Topical antibiotics without steroids for chronically discharging ears with underlying eardrum perforations

BACKGROUND

Chronic suppurative otitis media (CSOM) causes ear discharge and impairs hearing.

OBJECTIVES

Assess topical antibiotics (excluding steroids) for treating chronically discharging ears with underlying eardrum perforations (CSOM).

SEARCH STRATEGY

The Cochrane Ear, Nose and Throat Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library Issue 1, 2005), MEDLINE (January 1951 to March 2005), EMBASE (January 1974 to March 2005), LILACS (January 1982 to March 2005), AMED (1985 to March 2005), CINAHL (January 1982 to March 2005), OLDMEDLINE (January 1958 to December 1965), PREMEDLINE, metaRegister of Controlled Trials (mRCT), and article references.

SELECTION CRITERIA

Randomised controlled trials; any topical antibiotic without steroids, versus no drug treatment, aural toilet, topical antiseptics, or other topical antibiotics excluding steroids; participants with CSOM.

DATA COLLECTION AND ANALYSIS

One author assessed eligibility and quality, extracted data, entered data onto RevMan; two authors inputted where there was ambiguity. We contacted investigators for clarifications.

MAIN RESULTS

Fourteen trials (1,724 analysed participants or ears). CSOM definitions and severity varied; some included otitis externa, mastoid cavity infections and other diagnoses. Methodological quality varied; generally poorly reported, follow-up usually short, handling of bilateral disease inconsistent. Topical quinolone antibiotics were better than no drug treatment at clearing discharge at one week: relative risk (RR) was 0.45 (95% confidence interval (CI) 0.34 to 0.59) (two trials, N = 197). No statistically significant difference was found between quinolone and non-quinolone antibiotics (without steroids) at weeks one or three: pooled RR were 0.89 (95% CI 0.59 to 1.32) (three trials, N = 402), and 0.97 (0.54 to 1.72) (two trials, N = 77), respectively. A positive trend in favour of quinolones seen at two weeks was largely due to one trial and not significant after accounting for heterogeneity: pooled RR 0.65 (0.46 to 0.92) (four trials, N = 276) using the fixed-effect model, and 0.64 (95% CI 0.35 to 1.17) accounting for heterogeneity with the random-effects model. Topical quinolones were significantly better at curing CSOM than antiseptics: RR 0.52 (95% CI 0.41 to 0.67) at one week (three trials, N = 263), and 0.58 (0.47 to 0.72) at two to four weeks (four trials, N = 519). Meanwhile, non-quinolone antibiotics (without steroids) compared to antiseptics were more mixed, changing over time (four trials, N = 254). Evidence regarding safety was generally weak.

AUTHORS' CONCLUSIONS

Topical quinolone antibiotics can clear aural discharge better than no drug treatment or topical antiseptics; non-quinolone antibiotic effects (without steroids) versus no drug or antiseptics are less clear. Studies were also inconclusive regarding any differences between quinolone and non-quinolone antibiotics, although indirect comparisons suggest a benefit of topical quinolones cannot be ruled out. Further trials should clarify non-quinolone antibiotic effects, assess longer-term outcomes (for resolution, healing, hearing, or complications) and include further safety assessments, particularly to clarify the risks of ototoxicity and whether quinolones may result in fewer adverse events than other topical treatments.

Antibiotics for the prevention of acute and chronic suppurative otitis media in children

BACKGROUND

Acute otitis media (AOM) is a common childhood illness. These middle ear infections may be frequent and painful. AOM may be associated with perforation of the tympanic membrane and can progress to chronic suppurative otitis media (CSOM).

OBJECTIVES

To determine the effectiveness of long-term antibiotics (for longer than six weeks) in preventing any AOM, AOM with perforation and CSOM.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2006), MEDLINE (January 1966 to March Week 3 2006), OLD MEDLINE (1950 to 1965), EMBASE (1990 to December 2005) and the references of relevant studies.

SELECTION CRITERIA

All randomised controlled trials of long-term (longer than six weeks) antibiotics versus placebo or no treatment for the prevention of AOM, AOM with perforation, or CSOM were eligible.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted the data for: any AOM; episodes of AOM; any recurrent AOM; episodes of illness; any side effects; any antibiotic resistance, as well as outcomes at end of intervention (any AOM); and following cessation of intervention (any AOM). For dichotomous outcomes, the summary risk ratio (fixed and random-effects models) was calculated. For rate outcomes, the summary incidence rate ratio was calculated.

