|Year : 2018 | Volume
| Issue : 3 | Page : 148-156
Evaluation of the hearing results after mastoidotympanoplasty operation with or without ossiculoplasty: A percentage change versus absolute change; a different methodology
Produl Hazarika1, Seema Elina Punnoose1, John Victor1, Joyse Zachariah1, Mrinmoy Hazarika2
1 Department of ENT, NMC Specialty Hospital, Abu Dhabi, UAE
2 University of Chicago Booth School of Business, Chicago, USA
|Date of Web Publication||11-Jan-2019|
Dr. Produl Hazarika
Department of ENT, NMC Specialty Hospital, P. O. Box 6222, Abu Dhabi
Source of Support: None, Conflict of Interest: None
Purpose: Our article provides a comprehensive review of parameters of percentage change of the results regarding the documented hearing results (not based on any particular classification) in ear surgeries in chronic suppurative otitis media (CSOM) cases. Materials and Methods: Our series is a prospective cohort observational study in 230 cases of CSOM from 2009 to 2016 wherein we have evaluated the hearing improvement with a parameter of percentage change of hearing improvement between preoperative and postoperative period in various types of ear surgeries. Statistics and Results: A statistically significant difference was seen in 4 out of the 14 surgical groups, namely, in mastoidotympanoplasty, modified radical mastoidectomy (MRM), and MRM with tympanoplasty and in tympanoplasty. The rest of the 10 surgical groups had <10 cases, and therefore, the P significance could not be determined; however, these groups still showed hearing improvement. Conclusion: The superiority of the surgical techniques such as mastoidotympanoplasty, MRM, MRM with tympanoplasty and in tympanoplasty as demonstrated in our study aims to find an ideal surgical procedure in CSOM which gives the best chance to improve or preserve the hearing with complete eradication of the disease.
Keywords: Chronic suppurative otitis media, hearing result, mastoidotympanoplasty, percentage change of hearing
|How to cite this article:|
Hazarika P, Punnoose SE, Victor J, Zachariah J, Hazarika M. Evaluation of the hearing results after mastoidotympanoplasty operation with or without ossiculoplasty: A percentage change versus absolute change; a different methodology. Indian J Otol 2018;24:148-56
|How to cite this URL:|
Hazarika P, Punnoose SE, Victor J, Zachariah J, Hazarika M. Evaluation of the hearing results after mastoidotympanoplasty operation with or without ossiculoplasty: A percentage change versus absolute change; a different methodology. Indian J Otol [serial online] 2018 [cited 2019 Mar 21];24:148-56. Available from: http://www.indianjotol.org/text.asp?2018/24/3/148/249867
| Introduction|| |
Chronic suppurative otitis media (CSOM) has always been a subject of active speculation with differences in opinion and controversies regarding its surgical techniques and approaches including the use of optical instruments, graft materials, and various types of prosthesis during ossicular reconstruction. Hearing preservation and hearing improvement along with eradication of disease process in a single sitting surgery have always been an ideologically preferred process for all the otologists alike. This idea of improvement in hearing has led to innovations in the methods of surgical treatment with the emergence of myriad of conflicting opinions including questioning the superiority of endoscopic approach versus microscopic approach.
Tympanoplasty has revolutionized the treatment of CSOM. Hundreds of variations of surgical techniques both major and minor with their expected results of hearing have been described in recent literature. Controversies have been raised at every step of the operation from incision to the material used for packing to the use of endoscope and microscope. No less confusing are the statistics published by the various authors. Different methods have been adopted by various authors to report the pure tone audiometric postoperative hearing results. However, there is no general consensus among the authors regarding the standard criteria for reporting of hearing results.
