Indian Journal of Otology

ORIGINAL ARTICLE
Year
: 2020  |  Volume : 26  |  Issue : 1  |  Page : 4--8

Comparative study of tympanoplasty and its outcome in various age groups using the middle ear risk index scale


Sushil Kumar Aggarwal, Reskey Dev 
 Department of ENT, Banaras Hindu University, Varanasi, Uttar Pradesh, India

Correspondence Address:
Dr. Sushil Kumar Aggarwal
Department of ENT, Banaras Hindu University, Varanasi - 221 005, Uttar Pradesh
India

Abstract

Introduction: Otitis media is an important and a highly prevalent disease of the middle ear and poses serious health problem world-wide especially in developing countries where large percentage of the population lacks specialized medical care. With a large number of patients frequently undergoing tympanoplasty for chronic suppurative otitis media (CSOM), it is important to assess the severity of the disease and predict the outcome of the surgical management. Aims and Objectives: To study the efficiency of MERI in predicting the outcome of tympanoplasty in all age-groups. Materials and Methods: A prospective study was carried out in the department of Ear Nose and Throat (ENT), Banaras Hindu University (BHU), Varanasi, where all cases of chronic suppurative otitis media in the age-group of 8–40 years were included from September, 2017 to December, 2018. Total 74 patients with unilateral or bilateral perforation of tympanic membrane were included and these were followed-up for 4 months after surgery. Results: Maximum cases fell under MERI 1-3 (mild disease) and these patients had the best prognosis after tympanoplasty. Patients with unilateral perforation had better success rate as compared to patients with bilateral perforation. Conclusion: Our study showed that myringoplasty is a good treatment modality in the paediatric population and MERI scoring can be useful in predicting the outcome of tympanoplasty in all age-groups.



How to cite this article:
Aggarwal SK, Dev R. Comparative study of tympanoplasty and its outcome in various age groups using the middle ear risk index scale.Indian J Otol 2020;26:4-8


How to cite this URL:
Aggarwal SK, Dev R. Comparative study of tympanoplasty and its outcome in various age groups using the middle ear risk index scale. Indian J Otol [serial online] 2020 [cited 2020 Jun 4 ];26:4-8
Available from: http://www.indianjotol.org/text.asp?2020/26/1/4/278738


Full Text



 Introduction



There are many factors which influence the success rate of tympanoplasty.[1] These include age of the patient, size and site of the perforation, status of the ear (dry or discharging), and the surgical technique, but their real role is still unclear.[2],[3],[4],[5],[6] Therefore, the reported success rate of tympanoplasty is extremely variable, ranging from 35% to 92%.[7],[8] Furthermore, Bluestone et al.[3] considered the postoperative recurrence of negative middle ear pressure or serous effusion as a surgical failure. There is no agreement as to the timing of the procedure.[5] Some authors prefer to perform surgery as soon as possible to prevent disease progression, ossicular chain erosion, and the formation of cholesteatoma, avoid hearing loss in the speech development period, and allow swimming activities.[3],[5],[9],[10] Others prefer to delay the operation because of the high incidence of upper respiratory infections during childhood, unpredictable Eustachian tube function, immature immunity, possible spontaneous healing, and the possibility of preventing recurrent middle ear infection because of the adequate ventilation allowed by tympanic perforation during the period of Eustachian immaturity.[5],[11]

Many previous studies in the literature have found good correlation between middle ear risk index (MERI) developed by Kartush and success of tympanoplasty. MERI scoring can be useful in predicting the outcome of tympanoplasty,[12] with low MERI having a good surgical outcome. Our study is different from previous studies in that we have used MERI in predicting the outcome of tympanoplasty in our cases.

Aims and objectives

The aim and objectives of this study are as follows:

To study MERI and result of tympanoplasty according to the risk categoryTo assess the result of surgical treatment of chronic suppurative otitis media (CSOM) and its relation to MERITo determine if the age of the patient is a factor influencing the success rate of tympanoplasty.

