Abstract
Background: Chronic otitis media (COM) is a condition usually seen in patients attending the ENT department. Chronic inactive mucosal disease (CIMD) is characterized by tympanic membrane (TM) perforation with hearing loss. Endoscopic tympanoplasty (ET) is a surgical method to repair TM perforation with minimal invasion. Objective: The present analysis was done to find out the outcome of ET surgeries in CIMD. Methods: Retrospective data analysis was done in 30 patients underwent ET with endoscopic under-lay technique at Al-Ameen medical college, Vijapur, India. Results: Average age of patients was 34.17±9.52 years. Majority (40%) patients were from 18-30 years of age group. There were 12 (40%) males and 18 (60%) females. Right-side and left-side CIMD was equally distributed in 30 patients. Sixteen (53.3%) and 14 (46.7%) patients were having right and left TM perforation, respectively. TM perforation size was small, medium and large in 43.3%, 30% and 26.7% of patients, respectively. Twenty-eight (93.3%) patients had temporalis fascia and 2 (6.7%) patients had tragal cartilage as graft material. Two (6.7%) patients had graft rejection without improvement in hearing. No patient had complication or any miscellaneous issues. Eighteen (60.0%), 11 (36.7%) and 1 (3.3%) pre-operative patient with pure-tone average (PTA) had mild, moderate, and severe conductive hearing loss (CHL), respectively. All patients with PTA were improved after surgery. Conclusion: ET is an effective, minimally invasive, and less painful surgical technique for repair of central TM perforations in CIMD.
Keywords
Chronic Otitis Media, Chronic Inactive Mucosal Disease, Endoscopic Tympanoplasty, Tympanic Membrane Perforation
1. Introduction
Chronic otitis media (COM) is a condition usually seen in patients attending the ENT department. COM may be present with active or inactive type of mucosal diseases. Chronic inactive mucosal disease (CIMD) is characterized by permanent tympanic membrane (TM) perforation without mucosal disease or ear discharge. CIMD causes hearing loss
| [1] | Islam MA, Haque A. Ahmed K, Bari MS, Hoque MM, Khan MK, et al. Outcome of Surgery in Chronic Inactive Mucosal Otitis Media. Mymensingh Medical Journal. 2018, 27(3), 617-25. https://pubmed.ncbi.nlm.nih.gov/30141454/ |
| [2] | Maharjan M, Phuyal S, Shrestha M, Bajracharya R. Chronic Otitis Media and Subsequent Hearing Loss in Children from the Himalayan Region Residing in Buddhist Monastic Schools of Nepal. Journal of Otology. 2020, 15, 144-8. https://doi.org/10.1016/j.joto.2020.09.001 |
[1-2]
. Majority of the TM perforations which are small in sizes heal spontaneously. However, persistent perforations need surgical repair. Tympanoplasty and myringoplasty are commonly used procedures for the treatment of chronic otitis media
| [1] | Islam MA, Haque A. Ahmed K, Bari MS, Hoque MM, Khan MK, et al. Outcome of Surgery in Chronic Inactive Mucosal Otitis Media. Mymensingh Medical Journal. 2018, 27(3), 617-25. https://pubmed.ncbi.nlm.nih.gov/30141454/ |
| [2] | Maharjan M, Phuyal S, Shrestha M, Bajracharya R. Chronic Otitis Media and Subsequent Hearing Loss in Children from the Himalayan Region Residing in Buddhist Monastic Schools of Nepal. Journal of Otology. 2020, 15, 144-8. https://doi.org/10.1016/j.joto.2020.09.001 |
| [3] | Cho YS, Park MH, Han UG, Son SE, Moon IJ. Outcomes and Learning Curve of Endoscopic Tympanoplasty: A Retrospective Analysis of 376 Patients. Laryngoscope Investigative Otolaryngology. 2022, 7(6), 2064-68. https://doi.org/10.1002/lio2.961 |
| [4] | Swapna UP, Smitha B, Kumar KS. Effectiveness of Underlay Myringoplasty in Inactive Mucosal Chronic Otitis Media: A Prospective Study. International Journal of Medical Research and Review. 2020, 8(6), 398-403. https://doi.org/10.17511/ijmrr.2020.i06.04 |
[1-4]
.
