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Issue Year : 2004, Issue Number : 2, Issue Month : December
Written By : Muhammad Ashfaq, Muhammad Umar Aasim, Nasirullah Khan
Belongs To : Department of ENT, Combined Military Hospital, Kharian
MYRINGOPLASTY: Anatomical and functional results
Abstract
Myringoplasty is an established procedure. However, the quest is on to improve the results further by studying the different factors that could possibly affect the outcome. The objectives of myringoplasty are essentially to restore the eardrum integrity and improve hearing level. We have retrospectively reviewed the myringoplasty operations performed in ENT department Combined Military Hospital Kharian, between January 2000 to December 2002, corresponding to 105 surgical interventions. It has been tried to find out the possible factors that affect the anatomical and functional outcome. We analyzed functional results in ears with anatomic success. 73% of patients had successful surgery and 65% of these patients had good functional outcome. This series suggest that patient with smaller perforation and shorter duration of disease has better anatomical and functional outcome.
Article

Introduction


Tympanic membrane perforation is not an uncommon finding in otological practice. Usually it results from ear infection of acute or chronic onset or trauma. Historically tympanic membrane perforations have been repaired by a number of techniques starting from applying chemicals to the edges of perforation [1] to use of different graft materials [2]. However temporalis fascial graft has increasingly become more popular for repairing the eardrum [3].

Myringoplasty is the term for closure of drum perforation. This definition is unrelated to the size of perforation, the approach, the condition of mucosa, or tubal function. Tympanic membrane for descriptive purposes is divided into four quadrants, which are anterior, posterior, superior and inferior. The size of various perforations is labeled in relation to these quadrants as very small, small, medium, and large. Further they may be classified as anterior, inferior, posterior, total and subtotal perforations. Eardrum can be repaired by a number of tissues like temporalis fascia, perichondrium, and can be approached by endaural postaural or transcanal route. Graft can be placed by underlay, overlay and sandwich technique [4].

The reported success rate for closure of tympanic membrane perforation and functional improvement is very variable. However factors which are commonly related to the successful outcome are size and site of perforation, duration of discharging ear and the associated pathology in middle ear [3,5]. The purpose of this study was to evaluate the anatomical and functional results of myringoplasty and to find out the possible factors which affect these results.

MaterialS and methods

Patients attending ENT out patient department of PNS Shifa Karachi between January 2002 to December 2003 were included in the study with following inclusion criteria. Patients of clinical diagnosis of allergic rhinitis tubotympanic chronic suppurative otitis media, both sexes, above the age of 14 years and below 45 years were included in the study. Patients requiring any other procedure upon middle ear than myringoplasty were not included in the study. The characteristics more frequently seen for operating ears were central localization of tympanic membrane perforation, dry ear for at least two months, good eustachian tube function, no focus of infection in nose or throat and underlay technique.  Temporalis fascia was harvested and placed in a press to obtain a thin dry graft of uniform thickness. Only those patients were included in the study that had a regular follow-up till six months.

All the surgical procedures were done as indoor cases and under general anaesthesia with endotracheal intubation and preferably hypotensive anaesthesia. In 60(57.1%) cases endaural approach was used and 39(37.1%) postaural approach was used. Six cases (5.7%) transcanal approach was used. All the patients were treated with underlay technique. A posterior tympanomeatal flap was used in 93(88.6%) patients, an anterior flap was raised in 6(5.7%). In 6(5.7%) pop in technique was used. External auditory meatus was packed with gelfoam and Bismuth iodoform paraffin paste (BIPP) dressing. Per-operatively all the patients received single dose of Gentamicin. Post operatively patients received amoxycillin-Clavulanic acid combination for seven days. Pressure dressing was removed on 3rd post op day and stitches and BIPP dressing on 7th post-operative day. Antibiotics were continued for 7 days. Antibiotic eardrops were advised after removal of BIPP dressing and continued for 2 weeks. Patients were advised to protect the ears from water till the graft was well taken. Regular follow-up was carried out on fortnightly  basis for 2 months and then on monthly basis for four months. Pure tone audiometry was done preoperatively and at the end of three months and six months postoperatively. Results were statistically analyzed using SPSS version 10. Statistical significance was accepted as p<0.05.

Results

A total of 105 patients were included. Age ranged from 14 to 45 years with mean age of 28 years. The distribution of sex, side of operation, site and size of perforation is shown in table I. The history of ear discharge ranged from 2months to 7 years with mean duration of discharge around 2 years. Rinnes test was positive in 32 (30.4%) and negative in 73(69.5%) patients.

Pure tone audiometry was done in all the cases preoperatively. Postoperatively audiometry was done at the end of 3 months and six months. Averages of air conduction at 500 Hz, 1,2 and 4 kHz are displayed in Fig 1.

Graft was well taken in 73(69.5%) cases. A small hole was left in 22(21%) cases, incompletely taken in 4(3.8%) and complete failure in 6(5.7%).
Out of 93 patients with central perforation whether small or large 65(69%) had graft well taken. Out of 5 patients with posterior central perforation 4(80%) had graft well taken and out of 7 patients with anterior perforation 4(57.7%) had graft take-up.
In patients with perforation size less than 25% of tympanic membrane, 10(91%) had graft well taken, those patients with perforation size between 25-50%, 37(88%) had graft take-up. Patients with larger perforation 26(50%) had graft well taken up.