MAIN RESULTS

Sixteen studies involving 1483 children met our inclusion criteria. All studies enrolled children at increased risk of AOM, and in seven studies the children were prone to otitis media. The majority of studies were high quality and most (15 studies) reported data for our primary outcomes. None reported AOM with perforation or CSOM. Long-term antibiotics reduced any episode of AOM (13 studies, 1358 children, risk ratio (RR) 0.62, 95% CI 0.52 to 0.75; random-effects model) and number of episodes of AOM (12 studies, 1112 children, incidence rate ratio (IRR) 0.48, 95% CI 0.37 to 0.62; random-effects model). Approximately five children would need to be treated long term to prevent one child experiencing AOM whilst on treatment. Antibiotics prevented 1.5 episodes of AOM for every 12 months of treatment per child. Statistical heterogeneity was explored. Long-term antibiotics were not associated with a significant increase in adverse events (11 studies, 714 children, RR 1.99, 95% CI 0.25 to 15.89; random-effects model).

AUTHORS' CONCLUSIONS

For children at risk, antibiotics given once or twice daily will reduce the probability of AOM while the child is on treatment. Antibiotics will reduce the number of episodes of AOM per year from around three to around 1.5. We believe that larger absolute benefits are likely in high-risk children. These conclusions were not affected by sensitivity analyses.

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.

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.

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.

A prospective cohort study of the silk fibroin patch in chronic tympanic membrane perforation

OBJECTIVES/HYPOTHESIS

Silk fibroin patching has been used to repair acute tympanic membrane perforations. Here, we describe the advantages and outcomes of this technique for chronic tympanic membrane perforations.

STUDY DESIGN

Individual cohort study.

METHODS

Forty patients were enrolled; half underwent perichondrium myringoplasty, and the silk fibroin patch technique was applied in the remaining patients. We compared the closure, otorrhea, and complication rates; closure time; postoperative hearing gain; and patient satisfaction between the two groups.

RESULTS

Demographic data (gender, site, age, duration, preoperative air-bone gap, and perforation size and location) were not significantly different between the two groups. The closure rates and times, complication rates, and postoperative hearing gains were also similar in both groups. The mean operative time, otorrhea rate, and complication rate were also significantly better in the silk fibroin patch group. The intraoperative dizziness scores were higher in the conventional perichondrium myringoplasty group.

CONCLUSIONS

Success rates were similar for the silk fibroin patch technique and conventional perichondrium myringoplasty; however, patching was an easier, faster procedure. Our results suggest that the silk fibroin patch technique is a suitable treatment for chronic tympanic membrane perforation.

LEVEL OF EVIDENCE

2b Laryngoscope, 126:2798-2803, 2016.

Endoscopic type I tympanoplasty is as effective as microscopic type I tympanoplasty but less invasive-A meta-analysis

BACKGROUND

Endoscopic type I tympanoplasty was originally introduced in the 1990s, and the extensive spread of this practice can be easily observed. The conventional technique performed involves the repair of a tympanic membrane perforation, and is defined as microscopic type I tympanoplasty.

OBJECTIVE OF REVIEW

The aim of this study was the comparison of postoperative outcomes of both the endoscopic and the microscopic type I tympanoplasty.

TYPE OF REVIEW

We conducted a meta-analysis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines.

SEARCH STRATEGY

A systematic literature search was performed in the databases of PubMed, Embase, Cochrane Library, Clarivate Analytics-Web of Science, ClinicalTrials.gov, World Health Organization Library, and Scopus by inserting, 'myringoplasty OR (tympanoplasty AND perforation)' into the search query. We applied only a 'human' filter. We excluded non-English studies. Additional records were identified by checking the references of relevant studies.

EVALUATION METHOD

Comparative studies were included in our analysis. We calculated the pooled odds ratio (OR) with 95% confidence interval (CI) for dichotomous outcomes and weighted mean difference (WMD) with a 95% CI for continuous outcomes. Additionally, we assessed the risk of bias and estimated the quality of evidence for each outcome.

