|Year : 2020 | Volume
| Issue : 2 | Page : 71-74
Study on use of platelet-rich plasma in myringoplasty
Fayis Mohammed Anwar, Vijendra S Shenoy, Panduranga M Kamath, Suja Sreedharan, D Deviprasad, Haneesh Amit Domah
Department of ENT and Head and Neck Surgery, Kasturba Medical College, Mangalore Manipal Academy of Higher Education, Karnataka, India
|Date of Submission||30-Oct-2018|
|Date of Decision||21-Feb-2020|
|Date of Acceptance||04-Mar-2020|
|Date of Web Publication||17-Jul-2020|
Dr. Vijendra S Shenoy
Department of ENT and Head and Neck Surgery, Kasturba Medical College, Manipal Academy of Higher Education, Mangalore, Karnataka
Source of Support: None, Conflict of Interest: None
Aim: This study aims to analyze the use of autologous platelet-rich plasma (PRP) to improve graft uptake and benefit on hearing after myringoplasty. Objectives: The objective is to compare pre- and post-operative graft uptake and audiological benefit following myringoplasty with and without PRP. Materials and Methods: A total of 70 patients diagnosed with chronic suppurative otitis media tubotympanic type were divided into groups of 35 each. Patients in group one who underwent myringoplasty with PRP while in second group underwent myringoplasty without PRP. Pre- and post-operative graft status and pure tone audiometry were performed for all the patients, and the outcomes were compared. Results: Of 35 patients in each group; four in the study group and eight in the control group had residual perforation. Graft uptake in case group was 88.57% and graft uptake in the control group was 77.1%. Result was better in cases that underwent myringoplasty with PRP. Of 35 patients in case group, audiological improvement (>10 dB) was seen in 31 patients (88.57%), whereas in the control group of 35 patients, 27 (77.1%) had audiological benefits. Conclusion: This study shows there is a definite benefit using PRP in myringoplasty. As the PRP can be easily prepared, PRP myringoplasty can be routinely performed.
Keywords: Myringoplasty, platelet-rich plasma, tympanic membrane
|How to cite this article:|
Anwar FM, Shenoy VS, Kamath PM, Sreedharan S, Deviprasad D, Domah HA. Study on use of platelet-rich plasma in myringoplasty. Indian J Otol 2020;26:71-4
|How to cite this URL:|
Anwar FM, Shenoy VS, Kamath PM, Sreedharan S, Deviprasad D, Domah HA. Study on use of platelet-rich plasma in myringoplasty. Indian J Otol [serial online] 2020 [cited 2020 Oct 31];26:71-4. Available from: https://www.indianjotol.org/text.asp?2020/26/2/71/289941
| Introduction|| |
The success rate of graft take-up after myringoplasty varies widely, ranging from 70% to 90%. Therefore, there remains a necessity to search for novel methods to improve the healing of the tympanic membrane (TM) after myringoplasty to improve the surgical outcomes.
The long-standing knowledge about platelets pertains to their role in clotting of blood. However, they also contain a large amount of proteins, numbering in the hundreds, called growth factors. The latter plays an essential role in the healing of injuries.,
PRP consists of plasma containing a higher density of platelets as compared to that in blood. The platelet concentration, as well as the growth factor concentration, can, therefore, be up to 5–10 times the normal found in blood.
There are four general categories of preparation of PRP based on its leukocyte and fibrin content: leukocyte-rich PRP, leukocyte reduced PRP (leukocyte reduced or pure PRP), leukocyte platelet-rich fibrin, and pure platelet-rich fibrin. The efficacy of certain growth factors in healing various injuries, and the concentrations of these growth factors found within PRP are the theoretical basis for the use of PRP in tissue repair.,
PRP provides a simple, easily preparable, and minimally invasive method to get a high concentration of autologous growth factors, which can then be easily introduced into the surgical site during a surgical procedure.,,,,
In a pilot study, El-Anwar et al. were the first authors to demonstrate a positive effect of PRP on the healing of large TM perforations with perfect results in the first trial of human PRP applications in myringoplasty.
This study focuses on the use of prepared autologous PRP which is placed on the lateral surface of the graft and TM remnant postmyringoplasty; results were then noted postoperatively with respect to the uptake of the graft.
