Research

Original Investigation

Preoperative Factors Affecting Tympanic Membrane

Regeneration Therapy Using an Atelocollagen and Basic
Fibroblast Growth Factor
Nobuhiro Hakuba, MD, PhD; Naohito Hato, MD; Masahiro Okada, MD; Kazuyo Mise, MD; Kiyofumi Gyo, MD

IMPORTANCE The use of growth factors to achieve closure of perforated tympanic

membranes (TMs) has recently become popular. However, preoperative factors affecting
treatment outcomes have seldom been discussed.

OBJECTIVE To evaluate preoperative factors contributing to the success or failure of healing

of perforated TMs.

DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of 153 patients (48 males
and 105 females) in whom the duration of perforation was longer than 6 months prior to
treatment and who were observed for at least 1 year after treatment between July 2009 and
June 2012. Eight factors considered likely to affect the outcome of perforation closure were
statistically evaluated using multivariate logistic regression analysis.

INTERVENTIONS Each perforated TM was filled with a synthetic graft material (atelocollagen
sponge and silicone membrane) containing human basic fibroblast growth factor to promote
wound healing after TM perforation closure.

MAIN OUTCOMES AND MEASURES Complete closure vs residual perforation.

RESULTS After 1 year of follow-up, 101 patients (66.0%) achieved complete closure, 30
patients (19.6%) had residual pinhole perforations (<1 mm diameter), and 22 patients (14.4%)
had larger residual perforations. Multivariate logistic regression analysis adjusted for each
explanatory variable identified a TM without calcification (odds ratio [OR], 2.68 [95% CI,
1.17-6.15]; P = .03) and a perforation not involving the tympanic annulus (odds ratio, 2.75
[95% CI, 1.09-6.94]; P = .04) as significant. Insignificant factors included perforation margin
identified on microscopy (OR, 0.24 [95% CI, 0.99-6.27]; P < .001), perforation margin
without epithelial migration (OR, 7.27 [95% CI, 0.66-80.49]; P = .11), absence of preoperative
otorrhea (P = .38), no previous ear operations (P = .82), perforation size (P = .14), and patient
age (P = .26).

CONCLUSIONS AND RELEVANCE Tympanic membrane regeneration therapy can be applied to

all patients, except those with cholesteatoma or malignant neoplasm. However, patients with
severe calcification of the TM and those with marginal perforations close to the fibrous
annulus should be treated more prudently to achieve perforation closure.

Author Affiliations: Department of

OtolaryngologyHead and Neck
Surgery, Ehime University School of
Medicine, Ehime, Japan.
Corresponding Author: Nobuhiro
Hakuba, MD, PhD, Department of
OtolaryngologyHead and Neck
Surgery, Ehime University School of
Medicine, Ehime, Shizugawa-cho,
JAMA Otolaryngol Head Neck Surg. 2015;141(1):60-66. doi:10.1001/jamaoto.2014.2613 Toon-city, Ehime 791-0295, Japan
Published online October 23, 2014. (hakuba@m.ehime-u.ac.jp).

