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Year : 2016  |  Volume : 22  |  Issue : 1  |  Page : 28-30

Smoking and its influence on success of tympanoplasty: A prospective study

Department of ENT, People’s College of Medical Science and Research Centre, Bhopal, Madhya Pradesh, India

Date of Web Publication16-Feb-2016

Correspondence Address:
Leena Jain
Department of ENT, People’s College of Medical Science and Research Centre, Bhopal - 462 037, Madhya Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0971-7749.176565

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Objective: To compare the surgical outcome of tympanoplasty in smokers and nonsmokers. Design: Prospective cohort study. Setting: Tertiary Care Center in Central India. Patients: The study included 245 male patients who underwent type 1 tympanoplasty and were subsequently divided into 2 groups. Group A: Nonsmokers (115 patients). Group B: Smokers (130 patients). All the cases were operated by postaural route and underlay technique. Revision cases and patients with systemic disease were excluded from the study. Main Outcome Measures: The success rate and hearing gain at the last follow-up i.e., 6 months from the day of surgery. Results: The overall success rate of tympanoplasty in our study is 91.3% in nonsmokers and 73% in smokers. Most of the patients were in the age group 15–30 years. Smokers had significantly longer duration of complaints associated with chronic suppurative otitis media. Preoperatively, eustachian tube dysfunction was assessed by tympanometry and it showed a significant difference in both the operated and the nonoperated ears of smokers. Sclerosis in X-ray mastoid Schuller's view was seen more in smokers than in nonsmokers (P = 0.001). There was a significant difference in otomicroscopic findings of smokers and nonsmokers i.e. more patients with grade 3 and 4 pars tensa retractions in the contralateral ear (P = 0.0001). Mean gain in the postoperative air-bone gap was significantly more in nonsmokers as compared to smokers (P = 0.013). Conclusion: Smoking is a definitive risk factor in the success of tympanoplasty in terms of graft take up and hearing gain.

Keywords: Eustachian tube dysfunction, Hearing outcome, Smoking, Tympanoplasty

How to cite this article:
Jain L, Qureshi S, Maurya A, Jadia S, Jain M. Smoking and its influence on success of tympanoplasty: A prospective study. Indian J Otol 2016;22:28-30

How to cite this URL:
Jain L, Qureshi S, Maurya A, Jadia S, Jain M. Smoking and its influence on success of tympanoplasty: A prospective study. Indian J Otol [serial online] 2016 [cited 2021 Jul 28];22:28-30. Available from: https://www.indianjotol.org/text.asp?2016/22/1/28/176565

  Introduction Top

Chronic suppurative otitis media (CSOM) is a long-standing infection of part or whole of middle ear cleft and it is still one of the most common ear diseases in developing countries. Many factors are being implicated for tubotympanic type of CSOM including patient factors, surgeon factors, and environmental factors and all these are changing from time to time. Surgery is the mainstay of treatment for CSOM with permanent perforation. The goal of successful tympanoplasty is to create a sound conducting mechanism in a well-aerated mucosal middle ear cleft.[1]

Cigarette smoking changes mucus quality, quantity and causes ciliated cell destruction in the middle ear and eustachian tube (ET).[2] Tobacco smoke is a well-known etiological factor of laryngeal, bronchogenic carcinoma, atherosclerotic heart disease, and seems to affect the success of tympanoplasty also. The relationship between active smoking and middle ear disease has not been studied thoroughly and it lacks the proper data. Hence, this study was undertaken to assess the preoperative disease ear status, postoperative graft taken up, and hearing gain in smokers in comparison to nonsmoker.

  Material and Methods Top

The present prospective cohort study was carried out from May 2013 to March 2015 in the Department of ENT in Tertiary Care Center in central India among the male patients who underwent type 1 tympanoplasty with or without cortical mastoidectomy. Out of 245 patients, 130 were smokers and 115 were nonsmokers. The patients who are currently smoking and had the habit for more than 5 years were considered as the smokers in the study. Informed consent was taken from each patient prior to the study. Ethical clearance was obtained from Institutional Ethical Committee.

All the patients were subjected to thorough clinical and audiological evaluation. Radiological examination by X-ray mastoid (Schuller's view) was done for each case. Patients of age 15–50 years and with dry permanent central perforation were taken into the study. Preoperative tympanometry to assess ET function in both the groups was done for each patient. The results were recorded and evaluated depending on the graft take up and hearing gain at 6-month follow-up.

Statistical analysis was done using Statistical Package of Social Science (SPSS Version 19; Chicago Inc., USA). Data comparison was done by applying specific statistical tests i.e., Chi-square test and unpaired Students “t”-test to find out the statistical significance of the comparisons. Quantitative variables were compared using mean values and qualitative variables using proportions. Significance level was fixed at P < 0.05.

