|Year : 2011 | Volume
| Issue : 3 | Page : 120-122
Effect of smoking on outcome of tympanoplasty
Santosh Kumar Swain, Rankanidhi Samal, Santosh Kumar Pani
Department of ENT, Institute of Medical Sciences and SUM Hospital, Kalinga Nagar, Bhubaneswar, India
|Date of Web Publication||26-Dec-2011|
Santosh Kumar Swain
Department of ENT, IMS and SUM Hospital, Kalinga Nagar, Bhubaneswar 751 003, Odisha
Source of Support: None, Conflict of Interest: None
Objective : The effect of smoking on the outcome of tympanoplasty is to be confirmed. We sought to determine the effect of smoking habit on the results of tympanoplasty over 158 patients for a period of 2years. Setting : Tertiary care hospital. Materials and Methods : The study was carried out among 158 post operative tympanoplasty, smokers were 28 and non-smoker were 130. Results : Patients without smoking habit have 93% graft uptake with 94% improved hearing after tympanoplasty. Those were with smoking habit, have 68% graft uptake with 79% improved hearing. The average hearing improvement was 20 dB among nonsmokers and 16 dB among smokers. Conclusion : This study support the poor outcome of tympanoplasty among smokers in comparison to non-smokers.
Keywords: Perforation, Smoking, Tympanoplasty
|How to cite this article:|
Swain SK, Samal R, Pani SK. Effect of smoking on outcome of tympanoplasty. Indian J Otol 2011;17:120-2
| Introduction|| |
Chronic suppurative otitis media (CSOM) is a very common disease in the developing countries, especially among the younger population. Perforation and hearing loss are the two sequelae of CSOM. To improve the hearing status, tympanoplasty is evolved over the long history of otology. The term tympanoplasty was first used in 1953 by Wullstein to describe surgical techniques for reconstruction of the middle ear hearing mechanism that had been impaired or destroyed by chronic ear disease. 
A large number of factors, e.g., Eustachian tube More Details function, middle ear mucosa, graft materials, allergy, site of perforation, air-bone gap, ossicular status were found to have its effect on the result of tympanoplasty.  Another less studied factor smoking habit of patient undergoing tympanoplasty has a greater impact over success of tympanoplasty. It was reported that patient with active or passive smokers has less success rate over tympanoplasty outcome. A comparative study was done to assess the effect of smoking on the middle ear status, postoperative graft uptake and hearing improvement of tympanoplasty.
| Materials and Methods|| |
The study was carried out from 2009 August to 2011 July at Institute of Medical Sciences and SUM Hospital, Bhubaneswar among the patients who had undergone tympanoplasty. The series include 158 cases of tympanoplasty operated for central perforation. Out of the 158 patients, 130 patients are non-smoker and 28 patients are smokers. The smokers included are only active and regular smokers. The currently smoking habit and those quit less than 2 years are considered as smokers in this study. Depending on the chronicity of exposure of smoking, smokers are divided into smoker of less than 10 years and smokers of more than 10 years.
All patients were subjected to full clinical evaluation and routine investigations. Radiological examination by Schuller's view of mastoid air cells was done in all cases. In addition, pure tone audiometry was done to assess the air-bone gap. Patients above 15 years of age and below 50 years, only with central perforation having dry ear for at least 6 weeks were included in the study. In all patients, tympanoplasty was done by the post-auricular approach, underlay technique using temporalis fascia graft after making bed by medicated abgel. External auditory canal was packed by neosporin ointment soaked gauze for 10 days. The results were evaluated depending upon the graft take up and hearing gain over 6 months postoperatively.