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 Tympanic Membrane Regeneration Therapy
M
inimally invasive ambulatory surgical procedures,
using growth factors such as autologous serum
eardrops 1 and basic fibroblast growth factor
2-4
(BFGF), have recently been developed in efforts to achieve
closure of perforated tympanic membranes (TMs). Such ap-
proaches are effective even when perforations are large be-
cause the regenerative activity of the TM is reduced at the per-
foration margins.3 However, preoperative factors affecting
therapy outcomes remain controversial. Commencing in 2000,
we have used an atelocollagen and BFGF to promote regen-
eration of the TM and close perforations. Herein, we provide
the details of our treatment and discuss preoperative factors
affecting closure outcomes.
Methods
Candidates for Tympanic Membrane Regeneration Therapy
The study was approved by the ethics committee of Ehime Uni-
versity Hospital and was applied only to patients who pro-
vided written informed consent. Among the 214 patients who
presented to the outpatient clinic for TM regeneration at the
otorhinolaryngology department of Ehime University Hospi-
tal between July 2009 and June 2012 and underwent TM re-
generation therapy using an atelocollagen and silicone mem-
brane and BFGF, 153 patients (48 males and 105 females) in
whom the duration of perforation was longer than 6 months
prior to treatment and who were observed for at least 1 year
after treatment were included in the study. The patients ages
ranged from 13 to 90 years, with a mean (SD) age of 64.9 (15.1)
years. We believe that patients should be at least 10 years old
at the time of operation and explained our methods, includ-
ing local anesthesia, to the patient and their family. If the pa-
tient and their family wished and consented, we attempted the
treatment. No patient was unable to tolerate the procedure.
Candidates for TM regeneration therapy were selected on
the basis of their medical history and microscopic or fiber-
scopic findings of the TM. Fiberscopy allowed us to clearly iden-
tify marginal perforations, even when this was not possible mi-
croscopically. Patients with clear evidence of secondary
cholesteatoma arising from the perforation margin (as evi-
dent fiberscopically or microscopically), or malignant neo-
plasm of the middle ear, were excluded. However, patients with
marginal perforations (evident microscopically) were not ex-
cluded.
Patients with otorrhea on initial examination were not ex-
cluded. If otorrhea was evident at the initial examination, we
sought to treat the condition and temporarily dry the TM using
appropriate treatment (eg, antibiotics). We usually irrigated the
middle ear with saline 2 to 3 times per week and cleaned the
ear canal using Burow or pyoktanin solution for at least 3
months before starting regenerative therapy. Such therapy was
given even if otorrhea persisted, provided that computed to-
mography (CT) yielded no evidence of excessive formation of
granulation tissue in the middle ear.
Computed tomography scanning was performed in all pa-
tients with otorrhea, thickening of the middle ear mucosa, or
migration of part of the perforation margin to the back of the
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Original Investigation Research
TM. If CT revealed a suspected shadow around the ossicles,
at the back of the TM, or in the tympanic attic, that patient was
excluded. Also, those exhibiting poor aeration of the mastoid
antrum, suggestive of excessive formation of granulation tis-
sue in the middle ear or secondary cholesteatoma arising from
the perforation margin, were excluded and were advised to un-
dergo tympanoplasty. The preoperative factors were deter-
mined in each patient using TM photographic records re-
viewed for all patients for the purposes of the study.
Tympanic Membrane Regeneration Therapy Procedure
In this procedure, a perforated TM is filled with a synthetic graft
material (atelocollagen sponge and silicone membrane; Teru-
dermis, Olympus Terumo Biomaterials) to which human fi-
broblast growth factor is applied to promote wound healing
(BFGF preparation; Fibrast Spray, Kaken Pharma Co).5,6 The de-
tails are as follows:
1. A small cotton ball soaked in anesthetic solution (lido-
caine hydrochloride, 4% ) is placed on the margin of the per-
forated TM for approximately 20 minutes to achieve sur-
face anesthesia.
2. The perforation margin is circumferentially dissected with
a sharp pick to expose fresh tissue.
3. The atelocollagen membrane is trimmed to an appropriate
size with scissors and forceps and inserted into the perfo-
ration, making sure that the silicone membrane faces out-
ward and no gap remains. During this step, the silicone mem-
brane should be trimmed into a circle slightly larger than
the perforation to allow the membrane to tightly fit the TM
and so that the atelocollagen membrane can be immobi-
lized.
4. Using a long thin needle, 0.1 to 0.2 mL of BFGF solution (100
g/mL) is applied from a gap between the silicone mem-
brane and the perforation onto the atelocollagen mem-
brane to complete the procedure. The entire procedure is
completed in approximately 30 minutes. The silicone mem-
brane is removed at a follow-up visit 2 to 3 weeks after the
procedure. If a perforation remains, steps 1 to 4 are re-
peated until the perforation is completely closed.
Evaluation of the Outcome of Tympanic Membrane Closure
and Identification of Factors Affecting the Outcome
The outcome of TM closure was evaluated on the basis of the
condition of the TM after at least 1 year of postoperative follow-
up. The effects of 8 factors considered likely to affect the out-
come of perforation closure were statistically evaluated by mul-
tivariate logistic regression analysis: (1) identifiable perforation
margin, (2) perforation margin without epithelial migration,
(3) TM calcification, (4) central perforation, (5) otorrhea, (6)
prior ear operation, (7) perforation size, and (8) age. Logistic
regression analysis was performed with residual perforation
as the objective variable and the 8 factors as the explanatory
variables. All variables were analyzed as Boolean variables of
Yes (1) and No (0). Differences were deemed to be statis-
tically significant for P values less than .05. The 8 factors that
might produce a better outcome are detailed as follows:
1. Perforation margin identified on microscopy: patients with-
out markedly curved ear canals such that the entire circum-
61
 Research Original Investigation Tympanic Membrane Regeneration Therapy