Tympanoplasty is a surgical procedure for repairing perforated tympanic membrane (TM) in middle ear to restore the hearing. Since last few decades, there is much advancement in tympanoplasty surgeries including endoscopic tympanoplasty (ET). The use of endoscopes in ear surgery began in the 1990s
| [3] | Cho YS, Park MH, Han UG, Son SE, Moon IJ. Outcomes and Learning Curve of Endoscopic Tympanoplasty: A Retrospective Analysis of 376 Patients. Laryngoscope Investigative Otolaryngology. 2022, 7(6), 2064-68. https://doi.org/10.1002/lio2.961 |
| [4] | Swapna UP, Smitha B, Kumar KS. Effectiveness of Underlay Myringoplasty in Inactive Mucosal Chronic Otitis Media: A Prospective Study. International Journal of Medical Research and Review. 2020, 8(6), 398-403. https://doi.org/10.17511/ijmrr.2020.i06.04 |
| [5] | Choi SW, Moon IJ, Choi JE, Kang WS, Moon IS, Kong SK, et al. Outcomes of Endoscopic Tympanoplasty for Large Perforations: A Multicenter Retrospective Study in South Korea. Clinical and Experimental Otorhinolaryngology. 2023, 16(2), 125-31. https://doi.org/10.21053/ceo.2022.01599 |
| [6] | Akyigit A, Sakallıoglu O, Karlidag T. Endoscopic Tympanoplasty. Journal of Otology. 2017, 12(2), 62-67. https://doi.org/10.1016/j.joto.2017.04.004 |
| [7] | Hsu YC, Kuo CL, Huang TC. A Retrospective Comparative Study of Endoscopic and Microscopic Tympanoplasty. Journal of Otolaryngology - Head & Neck Surgery. 2018, 47: 44. https://doi.org/10.1186/s40463-018-0289-4 |
[3-7]
. Development in endoscopic technologies emphasize surgeons to perform endoscopic surgeries with high magnification, clear visualization, and ease of surgical access. ET has been considered as much safer surgical procedure than conventional tympanoplasty. ET allows a more comprehensive, directed surgical clearance in the middle ear in a less invasive manner. Advancement in endoscopic and surgical training procedures allows less invasive repair of TM perforations. The unique advantage of the endoscope is in placement of the objective lens into middle ear space, giving a broad width and depth of field to the visualization of middle ear structures. Thus, endoscopic technique can be demonstrated itself as ideal for teaching, with a simultaneous view of the operative field in middle ear by surgeons
| [3] | Cho YS, Park MH, Han UG, Son SE, Moon IJ. Outcomes and Learning Curve of Endoscopic Tympanoplasty: A Retrospective Analysis of 376 Patients. Laryngoscope Investigative Otolaryngology. 2022, 7(6), 2064-68. https://doi.org/10.1002/lio2.961 |
| [4] | Swapna UP, Smitha B, Kumar KS. Effectiveness of Underlay Myringoplasty in Inactive Mucosal Chronic Otitis Media: A Prospective Study. International Journal of Medical Research and Review. 2020, 8(6), 398-403. https://doi.org/10.17511/ijmrr.2020.i06.04 |
| [5] | Choi SW, Moon IJ, Choi JE, Kang WS, Moon IS, Kong SK, et al. Outcomes of Endoscopic Tympanoplasty for Large Perforations: A Multicenter Retrospective Study in South Korea. Clinical and Experimental Otorhinolaryngology. 2023, 16(2), 125-31. https://doi.org/10.21053/ceo.2022.01599 |
| [6] | Akyigit A, Sakallıoglu O, Karlidag T. Endoscopic Tympanoplasty. Journal of Otology. 2017, 12(2), 62-67. https://doi.org/10.1016/j.joto.2017.04.004 |
| [7] | Hsu YC, Kuo CL, Huang TC. A Retrospective Comparative Study of Endoscopic and Microscopic Tympanoplasty. Journal of Otolaryngology - Head & Neck Surgery. 2018, 47: 44. https://doi.org/10.1186/s40463-018-0289-4 |
| [8] | Bianchini AJ, Berlitz VG, Mocelin AG, Ribeiro JF, Keruk JG, Hamerschmidt R. Endoscopic or Microscopic Tympanoplasty Advantages and Disadvantages: A Theory Domain Systematic Review. International Archives of Otorhinolaryngology. 2023, 27(3), e528-e535. https://doi.org/10.1055/s-0042-1748808 |
| [9] | Mutlu F, Durmus K, Ozturk M, Deger HM. Comparison of Anterior Tab Flap and Underlay Tympanoplasty Techniques in Anterior Tympanic Membrane Perforations. Journal of Surgery and Medicine. 2021, 5(9), 917-920. https://doi.org/10.28982/josam.982871 |
[3-9]
.
