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KEYWORDS
Myringoplasty;
Tympanic perforation;
Children;
Cartilage
Abstract Introduction: Tympanoplasty is a surgical operation involving the repair of the tympanic membrane without any ossicular chain damage.
Objective: To analyze prognostic factors inuencing the success of myringoplasty in children
under 17 years.
Method: We present a retrospective study (20002011) reviewing a total of 63 children between 7
and 16 years who had undergone a primary tympanoplasty which was bilateral in 7 cases. Anatomical success was dened as an intact graft at the last follow-up visit with a minimum of 6 months.
Hearing success was considered if the post-operative air bone gap (ABG) was less than 10 dB
calculated on 500 Hz, 1000 Hz and 2000 Hz.
Results: We recorded 70 operated ears. The mean age was 14.25 years [716] with a sex-ratio of
0.52. The perforation was subtotal in most cases (31.4%). We used conchal cartilage graft in 20%,
tragus cartilage in 27% and temporalis fascia in 53%. Postoperatively, perforation closure was
observed in 92.8% (n = 65) and hearing improvement in 65%. We obtained better audiological
and anatomical results with conchal graft (85% and 100% respectively) compared with tragus cartilage and temporalis fascia without a statistically signicant difference. Signicant factors inuencing surgical outcome were age older than 12 years (p = 0.02), absence of allergic rhinitis
(p < 0.001), dry middle ear (p = 0.001), preoperative conductive hearing loss (p = 0.04) and placement of the graft under the malleus handle (p = 0.04).
Conclusion: Myringoplasty is a valid treatment for tympanic membrane perforation in pediatric
population. If performed properly, it has a good chance of restoring a childs hearing.
2014 Hosting by Elsevier B.V. on behalf of Egyptian Society of Ear, Nose, Throat and Allied Sciences.
1. Introduction
Tympanoplasty involves the repair of the tympanic membrane
when the lesion is a tympanic perforation without any ossicu* Corresponding author at: 20 Abou el Walid Ebn Roched, Riadh
Andalos City, 2058 Ariana, Tunis, Tunisia. Tel.: +216 52875691.
E-mail address: inesnacef@gmail.com (I. Nacef).
Peer review under responsibility of Egyptian Society of Ear, Nose,
Throat and Allied Sciences.
http://dx.doi.org/10.1016/j.ejenta.2014.10.007
2090-0740 2014 Hosting by Elsevier B.V. on behalf of Egyptian Society of Ear, Nose, Throat and Allied Sciences.
42
ossicular chain erosion, improvement of the auditory function
and, therefore, development of language and water activities.1
Nevertheless, its use in children remains a matter of debate
regarding the optimal age of the procedure, its indications
and the appropriate surgical approach. Many factors may
inuence the surgical outcome of tympanoplasty in pediatric
population.
2. Objectives
The aim of our study is to evaluate the outcome of myringoplasty among patients under 17 years by analyzing prognostic
factors inuencing the success of tympanoplasty in this
population.
3. Methods
We conducted a retrospective study between January 2000 and
December 2011, reviewing a total of 63 medical records of
patients younger than 17 years who underwent a primary tympanoplasty type 1 without mastoidectomy. All the patients had
chronic suppurative otitis media with perforation in the pars
tensa.
Tympanoplasty was unilateral in 56 cases and bilateral in 7 of
them. The total number of operated ears was 70. Regarding the
bilateral cases, a six month interval was contemplated between
both surgeries. For each patient we analyzed: age, gender, history of adenoidectomy or tonsillectomy, condition of the
affected and the contralateral ear, size, type and location of
the perforation, surgical technique, graft material and its placement. All cases with the presence of cholesteatoma, who had any
type of previous or concurrent ossicular chain reconstruction or
had no follow-up data available were excluded from the study.
Size of the perforation was considered large when it exceeded
the quarter area of the tympanic membrane. It was classied
anterior or posterior relative to the long process of the malleus.
All children were submitted to general anesthesia. All tympanoplasties were performed using an underlay technique via a postauricular approach. Anatomical success of the myringoplasty,
evaluated by microscopy, was dened as an intact graft without
lateralization, retraction, inammation or infection at the last
follow-up visit with a minimum of 6 months. Children were
observed for an average time period of 28 months after surgery
varying between 6 months and 6 years.