Out of 73 patients who had graft well taken 56(76%) had hearing improvement on pure tone audiometry. 6(8%) had deterioration in hearing and 11(15%) had no change in hearing. Out of these patients with successful surgery 30 patients had one or less than one-year history of ear discharge. In this group 24(80%) had hearing improvement as compared to the rest 43 with more than one-year history of ear discharge 30(74%) had hearing improvement.

There were 67(63%) patients under the age of 30 years and 38(37%) over the age of 30 years. In the first group success rate was 67%(46 patients) and in the second 71% (27 patients).

There was no statistically significant difference in results in male or female, right or left ear.

Six patients had complications. Three developed discharging ear during third week postoperatively that was managed by oral antibiotics and aural toilet. Residual perforation healed in two but persisted in one patient. One patient developed perichondritis and two patients had wound dehiscence that was successfully managed.

Discussion

Myringoplasty is the surgical technique used to restore the anatomy and function of the middle ear. More than fifty years have passed since Zollner and Wullstein described the importance of this type of surgery because of its good results. It is performed when the ear has a perforation of the tympanic membrane without any ossicular damage. The procedure can be done by endaural, postaural or transmeatal approach [6] under local or general anaesthesia.

Repair of eardrum by doing myringoplasty may confer considerable benefits to patients with tympanic membrane perforation. These benefits include prevention of ear infections and aural discharge and improvement in hearing. In addition myringoplasty has been advocated to protect against long-term middle ear damage by preventing the ossicular pathology and preventing the migration of squamous epithelium around the margins of perforation with possible consequent cholesteatoma formation [7.8].

This article examines the surgical and audiologic results of myringoplasty and what factors affect these outcomes. Different studies have claimed a success rate between 70 to 90 percent in achieving closure of perforation [9,10].

However improvement in hearing is not observed in all the cases. We have attained closure of perforation in 73 % and improvement in hearing in 65% of the patients with successful graft take-up.

We found no difference in results in male or female, in right or left ear. Frade Gonzalez  and et al found operation was more successful in younger patients. However we found slightly more success in patients above the age of 30 rather than younger to it. This may be as a result of the fact that in younger age group we also included patients  up to the age of 14 years and the upper age limit is restricted to 45 years.  He also found the surgery in patients with smaller perforation, short duration of disease and central or posterior perforations was more successful in terms of anatomical and functional results. We have also observed similar results. In anterior perforations success was less probably due to technical difficulties in tucking the graft [11].
 
In another study carried out by Lee P, Kelly G, hearing improvement was seen in patients with shorter duration of disease and smaller size of perforation. This may be due to lesser pathological changes in the middle ear [12,13].

In a study in combined military hospital Rawalpindi Intisar and Ayub found 77.5 % success in closing the perforation. Our results in achieving an intact ear drum are similar [14].
 
Conclusion

This study was conducted to evaluate the anatomical and functional results of myringoplasty. We should not only strive to repair the ear drum but also educate the patients to report earlier for the treatment as functional outcome is dependent on an early intervention. Longer the duration of disease more the chances of poor functional outcome.
Reference
1. Harold L. Mawson’s Diseases of the ear 5th edition 1988; 18: 438-441.

2. Sarac S, Gursel B. Use of homograft dehydrated temporal fascia in tympanoplasty. Otol Neurotol 2002; 23(4): 416-21.

3. Singh M, Rai A, Bandyopadhyay S, Gupta SC. Comparative study of the underlay and overlay techniques of myringoplasty in large and subtotal perforations of the tympanic membrane. mangalsingh@hcl_infinet.com.

4.  Fernandes SV.Compositechondroperichondrial clip tympanoplasty: the triple "C" technique. Otolaryngol Head Neck Surg 2003; 128(2): 267-72. 

5. Lin C, Er B.Y. Zhang H, Feng W, Hu Y. The selection of tympanoplastic type in treating chronic suppurative otitis media. <http://www.ncbi.nlm.nih.gov 1999;13(7):307-8. 

6. Vojnosanit P. ] Ristic B, Jakovljevic B, Matkovic      S. Transmeatal direct myringoplasty. Article in Serbo-Croatian (Cyrillic) 2001; 58(6) : 595-8.

7. Bluestone CD, Cantekin EI, Douglas GS. Eustachian tube function related to the results of tympanoplasty in children. Laryngoscope 1979; 89 : 450-8

8. Bailey H.A.T. Contraindications to tympanoplasty: Absolute and relative contraindications. aryngoscope 1976 ;86:67-9.

9. Frade G.C, Castro V.C, Cabanas R.E, Elhendi W, Lago P, Labella C. T.V Prognostic factors influencing anatomic and functional outcome in myringoplasty. Acta Otorrinolaringol Esp. 2002 ; 53(10) :729-35.

10. Perez-Carro RA, Farina CJL, Ibarra UI, Gonzalez GI, Clemente GA. Myringoplasty: our results. Acta Otorrinolaringol Esp. 2002; 53(7): 457-60.

11. Frade GC, Castro VC, Cabanas RE, Elhendi W, Vaamonde LP, Labella CT. Prognostic factors influencing anatomic and functional outcome in myringoplasty  Acta Otorrinolaringol Esp 2002 ;53(10) :729-35.

12. Lee P, Kelly G, Mills RP. Myringoplasty: does the size of the perforation matter? Clin Otolaryngol 2002 ;27 (5) : 331-4.

13. Lin C. Er BY, Feng W, Hu Y Related Articles, The selection of tympanoplastic type in treating chronic suppurative otitis media <http://www.ncbi.nlm.nih.gov 1999 ;13(7):307-8.
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