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ORIGINAL ARTICLE
Year : 2016  |  Volume : 22  |  Issue : 3  |  Page : 171-176

Retrospective evaluation of the surgical result of tympanoplasty for inactive chronic otitis media and comparison of endoscopic versus microscopic tympanoplasty


Department of ENT, M.S. Ramaiah Medical College, Bengaluru, Karnataka, India

Date of Web Publication8-Aug-2016

Correspondence Address:
Dr. Rajiv Ranganath Sanji
85, 6th Cross, AG's Layout, New BEL Road, Bengaluru - 560 054, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-7749.187973

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  Abstract 

Context: The evaluation of techniques of middle ear surgery is fraught with difficulty due to varieties of surgical technique and several confounding factors. Although endoscopic middle ear surgery has been described in English literature for decades, there are limited data comparing surgical result with microscopic tympanoplasty as highlighted by recent systematic reviews of literature. Aims: (1) To evaluate the surgical result of tympanoplasty only for patients with inactive chronic otitis media of mucosal type in our institution. (2) To compare the surgical result obtained by endoscopic tympanoplasty with postaural approach microscopic tympanoplasty. Settings and Design: This retrospective study carried out in M.S. Ramaiah Hospitals, Bengaluru, Karnataka, India. Materials and Methods: Retrospective study of the inpatient and outpatient records of patients with inactive chronic otitis media operated by a single surgeon from May 2010 to September 2015. Statistical Analysis Used: Chi-square test was used to compare the qualitative results and Student's t-test was used to compare quantitative results with a level of significance of P= 0.05. Results: A total of 44 ears in 42 patients were analyzed. There were 16 ears operated by transcanal endoscopic method, and 28 ears operated by postaural microscopic post method. The operative time was significantly less (difference of means 16.2 min) for endoscopic versus microscopic approach. Primary transcanal endoscopic superior flap tympanoplasty had statistically comparable surgical success with postaural microscopic anterior vascular strip tympanoplasty (92.9% vs. 88.5%).Discussion: In this retrospective study, by appropriate case selection, we have attempted to reduce the factors which may confound the result of tympanoplasty, such as the use of ancillary procedures such as cortical mastoidectomy. The transcanal endoscopic and postaural microscopic approach as practiced by us had similar outcomes. We found reduced operative time for transcanal endoscopic approach to tympanoplasty. Conclusions: Tympanoplasty alone for inactive chronic otitis media of mucosal type is an effective primary treatment option. Transcanal endoscopic approach is surgically as effective as postaural microscopic approach and may be associated with reduced operative time. Additional evaluation is required for revision cases and for comparing the audiometric result.

Keywords: Chronic otitis media, Endoscopic tympanoplasty, Microscopic tympanoplasty, Tympanoplasty


How to cite this article:
Sanji RR, Channegowda C, Patil SB. Retrospective evaluation of the surgical result of tympanoplasty for inactive chronic otitis media and comparison of endoscopic versus microscopic tympanoplasty. Indian J Otol 2016;22:171-6

How to cite this URL:
Sanji RR, Channegowda C, Patil SB. Retrospective evaluation of the surgical result of tympanoplasty for inactive chronic otitis media and comparison of endoscopic versus microscopic tympanoplasty. Indian J Otol [serial online] 2016 [cited 2019 Sep 19];22:171-6. Available from: http://www.indianjotol.org/text.asp?2016/22/3/171/187973


  Introduction Top


There is abundant literature about surgery for chronic otitis media. Still, the evaluation of tympanoplasty for mucosal type of chronic otitis media is fraught with difficulty due to several confounding factors, some of which are as follows.