Howev er, reliable data on ET for repair of central TM per forations without mucosal disease is limited
| [3] | Cho YS, Park MH, Han UG, Son SE, Moon IJ. Outcomes and Learning Curve of Endoscopic Tympanoplasty: A Retrospective Analysis of 376 Patients. Laryngoscope Investigative Otolaryngology. 2022, 7(6), 2064-68. https://doi.org/10.1002/lio2.961 |
| [4] | Swapna UP, Smitha B, Kumar KS. Effectiveness of Underlay Myringoplasty in Inactive Mucosal Chronic Otitis Media: A Prospective Study. International Journal of Medical Research and Review. 2020, 8(6), 398-403. https://doi.org/10.17511/ijmrr.2020.i06.04 |
| [5] | Choi SW, Moon IJ, Choi JE, Kang WS, Moon IS, Kong SK, et al. Outcomes of Endoscopic Tympanoplasty for Large Perforations: A Multicenter Retrospective Study in South Korea. Clinical and Experimental Otorhinolaryngology. 2023, 16(2), 125-31. https://doi.org/10.21053/ceo.2022.01599 |
| [6] | Akyigit A, Sakallıoglu O, Karlidag T. Endoscopic Tympanoplasty. Journal of Otology. 2017, 12(2), 62-67. https://doi.org/10.1016/j.joto.2017.04.004 |
| [7] | Hsu YC, Kuo CL, Huang TC. A Retrospective Comparative Study of Endoscopic and Microscopic Tympanoplasty. Journal of Otolaryngology - Head & Neck Surgery. 2018, 47: 44. https://doi.org/10.1186/s40463-018-0289-4 |
| [8] | Bianchini AJ, Berlitz VG, Mocelin AG, Ribeiro JF, Keruk JG, Hamerschmidt R. Endoscopic or Microscopic Tympanoplasty Advantages and Disadvantages: A Theory Domain Systematic Review. International Archives of Otorhinolaryngology. 2023, 27(3), e528-e535. https://doi.org/10.1055/s-0042-1748808 |
| [9] | Mutlu F, Durmus K, Ozturk M, Deger HM. Comparison of Anterior Tab Flap and Underlay Tympanoplasty Techniques in Anterior Tympanic Membrane Perforations. Journal of Surgery and Medicine. 2021, 5(9), 917-920. https://doi.org/10.28982/josam.982871 |
[3-9]
. This retrospective study was performed to determine the clinical benefits of ET in the management of TM perforations by evaluating the surgical outcomes. The results of this study might be helpful in better understanding and provision of precise backup on ET surgery in CIMD management.
2. Materials and Methods
2.1. Study Approval
Access to the medical data was done after approval from the institutional ethics committee (IEC) of Al-Ameen medical college and hospital, Vijapur, Karnataka, India. The study was performed as per good clinical practices (GCP) guidelines. The written in formed consent was taken wherever required. Patient identity and medical details were kept confidential, undisclosed, and to limited access.
2.2. Study Site
This retrospective cohort study was included 30 patients, who underwent ET at ENT department, Al-Ameen medical college and hospital, India from December 2022 to October 2023.
2.3. Study Objectives
The pri mary objective of the study was to evaluate and document the evidences for endoscopic tympanoplasty in patient with chronic otitis media with inactive mucosal disease. Also, the objective was to evaluate an expediency of endoscopic tympanoplasty (ET) in improvement of visibility of middle ear during the surgical repair of tympanic membrane perforations.
2.4. Study Design
The study was retrospective, single centre, and observational study.
2.5. Inclusion and Exclusion Criteria
As per eligibility criteria, patients from 18-50 years of age suffering from COM with inactive mucosal disease were included in the study. Patients suffering from CIMD with dry and stable TM perforations or traumatic TM perforations were included in the study. Patients who had regular follow-up of at least six months after sur gery were included. Patient suffering from COM with active mucosal disease and sensorineural hearing loss were excluded from the study. Patients with active COM or cholesteatoma or those requiring simultaneous mastoidectomy, and with sensorineural or mixed hearing loss were excluded from the study.
2.6. Study Procedure and Data Collection
Patient demographics, complaints, disease history, previous history of trauma or surgeries to the ear, any associated symptoms like tinnitus and vertigo, graft success rate, pre and post operative hearing abilities, surgery time, post operative care and complications were noted.
Data regarding the preoperative analysis including patient’s demographic and clinical examination details, speech audiometry (SA), pure-tone audiometry (PTA), temporal bone computed tomography (CT) scans, and endoscopic examination details were noted. Other factors such nasal allergy, deviated nasal septum, sinusitis, rhinitis, absence of any focus of infection, conductive hearing loss less than 40dB, and adequate cochlear reserve were noted.
As per patient’s data, tympanoplasty surgeries were performed with endoscopic approach and double door technique via transcanal route. During surgeries the margins were refreshed. The anterior door was made by making anterior incision almost 4 mm away from annulus. Tympanomeatal flap was elevated from sulcus and entered in middle ear. Eustachian tube opening was visualized and washed with normal saline. The posterior door was made by making posterior incision almost 7 mm away from annulus from 12’o clock position to 6’o clock position. Tympanomeatal flap was elevated till annulus. After entrance in middle ear, malleus bone was divided and ossicular chain was inspected. Previously harvested, shaped, and dried temporalis graft was placed under the annulus and malleus handle. The graft was placed over the anterior bone through the anterior door. Graft was also placed over the posterior part of the bone. Tympanomeatal flap was then placed back.