  Results Top

All the 245 male patients who underwent type 1 tympanoplasty were divided into two groups, the smokers and nonsmokers. In this study 130 (53.06%) patients were smokers and 115 (46.93%) were nonsmokers. The mean age of the patients was 24.3 years standard deviation (SD) ±10.63 [Table 1]. All the patients had main complaints of ear discharge and hearing loss with complaint of hearing loss being more common in smokers (19.2%). The study showed highly significant difference (P = 0.001) in the radiological and otomicroscopic findings of smoker and nonsmokers. Sclerosis of mastoid, grade 3 and 4 retractions, and tympanosclerotic patches were significantly more associated in smokers. There was highly significant difference in the ET function of two groups (P = 0.001).
Table 1: Demographic distribution of study subjects

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ET dysfunction was present in 38.5% of smokers as opposed to 8.7% in nonsmoker. Type B and C curve in tympanometry of contralateral ear was significantly (P = 0.001) more in smokers [Table 2]. The study also showed that preoperatively most of the patients (42.3%) in smoking group had hearing loss in the range 31–40 dB, whereas 34.7% nonsmoker had hearing loss in 21–30 dB. This signifies more severe disease in smoker as compared to nonsmoker [Table 3].
Table 2: Eustachian tube function of disease and contralateral ear among nonsmoker and smokers

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Table 3: Preoperative hearing loss among nonsmoker and smokers

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There is significant (P = 0.013) gain in the postoperative air-bone gap in nonsmokers as compared to smokers, mean value being 12 SD ± 9.5 dB and 9.34 SD ± 6.7 dB, respectively [Figure 1]. The study showed highly significant difference (P = 0.001) in the graft take up rate of smokers as compared to nonsmokers. The failure rate of tympanoplasty was 8% in nonsmokers as against 27% in smokers [Figure 2].
Figure 1: Mean postoperative AB gap gain among nonsmoker and smokers

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Figure 2: Postoperative disease ear status among nonsmoker and smokers

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  Discussion Top

CSOM is still the most common ear disease in developing countries such as India. Surgical success or outcome of tympanoplasty has many prognostic factors implicated such as low socioeconomic background, age, comorbid condition, surgical skill, and ET dysfunction.[3] Our study showed that there was a negative influence on the surgical outcome of tympanoplasty in smokers as compared to nonsmokers.

In 2009, Kaylie et al.[4] in their study found that smokers have significantly worse chronic disease and hearing outcome as compared to nonsmokers. In our study, also overall graft take up rate in smokers is 73% as against 91.3% in nonsmokers. This finding was also shared by a similar study by Becvarovski and Kartush in 2011.[1] They found delayed surgical failure in 20% of nonsmokers compared with 60% of smokers (P = 0.050).

The preoperative ET function is considered an important predictive factor for the result of tympanoplasty.[5] A study conducted by Dubin et al. in 2002, ET dysfunction after tobacco smoke exposure was found to be a causative factor in developing otitis media.[6] In our study, ET dysfunction was significantly more in smoker in both diseased and contralateral ear (P = 0.001), but proper data is lacking to assess ET dysfunction as an independent variable in smokers for the success of tympanoplasty.

In our study, there is statistically significant difference in the mean postoperative air-bone gap gain among smokers 9.34 ± 6.7 dB as compared to nonsmokers 12 ± 9.5 dB. Similar findings were also seen in the study by Swain et al. in July 2011,[7] they showed an average gain in nonsmokers being 20 dB and 16 dB in smokers.

Smoking changes mucus quality, quantity and causes ciliated cell destruction and abnormalities in ciliary function in the middle ear and the ET. The potential vasoconstrictor effects of nicotine may have compromised vascular supply to the graft,[8] the combination of these factors may increase the chance of failure significantly higher in smoking group as compared to the nonsmoking group.

  Conclusion Top

CSOM is still the most common presentation in ENT outpatient department and outcome of tympanoplasty is the main cause of worry to any ENT surgeon. Many factors are implicated in the success of tympanoplasty, and we found smoking as an important risk factor, it not only affects healing of perforation but also ET function and hearing outcome. Thus, we recommend the patients to quit smoking in pre- and post-operative period to have better surgical outcomes. More number of long-term and big scale studies are required to prove smoking as one of the definitive prognostic factors.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Becvarovski Z, Kartush JM. Smoking and tympanoplasty: Implications for prognosis and the Middle Ear Risk Index (MERI). Laryngoscope 2001;111:1806-11.  Back to cited text no. 1
Gulya AJ. Environmental tobacco smoke and otitis media. Otolaryngol Head Neck Surg 1994;111:6-8.  Back to cited text no. 2
Lin YC, Wang WH, Weng HH, Lin YC. Predictors of surgical and hearing long-term results for inlay cartilage tympanoplasty. Arch Otolaryngol Head Neck Surg 2011;137:215-9.  Back to cited text no. 3
Kaylie DM, Bennett ML, Davis B, Jackson CG. Effects of smoking on otologic surgery outcomes. Laryngoscope 2009;119:1384-90.  Back to cited text no. 4
Sato H, Nakamura H, Honjo I, Hayashi M. Eustachian tube function in tympanoplasty. Acta Otolaryngol Suppl 1990;471:9-12.  Back to cited text no. 5
Dubin MG, Pollock HW, Ebert CS, Berg E, Buenting JE, Prazma JP. Eustachian tube dysfunction after tobacco smoke exposure. Otolaryngol Head Neck Surg 2002;126:14-9.  Back to cited text no. 6
Swain SK, Samal R, Pani SK. Effect of smoking on outcome of tympanoplasty. Indian J Otol 2011;17:220-2.  Back to cited text no. 7
Furey SA, Schaanning J, Spoont S, Birkhead NC. The comparative effects on circulation of smoking tobacco and lettuce leaf cigarettes. Angiology 1967;18:218-23.  Back to cited text no. 8


  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3]

This article has been cited by
1 What Effect Does Smoking Have on the Surgical Closure of Tympanic Membrane Perforations? A Review
Vikranth Visvanathan,Vamsidhar Vallamkondu,Sanjiv K. Bhimrao
Otology & Neurotology. 2018; 39(10): 1217
[Pubmed] | [DOI]


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