RESULTS

Our systematic search yielded 16 studies (involving 1179 interventions), eligible for analysis. The pooled graft uptake rate (OR: 1.21, CI: 0.82-1.77; I2  = 0.0%), the postoperative hearing results (WMD = -1.13; 95% CI: -2.72-0.45; I2  = 78.1%) and the operation time (WMD = -21.11; 95% CI: -42.60-0.38; I2  = 99.3%), were all comparable amongst the two techniques. In contrast, the endoscopic type I tympanoplasty outperforms when regarding the pooled canaloplasty rate (OR = 7.96; 95% CI: 4.30-14.76; I2  = 0.0%, P = 1.000) and features an increase in desirable cosmetic results (OR = 19.29; 95% CI: 11.37-32.73; I2  = 0.0%, P = 0.839), when compared with the microscopic approach.

CONCLUSIONS

Based on our meta-analysis, the surgical outcomes of endoscopic type I tympanoplasty in terms of graft uptake rate, postoperative hearing results and operation time were comparable to the microscopic type I tympanoplasty. In regards to cosmetics, an increase in desirable results was achieved in the endoscopic group, particularly the incidence of canaloplasty which proved to be significantly lower.

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.

The Effect of PRP-enriched Gelfoam on Chronic Tympanic Membrane Perforation: A Double-blind Randomized Clinical Trial

OBJECTIVE

To evaluate the effect of PRP-enriched gelfoam on the healing of chronic TM perforation in comparison with gelfoam alone.

METHODS

In this double-blind randomized clinical trial Patients with chronic tympanic membrane were randomly allocated to two groups; intervention group underwent tympanoplasty with platelet rich plasma (PRP)- enriched gel foams and control group underwent operation with conventional gel foams alone. Patients information was recorded 4 and 12 months after surgery.

RESULTS

Eventually 24 patients (12 males and 12 females) with a mean age of 43.33 ± 12.34 years in intervention and 41.33 ± 10.02 years in control group underwent analysis (p = 0.667). Complete TM healing was seen in 8 (66.67%) patients in intervention group and 3 (25%) patients in control group three months after intervention (p = 0.031, OR = 5.98).

CONCLUSION

Addition of PRP to conventional gelfoams used in TM perforation repair increases the complete healing rate of TM perforation with less morbidity and complications.

Prevalence of hearing loss and clinical otologic manifestations in patients with 22q11.2 deletion syndrome: A literature review

BACKGROUND

Hearing loss and otitis media are frequently reported in patients with 22q11.2 deletion syndrome.

OBJECTIVE OF REVIEW

Our objective was to review the current literature on the prevalence of hearing loss and otologic manifestations in patients with 22q11.2 deletion syndrome.

TYPE OF REVIEW

Systematic review.

SEARCH STRATEGY

We conducted a systematic search in PubMed and Embase combining the term "22q11.2 deletion syndrome" and synonyms with "hearing loss" and "otologic manifestations" and synonyms.

EVALUATION METHOD

We screened title/abstract and full text of all retrieved articles on pre-defined in- and exclusion criteria. The remaining articles were assessed on risk of bias. Outcome measures included the prevalence of hearing loss and otologic manifestations such as otitis media.

RESULTS

Our search yielded 558 unique studies of which a total of 25 articles were included for critical appraisal and data extraction. Twenty-one studies reported on hearing loss, and 21 studies on otologic manifestations. The prevalence of hearing loss varied from 6.0% to 60.3%, where in most studies conductive hearing loss was most prevalent. Rates of recurrent or chronic otitis media varied from 2.2% to 89.8%.

CONCLUSION

Although a very broad range in prevalences is reported in different studies, hearing loss and recurrent or chronic otitis media are frequently present in patients with 22q11.2 deletion syndrome. Regular check-ups and audiometric testing are advised in these patients.

Otomycosis with Perforated Tympanic Membrane: Self medication with Topical Antifungal Solution versus Medicated Ear Wick

OBJECTIVES

In otomycosis with tympanic membrane perforation, many physicians prefer to insert an ear wick medicated with antimycotic cream. This needs multiple visits to the clinic and keeps the ear blocked for several days. Direct instillation of alcohol based antimycotic solution causes severe burning if it reaches the middle ear. In this work we compare patient's self medication with clotrimazole antimycotic solution used on Q-tips with physician-inserted ear wicks; in terms of safety, efficacy and patient satisfaction. STUDY DESIGN #ENTITYSTARTX00026;

SETTING

Prospective controlled study in ambulatory setting.

