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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 21  |  Issue : 4  |  Page : 266-269

Has mastoid pneumatization any bearing on tympanoplasty?


Department of ENT, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India

Date of Web Publication16-Oct-2015

Correspondence Address:
Abhinav Srivastava
Department of ENT, Rohilkhand Medical College and Hospital, Pilibhit Bypass Road, Bareilly - 243 006, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-7749.165758

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  Abstract 

Aims: The importance of the mastoid in determining the success or failure of tympanic membrane reconstruction has been a topic of debate since long. A decrease in the mastoid air cell volume has been shown to be related to atelectatic ear diseases, cholesteatoma, and chronic otitis media with effusion. The aim of this study was to see the surgical outcome in cases of type I tympanoplasty in well-pneumatized and sclerotic mastoids.
Materials and Methods: Eighty patients undergoing type I tympanoplasty were randomly selected. X-ray of the mastoid (Schullers' view) was advised in all the patients. The patients were divided into two groups. Group I having fully pneumatized mastoid and group II having sclerotic mastoid. These cases were followed up for a period of 1-year for the graft uptake. Results: It was seen that the graft uptake rate was better in well-pneumatized mastoid as compared to sclerotic mastoid. The results were analyzed and were found to be statistically significant with Chi-square value 3.94 and P = 0.047. Conclusion: As per the study, it can be concluded that graft uptake rate in cases of tubo tympanic chronic suppurative otitis media was better in well-pneumatized mastoids as compared to sclerotic mastoid.

Keywords: Pneumatized mastoid, Sclerotic mastoid, Tympanoplasty


How to cite this article:
Mohan C, Sharma S, Srivastava A. Has mastoid pneumatization any bearing on tympanoplasty?. Indian J Otol 2015;21:266-9

How to cite this URL:
Mohan C, Sharma S, Srivastava A. Has mastoid pneumatization any bearing on tympanoplasty?. Indian J Otol [serial online] 2015 [cited 2020 Feb 23];21:266-9. Available from: http://www.indianjotol.org/text.asp?2015/21/4/266/165758


  Introduction Top


The condition of the middle ear cleft in determining the success or failure of tympanic membrane reconstruction is important for surgical outcome. Mastoid air cells buffer the middle ear against the development of negative pressure and acts as an air reservoir, which can be used up during eustachian tube dysfunction. Therefore, well-pneumatized mastoid acts as an alternative aeration channel for middle ear if the ventilatory function of eustachian tube is compromised due to any pathology. The graft uptake rate after type I tympanoplasty is adversely affected by the chronic disease of the middle ear with small mastoid volume.[1]

The long-term success rate of type I tympanoplasty in ears having small mastoid volume and preoperative dysfunction of the eustachian tube are disappointing despite the overall high success rate of type I tympanoplasty.[2]

Both eustachian tube dysfunction and pneumatization of the mastoid is to be taken into consideration while evaluating the effect of mastoid pneumatization on graft uptake in cases of type I tympanoplasty. Hence, we have tried to compare the effect of mastoid pneumatization on surgical outcome of type I tympanoplasty, only in those cases who had good Eustachian tube function.

Aims and objectives

The aim of this study was to assess the outcome of type I tympanoplasty in well pneumatized and sclerotic mastoid in tubo tympanic type of chronic suppurative otitis media (CSOM) in terms of rate of uptake of the graft.


  Materials and Methods Top


The study was conducted in the Department of ENT and Head and Neck Surgery in a Tertiary Care Hospital of Western Uttar Pradesh for a period of 1-year from March 2014 to March 2015. The patients suffering from tubo tympanic CSOM were randomly selected. A total of 80 patients undergoing type I tympanoplasty were divided into two groups. Group I consisting of 45 patients with well-pneumatized mastoid and group II consisting of 35 patients with sclerotic mastoids. The patients were followed up for a period of 1-year for surgical outcome. Well taken up graft after the 1-year period was considered to be successful surgical outcome.

Selection criteria

A total of 80 patients undergoing type I tympanoplasty for tubo tympanic CSOM were randomly selected and included in this study. Only two parameters were taken into consideration that is, pneumatization of the mastoid and moderate sized central perforation of the tympanic membrane so as to avoid any disparity in comparison of the two groups. All the patients had dry ears.