 Materials and Methods



This was a prospective study carried out in the Department of Ear, Nose, and Throat (ENT), Sir Sunder Lal Hospital, Banaras Hindu University (BHU), Varanasi, Uttar Pradesh, India. All cases of CSOM in the age group of 8–40 years attending the Outpatient Department of ENT, BHU, from September 2017 to December 2018, were included in this study. All the cases underwent detailed general physical examination and examination of ENT. The relevant details were recorded, and cases were then subjected to routine investigations along with a battery of otological investigations as follows:

Audiological testsPure-tone audiometry (PTA)Impedance audiometry.OtomicroscopyEustachian tube function assessment by tympanometry.

Preoperative assessment of status of the ear before surgery (quiescent/inactive), Eustachian tube function, and type of hearing loss (conductive/mixed/sensorineural hearing loss) were done and recorded. Risk categories were derived from the MERI scoring chart given below [Table 1], and the severity of the disease was noted. All the patients underwent tympanoplasty under same setup and by the same surgeon using postaural approach and the temporalis fascia as the graft material.{Table 1}

All the patients were followed up every 2 weeks for the 1st month. Thereafter, they were followed up monthly for at least 4 months, during which the assessment of graft uptake by otoscopy, subjective evaluation (hearing, tinnitus, and any other complaints), and repeat PTA and Eustachian tube function assessment was done. These findings were then evaluated and compared with preoperative findings.

Observations

The present study was carried out in 74 patients with unilateral or bilateral perforation of the tympanic membrane (TM). All cases of tubotympanic type of CSOM were included in the study and followed up to 4 months of surgical treatment.

MERI scoring was carried out for all the 74 patients involved in the study, dividing patients into various risk categories, and the result of tympanoplasty according to MERI score was assessed for each case [Table 2].{Table 2}

It was observed that the maximum number of ears (86%) fall under MERI 1–3, i.e., mild disease followed by (14%) the ears with MERI score of 4–6, i.e., moderate disease. None of the patients were present in MERI score of 7–12 [Table 2].

On comparing the results of tympanoplasty, it was observed that the ears which fall under the risk category of MERI 1–3 (mild disease) had the best result (91%) followed by MERI 4–6 (moderate disease) (60%). P value was considered statistically significant (P = 0.008).

Type I tympanoplasty was carried out in 62 patients aged between 8 and 40 years [Table 3]. Of 15 students who were under <10 years age, graft was intact in 13 patients, i.e., success rate was 87% and 2 (13%) had graft failure. Similarly, of 47 patients who were under more than 10 years of age, 42 had intact graft, i.e., success rate was 89% and 5 (11%) had perforation. The overall success rate in these two groups was 55 of 62, i.e., 89%. P value was not statistically significant (P = 0.77).{Table 3}

Preoperative and postoperative audiometric patterns of 62 patients with healed graft were compared, and the amount of air-conduction (AC) gain achieved was noted [Table 4]. It was observed that the maximum number of ears, i.e., 36 (58%) achieved AC gain of ≥10 db. There was no statistically significant association between age and postoperative AC gain ≥10 db (P = 0.86).{Table 4}

Forty-seven of the 74 patients (63%) had a discharging ear. Surgery was successful in 43 (91%) of these cases and in 21 (78%) of the 35 patients with dry ears [Table 5]. P value was not statistically significant (P = 0.09).{Table 5}

Forty-nine of the 74 patients had unilateral and 18 had bilateral perforations [Table 6]. The surgical success rate was 92% in the former and 78% in the latter group (P = 0.11).{Table 6}

 Discussion



CSOM is defined as chronic inflammation of the middle ear and mastoid mucosa with TM perforation. Generally, patients with tympanic perforations which continue to discharge mucoid material for 6 weeks–3 months despite medical treatment are recognized as CSOM cases.[13],[14] Patients suffering from CSOM of tubotympanic type with permanent perforation are handicapped not only because of hearing loss but also from recurrent otorrhea. CSOM produces mild-to-moderate conductive hearing loss in more than 50% of cases. In children, louder auditory stimuli is required than adults to perform optimally, and hence, CSOM in children inhibits language and cognitive development.[15],[16]