In the present series, we attempt to present our experience with the different types of surgeries for advanced CSOM with disturbed middle ear sound transmission system which combines a high probability for eradication of the disease with the modest preservation and improvement in hearing status. The principal feature of this method entails microscopic endaural or postaural approach with canalplasty and combination of different mastoid surgeries and use of different types of prosthesis. Improvement of hearing in our series has been expressed as a percentage change versus absolute change; a different methodology was adopted by our coauthor from the University of Chicago Booth School of Business who discussed with an apt example as to why percentage change is better appreciated than absolute change in statistical analysis of postoperative hearing results.
| Materials and Methods|| |
Our present study period ranges from 2009 to 2016 and consists of 230 cases selected from a total of 300 operated cases of CSOM. The rest of the cases could not be included in this study because data of the postoperative hearing status could not be retrieved from the file. All the patients who had deafness up to 55 dB were of the conductive deafness type. Patients with >55 dB had mixed hearing loss but with an air-bone gap. Patients having a pure sensorineural hearing loss with CSOM were not included as part of this series as they were operated with the main objective of achieving a dry ear only. All the cases were operated in the Department of ENT of NMC Specialty Hospital in Abu Dhabi, UAE, by a team of surgeons headed by the senior author with an international standard surgical technique. Steps of the surgical procedure have not been discussed here and it is beyond the scope of our present studies.
The surgical procedures were grouped as 14 different surgical subgroups as modified radical mastoidectomy (MRM), MRM with incus [Figure 1], tympanoplasty with Applebaum [Figure 2], MRM with tympanoplasty, mastoidotympanoplasty, myringoplasty, mastoidotympanoplasty with tragus, tympanoplasty with partial ossicular replacement prosthesis (PORP), tympanoplasty with titanium [Figure 3]a, [Figure 3]b, [Figure 3]c, Tympanoplasty, tympanoplasty with incus, combined approach tympanoplasty (CAT) [Figure 4], MRM with tympanoplasty with Teflon Piston, tympanoplasty with total ossicular replacement prosthesis (TORP) was done for patients having cholesteatoma in attic, antrum, mastoid cavity with evidence of ossicular destruction but having mostly the attic perforation wherein either temporalis fascia or tragal perchondrium was used as graft material.
|Figure 2: Applebaum prosthesis in-between the partially destroyed long process of incus and stapes head|
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|Figure 3: (a) showing the titanium prosthesis (b) Another titanium prosthesis in a different patient (c) computed tomography temporal bone scan of titanium implant in position in right ear|
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Mastoidotympanoplasty was done in patients having mostly mucosal disease in middle ear and attic without any ossicular chain abnormality. All the cases were selected for the planned surgical procedure after meticulous clinical examination with clear-cut clinical diagnosis of tubotympanic and atticoantral type of CSOM with conductive or mixed hearing loss. All the patients had dry ear and have undergone various investigations such as otoendoscopy, audiogram, X-ray PNS, X-ray mastoid, and computed tomography (CT) scan of temporal bone before surgery. The first postoperative audiogram was done 1 month after the surgery, and the difference between the mean preoperative and postoperative pure tone averages across the frequencies of 0.5 1, 2 and 4 KHz were analyzed. Cases that have a documented hospital record of postoperative audiograms have been included in this study. Our patients were mostly migratory expatriates, few of them did not return for a postoperative audiogram.
Based on the age of the patients, they have been grouped into buckets of <18, 18–25, 26–35, 36–45, 46–55, 56–65, and >65. All the cases in our study who were having deafness of up to 55 dB have purely conductive deafness whereas patients having deafness above 55 dB were of mixed hearing loss but having an air-bone gap of minimum 10 dB and above.
The approach and type of surgical procedure were decided after detailed evaluation and findings as per clinical examinations, audiogram, CT temporal bone scan findings, and most importantly patient compliance.
MRM with incus was done in patients having cholesteatoma in the middle ear, attic, and antrum with destruction of stapes superstructure and destruction of long process of incus, where patients own incus (autoincus) was used to fix between malleus handle and stapes footplate.
MRM with tympanoplasty with no ossicular abnormality but having >30dB hearing loss.
Myringoplasty was done in patients who had small-to-moderate size central perforation with findings of well-pneumatized mastoid in CT temporal bone scan having deafness 30 dB or less.
Mastoidotympanoplasty with tragus was done in patients having middle ear disease with incudostapedial dislocation, or erosion where tragal cartilage was used as a bridge.
Tympanoplasty was done in patients having pure middle ear disease with large central perforation with hearing loss >30 dB and with no ossicular defects.
