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 Table of Contents  
ORIGINAL ARTICLE
Year : 2013  |  Volume : 19  |  Issue : 4  |  Page : 164-168

Pre and post operative evaluation of hearing in chronic suppurative otitis media


1 Department of ENT, Himalayan Institute of Medical Sciences, HIHT University, Jollygrant, Doiwala, Dehradun, India
2 Department of ENT, All India Institute of Medical Sciences (AIIMS), Rishikesh, India

Date of Web Publication7-Jan-2014

Correspondence Address:
Saurabh Varshney
All India Institute of Medical Sciences (AIIMS), Rishikesh - 249 201, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-7749.124505

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  Abstract 

Aim: To evaluate pre- and postoperative hearing status in patients of chronic suppurative otitis media (CSOM) undergoing mastoidectomy with tympanoplasty. Study type- Prospective. Materials and Methods: Eighty cases of CSOM were included. All patients underwent a pre-operative pure-tone audiometry (PTA) to find out the hearing status and to obtain documentary evidence for the same, and X-ray mastoid (bilateral Schullre's view) to assess the pathology and surgical anatomy of the mastoid. All patients included in the study were categorized into three groups according to the surgery planned: Group-A: Tympanoplasty, Group-B: Canal wall up (CWU) mastoidectomy with tympanoplasty, and Group-C: Canal wall down CWD mastoidectomy with reconstruction. Post-operatively, after 10 weeks and 6 months, audiological examination (PTA) was carried out to compare pre- and post-operative hearing status. Results: In this study we found that postoperative hearing results were better in the case of safe CSOM as
compared with unsafe CSOM and of tympanoplasty as compared with tympanoplasty with mastoidectomy.

Keywords: Chronic suppurative otitis media, Tympanoplasty, Mastoidectomy


How to cite this article:
Kabdwal N, Varshney S, Bist SS, Bhagat S, Mishra S, Agarwal V. Pre and post operative evaluation of hearing in chronic suppurative otitis media. Indian J Otol 2013;19:164-8

How to cite this URL:
Kabdwal N, Varshney S, Bist SS, Bhagat S, Mishra S, Agarwal V. Pre and post operative evaluation of hearing in chronic suppurative otitis media. Indian J Otol [serial online] 2013 [cited 2019 Apr 20];19:164-8. Available from: http://www.indianjotol.org/text.asp?2013/19/4/164/124505


  Introduction Top


Chronic suppurative otitis media (CSOM) is one of the most common ear diseases in the developing countries. CSOM is defined as a persistent disease, insidious in onset, often capable of causing severe destruction of middle ear structure and irreversible sequel, which is clinically manifested with deafness and discharge more than 3 months. [1] Incidence of CSOM varies from 0.5% to 2.0% in developed countries, whereas in developing countries it ranges from 3% to 57%. In India incidence of CSOM ranges up to 30%, with a prevalence rate of 16/1000 population in urban and 46/1000 in rural areas. [2],[3] Hearing loss in CSOM is usually conductive and is attributed to alteration in the normal mechanism of sound conduction from external to the inner ear, usually because of ossicular chain discontinuity. [4] Middle ear surgery for hearing gain is being performed for many years. Tympanoplasty is defined as a procedure to eradicate disease in the middle ear and to reconstruct hearing mechanism with or without tympanic membrane grafting. This procedure can be combined with an intact canal wall (ICW) or canal wall down (CWD) mastoidectomy to eradicate disease from the mastoid area. [5] The role of tympanoplasty is to restore sound pressure transformation at the oval window by coupling an intact tympanic membrane with a mobile stapes footplate via an intact or reconstructed ossicular chain and to provide sound protection for the round window membrane by a closed, air-containing, mucosa-lined middle ear. [4] Closure of a tympanic membrane perforation restores the vibratory area of the membrane and affords round window protection, thus improving hearing; however, high-frequency audiometry demonstrates a persistent air-bone gap (ABG), despite successful closure of a perforation. [6]


  Materials and Methods Top


This was a prospective study, carried out at Department of Otorhinolaryngology, Himalayan Institute of Medical Sciences, Dehradun, a tertiary care centre in the state of Uttarakhand, from November 2010 to October 2011. A total of 80 patients were included in the study.