Our study further aimed at evaluating any audiological benefit in cases of TM perforation treated with PRP and myringoplasty.
| Materials and Methods|| |
Our study was a randomized controlled trial with 70 patients (divided into two groups of 35 each) who were having TM perforation caused by chronic suppurative otitis media or CSOM, of the tubotympanic type, for whom myringoplasty was performed from September 2016 to August 2018 in Kasturba Medical College, Mangalore. The study was approved by the Institutional Ethical Committee, and informed written consent was obtained from the patients. All the patients underwent a meticulous history taking and thorough clinical examination as well as routine laboratory testing and pure tone audiometry.
The patients included had a TM perforation (small, medium, large, or subtotal), and apparent absence of discharge and healthy middle ear mucosa for at least 2 months prior to surgery.
Patients presenting with sensorineural hearing loss, active ear discharge, cholesteatoma, immunocompromised status, or suspected ossicular pathology were excluded from the study.
Patients were divided into two groups, with 35 patients in each group. The case group consisted of patients undergoing myringoplasty with the use of autologous PRP, while the control group consisted of patients undergoing myringoplasty without the use of autologous PRP.
Myringoplasty was performed using an underlay technique under general anesthesia. A postauricular approach was used for access, and a temporalis fascia graft was used to repair the TM defect.
All the patients in this study were assessed with respect to postoperative graft uptake and improvement in hearing at 3 months' postoperatively. The audiological benefit was assessed as improvement in hearing >10 dB as used by Sergi et al.
Preparation of autologous platelet-rich plasma and application
Using a 16 or 18 G syringe, 5 ml of blood were withdrawn from a peripheral vein of the patient after induction of anesthesia. Centrifugation was then carried out immediately, at 3200 rpm for a total of 12 min. This caused the blood to be divided into three layers. The top layer consisted of platelet-poor plasma, the middle layer contained about 1.5 ml3 of PRP as well as a buffy coat of white blood cells, and the bottom layer consisted of red blood cells (RBCs). The layer of PRP was easily extractable at the time of use.
Once the graft was placed over the TM remnant, this extracted PRP was then placed into the external auditory canal (EAC) over the lateral aspect of the newly grafted TM. Large fragments of gel foam were then placed in support of the PRP. Thereafter, a medicated ear wick was kept over the gel foam.
Statistical analysis for data was done using Chi-square test and Fischer's exact test. Statistical package SPSS version 17.0 (IBM corp, USA) was used to do the analysis. P < 0.05 was considered statistically significant.
| Results|| |
In our study, a maximum number (68.6%) of patients was seen in the age group of 31–40 years. With regard to age distribution, both groups were statistically similar with P = 0.958. The youngest patient was 16 years old and the oldest 48 years old.
Of the 70 patients studied, 42 were female and 28 were male, with P = 0.626, which was not statistically significant. Out of 35 patients in the case group, 22 were female and 13 were male; in the control group, 20 were female and 15 were male.
A total of 56 unilateral cases of ear disease and 14 bilateral cases were included in the study. The presence of bilateral ear disease at the time of myringoplasty did not seem to have any influence on the graft uptake. In addition, in our study, there was no statistically significant difference (P = 0.550) for the success rate based on laterality.
In our study, a maximum number (47.1%) of patients was seen with medium central perforation. Out of 35 patients in the case group, 17 patients (48.6%) had medium central perforation and in the control group, 16 patients (45.7%) had medium central perforation. Both groups regarding size of perforation were statistically similar to P = 0.992.
The majority of perforations in our study was found to be central (58.6%). These included perforations which involved both anterior and posterior quadrants, as well as large and subtotal perforations. This showed no statistical significance in cases and controls (P = 0.959.). Anterior perforation was seen in 24.3% and posterior perforations were seen in 17.1% of the patients.
Of 35 patients in each group, four in the study group and eight in the control group had residual perforation and ear discharge. There was no significant difference found between the two groups with P = 0.205.