CAT was done in patients having minimal cholesteatoma or cholesterol granuloma in attic and antrum with well-pneumatized mastoid in the opposite ear on CT temporal bone scan.
Tympanoplasty with Teflon was done in patients having a mucosal disease with complete absence of stapes superstructure and long process of incus where in the Teflon piston was fixed from neck of malleus to footplate of stapes.
Tympanoplasty with Applebaum prosthesis, tympanoplasty with PORP, tympanoplasty with titanium prosthesis and tympanoplasty with TORP were done in patients having cholesterol granuloma and granulation tissue with absent stapes superstructure and long process of incus.
All the patients of the mastoidtympanoplasty group have routinely undergone a canalplasty with widening of the aditus through mastoidotomy or lateral atticotomy.
| Statistics and Results|| |
Results have been plotted in different tables.
[Table 1] and [Graph 1] shows types and number of surgical procedures performed and its average percentage change of hearing loss (postoperative versus preoperative). [Table 2] and [Graph 2] shows types and number of cases with the percentage of change of hearing comparing preoperative and postoperative period. [Table 3] and [Graph 3] shows the laterality of the surgical procedures, its number with percentage change in hearing improvement. [Table 4]a and [Table 4]b represents the standard deviation of the procedures showing variation in average percentage improvement of hearing loss as well as stable average percentage hearing change. [Table 5] and [Graph 4] shows male versus female average preoperative and postoperative hearing and average of percentage change in hearing in the postoperative period, respectively. [Table 6] and [Graph 5] shows that the age of the patients that have been grouped in to the buckets of below 18, 18–25, 26–35, 36–45, 46–55, 56–65, and 65 and above along with their average of preoperative and postoperative hearing loss including percentage change of hearing in the postoperative period.
| Discussion|| |
Mastoidotympanoplasty operation has been performed with a single aim of achieving a dry ear status with improvement or preservation of hearing in patients suffering from CSOM who have an adequate cochlear reserve. Although tympanomastoid surgery has been widely discussed in various forums; emphasis was mostly on surgical techniques and methods. The hearing results after various surgical procedures were eminently debatable because different methods have been used by different authors to report the postoperative pure tone audiometric results in middle ear surgery in the literature.
The parameters most often used to report postoperative hearing results in major series are the mean hearing gain, postoperative hearing level, and air-bone gap or sometimes described as hearing gain exceeding 10 or 20 dB, as diminution of the air-bone gap within 10, 15, 20, or 30 dB,, or attainment of social hearing. The committee on conservation of the American Academy of Ophthalmology and Otolaryngology recommended stating the mean hearing gain in the range of 500–2000 Hz, a reduction of air-bone gap to 10 dB and less, 20 dB and less and 30 dB and less, as well as any deterioration of conductive hearing for reporting the hearing results. The American Otosclerosis study group recommended that hearing improvement could be best estimated by observing the degree of closure of the air-bone gap and the best way of assessing the improvement in a series of cases is by the percentage closure of air-bone gap.
In the present series, we are analyzing our results with average of percentage change of hearing loss and improvement in our cases during preoperative and postoperative period along with comparison of age, sex, and different surgical techniques. Significance testing has been done when there were >10 observations. Preoperative and postoperative hearing loss numbers were run through a paired sample t-test. P < 0.05 was considered to be statistically significant.
Mastoidotympanoplasty was done in 100 cases in the present series who had an average preoperative hearing loss of 48.2 dB and an average postoperative hearing loss of 32.6 dB. Average percentage change of postoperative versus preoperative hearing loss was –31.0%, with a standard deviation of 16.8%. The improvement in hearing is statistically significant. These 100 cases of CSOM have central perforation with middle ear as well as mastoid mucosal disease with an intact ossicular chain.
MRM was done in 14 cases in those who had attic perforation with cholesteatoma in attic and mastoid with intact ossicular chain. The average preoperative hearing loss in this group was 46.5 dB, and average postoperative hearing loss was 37 dB. Average percentage change of postoperative versus preoperative hearing loss was – 21.7%, with a standard deviation of 14.3%. The improvement in hearing is statistically significant.