The inclusion criteria were as follows: Patients aged more than 12 years, diagnosed as having CSOM, having pure conductive hearing loss, and posted for ear surgery. The exclusion criteria were as follows: Patients who were less than 12, had malignancy of middle ear, otitis externa, previous history of ear surgery, complications of CSOM, history of ear trauma, and mentally retarded.

The selected patients were subjected to a detailed history and complete ear, nose, and throat examination. The ears were examined by otoscopy initially and subsequently by a microscope and otoendoscope to establish a pre-operative diagnosis of safe or unsafe disease.

All patients underwent a pre-operative pure-tone audiometry (PTA) to find out the hearing status and to obtain documentary evidence for the same, and X-ray mastoid (bilateral Schullre's view) to assess the pathology and surgical anatomy of the mastoid.

All patients included in the study were categorized into three groups according to the surgery planned: Group-A: Tympanoplasty, Group-B: Canal wall up (CWU) mastoidectomy with tympanoplasty, and Group-C: CWD mastoidectomy with reconstruction.

Post-operatively, after 10 weeks and 6 months, audiological examination (PTA) was carried out to compare pre-and post-operative hearing status.


  Results Top


A total of 80 cases were selected for this study and divided into 'safe' and 'unsafe' CSOM based on history, clinical findings, and intra-operative findings. The number of cases with safe CSOM was 61 (76.25%) and that with unsafe CSOM was 19 (23.75%). The patients were aged between 14 and 74 years (mean age: 32.2 years). The number of male and female patients was 48 (60.00%) and 32 (40.00%) (M:F = 1.5:1.0), respectively.

The primary complaints of the patients were ear discharge in 80 (100%) cases and hearing loss in 74 (92.50%) cases. The duration of ear discharge ranged from 6 months to 50 years. Maximum number of patients, that is, 30 (37.50%) cases, had duration of ear discharge of 10-15 years. Duration of hearing loss complaint was present from 6 months to 30 years. Maximum number of patients, that is, 34 (42.50%) cases, complained of hearing loss from 1 to 5 years, whereas 6 (07.50%) cases had no hearing loss.

Based on intra-operative findings, the patients were reclassified into safe CSOM (53 (66.25%)) and unsafe CSOM cases (27 (33.75%)). Intra-operatively, eight (10.00%) cases, which were clinically diagnosed as safe, were found to be unsafe.

In our study, 53 (66.25%) cases underwent Group-A surgery, 23 (28.75%) cases Group-C surgery, and 4 (05.00%) cases Group-B surgery.

Pre-operative hearing status [Table 1]

Hearing loss was assessed by PTA in three frequencies, 500, 1000, and 2000 Hz, and ABG was calculated.
Table 1: Pre-operative degree of hearing loss in safe and unsafe CSOM according to WHO criteria

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Comparison of pre- and postoperative hearing at first follow-up of 10 weeks [Table 2]

In our study average pre-operative hearing loss in 80 cases of CSOM was 33.58 dB. Postoperatively, at first follow-up of 10 weeks, average hearing loss in 80 cases was 26.35 dB. Hence, postoperatively at 10 weeks an average gain of 7.23 dB was seen.
Table 2: Hearing evaluation at 10 weeks (first follow-up)

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A total of 53 cases were in Group-A (tympanoplasty) where average hearing loss pre-operatively was 31.98 dB and postoperatively at 10 weeks average hearing loss was 24.18 dB. Hence, an average gain of 7.8 dB was noticed in Group-A.

A total of 4 cases were in Group-B (CWU mastoidectomy with tympanoplasty) where average hearing loss pre-operatively was 30.00 dB and postoperatively at 10 weeks average hearing loss was 26.5 dB. Hence, an average gain of 3.5 dB was noticed in Group-B.

A total of 23 cases were in Group-C (CWD mastoidectomy with tympanoplasty) where average hearing loss pre-operatively was 37.91 dB and postoperatively at 10 weeks average hearing loss was 31.30 dB. Hence, an average gain of 6.61 dB was noticed in Group-C.

Overall, postoperatively at 10 weeks an average gain of 11.76 dB and an average loss of 6.94 dB was seen in all 80 cases of CSOM.

Comparison of pre- and postoperative hearing at second follow-up of 6 months [Table 3]

A total of 30 (37.50%) patients were examined at second follow-up of 6 months, of which 15 had safe CSOM and 15 patients had unsafe CSOM.
Table 3: Hearing evaluation at 6 months (second follow-up)

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On second follow-up at 6 months, average pre-operative hearing loss in 30 cases of CSOM was 32.64 dB and average hearing loss in 30 cases was 24.1 dB. Postoperatively, at months, an average gain of 8.54 dB was observed.

