients with TMRs. We included data from 2 randomized controlled trials (76 patients) and 25 observational studies (1490 patients). Seven studies (329 patients) investigated excision of the TMR with and without ventilation tube placement, 3 studies (207 patients) investigated the wait-and-see policy and 17 studies (1030 patients) investigated tympanoplasty for the treatment of TMRs.

Conclusions and relevance

This study provides all the studies that have been published on the surgical management and wait-and-policy for tympanic membrane retractions. No high level of evidence comparative studies has been performed. The evidence for the management of tympanic membrane retractions is heterogenous and depends on many factors such as the patient population, location and severity of the TMR and presence of other ear pathologies (e.g., perforation, risk of cholesteatoma and serous otitis media).

Supplementary Information

The online version contains supplementary material available at 10.1007/s00405-021-06719-3.

The Natural Course of Tympanic Membrane Retractions in the Posterosuperior Quadrant of Pars Tensa: A Watchful Waiting Policy

INTRODUCTION

Tympanic membrane retraction (TMR) is a relatively common otologic finding. Currently, there is no consensus on the optimal treatment of TMR. Some ENT-surgeons advocate surgical correction while others opt for a watchful-waiting policy. Our aim was to investigate the natural course of retraction pockets in the posterosuperior quadrant of the pars tensa in a large cohort of patients.

METHODS

An observational retrospective cohort study was conducted including patients of all ages with a posterosuperior pars tensa retraction. Primary outcome measure was difference between audiometry at first and last visits. Secondary outcomes were patients' complaints, otoscopic outcomes (Sade classification), and complications (perforation, ossicular chain damage, and/or cholesteatoma).

RESULTS

A total of 71 patients with 81 ears and a median age of 23 years (IQR 14-47) were included. The median duration of follow-up was 64 months (IQR 44-102). The mean air-bone gap at first and last visits was 17.9 dB (SD 11.3) and 15.5 dB (SD 12.9), respectively, with a mean improvement of 2.4 dB (p = 0.08). In 10 ears (12%) the hearing level (air-bone gap) deteriorated with 10 dB or more. Patients who presented with a TMR Sade grade I at first visit had significantly better audiometric outcomes than patients presenting with Sade grade III (p = 0.001). Progression to cholesteatoma occurred in one patient (1%), progression to perforation occurred in five patients (6%), and progression to ossicular chain damage occurred in five patients (6%).

CONCLUSIONS

Otoscopic findings and audiometric results remained stable in most TMRs without treatment. Additionally, audiometry did not worsen during last follow-up. Progression to cholesteatoma, perforation, or ossicular chain damage was rare. Shared decision making regarding TMRs should include a discussion of a wait-and-see policy.

Developmental aspects of the tympanic membrane: Shedding light on function and disease

The ear drum, or tympanic membrane (TM), is a key component in the intricate relay that transmits air-borne sound to our fluid-filled inner ear. Despite early belief that the mammalian ear drum evolved as a transformation of a reptilian drum, newer fossil data suggests a parallel and independent evolution of this structure in mammals. The term "drum" belies what is in fact a complex three-dimensional structure formed from multiple embryonic cell lineages. Intriguingly, disease affects the ear drum differently in its different parts, with the superior and posterior parts being much more frequently affected. This suggests a key role for the developmental details of TM formation in its final form and function, both in homeostasis and regeneration. Here we review recent studies in rodent models and humans that are beginning to address large knowledge gaps in TM cell dynamics from a developmental biologist's point of view. We outline the biological and clinical uncertainties that remain, with a view to guiding the indispensable contribution that developmental biology will be able to make to better understanding the TM.