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ORIGINAL ARTICLE
Year : 2019  |  Volume : 25  |  Issue : 2  |  Page : 81-84

A comparative study of microscopic myringoplasty and endoscopic myringoplasty in patients with mucosal type of chronic otitis media


Department of ENT, NRI Medical College and General Hospital, Guntur, Andhra Pradesh, India

Date of Web Publication16-Aug-2019

Correspondence Address:
Dr. Vijaya Sundaram Sundararajan
Department of ENT, NRI Medical College and General Hospital, Mangalagiri, Chinakakani, Guntur, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/indianjotol.INDIANJOTOL_67_18

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  Abstract 


Background: Conventionally, over the decades, myringoplasty had been done using an operating microscope. Earlier endoscopes were used mainly for diagnostic and documentation purposes only. Currently, they are becoming popular in otological surgeries. Hence, this study aims to compare the outcome of endoscopic myringoplasty and microscopic myringoplasty in patients with inactive mucosal type of chronic otitis media (COM). Methods: This is a prospective comparative study done in a rural tertiary health-care (NRI Medical College and General Hospital) center from March 2016 to March 2018 after obtaining clearance from the Institutional Human Ethics Committee. Eighty patients underwent myringoplasty; they were block randomized into forty each for microscope and endoscope assisted. The results of surgery were compared at the end of 6 months postsurgery. Results: The hearing gain between the two study groups was not statistically significant (P = 0.36). The average duration in microscopic myringoplasty was 82.25 ± 10.8 min and in endoscopic myringoplasty was 56.43 ± 8.6 min, and this difference was statistically significant (P = 0.00). The graft success rate in both the groups was the same. The postoperative complications in both groups was not statistically significant (P = 0.49). Conclusions: Endoscopic myringoplasty is more advantageous than microscopic myringoplasty in terms of duration of surgery, cost of the instrument, and better magnification. As it is a one-hand-held technique and requires experience, microscopic myringoplasty is still the most-accepted procedure performed. Hence, both microscopic myringoplasty and endoscopic myringoplasty are equally effective in the treatment of COM.

Keywords: Endoscope, micro, microscope, myringoplasty


How to cite this article:
Sundararajan VS, Prabhakar Rao YS, Stephenson BR. A comparative study of microscopic myringoplasty and endoscopic myringoplasty in patients with mucosal type of chronic otitis media. Indian J Otol 2019;25:81-4

How to cite this URL:
Sundararajan VS, Prabhakar Rao YS, Stephenson BR. A comparative study of microscopic myringoplasty and endoscopic myringoplasty in patients with mucosal type of chronic otitis media. Indian J Otol [serial online] 2019 [cited 2019 Nov 13];25:81-4. Available from: http://www.indianjotol.org/text.asp?2019/25/2/81/264674




  Introduction Top


Chronic otitis media (COM) is defined as chronic inflammation of the mucoperiosteal lining of the middle ear cleft.[1] It causes persistent ear discharge and leads to progressive deafness. The patient can develop intracranial and extracranial complications.[1]

Poor socioeconomic status, illiteracy, overcrowding, and poor hygiene are all factors which play an important role in this disease.[2] The prevalence surveys estimate that the global burden of illness from COM involves around 65–330 million individuals with draining ears.[3] Over 90% of the burden is borne by countries in the South-East Asia and Western Pacific regions, Africa, and several ethnic minorities in the Pacific Rim. Among this, India was found to have the highest prevalence (around 7.8%).[3]

If the tympanic membrane (TM) is dry or inactive for 3–6 months, myringoplasty can be performed. Commonly, temporalis fascia is used for grafting because of its availability in proximity and its thickness is similar to that of normal TM.[4] One other added advantage is its low basal metabolic rate.

Conventionally, over the decades, myringoplasty has been done using an operating microscope.[5] Middle ear endoscopy was first introduced by Mer et al. in 1967, but it was mainly used for diagnostic and photographic purposes.[6]

Recently, their uses in otological procedures are becoming popular, and the surgical success of endoscopic-assisted myringoplasty ranges between 80% and 100%. The endoscope has better magnification and field of view: the whole tympanic ring and ear canal at the same time. This provides a complete view of the middle ear space, TM, and ear canal without the need for continuous repositioning of the patient's head and the microscope.[7] Even though it is as effective as an operating microscope, it has its own flaws. Endoscopes are held with the nondominant hand of the surgeon which restricts the surgeon to one-hand-held technique.

This study aimed to compare the outcomes of endoscopic myringoplasty and microscopic myringoplasty in patients with dry perforation over a period of 2 years.