METHODOLOGY

Forty consecutive patients with otomycosis with tympanic membrane perforation were included in the study. Diagnosis of otomycosis was both clinical and with mycological culture. Mean pure tone average (PTA) in the involved ear was measured after cleaning fungal debris. Patients were then, randomized into two groups; Q-tip group patients (n=20) were taught to self-medicate their ears two times daily with the clotrimazole solution on suitable Q-tips for three weeks. In ear wick group (n=20), a gauze wick impregnated with clotrimazole cream was inserted in the ear. Wick was changed every third day for two more visits (one week overall). Patients were followed up for 3 months.

RESULTS

After three weeks all patients in Q-tip group and ear wick group had relief of their ear itching and complete disappearance of fungal growth in the deep meatus and on the tympanic membrane. PTA was 22 ± 11dB in Q-tip group and 25 ± 12 dB in ear wick group; the difference was not statistically significant (p= 0.11). Patients in ear wick group had sense of ear blocking and wetness during period of treatment. Transient burning sensation was reported by 2 patients in Q-tip group. During three months, there was recurrence of otomycosis in 5 patients from ear wick group and no recurrence in Q-tip group (p=0.04).

CONCLUSION

Self medication with clotrimazole solution on Q-tips and physician inserted medicated wicks are equally safe in treating otomycosis with perforated tympanic membrane. However, self medication with antimycotic solution on Q-tips gives more patient satisfaction and less rate of otomycosis recurrence.

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.

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.

Tympanic Membrane Perforation After Intratympanic Steroid Injection: A Systematic Review and Meta-analysis

OBJECTIVE

We investigated the incidence of tympanic membrane (TM) perforations induced after intratympanic steroid injection (ITSI) in patients with sudden sensorineural hearing loss (SSNHL) through a systematic review and meta-analysis.

DATA SOURCES

PubMed, Embase, and MEDLINE.

REVIEW METHODS

Primary database searches were performed, and 1901 records were identified. After removal of 1802 articles through abstract screening, the remaining 99 full-text journals were assessed for eligibility to be included in the study. Fifty-eight studies that used either ventilation tubing (VT) or tympanocentesis (TC) for ITSI were selected for analysis. The subjects were divided into VT and TC groups. The rate of TM perforation after ITSI in 2 groups, sites of ITSI, needle gauge, and influence on residual hearing were investigated.

RESULTS

The cohorts comprised patients who underwent VT (n = 257, 9.6%) and TC (n = 2415, 90.4%). The proportion of TM perforation after ITSI in each group was 0.073 (95% CI, 0.0469-0.1113) and 0.010 (95% CI, 0.0045-0.0215), respectively, which suggested that the VT group showed a significantly higher TM perforation rate than the TC group (P < .001). In the subgroup analyses, there was no significant difference in the odds ratio for the rate of TM perforation according to the injection site and needle gauge for TC. The proportion of surgical repair showed no significant difference between the 2 groups.

CONCLUSION

ITSI via VT may have a significantly higher risk of TM perforation than ITSI via TC, although those are relatively small overall. ITSI should be performed in the direction to minimize possible adverse effects.

Multifaceted tannin crosslinked bioinspired dECM decorated nanofibers modulating cell-scaffold biointerface for tympanic membrane perforation bioengineering