Figure. Representative Cases Before and After Tympanic Membrane Regeneration Therapy

A Unidentified Perforation Margin B Calcification of the Tympanic Membrane

Complete closure Complete closure

Before therapy After therapy Before therapy After therapy

Residual perforation Residual perforation

Before therapy After therapy Before therapy After therapy

C Marginal Perforation Close to the Fibrous Annulus D Large Perforation

Complete closure Complete closure

Before therapy After therapy Before therapy After therapy

Residual perforation Residual perforation

Before therapy After therapy Before therapy After therapy

ference of the TM perforation margin could be viewed mi- 2. Perforation margin without epithelial migration: patients in
croscopically (Figure, A). whom the perforation margin had not partially migrated to

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 Tympanic Membrane Regeneration Therapy
the back of the TM but with no CT evidence of secondary
cholesteatoma.
3. Tympanic membrane without calcification: patients with-
out marked calcification of the remaining TM involving 2
or more quadrants (Figure, B).
4. Central perforation: patients with central perforation not too
close to the fibrous annulus (Figure, C).
5. No preoperative otorrhea: patients not found to have otor-
rhea at the initial examination or who were found to have
otorrhea but who were effectively treated with antibiotics
chosen via sensitivity testing, middle ear irrigation, and ear
canal cleaning.
6. No prior ear operation: patients who had not undergone ear
operations, such as myringoplasty (including the simpli-
fied method) and tympanoplasty.
7. Small or medium perforation: patients with a small or me-
dium perforation of the TM involving only 1 or 2 quadrants
(Figure, D).
8. Not old age: patients younger than 60 years.
Results
Outcome of Closure of Perforated Tympanic Membrane
The causes of the perforated TM in the 153 patients in whom
the duration of perforation was longer than 6 months prior to
treatment and who were observed for at least 1 year after treat-
ment included chronic otitis media in 98 patients, traumatic
perforation in 13 patients, perforation following myrin-
gotomy or tube placement in 19 patients, and reperforation fol-
lowing tympanoplasty in 14 patients. Nine of the 153 patients
developed reperforation more than 1 year after TM perfora-
tion closure by regeneration therapy and underwent reopera-
tion. The mean (range) duration of perforation prior to treat-
ment was 32.0 years (6 months to 83 years).
Small, medium, and large perforations, defined as those
involving 1, 2, and 3 or more quadrants of the TM, respec-
tively, were found in 73 (47.7%), 55 (35.9%), and 25 (16.3%) pa-
tients before treatment.
Seventeen patients were recognized as having otorrhea at
the first visit. We applied ear treatments, as mentioned, for at
least 8 weeks. In 8 patients, the otorrhea stopped, whereas 9
patients underwent regenerative therapy despite the pres-
ence of otorrhea. The mean time it took for the ear treatment
to heal the otorrhea was 3.9 weeks.
At 3 months after treatment, 129 patients (84.3%) achieved
complete closure, 9 patients (5.9%) were found to have per-
forations smaller than 1 mm in diameter (residual pinhole per-
foration), and 15 patients (9.8%) were found to have perfora-
tions of 1 mm or larger in diameter (larger residual perforation).
In the latest evaluation performed 1 year after operation, 101
patients (66.0%) achieved complete closure, 30 patients (19.6%)
had residual pinhole perforations, and 22 patients (14.4%) had
larger residual perforations.
Of the 101 patients who achieved complete closure, 52, 37,
and 12 patients had small, medium, and large perforations be-
fore operation, with a closure rate of 71% (52 of 73), 67% (37 of
55), and 48% (12 of 25), respectively. When stratified by pre-
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Original Investigation Research
treatment perforation size, the mean number of operations to
complete closure was 1.3, 1.4, and 1.8 in patients with small,
medium, and large perforations, respectively.
Of the 30 patients with residual pinhole perforations, the
mean (SD) improvement in hearing was 8.9 (7.9) dB, which was
not significantly different from that in the complete closure
group (t test). During 24 months of postoperative follow-up,
pinhole perforations developed a mean (SD) of 7.5 (8.5) months
after the regeneration therapy. Patients with residual pinhole
perforations were observed every 3 to 4 months on an outpa-
tient basis and were advised to undergo a second operation if
enlargement of the pinhole perforations and worsening of hear-
ing were observed. At last follow-up, 4 patients with pinhole
perforations were found to have progressed to small perfora-
tions and had undergone a second session of regeneration
therapy. Of the 22 patients with residual perforations, during
21 months of posttreatment follow-up, reperforations devel-
oped a mean (SD) of 2.3 (4.2) months after the regeneration
therapy.
Postoperative epithelial pearl formation in the TM was ob-
served in 6 patients (3.9%) at the dissected perforation mar-
gin in all cases.
Relationship Between Preoperative Factors Likely to Affect
Closure Outcome and the Rate of Complete Closure or
Residual Perforation
The Table summarizes the 8 factors likely to affect the out-
come of perforation closure and the rate of complete closure
or residual perforation after at least 1 year of follow-up. Logis-
tic regression analysis adjusted for each explanatory variable
identified a TM without calcification (odds ratio, 2.68 [95% CI,
1.17-6.15]; P = .03) and a perforation not involving the tym-
panic annulus (odds ratio, 2.75 [95% CI,1.09-6.94]; P = .04) as
significant (Table).
Discussion
Regeneration therapy based on the novel concept of tissue en-
gineeringcreating new tissue in situis referred to as in situ
tissue engineering.7 Based on this concept, 3 factors, includ-
ing growth factors, scaffolds, and new cells, are required to pro-
duce new tissue. Basic fibroblast growth factor, a growth fac-
tor that was identified following the identification of epidermal
growth factor, is known to directly promote the proliferation
of vascular endothelial cells and fibroblasts via its receptor and
formation of well-vascularized granulation tissue in vivo.8 Ba-
sic fibroblast growth factor has been used by dermatologists
for the treatment of pressure sores,9 ulcers,10 and burns.11 Re-
cent advances in the development of scaffold materials for in
situ tissue engineering include the development of synthetic
graft materials with lower antigenicity and high biocompat-
ibility. Collagen is highly compatible with surrounding tis-
sue, can serve as a scaffold for newborn cells and tissues, and
is eventually absorbed12; consequently, it is considered an ex-
cellent synthetic graft material for perforation closure.13 The
addition of BFGF,2 a growth factor known to help wound heal-
ing by acting on fibroblasts and vascular endothelial cells to
63
 Research Original Investigation Tympanic Membrane Regeneration Therapy