  Methods Top


This was a prospective comparative study done on patients with COM attending the Department of Otorhinolaryngology, NRI Medical College and General Hospital, from March 2016 to March 2018. The study was approved by the Institution of Human Ethics Committee, and informed consent was obtained from each participant.

This study included patients with inactive mucosal type of COM with demonstrable degree of conductive hearing loss between 18 and 60 years of age. Patients with active mucosal disease, otomycosis, otitis externa, mixed hearing loss, upper respiratory tract infection, and recurrent cases and patients who were not fit for general anesthesia were excluded from the study.

Patients attending the Outpatient Department of ENT from March 2016 to March 2018 fulfilling the inclusion and exclusion criteria were block randomized and allotted into two groups. Group A were cases being operated by microscopic-assisted myringoplasty and Group B were cases being operated by endoscopic myringoplasty. The sample size was calculated to be eighty. Forty cases each were allotted to both the groups. Under GA, all patients were operated for myringoplasty with microscope or endoscope with temporalis fascia graft using endaural transcanal approach.[1],[4],[5].

Microscopic myringoplasty

The patient was positioned in supine position with the affected ear up infiltraton containing 2% lidocaine hydrochloride and 1:100000 epinephrine was given post –aurally and in the temporal region and in the external auditory canal. Temporalis fascia gaft was harvested. Freshening of the edges of the perforation was done using a sickle knife or an angled pick, which broke the adhesions between outer epithelial layer and inner mucosal layer. Then Rosen's transcanal incision was made from 12'o clock to 6'oclockposition which was extended further and tympanomeatal flap was elevated up to annulus. Elevation of annulus and incision of middle ear mucosa was done and the flap was pused anteriorly till the handle of mallcus was visible. Skeletonisation of handle of malleus was done. Then grafting was performed by underlay technique, medial to handle of malleus. Gel foam was kept and tympanometal flap was repositioned. Finally ointment and gel foam was placed in external auditory canal.

Endoscopic myringoplasty

The patient was positioned in supine position with the affected ear up Infliltration containing 2% lidocaine hydrochloride and 1:100000 epinephine. Transcanal injections were administred in all 4quadrqants using a 26-gauge needle under direct endoscopic view. Rigid endoscopes (Karl Storz) were used in our surgical techniques (4.0 –mm. 0°,18-cm-long lens) given post –aurally and in the temporal region and in the external auditory canal. Temporalis fascia graft was harvested. After being prepared 2mm larger than the perforation size, the graft was placed in an underlay manner. Absorbable gelatin sponge pledgets soaked with antibiotic drops(Ofloxacin ear solution, 0.3%) were placed lateral to the graft in the external auditory canal.

Patients attending the ENT and HNS outpatient department with the chief complaints of ear discharge and hearing impairment were screened. Those patients more than 18 years of age with dry central perforation of the TM and willing for surgery were included in the study after taking written and informed consent.

Size of the perforation was determined according to the number of quadrants it occupied. Tuning fork tests were done to determine the type and degree of hearing loss. Further, the patient was subjected to basic preoperative blood investigations. Pure tone audiometry (PTA) was done as per the method outlined by the American Speech and Hearing Association. Air-bone gap at frequencies 500 Hz, 1 KHz, and 2 KHz was noted, and hearing loss was calculated by taking the average of three. Plain X-ray of both mastoids' Law's view was taken. Further clinical examination was conducted using examination under microscope. After obtaining anesthetic clearance, the patients were taken up for underlay myringoplasty surgery.

Endoscopic myringoplasty was performed in 40 patients using a 0°, 17-cm long, 4-mm wide Hopkins' rog rigid endoscope. Microscopic myringoplasty was performed in 40 patients. Duration of surgery, outcome with respect to hearing gain, and graft success rate of both surgeries were followed up to postoperative period of the 6th month, and PTA was done at the 3rd and 6th postoperative months, respectively.


  Results Top


This study included eighty patients: 30 males and 50 females. The distribution of males and females in both groups is depicted in [Figure 1]; the distribution of age in the study population is depicted in [Figure 2].
Figure 1: Gender distribution

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Figure 2: Age distribution

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Preoperative hearing loss

The patients who underwent microscopic myringoplasty had an average of 33.63 ± 4.2 decibels hard of hearing by PTA. Among the patients who underwent endoscopic myringoplasty, the mean hearing loss was 34.25 ± 19.1 decibels. The difference was not statistically significant.