Usefulness of cortical mastoidectomy with tympanoplasty has been evaluated by many studies which describe varying utility of cortical mastoidectomy. A few systematic reviews of literature and prospective studies with large number of participants have demonstrated no particular difference in success rates with or without tympanoplasty.[1],[2],[3],[4]

There has been variation of results reported when tympanoplasty is performed for dry ears (inactive chronic otitis media) and wet ears.[5],[6] Surgeon experience and training are likely to affect the result of tympanoplasty.[7]

Variation of surgical technique used for tympanoplasty may affect the result. Some techniques previously studied include underlay or overlay graft placement;[8] type of canal incisions – tympanomeatal flap used anteriorly based, superiorly based or multiple flap,[9] placement of vascular strip incisions in postaural approach;[10] use of no canal incision techniques such as simple underlay myringoplasty.[11] It has been stated that meticulous use of techniques rather than the type of technique is important.[12]

There are several materials used for grafting in tympanoplasty, cartilage and temporalis fascia are commonly used graft materials. Previous studies indicate possibility of difference of surgical result with the type of graft material used.[13],[14]

Approach to the middle ear and the instruments and techniques used decide the site and length of incisions and extent of surgical dissection; these may influence postoperative pain scores and healing.[15] Transcanal tympanoplasty can be performed with both microscope and endoscope, but postaural approach is traditionally used with microscopic ear surgery.

Endoscopy in middle ear surgery has been described since several years, and endoscopes have been used for surgery of chronic otitis media since more than two and half decades.[16],[17],[18] Endoscopes have been predominately used as an observational adjunct to the microscope to improve visualization of the tympanic cavity,[19] but recent reports utilize the endoscope exclusively during surgical dissection.[14],[20] A systematic review of endoscopic ear surgery reports that data comparing patient outcomes following the use of an operative endoscope versus a microscope for tympanoplasty are lacking.[21]

Several factors may confound the comparison of endoscopic tympanoplasty with microscopic tympanoplasty such as varying equipment, techniques, materials, surgeon experience, and adjunctive procedures with tympanoplasty.

Reports with the use of varying types of equipment: for example, the use of narrow field and narrow diameter endoscopes in previously described studies has complicated the perception of the use of endoscopy in middle ear surgery.[22] At present, narrow diameter but wide angle endoscopes are preferred due to better visualization in narrow and tortuous external auditory canals.[23]

Considering many confounding factors previously described, it was difficult to apply the available results of previous studies regarding the surgical result of tympanoplasty to our institution. It was difficult to decide about effectiveness of tympanoplasty alone as a surgical treatment of inactive mucosal chronic otitis media. There was difficulty in comparing the result of endoscopic and microscopic tympanoplasty. Therefore, to generate information regarding the surgical result of microscopic and endoscopic tympanoplasty for chronic otitis media in dry ears after the elimination of all feasible confounding factors, this retrospective study was done. The aims of the study were:

  1. To evaluate the surgical result of tympanoplasty only for patients with inactive chronic otitis media of mucosal type in our institution
  2. To compare the surgical result obtained by transcanal endoscopic tympanoplasty with postaural approach microscopic tympanoplasty.



  Subjects and Methods Top


Setting

M.S. Ramaiah Hospitals: which are urban tertiary care hospitals in close proximity with each other and having the same quality of equipment for tympanoplasty.

Design

This was a retrospective study of inpatient and outpatient records.

Inclusion criteria

  1. Patients with inactive chronic otitis media (dry ear)
  2. Operated by the first author
  3. Tympanoplasty done between May 2010 and September 2015.


Exclusion criteria

  • Cortical mastoidectomy or mastoid antrotomy done with tympanoplasty
  • Case sheets unavailable.



  Materials and Methods Top


Surgical method

For the postaural microscopic tympanoplasty group, surgery was done with a Carl Zeiss Opmi Movena or Leica microscope. A modified Wilde incision was used from few millimeters cranial to the mastoid tip till the root of the helix, with dissection in layers. Periosteum was incised in a “T” shaped manner, and the annular ligament was exposed and dissected. Two-handed surgery then proceeded. The edges of the perforation were freshened, and any tympanosclerotic plaque was removed by microdissection and elevation of the epithelial layer of the tympanic membrane. Vascular strip was elevated posteriorly, and an anteriorly based tympanomeatal flap was prepared and elevated until anterior to the lateral process of the malleus. In case of inadequate anterior remnant, anterior tucking was done by tunneling in the anterior canal skin anterosuperiorly. Where required, curettage of the scutum and canalplasty were done to visualize the incudostapedial joint. After checking ossicular chain mobility and round window reflex, wet temporalis fascia graft was placed in an underlay fashion medial to the handle of malleus; middle ear and canal packing were done with gelfoam. Hemostasis was achieved with monopolar diathermy in the postaural tissue and with adrenaline (1:10,000) soaked gelatin foam in the middle ear. Postaural wound closure was done in layers.