Parameters related to surgery such as disease diagnosis, membrane perforation side (left and right), size of perforation, graft success and rejection rate, and surgical complications or any miscellaneous issues of all patients were noted and analyzed. Changes in number of pre and post operative cases of conductive hearing loss (CHL) was assessed on mild, moderate, and severe intensity scale. TM perforation size was assessed on small, medium and large perforation scale. Large TM perforation was defined as perforation >50% of total TM (more than three quadrants), and small perforation was <25% of total TM. Clean ear canal without tympanic membrane perforation was considered graft success.
2.7. Statistical Analysis
Data distribution was done according to skewness, kurtosis, and Shapiro-Wilk tests. Z values for skewness and kurtosis were evaluated to analyze normality of the data (data were considered normally distributed if − 1.96 < z < 1.96). The surgical success rate based on perforation size and graft material was analyzed using linear-by-linear association. The chi-square test was used to compare graft take rates, rejection rates and hearing improvement. All data are presented as mean ± standard deviation. Statistical significance was considered at 95% confidence interval i.e. p<0.05. All statistical analyses were performed using SPSS software.
3. Results
In present study, data of 30 patients suffering from CIMD was analyzed. All 30 participants underwent ET under lay technique as a primary surgery. The skewness of the data was 0.15. It suggested that the data was not skewed, thus suggesting it was normally distributed. The kurtosis of the data was -1.2, and it suggested that the data was normally distributed. Shapiro-Wilk test for the data was not significant (p = 0.131), suggesting that the data was normally distributed. There appeared to be only one mode/peak in the data, thus making it unimodal. Since all three criteria (skewness, kurtosis, Shapiro-Wilk test) were suggestive of normality, it appeared that the data was normally distributed (approximately followed a bell-shaped curve) (
Figure 1).
Figure 1. Distribution of age.
The mean of age of patients suffering from CIMD was 34.17 (9.52) years. The median (IQR) of age was 32.00 (27.25-43) years.
Forty percent of the patients were from age group of 18-30 years, 26.7% of the patients were from age group of 31-40 years, and 33.3% of the patients were from age group of 41-50 years (
Figure 2). There were 40% of male patients and 60% of female patients (
Figure 3).
Figure 2. Distribution of participants in terms of age.
Figure 3. Distribution of participants in terms of gender.
Half (50%) of patients had right-side CIMD and 50% patients had left-side CIMD (
Figure 4).
Figure 4. Distribution of participants as per diagnosis.
Sixteen (53.3%) and 14 (46.7%) patients were having right and left TM perforation, respectively (
Figure 5).
Figure 5. Distribution of participants as per perforation side.
TM perforation size was small, medium and large in 43.3%, 30% and 26.7% of patients, respectively (
Figure 6).
Figure 6. Distribution of participants as per the size of perforation.
Twenty-eight (93.3%) patients had temporalis fascia as graft material and 2 (6.7%) patients had tragal cartilage (revision surgery) as graft material (
Figure 7). Two (6.7%) patients had graft rejection without improvement in hearing, whereas 28 (93.3%) patients had successful grafting with ET surgery.
Figure 7. Distribution of participants in terms of graft material.
No patient had complication or miscellaneous issues. Eighteen (60.0%), 11 (36.7%) and 1 (3.3%) pre-operative patient had mild, moderate, and severe conductive hearing loss (CHL), respectively. All 30 patients with PTA were improved after surgery (
Figure 8).
Figure 8. Distribution of participants as per surgical technique.
Also, the details of above all parameters are given in
Table 1.
Table 1. Summary of clinical and demographic parameters.