Postoperative hearing gain

Among the patients who underwent microscopic myringoplasty, the postoperative PTA mean was 19.95 ± 6.2 decibels. The mean postoperative PTA among patients who underwent endoscopic myringoplasty was 19.11 ± 6.6 decibels. The average hearing gain in microscopic myringoplasty was 13.69 ± 7.1 decibels and among endoscopic myringoplasty was 15.09 ± 6.7 decibels [Table 1]. This difference among the hearing gain between two study groups was not statistically significant (P = 0.36).
Table 1: Postoperative hearing gain among the study groups

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Duration of surgery

The average duration in microscopic myringoplasty was 82.25 ± 10.8 min, and the mean duration in endoscopic myringoplasty was 56.43 ± 8.6 min [Table 2]. This difference was statistically significant (P = 0.00).
Table 2: Duration of surgery

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Graft success rate

The graft in microscopic myringoplasty was taken up in 34 patients and failed in six patients with a success rate of 85% [Table 3]. In endoscopic myringoplasty, graft was taken up successfully in 36 patients and failed in four patients with a success rate of 90%. Hence, the difference in the graft uptake was not statistically significant between the study groups (P = 0.49).
Table 3: Graft uptake rate

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Postoperative complications

In microscopic myringoplasty, 90% of patients had no complications and remaining 10% of patients had recurrent infections in the postoperative period [Table 4]. Whereas, in endoscopic myringoplasty, 95% of patients had no complaints, but 5% of patients had recurrent infections in the postoperative period.
Table 4: Postoperative complications

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  Discussion Top


In our study, we have compared endoscopic-assisted and microscopic-assisted myringoplasty in cases of inactive mucosal type of COM.

From our study, we have concluded that, between the two study groups, the postoperative hearing gain was similar and the difference was not statistically significant (P = 0.36).

In our study, we also studied the postoperative graft uptake rate between both the groups. Microscopic-assisted myringoplasty had a success rate of 85% whereas endoscopic-assisted myringoplasty had a success rate of 90%.

Another observation made from our study is the duration of surgery between both the groups. In microscopic-assisted myringoplasty, the average duration of surgery was 82.25 ± 10.8 min and, in endoscopic-assisted myringoplasty, the duration of surgery was 56.43 ± 8.6 min. This difference was statistically significant (P = 0.00). This can be explained due to the time taken to focus each structure to be visualized during surgery in case of microscopic-assisted myringoplasty. There are no studies done till date which compares the duration of surgery between two groups.

We also found that, among Group A, 10% of the patients had recurrent infections and 90% had nil complications and among, Group B, 95% of the patients had nil complications. This difference was also not significant.

Hence, from our study, we report that both endoscopic myringoplasty and microscopic myringoplasty are equally effective in the treatment of COM and the surgery can be chosen on the comfort of the operating surgeon.

The strengths in our study are it is a prospective comparative study and all the advantages and disadvantages between both the groups were studied.

Limitations in our study are small sample size and long-term follow-up was not done.


  Conclusions Top


  • Endoscopic myringoplasty is more advantageous than microscopic myringoplasty in terms of duration of surgery, cost of the instrument, better magnification, and versatility
  • Since the nondominant hand is used to hold the endoscope, only one hand is available for surgery, which restricts the surgeon
  • Microscopic myringoplasty surgery has the luxury of using two-handed technique, which provides better precision and an easier learning-curve. Thereby, it is still the most-accepted procedure performed
  • Hence, both microscopic myringoplasty and endoscopic myringoplasty are equally effective in the treatment of COM.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Shambaugh GE. Chronic suppurative otitis media. Arch Otolaryngol Head Neck Surg 1930;12:753-9.  Back to cited text no. 1
    
2.
Acuin J. Chronic suppurative otitis media. BMJ Clin Evid 2007;2007. pii: 0507.  Back to cited text no. 2
    
3.
World Health Organization. Chronic Suppurative Otitis Media: Burden of illness and Management Options. Geneva 27, Switzerland: World Health Organization; 2004.  Back to cited text no. 3
    
4.
Raj A, Meher R. Endoscopic transcanal myringoplasty-A study. Indian J Otolaryngol Head Neck Surg 2001;53:47-9.  Back to cited text no. 4
    
5.
El-Guindy A. Endoscopic transcanal myringoplasty. J Laryngol Otol 1992;106:493-5.  Back to cited text no. 5
    
6.
Shambaugh GE, Glasscock ME 3rd, Gulya AJ, Minor LB, Poe DS. Surgery of the Ear. Shelton, Ct.: Peoples Medical Publishing House-USA; 2010.  Back to cited text no. 6
    
7.
Tarabichi M. Endoscopic middle ear surgery. Ann Otol Rhinol Laryngol 1999;108:39-46.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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