For the transcanal endoscopic tympanoplasty group, surgery was done with Karl Storz of diameter 4 mm, length 18 cm wide angle Hopkins 2 Nasal telescope. Temporalis fascia graft was harvested from a small supra-aural hairline incision. The single-handed surgical technique was used, and no endoscope holder was used for this study. A superiorly based tympanomeatal flap was elevated by after a horizontal canal incision about 3–4 mm from the annulus extending from about 10o clock to 2o clock positions. The flap was elevated till the neck of the malleus. None of the cases required curettage to visualize the incudostapedial joint. Middle ear preparation by washing and placement of gelfoam was done. Underlay wet graft placement was done with an appropriately sized graft, and flap was replaced followed by packing the canal with gelatin foam. Diathermy was used only in the graft site; hemostasis in the middle ear was achieved with adrenaline (1:10,000) gelfoam pledgets.

All cases were operated under general anesthesia. Operative time was calculated from the time of incision to the time of closure; anesthesia induction and extubation time not included in the study.

Follow-up

Both groups received perioperative antibiotic cover with a cephalosporin and postoperative antibiotic cover extending up to 2 weeks with ciprofloxacin. Suture removal and canal toileting were done after 7th postoperative day. Valsalva maneuvre was not advised postoperatively.

Postoperative follow-up was done for a minimum of 2 months. Postsurgical healing was defined by complete closure of perforation with no gaping, and a vascularized and epithelialized graft seen with otoscopy.

Statistical analysis used

Chi-square test was used to compare the qualitative results and Student's t-test was used to compare quantitative results with a level of significance of P = 0.05. Statistical analysis was done with LibreOffice Calc version 5.0.2.2 (The Document Foundation, Berlin) with inbuilt statistical formulae.

Ethical considerations

The procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional or regional) and with the Helsinki Declaration of 1975 as revised in 2000.

No experimentation or procedures on animals were done in this study.

For this type of study, formal consent and Ethics Committee clearance are not applicable.


  Results Top


A total of 44 ears in 42 patients were analyzed. There were 16 ears operated by transcanal endoscopic method (ET group), and 28 ears operated by postaural microscopic post method (MT group).

The age range of the patients was from 7 years to 65 years [Figure 1]. There was no significance to the difference of the means of age in both the groups (34.63 years for ET group vs. 27.68 years for the MT group; t = 1.49, P = 0.16).
Figure 1: Age distribution of the patients in both groups

Click here to view


The ET group had eight ears in males and eight ears in females and the MT group had 12 ears in males and 16 ears in females. There was no significant difference in the gender distribution of both the groups (χ2 = 0.21, P = 0.65).

In the ET group, eight ears were right and eight ears were left; the MT group had 14 right and left ears each. There was no significant difference in the operated side between the groups.

Perforations were classified into small (≤ one quadrant of pars tensa), medium (one to two quadrants of pars tensa), large/subtotal (>2 quadrants of pars tensa), and multiple perforation for the purpose of analysis. The distribution of perforation sizes in both the groups is shown in [Figure 2]; there was no significant difference in the distribution of various perforation sizes with both the groups (χ2 = 0.1.06, P = 0.0.79).
Figure 2: The distribution of perforation sizes in both groups

Click here to view


Seven ears in the ET group had a myringosclerotic patch which was excised, whereas six in the MT group had myringosclerosis which was excised. The difference was not statistically significant (χ2 = 2.43, P = 0.12).

The mean operative time for the ET group was 78.13 min and for the MT group was 94.38 min. The difference was statistically significant (t = −2.95, P = 0.0099).

Although the operative time was more when myringosclerosis was present with both the groups, (difference in mean operative time with ET was 8.42 min and MT group was 9.14 min) statistical significance of difference of mean operative time could not be established between myringosclerotic ear and nonmyringosclerotic ear for each group.

There were two ears with revision surgery in each group, and the remaining were primary surgeries.

Among the primary tympanoplasties, 13 of 14 ears in the ET group had a closure of the perforation of the tympanic membrane (92.9% surgical success), whereas 23 of 26 ears in the MT group showed closure of the perforation (88.5% surgical success). There was no statistical difference in the closure rate of perforations between the two groups (χ2 = 0.1954, P = 0.66).