Table. Outcome of Tympanic Membrane Closure and Multivariate Analysisa

No. (%) Logistic Regression Analysis

Characteristic Complete Closure Residual Perforation OR (95% CI) P Value
Perforation Margin Identified on Microscopy
Yes (n = 117) 85 (73) 32 (27)
0.24 (0.99-6.27) <.001
No (n = 36) 16 (44) 20 (56)
Perforation Margin Without Epithelial Migration
Yes (n = 149) 99 (66) 50 (34)
7.27 (0.66-80.49) .11
No (n = 4) 2 (50) 2 (50)
Tympanic Membrane Without Calcification
Yes (n = 117) 84 (72) 33 (28)
2.68 (1.17-6.15) .03
No (n = 36) 17 (47) 19 (53)
Central Perforation
Yes (n = 119) 88 (74) 31 (26)
2.75 (1.09-6.94) .04
No (n = 34) 13 (38) 21 (62)
Without Preoperative Otorrhea
Yes (n = 144) 96 (67) 48 (33)
NA .38
No (n = 9) 5 (56) 4 (44)
Without Prior Ear Operation
Abbreviations: NA, not analyzed; OR,
Yes (n = 138) 91 (66) 47 (34)
NA .82 odds ratio.
No (n = 15) 10 (67) 5 (33) a
The outcome of tympanic
Small or Medium Perforation membrane closure was evaluated
Yes (n = 128) 89 (70) 39 (30) based on the condition of the
NA .14 tympanic membrane. The effects of
No (n = 25) 12 (48) 13 (52)
the 8 factors considered likely to
Age <60 y affect the outcome of perforation
Yes (n = 117) 77 (66) 40 (34) closure were statistically evaluated
NA .26 by multivariate logistic regression
No (n = 36) 24 (67) 12 (33)
analysis.