Parameters | Values |
Age (mean ± SD) Years | 34.17 ± 9.52 |
Age (median, IQR) Years | 32.00 (27.25 - 43.00) |
Age (Min-Max OR N%) Years | 18.00 - 50.00 |
Age Groups | |
18-30 Years | 12 (40.0%) |
31-40 Years | 8 (26.7%) |
41-50 Years | 10 (33.3%) |
Gender: Male; & Female | 12 (40.0%); 18 (60.0%) |
Diagnosis: LCIMD; & RCIMD | 15 (50.0%); 15 (50.0%) |
Perforation Side: Right & Left | 16 (53.3%) & 14 (46.7%) |
Size of Perforation | |
Small | 13 (43.3%) |
Medium | 9 (30.0%) |
Large | 8 (26.7%) |
Graft Material | |
Temporalis Fascia | 28 (93.3%) |
Tragal Cartilage (Revision Surgery) | 2 (6.7%) |
Surgical Technique (Endoscopic Under Lay Technique) | 30 (100.0%) |
Graft Rejection | |
Not Rejected | 28 (93.3%) |
Rejected | 2 (6.7%) |
Complication (None) | 30 (100.0%) |
Miscellaneous (None) | 30 (100.0%) |
PTA (Pre-Operative) | |
Mild CHL | 18 (60.0%) |
Moderate CHL | 11 (36.7%) |
Moderate Severe CHL | 1 (3.3%) |
PTA (Post-Operative) (Improved) | 30 (100.0%) |
4. Discussion
COM is an infection of the middle ear cleft. In inactive mucosal COM, there is perforation of tympanic membrane without ear discharge. Tympanoplasty is an effective surgical procedure to repair tympanic membrane defects. Tympanoplasty has been done for restoration of hearing
| [3] | Cho YS, Park MH, Han UG, Son SE, Moon IJ. Outcomes and Learning Curve of Endoscopic Tympanoplasty: A Retrospective Analysis of 376 Patients. Laryngoscope Investigative Otolaryngology. 2022, 7(6), 2064-68. https://doi.org/10.1002/lio2.961 |
| [4] | Swapna UP, Smitha B, Kumar KS. Effectiveness of Underlay Myringoplasty in Inactive Mucosal Chronic Otitis Media: A Prospective Study. International Journal of Medical Research and Review. 2020, 8(6), 398-403. https://doi.org/10.17511/ijmrr.2020.i06.04 |
| [5] | Choi SW, Moon IJ, Choi JE, Kang WS, Moon IS, Kong SK, et al. Outcomes of Endoscopic Tympanoplasty for Large Perforations: A Multicenter Retrospective Study in South Korea. Clinical and Experimental Otorhinolaryngology. 2023, 16(2), 125-31. https://doi.org/10.21053/ceo.2022.01599 |
| [6] | Akyigit A, Sakallıoglu O, Karlidag T. Endoscopic Tympanoplasty. Journal of Otology. 2017, 12(2), 62-67. https://doi.org/10.1016/j.joto.2017.04.004 |
| [7] | Hsu YC, Kuo CL, Huang TC. A Retrospective Comparative Study of Endoscopic and Microscopic Tympanoplasty. Journal of Otolaryngology - Head & Neck Surgery. 2018, 47: 44. https://doi.org/10.1186/s40463-018-0289-4 |
| [8] | Bianchini AJ, Berlitz VG, Mocelin AG, Ribeiro JF, Keruk JG, Hamerschmidt R. Endoscopic or Microscopic Tympanoplasty Advantages and Disadvantages: A Theory Domain Systematic Review. International Archives of Otorhinolaryngology. 2023, 27(3), e528-e535. https://doi.org/10.1055/s-0042-1748808 |
| [10] | Beckmann S, Anschuetz L. Minimally Invasive Tympanoplasty: Review of Outcomes and Technical Refinements. Operative Techniques in Otolaryngology-Head and Neck Surgery. 2021, 32, 143-149. https://doi.org/10.1016/j.otot.2021.05.014 |
| [11] | Bayram A, Marchioni D, Peng K, Joon Moon J, Cingi C. How Do You Perform Your Tympanoplasty, Endoscopically or Microscopically? ENT Updates. 2019, 9(2), 144-149. https://doi.org/10.32448/entupdates.594625 |
[3-8, 10, 11]
. Many comparative studies have been conducted to assess surgical outcomes in tympanoplasty, when using a conventional microscope
| [12] | Gulsen S, Baltac A. Comparison of Endoscopic Transcanal and Microscopic Approach in Type 1 Tympanoplasty. Brazilian Journal of Otorhinolaryngology. 2021, 87(2), 157-163. https://doi.org/10.1016/j.bjorl.2019.07.005 |
[12]
. The two common techniques of tympanoplasty are underlay and overlay. According to few scientific studies, the drum healing was more in underlay tympanoplasty than overlay approach
.