The follow-up ranged from 3 to 4 months. At 3 months' postoperatively, out of 35 patients in each group; four in the study group and eight in the control group had residual perforation. Graft uptake in the case group was 88.57% and graft uptake in the control group was 77.1%. Result was better in cases that underwent myringoplasty with PRP, but it was statistically not significant with P = 0.205 [Table 1].
In the case group, out of 17 patients who had medium central perforation, graft uptake was 100%. Out of eight patients in the case group who had large central perforation, graft uptake was 75%. Out of seven patients in the case group who had small central perforation, graft uptake was 85.71%. In the control group, out of 16 patients who had medium central perforation, graft uptake was 87.5%. Out of eight patients in the control group who had large central perforation, graft uptake was 62.5%. Out of eight patients in the control group who had small central perforation, graft uptake was 87.5%.
Out of 35 patients in the case group, audiological improvement (>10 dB) was seen in 31 patients (88.57%), whereas in the control group of 35 patients, 27 (77.1%) had audiological benefit. Audiological benefit (improvement > 10 dB) was better in cases who underwent myringoplasty with PRP, but it was statistically not significant with P = 0.205 [Table 2].
| Discussion|| |
PRP is a concentration of plasma protein with a higher amount of platelets which is derived from whole blood, centrifuged to avoid RBCs. Growth factors are present in higher concentration than in whole blood; and hence, PRP has been used to enhance the healing response across quite a few specialties, and it is also being used in traumatic injuries. Several different growth factors and cytokines are present which enhance healing of soft tissue and joints. It hastens epidermal, endothelial and epithelial regeneration, encourages angiogenesis, augments synthesis of collagen as well as healing of soft tissues, decreases scarring of the dermis, and promotes hemostatic response to injury. WBCs present in a high concentration in PRP makes it bactericidal., PRP does not have any side effects and can be harvested through a simple method without using any additives. PRP provides protection to the operated site and it will keep the graft in position and avert sagging of the posterior wall of the ear canal and also prevents complications associated with an EAC pack.,
Different constituents have been used in the past to treat TM perforations. These include epidermal growth factor, hyaluronan, heparin, fibroblast growth factor, and transforming growth factor.,,
The autologous PRP is simple and easy to be prepared with no reported side effects. El-Anwar et al. suggested that PRP is effective in graft uptake. Erkilet et al. suggested that PRP is effective in accelerating TM perforation healing in rats.
In our study, we analyzed functional results in patients suffering from CSOM, who underwent myringoplasty with and without PRP. We discuss the graft take up rate, clinical improvement, and audiological benefit in 70 patients who presented to our institution.
The results of myringoplasty with respect to size of perforation were found to vary. In our study, graft takes up rates were found to be more for medium central perforation (100%) and small central perforation (85.71%). However, a study conducted by El-Anwar et al. showed graft taken up in all cases of large central perforation with 100% success rate.
A study done by El-Anwar et al. showed better graft uptake in cases (100%) compared to control (81.25%) and it was statistically significant. A study done by Sankaranarayanan also showed better graft uptake in cases (96%) compared to the control group (80%). Our study showed better graft uptake in cases (88.57%) compared to the control group (77.1%) but it was not statistically significant. Graft uptake rates are less in both cases and controls in our study compared to other studies since ours is a teaching institute were the surgeries done by many surgeons [Table 3].
Study done by El-Anwar et al. showed audiological improvement (>10 dB) is better in cases (65.6%) compared to control (40.6%) group. In our study, audiological improvement (>10 dB) was seen in 31 cases (88.57%); whereas in the control group, only 27 (77.1%) had audiological benefits. However, in both studies, it is not statistically significant [Table 4].
| Conclusion|| |
PRP is a platelet concentrate with enriched growth factors. It helps in the TM closure following myringoplasty. It prevents displacement of the graft from the site. It has no noticeable side effect.
This study shows there is a definite benefit by using PRP in myringoplasty. As the PRP can be easily prepared, PRP myringoplasty can be routinely performed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Pacifici L, Casella F, Maggiore C. Platelet rich plasma (PRP): Potentialities and techniques of extraction. Minerva Stomatol 2002;51:341-50.
Shiomi Y, Shiomi Y. Surgical outcomes of myringoplasty using platelet-rich plasma and evaluation of the outcome-associated factors. Auris Nasus Larynx 2019. pii: S0385-8146 (19) 30116-6.