Auditory function was analyzed by performing preoperative and postoperative tone threshold audiometry at 3 months,
6 months and 1 year after surgery. Hearing restoration was
considered successful if the post-operative air bone gap
(ABG) was less than 10 dB, calculated on the frequencies of
500 Hz, 1000 Hz and 2000 Hz.
Statistical analysis was performed using SPSS 19. We
conducted a descriptive study of quantitative and qualitative
variables, as well as univariate Chi-square study of qualitative
variables. Statistical signicance was assigned to a p-value
60.05.
54.3%
32.8%
5.7%
7.2%
7-9 years
10-11 years
Figure 1
100%
85%
12-14 years
15-16 years
Age repartition.
92,8%
80%
60%
4. Results
We obtained a total of 70 ears divided in 24 males and 46
females (sex ratio of 0.5). The mean age was 14.25 years ranging from 7 to 16 years with greater frequency in patients
40%
8,5%
20%
0%
Figure 2
Tinnitus
Symptomatology.
43
Contributing factors
Audiological success
P value
Yes
No
Age
<12 years
P12 years
4 (44%)
61 (100%)
5 (56%)
Sex
Male
Female
16 (66.6%)
30 (65.2%)
Adenoidectomy/tonsillectomy
Yes
No
Anatomical success
P value
Yes
No
0.02
7 (77%)
58 (95%)
2
3
0.05
8 (33.4%)
16 (34.8%)
0.9
21 (87.5%)
44 (95.6%)
3 (12.5%)
2 (4.4%)
0.39
10 (71%)
36 (64%)
4 (29%)
20 (36%)
0.6
14 (100%)
51 (91%)
5 (9%)
0.24
Allergic rhinitis
Yes
No
4 (50%)
41 (66.1%)
4 (50%)
21 (33.8%)
0.37
5 (62.5%)
60 (96%)
3 (37.5%)
2 (4%)
0.0003
34 (60.7%)
12 (85.7%)
22 (39.3%)
2 (14.3%)
0.07
51 (91%)
14 (100%)
5 (9%)
0.24
Perforation site
Posterior
Anterior
Subtotal/total
*
Non marginal
*
Marginal
Inferior
Central
12 (63.1%)
7 (63.6%)
15 (65%)
*
15
3 (60%)
9 (75%)
7 (36.9%)
4 (36.4%)
8 (35%)
*
6
*
2
2 (40%)
3 (25%)
0.45
14 (73.7%)
11 (100%)
23 (100%)
5 (26.3%)
0.32
Operated ear
Dry
Discharging
45 (69%)
20 (31%)
5 (100%)
0.001
60 (92.3%)
5 (7.7%)
5 (100%)
0.003
Contralateral ear
Dry
Wet
26 (74.3%)
20 (57%)
9 (25.7%)
15 (43%)
0.13
32 (91.4%)
33 (94.3%)
3 (8.6%)
2 (5.7%)
0.64
Hearing loss
Conductive
Mixed
43 (71.6%)
4 (40%)
17 (28.4%)
6 (60%)
0.04
57 (95%)
8 (80%)
3 (5%)
2 (20%)
0.08
Graft material
Temporalis fascia
Conchal cartilage
Tragus cartilage
22 (59%)
12 (85%)
12 (63%)
15 (41%)
2 (15%)
7 (37%)
0.2
41 (95%)
10 (100%)
14 (82%)
2 (4.6%)
3 (17%)
0.13
Graft placement
Under the malleus
Over the malleus
Sandwich
28 (80%)
14 (51.8%)
4 (50%)
7 (20%)
13 (48.2%)
4 (50%)
0.04
30 (85.7%)
27 (100%)
8 (100%)
5 (14.3%)
0.06
allergic rhinitis was a factor highly correlated with graft reperforation (p = 0.0003).
In order of frequency, the perforation was subtotal in
31.4% (n = 22), anterior in 15.7% (n = 11), central in
17.1% (n = 12), posterior in 27.1%,19 inferior in 7.4%
(n = 5) and total in only one case (Fig. 3). Among the patients
with a subtotal perforation, two had a marginal one. The rate
of ABG closure in subtotal, anterior, posterior and inferior
perforation was 65%, 63.6%, 63.1% and 60% respectively
(Fig. 4). Even though reperforation was more frequent in posterior type (45%), no statistical correlation was found between
the location of initial perforation and reperforation.