Of the two ears in the MT group which were revision surgeries, both tympanic membranes underwent reperforation in the postoperative period; of the two revision surgeries in the ET group, one perforation closed completely, whereas the other tympanic membrane had a reperforation. The overall success rate (primary + revision) for the ET group was 87.5%, and for the MT group was 82.14%. The difference was not statistically significant (χ2 = 0.22, P = 0.64).

The overall success rate for primary tympanoplasty for inactive chronic otitis media at our institution was 90% (36 healed out of 40 tympanic membranes); and 84.1% (37 of 44) for primary with revision cases.

Of the reperforations which occurred, in the ET group, both of them were in the inferior part of the neotympanum, whereas in the MT group, four were anterior and one was anterosuperior [Figure 3].
Figure 3: Location of reperforation in both groups

Click here to view


In the MT group, one ear had posterosuperior flap bulging in the postoperative period which was managed with gelfoam repacking, and two ears had granulations in the external auditory canal which were managed with topical antibiotic-steroid drops. In one ear of the ET group, the inferior part of the flap was found displaced laterally during the first follow-up. It was repositioned, and canal packing with gelfoam was done; it closed without perforation.


  Discussion Top


Our study showed a surgical success rate for primary tympanoplasty for inactive chronic otitis media of 90%, which is in concordance with other published surgical success rates.[16]

Primary transcanal endoscopic superior flap tympanoplasty had statistically comparable surgical success as postaural microscopic anterior vascular strip tympanoplasty (92.9% vs. 88.5%). These results are comparable with other reported studies and reviews.[16],[21],[22]

There was significantly less operative time (difference of means 16.2 min) for endoscopic versus microscopic approach as described in this paper. This reduction of operative time may be attributed with smaller incision and minimal dissection with transcanal endoscopic tympanoplasty as compared to postaural microscopic tympanoplasty. Middle ear pathology like myringosclerosis may increase the operative time, but there was no significant difference with both groups.

The number of revision surgeries in this study was very small (four); hence, it was not feasible to get reliable data regarding revision tympanoplasty.

Although the number of canal complications in both groups was low, we did not find granulations in the external auditory canal in the endoscopic tympanoplasty group. We speculate that this may be due to limited canal skin elevation, dissection, and minimal bone exposure.

Among the cases with surgical failure (reperforation/residual perforation), the MT group had perforations in the anterior/anterosuperior quadrant, whereas the ET group had perforations located inferiorly. The grouping of reperforations in particular areas may suggest specific technical difficulties with each technique and that meticulous technique rather than type of technique is important to avoid surgical failure as has been suggested elsewhere. The difficulty of each technique may be identified, and solutions should be sought to improve the success rate.

We did not analyze audiometric outcomes in our study because of short duration of follow-up documented. A well planned and prospective study is preferable to analyze the audiometric outcomes. Considering the use of same graft material (temporalis fascia) for all our cases and technique (underlay placement), we do not anticipate significant differences in success between audiometric outcomes and surgical result – however, appropriate evaluation is required.

Graft site scarring and healing were not evaluated in this study. It is logical that a smaller incision and limited dissection may produce better scarring and less postoperative pain; these have been documented in the previous studies.

There are several confounding factors to be taken into account while evaluating the results of tympanoplasty. As much as possible, to avoid confounding factors, our study included only inactive chronic otitis media of mucosal type, tympanoplasty only and excluded ears where cortical mastoidectomy was done. All surgeries were performed by a single surgeon and surgical technique, instrumentation and anesthesia were maintained uniformly as described. Identification and elimination of confounding factors to avoid bias of results will improve future studies.

As our study was a nonrandomized retrospective analysis, it is possible that unanticipated or uncorrectable bias and selection bias may have affected the result. Better statistical conclusions will be obtained with a prospective study and with larger sample sizes.


  Conclusion Top


Tympanoplasty alone for inactive chronic otitis media of the mucosal type is an effective primary treatment option. Transcanal endoscopic approach is as effective as postaural microscopic approach and may be associated with reduced operative time. Additional evaluation is required for revision cases and also for comparing audiometric result.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3]


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