In this study all 15 cases of safe CSOM underwent type-I tympanoplasty. Pre-operative average hearing loss in 15 cases diagnosed as safe CSOM intra-operatively was 28.4 dB, whereas postoperatively at second follow-up of 6 months average hearing loss in cases of safe CSOM was 18.13 dB. Hence, postoperatively an average hearing gain of 10.27 dB was seen in patients of safe CSOM [Table 4].
Table 4: Comparison

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In 15 cases diagnosed as unsafe CSOM, the majority of the 11 (36.66%) underwent CWD mastoidectomy with tympanoplasty. Average hearing loss in these 15 cases was 34.13 dB pre-operatively, which at second follow-up of 6 months was 30.06 dB. Thus an average gain of 4.07 dB was observed.

A total of 15 cases were in Group-A (tympanoplasty) where average hearing loss pre-operatively was 28.4 dB and postoperatively at 6 months average hearing loss was 18.13 dB, Hence, an average gain of 10.27 dB was noticed in Group-A.

A total of 4 cases were in Group-B (CWU mastoidectomy with tympanoplasty) where average hearing loss pre-operatively was 30.00 dB and postoperatively at 6 months average hearing loss was 31.5 dB. Hence, an average loss of 1.5 dB was noticed in Group-B [Table 5].
Table 5: Comparison between group-A and group-B

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Overall, postoperatively at 6 months an average gain of 12.55 dB and an average loss of 9.83 dB were seen [Table 6].
Table 6: Group C result

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A total of 11 cases were in Group-C (CWD mastoidectomy with tympanoplasty) where average hearing loss pre-operatively was 35.63 dB and postoperatively at 6 months average hearing loss was 29.54 dB. Thus, an average gain of 6.09 dB was noticed in Group-C [Table 7].
Table 7: Comparison between CWU and CWD

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  Discussion Top


In this work we studied a total of 80 patients of CSOM to compare pre- and postoperative hearing status.

The most commonly affected age group was between 21 and 30 years, as observed by various other studies as well. [1],[7],[8] This early presentation may be due to increased awareness to health issues and difficulty in hearing affecting work efficiency, leading patients and parents to seek early medical intervention. The ratio of male to female patients was 1.50:1.00. Similar findings have been reported by several other authors. [3],[9],[10]

The duration of ear discharge ranged from 6 months to 50 years. A total 30 (37.50%) cases had duration of ear discharge between 10 and 15 years. The duration of disease in unsafe cases was generally seen to be longer. This particular finding may be a result of conversion of safe type of disease into unsafe disease over time. [11]

The duration of hearing loss was in all cases found to be lesser than duration of ear discharge. This may be attributed to difficulty in appreciating minor degrees of hearing loss by the patient. Hearing loss would be noticed only when the disease had progressed sufficiently to cause significant impairment of hearing by perforation or ossicular destruction.

In our study, on average postoperative hearing gain was seen in all three surgical categories and these findings are consistent with those of Saha, et al. [12] who also witnessed hearing gain postoperatively in all cases undergoing type-I tympanoplasty (Group-I) and simple mastoidectomy with tympanoplasty (Group-II). [12]

Goyal found an average hearing gain in both Group-A (type-I tympanoplasty) and Group-B (type-I tympanoplasty with cortical mastoidectomy), which was also similar to the findings of our study in Group-A (tympanoplasty) and Group-B (CWU mastoidectomy with tympanoplasty) at first follow-up of 10 weeks. On second follow-up at 6 months similar results were seen as compared with Goyal. But an average hearing loss of 1.5 dB was seen, which could be because of displacement of graft in Group-B. [13]

Shrestha, et al. [14] noticed a net gain of 8.0 dB in patients undergoing CWD mastoidectomy with tympanoplasty, which was also in accordance with our study where a net gain of 6.61 dB was noticed at 10 weeks and a gain of 6.09 dB at 6 months in Group-C (CWD mastoidectomy with tympanoplasty).