MRM tympanoplasty was done in 19 cases of those who had central perforation with granulation and cholesteatoma involving middle ear and mastoid with an intact ossicular chain. In these cases, the perforated ear drum was grafted with either a temporalis fascia graft or tragal perichondrium after clearing the ossicular chain from granulations and cholesteatoma. The average preoperative hearing loss in this group was 49.5 dB and average postoperative hearing loss was 32.8 dB. Average percentage change of postoperative versus preoperative hearing loss was –32.3%, with a standard deviation of 14.5%. The improvement in hearing is statistically significant.
Tympanoplasty was done in 56 cases in patients who had moderate-to-large size central perforation with minimal or no middle ear disease with an average preoperative hearing loss of 48.3 dB. Average postoperative hearing loss was 35.7 dB. Average percentage change of postoperative versus preoperative hearing loss was –26.1%, with a standard deviation of 17.3%. The improvement in hearing is statistically significant.
In the present series, out of 14 subgroup of surgical procedures only above four groups could be analyzed for statistical significance because other groups had <10 cases. However, mean hearing gain in these subgroups was substantial and comparable as shown in [Table 2]. It is also acknowledged in literature that postoperative hearing results are often unsatisfactory in patients with advanced ossicular lesions who had ossiculoplasty.,
In a comparative study of 760 tympanoplasties, Proctor analyzed the results, comparing the same with the MRM with tympanoplasty and radical mastoidectomy. According to him, Type 1 and Type 2 showed the best results and relatively poor results in Type 3 because of extensive destruction of the middle ear structure particularly the mucosal lining. Type 4 tympanoplasty gave unsatisfactory results. In another study of 26 cases of tympanoplasty showed remarkable improvement in postoperative hearing result with significant gain, least was 8.8 dB, and maximum was 13.7 dB.
Laterality of the operation in present series showed 119 in the left ear and 117 in the right ear and hearing improvement was better in left ear with average percentage change of hearing loss of –27.5% [Table 3]. No definitive cause could be attributed to explain this except probably the ease of working in our operating room setup.
Our series composed of 185 males and 95 female patients. Hearing improvement was statistically significant in both genders as shown in [Table 4]. In a larger series of 730 cases in 1971, they found 454 (62.9%) males and 276 (37.8%) females. Similar studies in 1965 and in 1970 males outnumbered the females. Our patient's age varied from below 18 years to above 65 years with maximum number of cases in the 36–45 bucket (70 cases). Hearing improvement in all the major age buckets were statistically significant. Lee and Schuknecht opined that age has no effect on the results of mastoidotympanoplastic surgery, if cochlear reserve is normal.
Improvement in hearing has been expressed as a percentage change ([post-pre]/pre × 100) vs. absolute change (post-pre). Expressing as a percentage change allows us to compare improvement in hearing across procedures. For example, the [Table 7] shows results from the two procedures: mastoidotympanoplasty and mastoidotympanoplasty tragus. If we look at just the absolute change, mastoidotympanoplasty tragus looks like the procedure with the best improvement in hearing, i.e., it has reduced the hearing loss by 16.3 dB, whereas the other procedure has reduced hearing loss by only 15.6 db. However, the percentage change of hearing loss is the right metric to use because it normalizes the different levels of preoperative and postoperative hearing loss across procedures. As per the percentage change, mastoidotympanoplasty is actually the procedure that brought about the best improvement in hearing, i.e., the hearing loss reduced by 31% whereas the hearing loss in the other procedure only reduced by 29.9%.
| Conclusion|| |
Since the early days, we have encountered a clinical dilemma in the application of various surgical techniques to deal with CSOM. It indeed becomes difficult to claim any single treatment to be unique but requires a combination of surgical procedures to achieve the goal of hearing improvement to our satisfaction. The results obtained from our current series shows that mastoidotympanoplasty which includes canalplasty, lateral atticotomy, mastoidotomy with or without ossiculoplasty is an ever-evolving procedure and can be used as a treatment of choice for improvement or preservation of hearing along with the eradication of disease.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]