| Results|| |
All the 158 patients were assessed by the graft take up along with average hearing gain over period of 6 months. Intraoperative middle ear status assessed during surgery and compared between smokers and non smokers. In this study, 82% patients (130) are non-smokers and 18% patients (28) are smokers. In our study, all smokers are male. Follow up of the operated patients are done after 1 st month, 3 rd months, and 6 th months. Among non-smokers, 13 patients show abnormal middle ear mucosa. Among 28 smokers, 11 patients show abnormal middle ear mucosa. After 6 months graft take up is seen in 121 (93%) patients among 130 non-smokers patients and 19 (68%) patients among 28 smokers. After 6 months, pure tone audiometry done in all successful graft take up patients to assess the postoperative hearing assessment. In pure tone audiometry 114 patients show improved hearing among nonsmoker category and 15 patients show improved hearing among smoker category. The average hearing gain in nonsmoker patients was around 20 decibel and in smoker patients 16 dB. The intraoperative middle ear status and outcome of tympanoplasty are mentioned in [Table 1] and data illustrated in [Figure 1]. Among 28 smoker patients, 10 patients were smokers of more than 10 years and 18 are less than 10 years. Patient out come due to chronicity of smoking shows abnormal middle ear mucosa (polypoidal) in seven patients those having habit of smoking for more than 10 years whereas four patients showed abnormal middle ear mucosa among smokers of less than 10 years. Among smokers, graft failure and poor hearing improvement are seen among smokers of more than 10 years. This is mentioned in [Table 2].
| Discussion|| |
Chronic suppurative otitis media is a common condition seen in patients attending the otolaryngology clinic. Surgical repair of tympanic membrane and tympanic membrane grafting have traveled a long way, after initial reports of tympanic membrane grafting filtered out of Germany in 1950s. 
Our study showed that there was worse outcome of postoperative tympanoplasty among smokers in comparison to non-smokers. Few previous studies reported the result. For example, in 2001, Zoran Becvarovski et al., in their study on effect of smoking, there was a trend toward smokers having a higher incidence of otorrhea preoperatively and requiring a more extensive surgical procedure. All patients had full take of the tympanic membrane graft after 6 months; however, delayed surgical failure was seen in 20% of non-smokers compared with 60% of smokers (P=0.050). No statistical significant difference was seen in hearing outcome. 
In 2009, Kaylie et al., in their study "Effects of smoking on otologic surgery outcome" stated that smokers have significantly worse chronic ear disease than nonsmokers. Surgery in smokers is more extensive and leads to worse hearing outcome than non-smokers. 
In our study, graft uptake is 93%, abnormal middle ear mucosa is 10% and hearing improvement is 94% among non-smokers whereas graft uptake is 68%, abnormal middle ear mucosa is 39% and improved hearing is 79% among smokers. The chi-square value is 18.8711 and statistically P value is 0.0001 which is significant.
Otitis media occurs when pathogenic bacteria move from the nasopharynx to the middle ear by way of the eustachian tube. Therefore, an early key step in the pathogenesis of otitis media is colonization of the upper airway with bacterial pathogen.  Smoking is ciliotoxic and cause decrease mucociliary clearance by respiratory epithelium, potentially facilitating the bacterial colonization which has worse effect on the disease process and outcome of tympanoplasty. Chronic inhalation of smoking is also associated with mucus hypersecretion, mucus pooling and leads colonization of pathogens.  It causes failure of tympanoplasty.
| Conclusion|| |
CSOM is one of the most common diseases in our country particularly in the low economic status, because of over-crowding, low hygine and ignorance. Smoking is associated with more severe middle ear disease preoperatively and also poor surgical outcome. The middle ear cleft is developmentally a part of upper respiratory tract and anatomically continuous with it. Smoking induces inflammation, which may result in epithelial injury, predisposes bacterial colonization in nose, nasopharynx, eustachian tube, and middle ear, which is responsible for poor outcome of tympanoplasty. The preoperative eustachian tube function is considered an important predictive factor for the result of tympanoplasty.  So, the preoperative eustachian tube function and middle ear mucosal status are poor in smokers than nonsmokers. More extensive surgery is often needed in smokers to eradicate the disease. Most significantly, smoking is associated with high chance of long term graft failure. A non-smoking patient, a longer dry ear, a healthy opposite ear, a relatively smaller perforation, and a senior surgeon were found to be significant prognostic factors positively influencing the successful tympanoplasty.
| Acknowledgments|| |
The authors thank Chidananda Dash and PK Brahma for help in the statistical analysis.
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[Table 1], [Table 2]