|Year : 2013 | Volume
| Issue : 2 | Page : 59-61
Our experience with single sitting bilateral myringoplasty
Rajnish Chander Sharma, Munish Saroch
Departments of Otorhinolaryngology and Head and Neck Surgery, Dr. R. P. Government Medical College, Kangra, Tanda, Himachal Pradesh, India
|Date of Web Publication||15-Jun-2013|
Rajnish Chander Sharma
Department of Otorhinolaryngology and Head and Neck Surgery, Deen Dyal Upadhaya Hospital, Shimla 171 001, Himachal Pradesh
Source of Support: None, Conflict of Interest: None
Background: Although bilateral same day myringoplasty scores over unilateral myringoplasty in terms of convenience and conservation of resources, it is rarely performed because of theoretical risk of postoperative sensorineural deafness. Objectives: This study was performed to evaluate single sitting bilateral myringoplasty. Materials and Methods: Twenty five patients (50 ears) opted for single sitting bilateral myringoplasty and underwent mini-endaural and permeatal routes with or without tympanomeatal flap. Other 25 patients (25 ears) opted for unilateral myringoplasty by post auricular route. Temporal fascia was used for graft by underlay technique in all patients. Results and Observations: Perforation closure was successful in 90% ears with single sitting bilateral myringoplasty and in 88% ears in the other group. Post operative assessment of hearing improvement started after 1.5 months in 90% ears of both the groups. None of the patients developed iatrogenic sensorineural hearing loss. Conclusion: Single sitting bilateral myringoplasty by any of conventional routes can be performed in most patients without much discomfort or apprehension of sensorineural hearing loss and results are comparable to that of other methods.
Keywords: Chronic suppurative otitis media, Myringoplasty, Sensorineural deafness, Tympanic membrane perforation
|How to cite this article:|
Sharma RC, Saroch M. Our experience with single sitting bilateral myringoplasty. Indian J Otol 2013;19:59-61
| Introduction|| |
Tympanic membrane (TM) helps in transmission of sound waves to middle ear sound conducting system and any breach in its intactness results in conductive deafness. The perforation of TM is because of chronic suppurative otitis media (CSOM) in a majority of outpatient cases while trauma accounts for only limited number of them.  Bilateral TM perforation is more common as a result of CSOM. Myringoplasty is a simple closure of TM indicated especially when healing does not occur after conservative measures. The closure of TM perforation restores the vibratory area, provides protection to round window, and prevents middle ear from allergens or external infections leading to improved hearing. Conventional myringoplasty is usually performed by post auricular route, per meatal or trans-canal route, per meatal with tympano-meatal flap raised, or mini-endaural route.  Different techniques like underlay, overlay and inlay (sandwich) are used for placing the graft.  The graft material used also varies from vein, fat, conchal cartilage, perichondrium to temporal fascia.  The major advantages of single sitting myringoplasty for bilateral TM perforations include single hospital stay, less expenses or off days from work, decreased waiting period for the surgery, and less morbidity due to anaesthesia or post operative complications.  However, bilateral same day conventional myringoplasty is rarely performed because of a theoretical risk of postoperative sensorineural deafness seen in 1.2-4.5% of cases.  We present here our experience of single sitting bilateral myringoplasty performed on 50 ears and unilateral myringoplasty on 25 ears.
| Materials and Methods|| |
Fifty patients between 20 and 50 years of age having bilateral perforation of TM were enrolled for the study after informed consent. They were divided into 2 groups based on their informed decision. Group-1 comprised of 25 patients who opted for single sitting bilateral myringoplasty on both ears and Group-2 comprised of another 25 patients who opted for unilateral myringoplasty at first visit. All patients were subjected to detailed clinical examination and routine baseline laboratory investigations. The patients having deviated nasal septum, ossicular dysfunction, otitis externa, wet or dry ear for less than 1month and sensorineural or mixed hearing loss were excluded from the study. The patients who were not fit for anesthesia or surgery were also excluded.