Tympanic membrane (TM) perforation leads to persistent otitis media, conductive deafness, and affects life quality. Ointment medication may not be sufficient to treat TM perforation due to the lack of an underlying tissue matrix and thus requiring a scaffold-based application. The engineering of scaffold biointerface close to the matrix via tissue-specific decellularized extracellular matrix (dECM) is crucial in instructing cell behaviour and regulating cell-material interaction in the bioengineering domain. Herein, polycaprolactone (PCL) and TM-dECM (from SD rats) were combined in a different ratio in nanofibrous form using an electrospinning process and crosslinked via tannic acid. The histological and biochemical assays demonstrated that chemical and enzymatic decellularization steps removed cellular/immunogenic contents while retaining collagen and glycosaminoglycan. The morphological, physicochemical, thermomechanical, contact angle, and surface chemical studies demonstrated that the tannin crosslinked PCL/dECM nanofibers fine-tune biophysical and biochemical properties. The multifaceted crosslinked nanofibers hold the tunable distribution of dECM moieties, assembled into a spool-shaped membrane, and could easily insert into perforated sites. The dECM decorated fibers provide a preferable biomimetic matrix for L929 fibroblast adhesion, proliferation, matrix adsorption, and f-actin saturation, which could be crucial for bioengineering. Overall, dECM patterning, surface hydrophilicity, interconnected microporosities, and multifaceted nanofibrous biosystem modulate cell-scaffold performance and could open opportunities to reconstruct TM perforation in a biomimetic fashion.

Paper Patching Versus Watchful Waiting of Traumatic Tympanic Membrane Perforations: A Meta-Analysis

OBJECTIVES/HYPOTHESIS

The aim of the study was to investigate the healing rates, the restoration of hearing, and the time for complete healing of paper patching versus watchful waiting for traumatic tympanic membrane perforations (TTMPs).

STUDY DESIGN

Systematic review with meta analysis.

METHODS

Publications were selected by a search on "PubMed," "Embase," and "Web of Science." A meta-analysis of risk ratios for paper patching (intervention arm) and watchful waiting (control arm) was performed.

RESULTS

Five studies describing 393 TTMPs were included in the quantitative meta-analysis. TTMP healing rates ranged between 84.2% and 95.2% in the intervention arm and between 76.7% and 84.8% in the control arm. The pooled risk ratio of healed TTMPs was significantly higher in the intervention arm than in the control arm (risk ratio: 1.12, 95% confidence interval: 1.04-1.21).

CONCLUSIONS

TTMPs have high healing potential with and without intervention. The healing rate of paper patching was superior to that of watchful waiting alone.

LEVEL OF EVIDENCE

NA Laryngoscope, 131:2091-2097, 2021.

Necessities, opportunities, and challenges for tympanic membrane perforation scaffolding-based bioengineering

Tympanic membrane (TM) perforation is a global clinical dilemma. It occurs as a consequence of object penetration, blast trauma, barotrauma, and middle ear diseases. TM perforation may lead to otitis media, retraction pockets, cholesteatoma, and conductive deafness. Molecular therapies may not be suitable to treat perforation because there is no underlying tissue matrix to support epithelium bridging. Chronic perforations are usually reconstructed with autologous grafts via surgical myringoplasty. Surgical treatment is uncomfortable for the patients. The grafting materials are not perfect because they produce an opaque membrane, fail in up to 20% of cases, and are suboptimal to restore acoustic function. Millions of patients from developing parts of the world have not got access to surgical grafting due to operational complexities, lack of surgical resources, and high cost. These shortcomings emphasize bioengineering to improve placement options, healing rate, hearing outcomes, and minimize surgical procedures. This review highlights cellular, structural, pathophysiological, and perforation specific determinants that affect healing, acoustic and surgical outcomes; and integrates necessities relevant to bioengineered scaffolds. This study further summarizes scaffolding components, progress in scaffolding strategies and design, and engenders limitations and challenges for optimal bioengineering of chronic perforation.

Comparison of type I tympanoplasty with acellular dermal allograft and cartilage perichondrium

Background: Acellular dermal allograft (AlloDerm) and cartilage perichondrium are two common materials used for repair of tympanic membrane perforations (TMPs). To date, comparative evaluations of their efficacy have rarely been reported. Aim/objectives: To compare anatomical and audiological outcomes between AlloDerm and cartilage perichondrium in type I tympanoplasty. Methods: A total of 61 patients of TMP were studied. In total, 27 patients (Group 1) underwent AlloDerm myringoplasty, and the remaining 34 patients (Group 2) underwent perichondrium myringoplasty. Operating time, closure rate and hearing gain were compared between Groups 1 and 2. Results: Successful closure rates at 6-month follow-up were 88.9% (Group 1) and 82.4% (group 2). The average improvement of air-bone gap (ABG) was 13.5 ± 11.8 dB for Group 1 and 13.1 ± 13.1 dB for Group 2. The difference in between preoperative and 6 months postoperative ABG values was statistically significant (p < .001). Conclusions and significance: Success rates and improvement of hearing level were similar for the AlloDerm (Group 1) and the cartilage perichondrium (Group 2) groups. However, AlloDerm requires shorter operative time and avoids the incisions in the harvest of allografts. Our results suggest that AlloDerm can be recommended as an attractive alternative to cartilage grafts.