Since last few decades, there is much advancement in tympanoplasty surgeries including endoscopic tympanoplasty (ET)
| [3] | Cho YS, Park MH, Han UG, Son SE, Moon IJ. Outcomes and Learning Curve of Endoscopic Tympanoplasty: A Retrospective Analysis of 376 Patients. Laryngoscope Investigative Otolaryngology. 2022, 7(6), 2064-68. https://doi.org/10.1002/lio2.961 |
| [6] | Akyigit A, Sakallıoglu O, Karlidag T. Endoscopic Tympanoplasty. Journal of Otology. 2017, 12(2), 62-67. https://doi.org/10.1016/j.joto.2017.04.004 |
| [7] | Hsu YC, Kuo CL, Huang TC. A Retrospective Comparative Study of Endoscopic and Microscopic Tympanoplasty. Journal of Otolaryngology - Head & Neck Surgery. 2018, 47: 44. https://doi.org/10.1186/s40463-018-0289-4 |
| [8] | Bianchini AJ, Berlitz VG, Mocelin AG, Ribeiro JF, Keruk JG, Hamerschmidt R. Endoscopic or Microscopic Tympanoplasty Advantages and Disadvantages: A Theory Domain Systematic Review. International Archives of Otorhinolaryngology. 2023, 27(3), e528-e535. https://doi.org/10.1055/s-0042-1748808 |
| [12] | Gulsen S, Baltac A. Comparison of Endoscopic Transcanal and Microscopic Approach in Type 1 Tympanoplasty. Brazilian Journal of Otorhinolaryngology. 2021, 87(2), 157-163. https://doi.org/10.1016/j.bjorl.2019.07.005 |
[3, 6-8, 12]
. ET appears to be associated with shorter surgical and anesthesia time, safer technique, and better postoperative pain outcomes, which makes it an ideal alternative for the management of chronic otitis media. In addition, positive factors related to the endoscopic approach to the tympanic membrane include its cost-effectiveness or lower cost, and shorter hospital stay
| [3] | Cho YS, Park MH, Han UG, Son SE, Moon IJ. Outcomes and Learning Curve of Endoscopic Tympanoplasty: A Retrospective Analysis of 376 Patients. Laryngoscope Investigative Otolaryngology. 2022, 7(6), 2064-68. https://doi.org/10.1002/lio2.961 |
| [6] | Akyigit A, Sakallıoglu O, Karlidag T. Endoscopic Tympanoplasty. Journal of Otology. 2017, 12(2), 62-67. https://doi.org/10.1016/j.joto.2017.04.004 |
| [7] | Hsu YC, Kuo CL, Huang TC. A Retrospective Comparative Study of Endoscopic and Microscopic Tympanoplasty. Journal of Otolaryngology - Head & Neck Surgery. 2018, 47: 44. https://doi.org/10.1186/s40463-018-0289-4 |
| [8] | Bianchini AJ, Berlitz VG, Mocelin AG, Ribeiro JF, Keruk JG, Hamerschmidt R. Endoscopic or Microscopic Tympanoplasty Advantages and Disadvantages: A Theory Domain Systematic Review. International Archives of Otorhinolaryngology. 2023, 27(3), e528-e535. https://doi.org/10.1055/s-0042-1748808 |
| [9] | Mutlu F, Durmus K, Ozturk M, Deger HM. Comparison of Anterior Tab Flap and Underlay Tympanoplasty Techniques in Anterior Tympanic Membrane Perforations. Journal of Surgery and Medicine. 2021, 5(9), 917-920. https://doi.org/10.28982/josam.982871 |
| [10] | Beckmann S, Anschuetz L. Minimally Invasive Tympanoplasty: Review of Outcomes and Technical Refinements. Operative Techniques in Otolaryngology-Head and Neck Surgery. 2021, 32, 143-149. https://doi.org/10.1016/j.otot.2021.05.014 |
[3, 6-10]
. In this study, underlay technique in ET was adopted as per the requirement of individual cases. Hence, a definite opinion on approach and outcome parameters was not possible.
Skewness, kurtosis, and Shapiro-Wilk test are common statistical criteria for data distribution analysis
| [14] | Cao LK, Duan T, Chen J, Xia CC, Song B. [The Value of Diffusion Kurtosis Imaging in Predicting Post-Surgery Early Recurrence of Hepatocellular Carcinoma]. Sichuan Da Xue Xue Bao Yi Xue Ban. 2018, 49(6), 914-919. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6511714/ |
[14]
. In present study, all three data distribution criteria viz. skewness, kurtosis, and Shapiro-Wilk test were suggestive of normality. From the results of the study, it appeared that demographically the data was normally distributed, and almost followed a bell-shaped curve.
Several studies supported ET surgery with better surgical outcomes and hearing restoration comparable to the conventional microscopic surgeries. According to research studies, endoscopic ear surgery has a shorter operative time without external incisions and can avoid mastoidectomy. The observations of this study were in line with the results obtained in previous research studies. In this study, the surgical outcomes obtained from patient’s data were noticeable from cosmetic point of view
| [3] | Cho YS, Park MH, Han UG, Son SE, Moon IJ. Outcomes and Learning Curve of Endoscopic Tympanoplasty: A Retrospective Analysis of 376 Patients. Laryngoscope Investigative Otolaryngology. 2022, 7(6), 2064-68. https://doi.org/10.1002/lio2.961 |
| [6] | Akyigit A, Sakallıoglu O, Karlidag T. Endoscopic Tympanoplasty. Journal of Otology. 2017, 12(2), 62-67. https://doi.org/10.1016/j.joto.2017.04.004 |
| [7] | Hsu YC, Kuo CL, Huang TC. A Retrospective Comparative Study of Endoscopic and Microscopic Tympanoplasty. Journal of Otolaryngology - Head & Neck Surgery. 2018, 47: 44. https://doi.org/10.1186/s40463-018-0289-4 |
| [8] | Bianchini AJ, Berlitz VG, Mocelin AG, Ribeiro JF, Keruk JG, Hamerschmidt R. Endoscopic or Microscopic Tympanoplasty Advantages and Disadvantages: A Theory Domain Systematic Review. International Archives of Otorhinolaryngology. 2023, 27(3), e528-e535. https://doi.org/10.1055/s-0042-1748808 |
| [12] | Gulsen S, Baltac A. Comparison of Endoscopic Transcanal and Microscopic Approach in Type 1 Tympanoplasty. Brazilian Journal of Otorhinolaryngology. 2021, 87(2), 157-163. https://doi.org/10.1016/j.bjorl.2019.07.005 |
[3, 6-8, 12]
.