Pre operative assessment
A thorough ears, nose and throat examination was carried out in all patients. Size and site of perforation and size of external auditory canal particular for permeatal route were noted after otoscopic examination. Pure tune audiometry and tuning fork test were performed for finding exact level of hearing loss. The patients were operated using 2% xylocaine with adrenaline (1:80000) for local anaesthesia. Buprenorphine (1 mg, I/V slowly) was used for sedation when required in apprehensive patients.
Surgical procedure and follow up
In patients for bilateral myringoplasty two separate routes, mini-endaural and permeatal routes with or without tympanomeatal flap, were used for each ear. The graft material used was temporal fascia harvested from a site anterior and deep to the tragus. Post auricular route was used for unilateral myringoplasty and temporal fascia graft was taken from the same incisional site. The TM was freshened and graft was put by underlay technique supported with gelfoam just near the Eustachian tube More Details opening and over the promontory. After putting the graft, the ear packing with gelfoam was given. Aseptic wound dressing done after surgery was changed on 3 rd day. All patients received antibiotics during postoperative period. Stitches were removed on 7 th day. Ear pack was removed on the 10 th day. All patients were instructed to avoid blowing, sneezing and swimming during the post operative period and were followed up regularly. Repeat audiogram to check the hearing improvement was carried out between 1.5 and 3 months. During follow up all patients were evaluated for level of discomfort, success for graft uptake, sensorineural hearing loss, convenience of trans-canal route, post auricular route and of bilateral myringoplasty.
| Results and Observations|| |
In total, 50 ears were operated in Group-1 using permeatal and mini-endaural techniques for 25 ears each. All 25 ears in Group-2 were operated by post-auriclular route. Immediate post operative period was uneventful in all cases. All patients in Group-1 remained hospitalized for first 10 days and felt inconvenience due to dressing of both ears and decreased hearing due to ear packs. The patients in Group-2 did not require hospitalization for more than a day, they did not report any inconvenience due to dressing but had to re-visit for change of dressing and ear pack removal. The average follow up period was between 6 months and 1 year. Perforation closure was successful in 45 (90%) ears in Group-1 and in the case of other 3 and 2 ears operated by permeatal and mini-endaural techniques respectively, the graft was not taken up successfully. The graft was taken up in 22 (88%) ears in Group 2. The overall successful grafts and post operative assessment of hearing improvement started after 1.5 months in 67 of 75 (90%) ears in the both groups. Hearing improved and the air-bone gap was closed to within 10 dB to 20 dB in them. Iatrogenic sensorineural hearing loss was not observed in any of the patients in both the groups.
| Discussion|| |
The study consists of single sitting bilateral myringoplasty on 50 ears by mini-endaural route in one ear and by permeatal route with or without tympanomeatal flap in other ear. In other 25 ears, where myringoplasty was done in one ear at a time, post auricular route was followed. Graft was put by underlay technique in all cases. The grafts were taken up successfully by majority (88% and 90%), irrespective of the surgical approach used and did not differ in terms of hearing gain; this is commensurate with what is already reported.  This is understandable as the hearing restoration depends on the graft being taken up successfully. Similar observation has been made by Sharma, et al.  as well. Apparently, our patients undergoing bilateral myringoplasty in single sitting felt more discomfort due to dressing, ear packs, and long hospital stay as compared to other patients who underwent surgery on one ear at a time. However, the latter group had uneasiness of revisit after 3-6 months or later for surgery on the second ear. It was also observed by us that some of these patients had dropped out from surgery on other ear apparently for this reason. This puts the patients undergoing bilateral myringoplasty in single sitting at advantage, and the surgeon too has reduced workload of rescheduling surgeries. The post auricular route procedure is occasionally associated with post surgery itching, deformity of pinna, visible scar abnormal, or decreased sensation in post auricular region.  However, the mini-endaural route, permeatal or post auricular route apparently do not differ in terms of hospital stay or hearing gain.
The sensorineural hearing loss does not appear to occur significantly in single sitting bilateral myringoplasty as was once considered;  this was not observed in the present study. This is perhaps due to improved operating techniques and availability of state of art operating microscopes and other instruments. Nevertheless, the possibility of such an event must be explained to the patient before surgery. We feel that single sitting bilateral myringoplasty when indicated can be performed in most patients without much discomfort or apprehension of sensorineural hearing loss and the results are comparable to that of other methods.
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