Of the total of 80 patients who had undergone type I tympanoplasty, 45 patients in group I had well-pneumatized mastoid and 35 patients in group II had sclerotic mastoid.

Both the groups were assessed audiologically. Intraoperatively the size, site, shape of the perforation, ossicular chain abnormality and status of the middle ear mucosa was assessed. Eustachian tube function was also assessed preoperatively using valsalva maneuver. It was assured that eustachian tube function was normal in all cases.

All cases with infection and active discharge, ossicular abnormalities, general medical illness such as diabetes, hypertension etc., chronic nasal, nasopharyngeal and sinus diseases, chronic tonsillitis and abnormal eustachian tube function were excluded from this study.

Surgical procedure

Patients undergoing type I tympanoplasty were put on antibiotics, a day before surgery, all the baseline investigations along with preoperative X-ray of the mastoid (Schullers' view) were done. Informed consent was obtained. Patients were operated under local anesthesia with postaural Wildes' incision in all cases. Graft material used was temporalis fascia and underlay grafting was done. Postoperatively antibiotics, decongestants, and nasal drops were continued for 3 days and sutures were removed on the 7th postoperative day. The patients were followed up at 6 weeks, 6 months, and at the end of 1-year, graft uptake was assessed and the results were analyzed statistically.


  Observation and Results Top


In this study a total of 80 patients undergoing type I tympanoplasty were divided into two groups. Group I consisting of 45 patients with well-pneumatized mastoid and group II consisting of 35 patients with sclerotic mastoids [Table 1] and [Figure 1].
Table 1: Mastoid pneumatization rate

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Figure 1: Pattern of mastoid pneumatization

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Eustachian tube function was normal in all cases. It was observed that in 6 (13.3%) cases of group I on 6 month follow-up, there was a pin head size residual perforation which was cauterized with TCA, and healed completely at final follow-up after 1-year. In 9 (25.7%) cases of group II, pinhead residual perforation was seen at 6 months follow-up and in 3 (8.6%) cases at final follow-up. However, all these perforations healed subsequently. So, these cases were taken as successful cases. The rate of graft uptake was compared in both the groups. The patients were followed up at 6 weeks, 6 months and at the end of 1-year. A surgery was considered successful when there was a complete closure of tympanic membrane perforation. The final outcome of the surgery as successful was taken as a fully taken up graft at the end of 1-year.

In Group I, out of 45 cases the graft was successfully taken up in 40 cases (88.8%). In group II, the graft was successfully taken up in 25 cases (71.42%) [Table 2] and [Figure 2]. Of 4 cases in group I and 6 cases in group II in whom the graft take up had failed one and three cases respectively had a middle ear infection. The results were statistically analyzed. No intraoperative or postoperative complication was seen in operative cases in both the groups.
Table 2: Graft uptake rate

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Figure 2: Graft uptake rate among Group I and Group II

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Data were analyzed using Statistical Package for Social Science (SPSS version 16.0, IBM, Chicago) software program for windows. Data were presented as proportions, and Chi-square test was used as to find out the proportion. The P < 0.05 is considered as statically significant. The results were analyzed and were found to be statically significant with χ2 value 3.94 and P = 0.047.


  Discussion Top


The function of mastoid air cells is thought to be of an air reservoir for middle ear cavity which compensates for the volume difference between the openings of the eustachian tube.[3] It has been postulated that the mastoid air cell system is one of the sources for middle ear aeration.[4] Flisberg et al. analyzed the prognosis of chronic middle ear disease with mastoid air cell size for the 1st time.[5] A study was done by bonding also suggested that the reason for unsuccessful tympanomastoidectomy in children depended on mastoid air cell system.[6] In a study by Anderson, it has been found that air cell volume decreases in parallel to chronicity of the middle ear disease which suggests that the presence of otitis media leads to underdevelopment of mastoid air cell volume.[7]

The mean volume of the mastoid air cells was reported to range between 5.8 and 12.2 ml as measured by X-ray and computed tomography scan on healthy ears.[8],[9] On 30 adult cadaver specimen, the mean volume of mastoid pneumatization was found to be 7.59 ± 3.9 ml.[10] It has been studied on the normal growth and development of mastoid air cell system from infancy to adolescence that the decrease mastoid cell development had a definitive role for the development of otitis media and other otological problems.[3] From this, it can be seen that mastoid pneumatization has some bearing on middle ear aeration.