The concept of surgical repair of TM perforation was started by Berthold in 1878,[17] with a thick skin graft by overlay technique. Repairing of the TM by performing tympanoplasty may lead to considerable benefits on patients with TM perforations. These benefits include the prevention of ear infections and aural discharge, improvement in hearing, ease of hearing aid usage, and elimination of the need to take water precautions when bathing or swimming.[18],[19] In addition, tympanoplasty has been suggested to protect against long-term middle ear damage by preventing the progression of ossicular pathology and preventing the migration of squamous epithelium around the margins of the perforation with possible consequent cholesteatoma formation.[20]

This study was conducted on 74 patients of CSOM, and they were evaluated for graft uptake and hearing improvement according to the age and MERI scale. Furthermore, efficacy of MERI scale to determine the success of surgical outcome after tympanoplasty was also evaluated. In our study, majority of patients were in the age group of 11–30 years (75%). In a study conducted by Hussain,[21] 66% of patients belonged to the age group of more than 25 years. Patient age has generally been considered as influencing surgical outcome, but the data reported in the literature are equivocal. Several authors in the literature have found better success with advancing age;[22],[23],[24],[25],[26] but, other authors have reported no significant correlation between age and surgical outcome. The former result may be due to the lower incidence of upper airway infections and better Eustachian tube function in later age and the relative immaturity of the immune system in younger children. We found no statistical difference in the success rate between our two age groups, a result that is in line with many author findings.[27],[28],[29],[30],[31] This may have been due to the fact that our patients were aged 8 years or more and were thus probably unaffected by the inefficient tube function observed in children under the age of 7.

In our study, majority of patients were males (55%), similar to the study conducted by Hussain,[21] in which 58.4% were males and 41.6% were females. Most of our patients presented with chief complaints of ear discharge (96%), similar to other studies done by Sheahan et al.[19] (in which ear discharge was present in 64% of patients) and Yazdi et al.[32] (ear discharge was present in 90% of cases).

Similarly, we found no significant association between discharging ear and success of graft intake. Forty-seven cases (64%) had ear discharge at the time of presentation, but 91% of patients with discharging ear had successful outcome after surgery. P= 0.09 was not significant. Many studies in the literature done by Albera et al.,[27] Onal et al.,[33] and Chandrasekhar et al.[34] found that otorrhea had no effect on the success of tympanoplasty. In our study also, cases with otorrhea most probably got improved due to better antibiotic and antihistaminic treatment given before and after the surgery.

In our study, 73% cases had unilateral perforation and 27% cases had bilateral perforation. The success rate was 92% in our cases with unilateral disease and 78% in those with bilateral perforation, without any statistical correlation. Our study showed that there is no association between contralateral TM perforation and success of tympanoplasty in the operated ear. The discrepancy between our results and other studies done by Denoyelle F et al.[35] and Kessler A et al,[24] which stated that a pathological contralateral ear independently influences the risk of graft failure, was not seen in our cases, as our patients did not show any inflammatory change in the contralateral ear.

In our study, 71 of 74 patients had conductive hearing loss, i.e., 96%, while 4% patients had mixed hearing loss. Of 71 patients of conductive hearing loss, 49% had mild conductive hearing loss and 45% had moderate conductive hearing loss.

In our study, 64 patients that are staged into MERI 1–3, i.e., mild disease had a graft acceptance rate of 91%, while of 10 patients having moderate disease, i.e., MERI 4–7, 60% had intact graft postoperatively. P value was highly significant, i.e., 0.008. Hence, there was a strong statistical relationship between MERI grading and successful tympanoplasty. Similar results were seen in the study by Nishant et al.[12] They found that ears that was staged MERI 1–3 had a graft acceptance rate of 86% and ears having severe disease, i.e., MERI 7–12 had 100% chance of graft rejection. As the MERI score goes on increasing, there are more chances of graft rejection. Thus, it can be concluded that MERI score can be useful in predicting the outcome of tympanoplasty. As our study did not include severe MERI, i.e., 7–12, more studies should be done on such cases to assess the prognosis after tympanoplasty.