Varshney, et al. compared the hearing results by the CWU versus CWD procedure and found postoperative hearing gain in both groups similar with the hearing results of both these groups in our study at first follow-up of 10 weeks, but a postoperative hearing loss of 1.5 dB was seen at second follow-up of 6 months in the CWU group in our study. [16]

Mathai noticed a definitive improvement of hearing in all cases that underwent myringoplasty (in the range of 20 to 30 dB) with closure or narrowing of ABG except in three cases where CHL persisted. This was in accordance with our study where definitive improvement was seen in 46 (86.8%) out of 53 cases who underwent tympanoplasty. Cases in which maximum gain in hearing was seen were in the < 25-dB group, followed by the 26- to 40-dB group, at both first and second follow-up. [15]

Shrestha and Sinha also noticed maximum improvement in hearing in the 0- to 10-dB group in all cases undergoing myringoplasty at all postoperative follow-ups. Our study also revealed maximum improvement in hearing in the < 25-dB group at both follow-ups of 10 weeks and 6 months. [1]


  Conclusion Top


In this study we found that postoperative hearing results were better in the case of safe CSOM as compared with unsafe CSOM and of tympanoplasty as compared with tympanoplasty with mastoidectomy.

 
  References Top

1.Shrestha S, Sinha BK. Hearing results after myringoplasty. Kathmandu Univ Med J 2006;4:455-9.  Back to cited text no. 1
    
2.Gupta A, Gupta. A study of prevalence of complications of suppurative otitis media in rural area of Loni. Ind J Otol 1996;2:177-83.  Back to cited text no. 2
    
3.Akinpelu OV, Amusa YB, Komolafe EO, Adeolu AA, Oladele AO, Ameye SA. Challenges in management of chronic suppurative otitis media in a developing country. J Laryngol Otol 2008;122:16-20.  Back to cited text no. 3
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4.Gulati SP, Sachdeva OP, Kumar A. Audiological profile in chronic suppuartive otitis media. Ind J Otol 2002;8:24-8.  Back to cited text no. 4
    
5.Slattery WH. Pathology and clinical course of inflammatory diseases of the middle ear. In: Glasscock ME, Gulya AJ, editors. Glasscock-Shambaugh Surgery of the Ear. 5 th ed. New Delhi: Reed Elsevier India Pvt. Ltd; 2003. p. 428-9.  Back to cited text no. 5
    
6.Slattery WH. Pathology and clinical course of inflammatory diseases of the middle ear. In: Glasscock ME, Gulya AJ, editors. Glasscock-Shambaugh Surgery of the Ear. 5 th ed. New Delhi: Reed Elsevier India Pvt. Ltd; 2003. p. 403.  Back to cited text no. 6
    
7.Singh RK, Safaya A. Middle ear hearing restoration using autologous cartilage graft in canal wall down mastoidectomy. Indian J Otol 2005;11:10-4.  Back to cited text no. 7
    
8.Ajalloueyan M. Experience with surgical management of cholesteatomas. Arch Otolaryngol Head Neck Surg 2006;132:931-3.  Back to cited text no. 8
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9.Chandra R, Mishra R. Some observations on the total and subtotal perforations of the tympanic membranes. Ind J Otolaryngol 1964;16:3-20.  Back to cited text no. 9
    
10.Rupa V, Raman R. Chronic suppurative otitis media: Complicated versus uncomplicated disease. Acta Otolaryngol 1991;111:530-5.  Back to cited text no. 10
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11.El-Sayed Y. Bone conduction impairment in uncomplicated chronic suppurative otitis media. Am J Otolaryngol 1998;19:149-53.  Back to cited text no. 11
[PUBMED]    
12.Ashok SK, Munshi DM, Ghosh SN. Evaluation of improvement of hearing in type I tympanoplasty and its influencing factors. Ind J Otol Head Neck Surg 2006;58:253-7.  Back to cited text no. 12
    
13.Goyal R. Role of cortical mastoidectomy in type I tympanoplasty. Ind J Otol 2010;16:8-12.  Back to cited text no. 13
    
14.Shrestha BL, Bhusal CL, Bhattarai H. Comparison of pre and post-operative hearing results in canal wall down mastoidectomy with type III tympanoplasty. JNMA J Nepal Med Assoc 2008;47:224-7.  Back to cited text no. 14
[PUBMED]    
15.Mathai J. Myringoplasty with temporalis fascia: Analysis of 200 cases. Ind J Otol Head Neck Surg 1999;51:9-12.  Back to cited text no. 15
    
16.Varshney PK, Gupta R. Canal wall up versus canal wall down procedure: Comparative evaluation. Ind J Otol. 2009;15:20-2.  Back to cited text no. 16
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]


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