In previous studies, tragal perichondrium was commonly used as graft material. Many research studies supported the use of temporalis fascia and tragal cartilage with successful closure of tympanic membrane perforations
| [15] | Shaikh AJ, Joshi SV, Telang RA, Sonawale SL, Thakur RT. Have We found an Ideal Grafting Material for Tympanoplasty? Cartilage Island Graft! International Journal of Otorhinolaryngology Clinics. 2022, 14(1), 26-30. https://doi.org/10.5005/jp-journals-10003-1417 |
[15]
. In present study, both graft materials showed successful closure of central TM perforations as well. The graft uptake rate in present study was 97.3% in terms of the absence of residual perforation, and only two cases had graft failures and postsurgical residual perforation. The overall graft success rate of ET for central TM perforations showed favorable outcomes compared to the conventional microscopic approach in patients suffering from CIMD.
In present study, underlay ET procedure not only showed positive surgical outcomes in mild TM perforations but also showed remarkable surgical outcome in 56.7% cases of moderate to large TM perforations with CIMD. Post surgery, 100% improvement in PTA was noted in all conductive hearing loss cases. This was suggestive of effectiveness of underlay ET in CIMD patients. In addition, no patients developed graft blunting, intraoperative and postoperative complications, or any miscellaneous issues during this study.
However, this study has some limitations. As the study was a retrospective analysis, missing data were unavoidable, which may have affected the results. The type of surgical technique (underlay) was de cided according to the preference of each surgeon, which might cause bias. The limitations of the present study were a small sample size. However, multicenter data with large sample size, and statistical power should be analyzed for more definitive conclusions.
5. Conclusions
Based on the data analysis, it was concluded that underlay ET is effective in treating the central TM perforation, without the need for an external incision. Regardless of the site and size of the perforation, ET is effective in treating large TM perforations. ET also provides lower surgical morbidity and better cosmetic results, which supports backup data for the philosophy of minimally invasive surgery. These results may help surgeons to achieve optimal results in selection of appropriate surgical method for tympanoplasty.
Abbreviations
CHL | Conductive Hearing Loss |
CIMD | Chronic Inactive Mucosal Disease |
COM | Chronic Otitis Media |
ET | Endoscopic Tympanoplasty |
IEC | Institutional Ethics Committee |
IQR | Interquartile Range |
PTA | Pure-tone Average |
TM | Tympanic Membrane |
Acknowledgments
The authors of the study are thankful to dean sir, all head of the departments, all professors, and supporting staff of department, and Dr Priyank Rajan of SRCC children's hospital for their technical support, guidance, moral support, and blessings.
Author Contributions
Aasiya Tai: Conceptualization, Data curation, Formal Analysis, Investigation, Methodology, Project administration, Resources, Software, Validation, Visualization, Writing – original draft, and Writing – review & editing.
Basavaraj Walikar: Conceptualization, Formal Analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, and Writing – review & editing.
Satish Rashinkar: Conceptualization, Formal Analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, and Writing – review & editing.
Ashfak Kakeri: Formal Analysis, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Visualization, and Writing – review & editing.
Anees Patel: Formal Analysis, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Visualization, and Writing – review & editing.
Data Availability Statement
The data is available from the corresponding author upon reasonable request.
Funding
This work is not supported by any external funding.
Conflicts of Interest
The authors declare no conflicts of interest.