Children with preoperative conductive hearing loss had
postoperative ABG closure in 71.6% versus 40% for those
5 (100%)
12 (100%)
44
<12 years
P12 years
7 (77%)
2
49 (80%)
12
5. Discussion
Adenoidectomy/Tonsillectomy
Yes
Non
3 (33%)
6
11 (18%)
50
Perforation site
Marginal
Non marginal
9 (100%)
2
59 (96%)
Operated ear
Dry
Discharging
9 (100%)
56 (91%)
5
Graft material
Temporalis fascia
Conchal cartilage
Tragus cartilage
1 (12%)
6 (66%)
2 (22%)
36 (59%)
8 (13%)
17 (28%)
Audiological success
Yes
No
4 (44%)
5
61 (100%)
21.87 dB
19.63 dB
Anatomical success
Yes
No
7 (77%)
2
58 (95%)
3
Table 2
25
20
15
10
5
0
Figure 3
65%
22
19
12
11
5
63,6%
63,1%
60%
Subtotal
Figure 4
Anterior
Posterior
Inferior
with tragus cartilage (63%) and temporalis fascia (59%), without a statistically signicant difference (p = 0.2). Although
better anatomical results were observed with conchal cartilage
graft (100%), we did not nd any statistical signicance in relation to closure of the perforation (p = 0.13).
The graft was placed in underlay for all cases, under the
malleus handle in 50% (n = 35), over it in 38.5% (n = 27)
and using the sandwich technique in 11.4% (n = 8). ABG
45
Table 3
Author
Year
Mean audiological
improvement (dB)
Castro et al.,1
Knapik et al.,9
Mendes et al.,13
Al Khtoum et al.,26
Ribeiro et al.,20
Our series
2013
2011
2008
2009
2011
12.53
9.1
7.6
11.4
12.6
19.77
Year
Percentage of hearing
improvement (%)
Mendes et al.,13
Knapik et al.,9
Castro et al.,1
Halim et al.,16
Umapathy11
Ribeiro et al.,20
Singh et al.,8
Uyar et al.,5
Al Khtoum et al.,26
Our series
2008
2011
2013
2009
2003
2011
2005
2006
2009
87.5
93
88
71.6
72
76.9
61
82.9
77
65
Knapik et al.,
Koumar et al.,2
Castro et al.,1
Halim et al.,16
Ribeiro et al.,20
Singh et al.,8
Umapathy.,11
Al Khtoum et al.,26
Our study
Year
2011
2010
2013
2005
2011
2005
2003
2009
94
67.3
84
92.7
85.7
80
90
85.7
92.8
46
Post-operatively, audiological success criteria have not yet
been standardized. Singh8 evaluated air conduction improvement while others evaluated both air conduction and speech
reception thresholds.10 Currently, many authors relied on
ABG improvement.9 ABG reduction varies in the literature
between 7.6 dB and 12.6 dB (Table 3) and hearing improvement between 61% and 93% (Table 4). We chose to evaluate
hearing improvement as a closure of the ABG within 10 dB.
In the study of Halim,16 bone conduction threshold used as
a parameter of the safety of otological surgery, did not change
post-operatively for both postaural and transmeatal approach.
Moreover, anatomical success rates reported in the present
study were similar to others in the literature (Table 5).
6. Conclusion
Myringoplasty is a surgical technique which provides good
anatomical and functional results in children with sequela of
chronic otitis media.1,2 If performed properly in the hands of
experienced surgeons, it has a good chance of restoring a
childs hearing. This study shows that tympanoplasty is a valid
treatment modality for tympanic membrane perforation in the
pediatric population. Signicant factors inuencing surgical
outcome of tympanoplasty in our study are: age older than
12 years, absence of allergic rhinitis, dry middle ear, preoperative conductive hearing loss and placement of the graft under
the malleus handle. However, a large study with a long follow
up is warranted in order to come to a denitive conclusion.
Conict of interest
Authors report no conict of interest in the publication of the
article. There were no nancial and personal relationships with
other people or organizations that could inappropriately inuence (bias) their work. There was no sponsorship for this study.
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