El-Anwar MW, El-Ahl MA, Zidan AA, Yacoup MA. Topical use of autologous platelet rich plasma in myringoplasty. Auris Nasus Larynx 2015;42:365-8.
Fouad YA, Abdelhady M, El-Anwar M, Merwad E. Topical platelet rich plasma versus hyaluronic acid during fat graft myringoplasty. Am J Otolaryngol 2018;39:741-5.
Sankaranarayanan G, Prithiviraj V, Kumar RV. A Study on Efficacy of Autologous Platelet Rich Plasma in Myringoplasty. Otolaryngol Online J 2013;3.
Creaney L, Hamilton B. Growth factor delivery methods in the management of sports injuries: The state of play. Br J Sports Med 2008;42:314-20.
Navarrete Álvaro ML, Ortiz N, Rodriguez L, Boemo R, Fuentes JF, Mateo A, Ortiz P. Pilot study on the efficiency of the biostimulation with autologous plasma rich in platelet growth factors in otorhinolaryngology: Otologic surgery (tympanoplasty type I). ISRN Surg 2011;2011. doi: 10.5402/2011/451020.
Saliba I. Hyaluronic acid fat graft myringoplasty: How we do it. Clin Otolaryngol 2008;33:610-4.
Gun T, Sozen T, Boztepe OF, Gur OE, Muluk NB, Cingi C. Influence of size and site of perforation on fat graft myringoplasty. Auris Nasus Larynx 2014;41:507-12.
Sergi B, Galli J, de Corso E, Parrilla C, Paludetti G. Overlay versus underlay myringoplasty: Report of outcomes considering closure of perforation and hearing function. Acta Otorhinolaryngol Ital 2011;31:366-71.
Güneri EA, Tekin S, Yilmaz O, Ozkara E, Erdaǧ TK, Ikiz AO, et al
. The effects of hyaluronic acid, epidermal growth factor, and mitomycin in an experimental model of acute traumatic tympanic membrane perforation. Otol Neurotol 2003;24:371-6.
Rick G, Craig J, Mark C. Platelet-rich plasma: Properties and clinical applications. J Lanc Gen Hosp 2007;2:73-8.
Bielecki TM, Gazdzik TS, Arendt J, Szczepanski T, Król W, Wielkoszynski T. Antibacterial effect of autologous platelet gel enriched with growth factors and other active substances: Anin vitro
study. J Bone Joint Surg Br 2007;89:417-20.
González Lagunas J. Platelet rich plasma. Rev Española Cirugía Oral Y Maxilofac 2006;2:89-99.
Salaheldin AH, Hussein A. Effect of platelet-rich plasma on nasal mucociliary clearance after submucous diathermy of inferior turbinate. Egypt J Ear Nose Throat Allied Sci 2012;13:71-5.
Jang CH, Park H, Cho YB, Choi CH. The effect of anti-adhesive packing agents in the middle ear of guinea pig. Int J Pediatr Otorhinolaryngol 2008;72:1603-8.
Anderson O, Takwoingi YM. Tri-adcortyl ointment ear dressing in myringoplasty: An analysis of outcome. Eur Arch Otorhinolaryngol 2007;264:873-7.
Cho KS, Lee DG, Shin DH, Park YD, Chon KM. The importance of vascular endothelial growth factor in the healing of acute tympanic membrane perforation. Am J Otolaryngol 2010;31:309-14.
Ozturk K, Yaman H, Cihat Avunduk M, Arbag H, Keles B, Uyar Y. Effectiveness of MeroGel hyaluronic acid on tympanic membrane perforations. Acta Otolaryngol 2006;126:1158-63.
Kaftan H, Herzog M, Miehe B, Hosemann W. Topical application of transforming growth factor-beta1 in acute traumatic tympanic membrane perforations: An experimental study in rats. Wound Repair Regen 2006;14:453-6.
Erkilet E, Koyuncu M, Atmaca S, Yarim M. Platelet-rich plasma improves healing of tympanic membrane perforations: Experimental study. J Laryngol Otol 2009;123:482-7.
[Table 1], [Table 2], [Table 3], [Table 4]