In our study, we have taken postoperative AC gain more than 10 db in the speech frequency of 250 Hz–4KHz as audiological success (this was in accordance with the guidelines delineated by the Committee on Hearing and Equilibrium of the American Academy of Otolaryngology–Head and Neck Surgery for the evaluation of results for the treatment of conductive hearing loss). It was observed that maximum number of ears (36, i.e., 58%) achieved AC gain of ≥10 db, while in other studies, this has been achieved to a level of 54%–78% when averaged over the frequency range of 250 Hz–4 KHz. There was no significant association between age and audiological outcome after successful type I tympanoplasty. In our study, a successful graft uptake produced a reduction in the air-bone gap of between 10-30 dB. Type I tympanoplasty gave good postoperative air-bone gap closure, with a gain of over 10 db in over 62% of cases. These results are comparable to that reported by Packer et al.[36] and Tos,[37] where average 12 db postoperative hearing improvement was seen in 60% of cases.

 Conclusion



Our study showed that tympanoplasty is a valid treatment modality for TM perforations in all age groupsMERI scoring can be useful in predicting the outcome of tympanoplasty in all age groupsThe evidence of a good audiological result in anatomically successful cases is associated with a highly probable return to normal function and lifestyle at any age.

Financial support and sponsorship

Nil.

Conflicts of interest

Dr. Sushil Kumar Aggarwal takes the responsibility for the integrity of the content of the paper. I also declare that this manuscript hasnot been submitted to any other journal for publication.