The Effect of Tympanic Membrane Perforation Site, Size and Middle Ear Volume on Hearing Loss

Objective

The aim of this study was to analyze the location and the size of perforation in cases with tympanic membrane perforation, its relation to the manubrium mallei and middle ear volume, and to investigate how these are correlated with the severity and frequencies of conductive hearing loss.

Methods

This prospectively designed study included the patients who presented to the the Department of Otorhinolaryngology at the Dokuz Eylül University with hearing loss or tinnitus complaints in the period from June 2014 through June 2017 and were identified to have tympanic membrane perforation in their otoscopic examination. Patients who underwent myringoplasty and type 1 tympanoplasty and whose air-bone gap was found lower than 10 dB in the postoperative audiological examination were included in the study. Effects of the perforation size, the perforation site, and the relationship of the perforation with the manubrium, as well as the effects of the middle ear volume on the severity and frequency of conductive hearing loss were compared.

Results

The study included 44 ears of 38 patients (13 male and 25 female) of whom six had tympanic membrane perforation in both ears. Air conduction threshold and air-bone gap were significantly found higher if the perforation area was wide (p<0.05), the perforation involved both the anterior and the posterior quadrants (p<0.05), had contact with the manubrium mallei (p<0.05), and the middle ear volume reduced (p<0.05).

Conclusion

Solely tympanic membrane perforation affects hearing function; nevertheless, hearing function are better in cases, which have perforations small in size, no contact with manubrium mallei and well pneumatized middle ears.

Topical fibroblast growth factor-2 for treatment of chronic tympanic membrane perforations

OBJECTIVE

To determine the efficacy of fibroblast growth factor-2 (FGF-2) in treating chronic nonhealing tympanic membrane (TM) perforations.

METHOD

Double-blinded, randomized placebo controlled phase 2 clinical trial for patients with chronic TM perforations of more than 3 months duration with a cross-over arm. Patients received either FGF-2 or placebo (sterile water) saturated gelatin sponge in the perforation after rimming the perforation under topical anesthesia. The perforation was then covered with Tisseel fibrin glue. The primary endpoint was complete closure of the TM perforation. Secondary end points included change in hearing and partial TM closure rates. The TM was examined every 3 weeks with otoendoscopy for closure. The treatment was repeated if there was incomplete closure every 3 weeks up to a total of three treatments per arm.

RESULTS

Seventy four patients were recruited for the study. Fifty seven met eligibility criteria and fifty four completed the study. Ten of 14 perforations closed completely in the placebo group (71.4%) and 23 of 40 perforations closed completely in the FGF-2 treatment group (57.5%), P value = .36. Pure tone averages and word recognition scores were not statistically significantly different between study groups post-treatment. After initial complete closure, re-perforation occurred in seven FGF-2 treated patients and two placebo patients making the effective final closure rate 40% for FGF and 57% for placebo, respectively.

CONCLUSION

No statistically significant difference in tympanic membrane perforation closure rate was found between the FGF-2 and placebo groups. There were no differences in hearing outcomes between the groups.

LEVEL OF EVIDENCE

1b.

Acellular Collagen Scaffold With Basic Fibroblast Growth Factor for Repair of Traumatic Tympanic Membrane Perforation in a Rat Model

OBJECTIVE

To evaluate the efficacy of acellular collagen scaffold (ACS) in combination with basic fibroblast growth factor (bFGF) for the repair of traumatic tympanic membrane (TM) perforation in a rat model.

STUDY DESIGN

A prospective controlled animal study in a rat model of traumatic TM perforation.

SETTING

Tertiary medical center.