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APA Style
Tai, A., Walikar, B., Rashinkar, S., Kakeri, A., Patel, A. (2024). Endoscopic Tympanoplasty in Chronic Otitis Media with Inactive Mucosal Disease. International Journal of Clinical and Experimental Medical Sciences, 10(3), 29-35. https://doi.org/10.11648/j.ijcems.20241003.11
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ACS Style
Tai, A.; Walikar, B.; Rashinkar, S.; Kakeri, A.; Patel, A. Endoscopic Tympanoplasty in Chronic Otitis Media with Inactive Mucosal Disease. Int. J. Clin. Exp. Med. Sci. 2024, 10(3), 29-35. doi: 10.11648/j.ijcems.20241003.11
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AMA Style
Tai A, Walikar B, Rashinkar S, Kakeri A, Patel A. Endoscopic Tympanoplasty in Chronic Otitis Media with Inactive Mucosal Disease. Int J Clin Exp Med Sci. 2024;10(3):29-35. doi: 10.11648/j.ijcems.20241003.11
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@article{10.11648/j.ijcems.20241003.11,
author = {Aasiya Tai and Basavaraj Walikar and Satish Rashinkar and Ashfak Kakeri and Anees Patel},
title = {Endoscopic Tympanoplasty in Chronic Otitis Media with Inactive Mucosal Disease
},
journal = {International Journal of Clinical and Experimental Medical Sciences},
volume = {10},
number = {3},
pages = {29-35},
doi = {10.11648/j.ijcems.20241003.11},
url = {https://doi.org/10.11648/j.ijcems.20241003.11},
eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.ijcems.20241003.11},
abstract = {Background: Chronic otitis media (COM) is a condition usually seen in patients attending the ENT department. Chronic inactive mucosal disease (CIMD) is characterized by tympanic membrane (TM) perforation with hearing loss. Endoscopic tympanoplasty (ET) is a surgical method to repair TM perforation with minimal invasion. Objective: The present analysis was done to find out the outcome of ET surgeries in CIMD. Methods: Retrospective data analysis was done in 30 patients underwent ET with endoscopic under-lay technique at Al-Ameen medical college, Vijapur, India. Results: Average age of patients was 34.17±9.52 years. Majority (40%) patients were from 18-30 years of age group. There were 12 (40%) males and 18 (60%) females. Right-side and left-side CIMD was equally distributed in 30 patients. Sixteen (53.3%) and 14 (46.7%) patients were having right and left TM perforation, respectively. TM perforation size was small, medium and large in 43.3%, 30% and 26.7% of patients, respectively. Twenty-eight (93.3%) patients had temporalis fascia and 2 (6.7%) patients had tragal cartilage as graft material. Two (6.7%) patients had graft rejection without improvement in hearing. No patient had complication or any miscellaneous issues. Eighteen (60.0%), 11 (36.7%) and 1 (3.3%) pre-operative patient with pure-tone average (PTA) had mild, moderate, and severe conductive hearing loss (CHL), respectively. All patients with PTA were improved after surgery. Conclusion: ET is an effective, minimally invasive, and less painful surgical technique for repair of central TM perforations in CIMD.
},
year = {2024}
}
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TY - JOUR
T1 - Endoscopic Tympanoplasty in Chronic Otitis Media with Inactive Mucosal Disease
AU - Aasiya Tai
AU - Basavaraj Walikar
AU - Satish Rashinkar
AU - Ashfak Kakeri
AU - Anees Patel
Y1 - 2024/09/26
PY - 2024
N1 - https://doi.org/10.11648/j.ijcems.20241003.11
DO - 10.11648/j.ijcems.20241003.11
T2 - International Journal of Clinical and Experimental Medical Sciences
JF - International Journal of Clinical and Experimental Medical Sciences
JO - International Journal of Clinical and Experimental Medical Sciences
SP - 29
EP - 35
PB - Science Publishing Group
SN - 2469-8032
UR - https://doi.org/10.11648/j.ijcems.20241003.11
AB - Background: Chronic otitis media (COM) is a condition usually seen in patients attending the ENT department. Chronic inactive mucosal disease (CIMD) is characterized by tympanic membrane (TM) perforation with hearing loss. Endoscopic tympanoplasty (ET) is a surgical method to repair TM perforation with minimal invasion. Objective: The present analysis was done to find out the outcome of ET surgeries in CIMD. Methods: Retrospective data analysis was done in 30 patients underwent ET with endoscopic under-lay technique at Al-Ameen medical college, Vijapur, India. Results: Average age of patients was 34.17±9.52 years. Majority (40%) patients were from 18-30 years of age group. There were 12 (40%) males and 18 (60%) females. Right-side and left-side CIMD was equally distributed in 30 patients. Sixteen (53.3%) and 14 (46.7%) patients were having right and left TM perforation, respectively. TM perforation size was small, medium and large in 43.3%, 30% and 26.7% of patients, respectively. Twenty-eight (93.3%) patients had temporalis fascia and 2 (6.7%) patients had tragal cartilage as graft material. Two (6.7%) patients had graft rejection without improvement in hearing. No patient had complication or any miscellaneous issues. Eighteen (60.0%), 11 (36.7%) and 1 (3.3%) pre-operative patient with pure-tone average (PTA) had mild, moderate, and severe conductive hearing loss (CHL), respectively. All patients with PTA were improved after surgery. Conclusion: ET is an effective, minimally invasive, and less painful surgical technique for repair of central TM perforations in CIMD.
VL - 10
IS - 3
ER -
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