promote neovascularization, proliferation of granulation tis-
sue, and reepithelialization14 to atelocollagen, is expected to
improve the rate of successful closure of perforated TMs and
extend the indications of the treatment.3,4,15-17 Lou et al2 and
Zhang and Lou4 reported that direct application of BFGF im-
proved healing and shortened the closure time of acute trau-
matic perforations. We performed regenerative therapy on pa-
tients with chronic cases in which the duration of perforation
prior to treatment was longer than 6 months. We suggest that
mechanical disruption of the edge of the perforation, and the
scaffold for newly formed cells and tissues, is required to stimu-
late the activity of TM stem cells.3 This is because the outer
squamous epithelium around the edge of a chronic perfora-
tion prevents TM closure.18
In our previous study reported in 2003,5 we compared the
outcome of 9 patients treated with atelocollagen and silicone
membrane plus BFGF therapy with the outcome of 5 patients
treated with saline for chronic otitis media and achieved a 100%
closure rate with the addition of BFGF, whereas the closure rate
was only 40% with the saline-only treatment. We also re-
ported the outcome of 87 patients treated using the same pro-
cedure and found that the proportions of patients with com-
plete closure, residual pinhole perforation, and larger residual
perforation were 92%, 6%, and 2%, respectively. 6 In the
present study, the rate of complete closure, residual pinhole
perforation, and larger residual perforation was 66.0%, 19.6%,
and 14.4% after at least 1 year of postoperative follow-up, in-
dicating a poorer outcome compared with the previous study.
Two possible reasons for the poorer treatment outcome in the
present study are suggested. One is that patients who would
have been considered inappropriate candidates for TM regen-
eration therapy in the previous study were allowed to un-
dergo the therapy if they wished and consented to do so after
being informed of the challenging situation. Another reason
may depend on the difference in the follow-up period after
treatment. In the initial study, not all patients were observed
for longer than 1 year. In this study, complete closure was
achieved in 101 patients (66.0%) after at least 1 year of post-
operative follow-up, although 129 (84.3%) had achieved com-
plete closure 3 months after the operation. Twenty-eight com-
plete closure cases worsened to pinhole perforation or larger
residual perforation with 1 year of postoperative follow-up. If
we defined the observation period after treatment to be lon-
ger, the success rate would be worse. Of the 214 patients who
presented to the outpatient clinic for TM regeneration, 61 were
not enrolled because they were lost to follow-up for at least 1
year after treatment or clinical information was missing. Fur-
thermore, the final decision on the choice of TM regeneration
therapy or other primary treatments depended on the pa-
tients wishes after they were informed about each method.
Thus, there was likely to have been selection bias in this study.
Logistic regression analysis of factors likely to affect the
outcomes of perforated TM closure revealed significant dif-
ferences between patients with and without calcification of the
TM and marginal perforations, which reduce blood supply to
the site of TM regeneration19 and thus to the residual TM. In

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 Tympanic Membrane Regeneration Therapy Original Investigation Research