SUBJECTS AND METHODS

Sprague-Dawley rats (N = 84) with unilateral traumatic perforation of the right TMs were randomized to receive ACS, bFGF, ACS in combination with bFGF (ACS/bFGF), or nothing (spontaneous healing without any interventions as a control group). The healing outcomes were evaluated by otoscopy, optical coherence tomography, histology, and transmission electron microscopy at 1, 2, and 4 weeks postoperatively. The hearing outcomes were assessed with auditory brainstem response testing.

RESULTS

ACS/bFGF resulted in higher perforation closure rates at an earlier stage than spontaneous healing, ACS, and bFGF. Based on histology, optical coherence tomography, and transmission electron microscopy, a trilaminar structure and uniform thickness with mature, densely packed collagen fibers were seen in the ACS/bFGF group. Auditory brainstem response evaluation also showed that ACS/bFGF treatment promoted faster functional hearing recovery as compared with the control group.

CONCLUSIONS

ACS is an effective TM scaffold and a carrier for bFGF. ACS/bFGF improves the TM closure rate, results in better-reconstructed TMs, and improves hearing. ACS/bFGF serves as a potential substitute for TM perforations in clinical settings.

Histological Study of The Healing of Traumatic Tympanic Membrane Perforation After Vivosorb and Epifilm Application

BACKGROUND

Untreated traumatic tympanic membrane perforations (TMPs) may lead to permanent perforations and hearing loss. There are many materials that have been previously used for repairing the TMPs.

AIMS AND OBJECTIVES

The purpose of this study is to evaluate the clinical and histological effects of Vivosorb (Vv) and Epifilm on healing of TMPs in a rat model.

MATERIAL AND METHODS

The posterior-inferior quadrant of the tympanic membranes (TMs) in right ears of 14 rats was perforated using a 20-g needle and then the animals were randomly divided into 2 equal groups (n = 7). The perforated right TMs were treated with either Vv (Vv group) or Epifilm (Ep group). The left TMs of 7 rats were perforated in same way and allowed to close spontaneously without any topical material applications (spontaneous closure group as sham control, SC). The left tympanic membranes of the other 7 rats were not perforated and used as normal controls (NC group). On postoperative 15th day, tympanic bullas were extracted from killed rats and examined morphometrically and histopathologically.

RESULTS

Perforation closure rate was 85.7% (6/7) in both Vv and SC groups. Perforations of Ep group closed in 7/7 (100%) ears. The thicknesses of the perforated membranes were increased in SC and especially Vv groups. Also, connective tissue fibrosis, blood clots, and epithelial degenerations were detected in SC and Vv groups. The mean fibroblastic reaction scores of Vv, Ep, and SC groups were 2.14(+), 0.57(+), and 1.71(+) respectively, on comparison with NC group. The mean neovascularization score was 1.42(+) in Vv group, 0.14(+) in Ep group, and 0.57(+) in SC group.

CONCLUSION AND SIGNIFICANCE

Vivosorb and especially Epifilm can improve the healing process in traumatic TMPs and additionally, Epifilm might be more preferred for the treatment of TMPs because of causing lesser fibrosis.

The effect of platelet-rich fibrin membrane on the repair of perforated tympanic membrane: an experimental study

CONCLUSION

Platelet-rich fibrin (PRF) membrane could be used successfully in the repair of tympanic membrane perforation and wound healing.

OBJECTIVES

To evaluate the effect of platelet-rich fibrin membrane in the repair of perforated tympanic membrane.

METHODS

After otoscopic examination, a 3-mm perforation was made in the posterior quadrant of both tympanic membranes of 50 adult male Sprague-Dawley rats. Venous blood was withdrawn from the rats, then centrifuged. PRF was obtained in membrane form. The membrane was placed on the right tympanic membrane perforation. The perforations on the left side were left to spontaneously heal and, thus, formed the control group. Daily examinations were made of 20 rats and the time to healing of the tympanic membrane was recorded. The remaining 30 rats were separated into five groups of six, and histopathological examination was made. Evaluation was made in respect of the presence of oedema in the lamina propria, neovascularization, fibroblastic reaction, and inflammatory cells.

RESULTS

The healing time of the tympanic membrane perforation was determined as mean 10.3 ± 2.18 days in the study group applied with PRF and 17 ± 2.40 days in the control group. Higher values in respect of fibrosis and neovascularization were obtained in the study group.