It has been observed that poor tubal function leads to a diminished success rate of tympanoplasty.[11] Nasal, sinus, and nasopharyngeal pathology are also considered to be responsible for eustachian tube dysfunction. The results of this study suggest that mastoid pneumatization probably helps significantly in the aeration of the middle ear. There appears to be a possible association between mastoid pneumatization and graft take up rates probably in the cases in whom eustachian tube function is affected due to pathology in the nasopharynx, because in case of eustachian insufficiency leading to poor aeration of middle ear cleft, mastoid pneumatization helps in providing aeration of the middle ear. It has been repeatedly stressed that a properly aerated middle ear is mandatory for a successful outcome of tympanoplasty. An aerating mastoidectomy is supposed to be beneficial in tympanoplasty procedures with the hope that this will help in aeration of the middle ear.[12] Our results suggest that there was a significant difference in graft uptake rates in well-pneumatized mastoids as compared to sclerotic mastoids. So, it can be concluded that graft uptake rate in cases of tubotympanic CSOM depends also on the condition of the mastoid.


  Conclusion Top


The status of the eustachian tube is important for a favorable outcome of results of tympanoplasty, but mastoid pneumatization also plays a part in the middle ear aeration. We have observed from this study that the results of tympanoplasty type I was better in pneumatized mastoid rather than sclerotic mastoids.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Jackler RK, Schindler RA. Role of the mastoid in tympanic membrane reconstruction. Laryngoscope 1984;94:495-500.  Back to cited text no. 1
    
2.
Holmquist J, Bergström B. The mastoid air cell system in ear surgery. Arch Otolaryngol 1978;104:127-9.  Back to cited text no. 2
    
3.
Lee DH, Shin JH, Lee DC. Three-dimensional morphometric analysis of paranasal sinuses and mastoid air cell system using computed tomography in pediatric population. Int J Pediatr Otorhinolaryngol 2012;76:1642-6.  Back to cited text no. 3
    
4.
Cohen D, Raveh D, Peleg U, Nazarian Y, Perez R. Ventilation and clearance of the middle ear. J Laryngol Otol 2009;123:1314-20.  Back to cited text no. 4
    
5.
Flisberg K, Ingelstedt S, Ortegren U. On middle ear pressure. Acta Otolaryngol Suppl 1963;182:43-56.  Back to cited text no. 5
    
6.
Bonding P. Tympanoplasty in children-when? A preliminary report. Acta Otolaryngol 1988;105:199-201.  Back to cited text no. 6
    
7.
Andréasson L. Correlation of tubal function and volume of mastoid and middle ear space as related to otitis media. Ann Otol Rhinol Laryngol 1976;85:198-203.  Back to cited text no. 7
    
8.
Flisberg K, Zsigmond M. The size of the mastoid air cell system. Planimetry – Direct volume determination. Acta Otolaryngol 1965;60:23-9.  Back to cited text no. 8
    
9.
Colhoun EN, O'Neill G, Francis KR, Hayward C. A comparison between area and volume measurements of the mastoid air spaces in normal temporal bones. Clin Otolaryngol 1988;13:59-63.  Back to cited text no. 9
    
10.
Todd NW, Pitts RB, Braun IF, Heindel H. Mastoid size determined with lateral radiographs and computerized tomography. Acta Otolaryngol 1965;60:23-9.  Back to cited text no. 10
    
11.
Salvinelli F, Casale M, Trivelli M, Greco F. Nasal and hearing impairment: Are they linked? Med Hypotheses 2002;58:141-3.  Back to cited text no. 11
    
12.
Hellström S, Stenfors LE. The original description of Shrapnell's membrane reviewed in the light of recent experimental studies. J Laryngol Otol 1983;97:985-9.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]


This article has been cited by
1 Growth pattern of temporal bone pneumatization: a computed tomography study with consecutive age groups
Pengfei Zhao,Heyu Ding,Han Lv,Jing Li,Xuehuan Liu,Zhenghan Yang,Zhenchang Wang
Surgical and Radiologic Anatomy. 2018;
[Pubmed] | [DOI]



 

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