turn, the supply of new cells, essential for in situ tissue engi-
neering, is inadequate,7 increasing the incidence of residual
perforation. The odds ratio showed that patients with mar-
ginal perforations were at approximately a 4.1-fold higher risk
of residual perforation than were those with central perfora-
tions. The 105 patients who achieved complete closure after
at least 1 year of postoperative follow-up consisted of 71%, 67%,
and 48% of the patients who had small, medium, and large per-
forations before operation, respectively, demonstrating that
patients with a smaller perforation achieved a higher closure
rate. The closure rate for regenerative therapy is certainly higher
than that for a paper patch20 in large perforations (48% vs 12%)
but was not significantly better for small perforations (71% vs
63%). Certainly, obtaining closure in half of large perforations
without surgery is worthwhile.
However, the statistical results suggested a limited effect
of preoperative perforation size on the outcome of regenera-
tion therapy and instead identified the location of perfora-
tion (ie, marginal or central perforation) as a more important
predictor of therapy outcome. Kim et al21 found no signifi-
cant effect of preoperative perforation size on the closure rate
after fat-graft myringoplasty. Perforation closure is more dif-
ficult to achieve in patients with a marginal perforation, even
when the perforation itself is small or medium sized, than in
patients with a large perforation whose margin can be com-
pletely identified. It is thus likely that the outcome of TM re-
generation therapy can be predicted by comprehensive ex-
amination of the perforation, including location of the
perforation, condition of the perforation margin, and the pres-
ence or absence of calcification of the remaining TM. How-
ever, additional studies with a larger number of patients are
needed to more precisely identify relevant factors.
Postoperative epithelial pearl formation was reported in
our previous study.22 In the present study, epithelial pearl for-
mation in the TM was observed in 6 patients (3.9%), in each
case at the dissected perforation margin, suggesting that the
lesion arose from the residual epithelium. Given that the in-
cidence of postoperative epithelial pearl formation after over-
lay myringoplasty is 2.5% to 7.0%,23-25 it seems unlikely that
the regeneration therapy induced epithelial pearl formation.
Conclusions
Tympanic membrane regeneration therapy can be applied to
all patients except those with cholesteatoma or cancer. How-
ever, in patients with severe calcification of the TM and those
with marginal perforations close to the fibrous annulus,
regenerative therapy should be given prudently to achieve
perforation closure, with patient consent being given only
after detailed explanation of the difficulties that might be
encountered.

ARTICLE INFORMATION REFERENCES growth factor and basic fibroblast growth factor on
Submitted for Publication: March 24, 2014; final 1. Kakehata S, Hirohe Y, Kitani R, et al. Autologous corneal epithelial wound healing and
revision received August 26, 2014; accepted serum eardrops therapy with a chitin membrane for neovascularization in vivo and in vitro. Ophthalmic
September 3, 2014. closing tympanic membrane perforations. Otol Res. 2013;49(3):150-160.

Published Online: October 23, 2014.
doi:10.1001/jamaoto.2014.2613.
Author Contributions: Dr Hakuba had full access
to all of the data in the study and takes
responsibility for the integrity of the data and the
accuracy of the data analysis.
Study concept and design: Hakuba, Hato.
Acquisition, analysis, or interpretation of data:
Hakuba, Okada, Mise, Gyo.
Drafting of the manuscript: Hakuba, Hato, Okada.
Critical revision of the manuscript for important
intellectual content: Hakuba, Mise, Gyo.
Statistical analysis: Mise, Gyo.
Obtained funding: Hakuba.
Administrative, technical, or material support: Hato,
Gyo.
Study supervision: Hakuba, Hato, Gyo.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was supported by
grants-in-aid for scientific research (23592486)
from the Ministry of Education, Science and
Culture, Japan.
Role of the Sponsor: The Ministry of Education,
Science and Culture had no role in the design and
conduct of the study; collection, management,
analysis, and interpretation of the data;
preparation, review, or approval of the manuscript;
and decision to submit the manuscript for
publication.
Neurotol. 2008;29(6):791-795.
2. Lou Z, Xu L, Yang J, Wu X. Outcome of children
with edge-everted traumatic tympanic membrane
perforations following spontaneous healing versus
fibroblast growth factor-containing gelfoam
patching with or without edge repair. Int J Pediatr
Otorhinolaryngol. 2011;75(10):1285-1288.
3. Kanemaru S, Umeda H, Kitani Y, Nakamura T,
Hirano S, Ito J. Regenerative treatment for
tympanic membrane perforation. Otol Neurotol.
2011;32(8):1218-1223.
4. Zhang Q, Lou Z. Impact of basic fibroblast
growth factor on healing of tympanic membrane
perforations due to direct penetrating trauma:
a prospective non-blinded/controlled study. Clin
Otolaryngol. 2012;37(6):446-451.
5. Hakuba N, Taniguchi M, Shimizu Y, Sugimoto A,
Shinomori Y, Gyo K. A new method for closing
tympanic membrane perforations using basic
fibroblast growth factor. Laryngoscope. 2003;113
(8):1352-1355.
6. Hakuba N, Iwanaga M, Tanaka S, et al. Basic
fibroblast growth factor combined with
atelocollagen for closing chronic tympanic
membrane perforations in 87 patients. Otol Neurotol.
2010;31(1):118-121.
7. Hori Y, Nakamura T, Kimura D, et al. Effect of
basic fibroblast growth factor on vascularization in
esophagus tissue engineering. Int J Artif Organs.
2003;26(3):241-244.
8. Yan L, Wu W, Wang Z, et al. Comparative study
of the effects of recombinant human epidermal
9. Ohura T, Nakajo T, Moriguchi T, et al. Clinical
efficacy of basic fibroblast growth factor on
pressure ulcers: case-control pairing study using a
new evaluation method. Wound Repair Regen. 2011;
19(5):542-551.
10. Morimoto N, Yoshimura K, Niimi M, et al. An
exploratory clinical trial for combination wound
therapy with a novel medical matrix and fibroblast
growth factor in patients with chronic skin ulcers:
a study protocol. Am J Transl Res. 2012;4(1):52-59.
11. Akita S, Akino K, Imaizumi T, Hirano A. Basic
fibroblast growth factor accelerates and improves
second-degree burn wound healing. Wound Repair
Regen. 2008;16(5):635-641.
12. Kawase T, Yamanaka K, Suda Y, et al.
Collagen-coated poly(L-lactide-co--caprolactone)
film: a promising scaffold for cultured periosteal
sheets. J Periodontol. 2010;81(11):1653-1662.
13. Truy E, Disant F, Tiollier J, Froehlich P, Morgon
A. A clinical study of human type IV collagen as
tympanic membrane grafting material: preliminary
noncomparative study. Arch Otolaryngol Head Neck
Surg. 1994;120(12):1329-1332.
14. Akasaka Y, Ono I, Tominaga A, et al. Basic
fibroblast growth factor in an artificial dermis
promotes apoptosis and inhibits expression of
alpha-smooth muscle actin, leading to reduction of
wound contraction. Wound Repair Regen. 2007;15
(3):378-389.
15. Mondain M, Ryan A. Effect of basic fibroblast
growth factor on normal tympanic membrane. Am J
Otolaryngol. 1994;15(5):344-350.