References

1Adkins WY, White B. Type I tympanoplasty: Influencing factors. Laryngoscope 1984;94:916-8.
2Juantegui M, Garin P, Gersdorff M. Myringoplasty: Anatomical and functional results with a three years follow up. Rev Laryngol 1994;115:45-8.
3Bluestone CD, Cantekin EI, Douglas GS. Eustachian tube function related to the results of tympanoplasty in children. Laryngoscope 1979;89:450-8.
4Manning SC, Cantekin EI, Kenna MA, Bluestone CD. Prognostic value of eustachian tube function in pediatric tympanoplasty. Laryngoscope 1987;97:1012-6.
5Blanshard JD, Robson AK, Smith I, Maw AR. A long term view of myringoplasty in children. J Laryngol Otol 1990;104:758-62.
6MacDonald RR 3rd, Lusk RP, Muntz HR. Fasciaform myringoplasty in children. Arch Otolaryngol Head Neck Surg 1994;120:138-43.
7Bluestone CD, Cantekin EI, Douglas GS. Eustachian tube function related to the results of tympanoplasty in children. Laryngoscope 1979;89:450-8.
8Yoon TH, Park SK, Kim JY, Pae KH, Ahn JH. Tympanoplasty, with or without mastoidectomy, is highly effective for treatment of chronic otitis media in children. Acta Otolaryngol Suppl 2007;(558):44-8.
9Podoshin L, Fradis M, Malatskey S, Ben-David J. Type I tympanoplasty in children. Am J Otol 1996;17:293-6.
10Raine CH, Singh SD. Tympanoplasty in children. A review of 114 cases. J Laryngol Otol 1983;97:217-21.
11Albu S, Babighian G, Trabalzini F. Prognostic factors in tympanoplasty. Am J Otol 1998;19:136-40.
12Kumar N, Madkikar NN, Kishve S, Chilke D, Shinde KJ. Using middle ear risk index and et function as parameters for predicting the outcome of tympanoplasty. Indian J Otolaryngol Head Neck Surg 2012;64:13-6.
13Kenna MA. Treatment of chronic suppurative otitis media. Otolaryngol Clin North Am 1994;27:457-72.
14Goycoolea MV, Hueb MM, Ruah C. DeWnitions and terminology. Otolaryngol Clin North Am 1991 24:757-61.
15Teele DW, Klein JO, Chase C, Menyuk P, Rosner BA. Otitis media in infancy and intellectual ability, school achievement, speech, and language at age 7 years. Greater boston otitis media study group. J Infect Dis 1990;162:685-94.
16Teele DW, Klein JO, Rosner BA. Otitis media with effusion during the first three years of life and development of speech and language. Pediatrics 1984;74:282-7.
17Berthold E. Myringoplastik zeitschrift fur. Ohernheilkunde 1978;12:134.
18Fisch U, May J. editors. Tympanoplasty, Mastoidectomy and Stapes Surgery. New York: Thieme; 1994.
19Sheahan P, O'Dwyer T, Blayney A. Results of type 1 tympanoplasty in children and parental perceptions of outcome of surgery. J Laryngol Otol 2002;116:430-4.
20Tos M, Lau T. Stability of tympanoplasty in children. Otolaryngol Clin North Am 1989;22:15-28.
21Hussain A. Outcome of Myrinoplasty. J Postgrad Med Inst Peshawar 2004;18:695-8.
22Smyth GD. Toynbee memorial lecture 1992: Facts and fantasies in modern otology: The ear doctor's dilemma. J Laryngol Otol 1992;106:591-6.
23Kotecha B, Fowler S, Topham J. Myringoplasty: A prospective audit study. Clin Otolaryngol Allied Sci 1999;24:126-9.
24Kessler A, Potsic WP, Marsh RR. Type 1 tympanoplasty in children. Arch Otolaryngol Head Neck Surg 1994;120:487-90.
25Emir H, Ceylan K, Kizilkaya Z, Gocmen H, Uzunkulaoglu H, Samim E, et al. Success is a matter of experience: Type 1 tympanoplasty: Influencing factors on type 1 tympanoplasty. Eur Arch Otorhinolaryngol 2007;264:595-9.
26Kumar S, Acharya A, Hadjihannas E, Panagamuwa C, McDermott AL. Pediatric myringoplasty: Definition of “success” and factors affecting outcome. Otol Neurotol 2010;31:1417-20.
27Albera R, Ferrero V, Lacilla M, Canale A. Tympanic reperforation in myringoplasty: Evaluation of prognostic factors. Ann Otol Rhinol Laryngol 2006;115:875-9.
28Caylan R, Titiz A, Falcioni M, De Donato G, Russo A, Taibah A, et al. Myringoplasty in children: Factors influencing surgical outcome. Otolaryngol Head Neck Surg 1998;118:709-13.
29Merenda D, Koike K, Shafiei M, Ramadan H. Tympanometric volume: A predictor of success of tympanoplasty in children. Otolaryngol Head Neck Surg 2007;136:189-92.
30Umapathy N, Dekker PJ. Myringoplasty: Is it worth performing in children? Arch Otolaryngol Head Neck Surg 2003;129:1053-5.
31Vartiainen E, Nuutinen J. Success and pitfalls in myringoplasty: Follow-up study of 404 cases. Am J Otol 1993;14:301-5.
32Karimi YA, Saedi B, Fayezizadeh M, Seifmanesh H. Association between audiometric profile and intraoperative findings in patients with chronic suppurative otitis media. Iran J Otorhinolaryngol 2011;23:63.
33Onal K, Uguz MZ, Kazikdas KC, Gursoy ST, Gokce H. A multivariate analysis of otological, surgical and patient-related factors in determining success in myringoplasty. Clin Otolaryngol 2005;30:115-20.
34Chandrasekhar SS, House JW, Devgan U. Pediatric tympanoplasty. A 10-year experience. Arch Otolaryngol Head Neck Surg 1995;121:873-8.
35Denoyelle F, Roger G, Chauvin P, Garabedian EN. Myringoplasty in children: Predictive factors of outcome. Laryngoscope 1999;109:47-51.
36Packer P, Mackendrick A, Solar M. What's best in myringoplasty: Underly or overlay, dura or fascia? J Laryngol Otol 1982;96:25-41.
37Tos M. Results of tympanoplasty. Acta Otolaryngol 1973;75:286-7.