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 Research Original Investigation Tympanic Membrane Regeneration Therapy

16. Kato M, Jackler RK. Repair of chronic tympanic
membrane perforations with fibroblast growth
factor. Otolaryngol Head Neck Surg. 1996;115(6):
538-547.
17. Ma Y, Zhao H, Zhou X. Topical treatment with
growth factors for tympanic membrane
perforations: progress towards clinical application.
Acta Otolaryngol. 2002;122(6):586-599.
18. Spandow O, Hellstrm S, Dahlstrm M, Bohlin
L. Comparison of the repair of permanent tympanic
membrane perforations by hydrocolloidal dressing
and paper patch. J Laryngol Otol. 1995;109(11):1041-
1047.
19. Gneri EA, Tekin S, Yilmaz O, 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(3):371-376.
20. Golz A, Goldenberg D, Netzer A, et al. Paper
patching for chronic tympanic membrane
perforations. Otolaryngol Head Neck Surg. 2003;
128(4):565-570.
21. Kim DK, Park SN, Yeo SW, et al. Clinical efficacy
of fat-graft myringoplasty for perforations of
different sizes and locations. Acta Otolaryngol.
2011;131(1):22-26.
22. Hakuba N, Hato N, Omotehara Y, Okada M, Gyo
K. Epithelial pearl formation following tympanic
membrane regeneration therapy using an
atelocollagen/silicone membrane and basic
fibroblast growth factor: our experience from a
retrospective study of one hundred sixteen
patients. Clin Otolaryngol. 2013;38(5):394-397.
23. Glasscock ME III. Tympanic membrane grafting
with fascia: overlay vs undersurface technique.
Laryngoscope. 1973;83(5):754-770.
24. Kartush JM, Michaelides EM, Becvarovski Z,
LaRouere MJ. Over-under tympanoplasty.
Laryngoscope. 2002;112(5):802-807.
25. Ryan JE, Briggs RJ, Ryan JE, et al. Outcomes of
the overlay graft technique in tympanoplasty. Anz J
Surg. 2010;80(9):624-629.

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