ORIGINAL ARTICLE

Pre and post operative evaluation of hearing

in chronic suppurative otitis media
Namita Kabdwal, Saurabh Varshney*, Sampan Singh Bist, Sanjeev Bhagat,
Sarita Mishra, Vinish Agarwal
Department of ENT, Himalayan Institute of Medical Sciences, HIHT University, Jollygrant, Doiwala, Dehradun,
*All India Institute of Medical Sciences (AIIMS), Rishikesh, India

Aim: To evaluate pre- and postoperative hearing status in patients of chronic suppurative otitis media (CSOM)
ABSTRACT
undergoing mastoidectomy with tympanoplasty. Study type- Prospective. Materials and Methods: Eighty cases of
CSOM were included. All patients underwent a pre-operative pure-tone audiometry (PTA) to nd out the hearing
status and to obtain documentary evidence for the same, and X-ray mastoid (bilateral Schullres view) to assess the
pathology and surgical anatomy of the mastoid. All patients included in the study were categorized into three groups
according to the surgery planned: Group-A: Tympanoplasty, Group-B: Canal wall up (CWU) mastoidectomy with
tympanoplasty, and Group-C: Canal wall down CWD mastoidectomy with reconstruction. Post-operatively, after
10 weeks and 6 months, audiological examination (PTA) was carried out to compare pre- and post-operative hearing
status. Results: In this study we found that postoperative hearing results were better in the case of safe CSOM as
compared with unsafe CSOM and of tympanoplasty as compared with tympanoplasty with mastoidectomy.

KEYWORDS: Chronic suppurative otitis media, Tympanoplasty, Mastoidectomy

INTRODUCTION wall down (CWD) mastoidectomy to eradicate disease

Chronic suppurative otitis media (CSOM) is one of the
most common ear diseases in the developing countries.
CSOM is defined as a persistent disease, insidious in
onset, often capable of causing severe destruction of
middle ear structure and irreversible sequel, which is
clinically manifested with deafness and discharge more
than 3 months.[1] Incidence of CSOM varies from 0.5%
to 2.0% in developed countries, whereas in developing
countries it ranges from 3% to 57%. In India incidence of
CSOM ranges up to 30%, with a prevalence rate of 16/1000
population in urban and 46/1000 in rural areas.[2,3] Hearing
loss in CSOM is usually conductive and is attributed to
alteration in the normal mechanism of sound conduction
from external to the inner ear, usually because of ossicular
chain discontinuity. [4] Middle ear surgery for hearing
gain is being performed for many years. Tympanoplasty
is defined as a procedure to eradicate disease in the
middle ear and to reconstruct hearing mechanism with
or without tympanic membrane grafting. This procedure
can be combined with an intact canal wall(ICW) or canal
from the mastoid area.[5] The role of tympanoplasty is
to restore sound pressure transformation at the oval
window by coupling an intact tympanic membrane with
a mobile stapes footplate via an intact or reconstructed
ossicular chain and to provide sound protection for the
round window membrane by a closed, air-containing,
mucosa-lined middle ear. [4] Closure of a tympanic
membrane perforation restores the vibratory area of the
membrane and affords round window protection, thus
improving hearing; however, high-frequency audiometry
demonstrates a persistent airbone gap (ABG), despite
successful closure of a perforation.[6]
MATERIALS AND METHODS
This was a prospective study, carried out at Department
of Otorhinolaryngology, Himalayan Institute of Medical
Access this article online
Quick Response Code:
Website:
www.indianjotol.org

Address for correspondence: Dr. Saurabh Varshney,

All India Institute of Medical Sciences (AIIMS), DOI:
Rishikesh - 249 201, Uttarakhand, India. 10.4103/0971-7749.124505
E-mail: drsaurabh68@gmail.com

164 Indian Journal of Otology | October 2013 | Vol 19 | Issue 4 |

 Kabdwal, etal.: Post operative hearing in CSOM

Sciences, Dehradun, a tertiary care centre in the state of Table 1: Pre-operative degree of hearing loss in safe
Uttarakhand, from November 2010 to October 2011. Atotal and unsafe CSOM according to WHO criteria
of 80patients were included in the study. Degree of Number of patients Number of patients
hearing loss (safe CSOM) (%) (unsafe CSOM) (%)
The inclusion criteria were as follows: Patients aged more than Minimal
12years, diagnosed as having CSOM, having pure conductive <25 dB 28(45.90) 00
hearing loss, and posted for ear surgery. The exclusion Mild
criteria were as follows: Patients who were less than 12, had 26-40 dB 23(37.70) 13(68.42)
Moderate
malignancy of middle ear, otitis externa, previous history of
41-55 dB 7(11.47) 6(31.57)
ear surgery, complications of CSOM, history of ear trauma,
Moderately severe
and mentally retarded.
56-70 dB 3(04.91) 00
Severe
The selected patients were subjected to a detailed history 71-90 dB 00 00
and complete ear, nose, and throat examination. The ears Profound
were examined by otoscopy initially and subsequently by a <91 dB 00 00
microscope and otoendoscope to establish a pre-operative Total 61(100.00) 19(100.00)
diagnosis of safe or unsafe disease. CSOM: Chronic suppurative otitis media

All patients underwent a pre-operative pure-tone audiometry Table 2: Hearing evaluation at 10 weeks (first
(PTA) to find out the hearing status and to obtain documentary follow-up)
evidence for the same, and X-ray mastoid(bilateral Schullres Pre-op hearing Post-op hearing Gain Loss
view) to assess the pathology and surgical anatomy of the mastoid. Total(80cases) 33.58 dB 26.35 dB 7.23 dB -
Group-A(53cases) 31.98 24.18 7.8 -
All patients included in the study were categorized Group-B(4cases) 30.00 26.5 3.5 -
into three groups according to the surgery planned: Group-C(23cases) 37.91 31.30 6.61 -
Group-A: Tympanoplasty, Group-B: Canal wall up (CWU)
mastoidectomy with tympanoplasty, and Group-C: CWD which were clinically diagnosed as safe, were found to be unsafe.
mastoidectomy with reconstruction.
In our study, 53(66.25%) cases underwent Group-A surgery,
Post-operatively, after 10weeks and 6months, audiological 23 (28.75%) cases Group-C surgery, and 4 (05.00%) cases
examination (PTA) was carried out to compare pre-and Group-B surgery.
post-operative hearing status.
Pre-operative hearing status [Table 1]
RESULTS Hearing loss was assessed by PTA in three frequencies, 500,
1000, and 2000Hz, and ABG was calculated.
A total of 80cases were selected for this study and divided into
safe and unsafe CSOM based on history, clinical findings, Comparison of pre- and postoperative hearing
and intra-operative findings. The number of cases with safe
at rst follow-up of 10 weeks [Table 2]
CSOM was 61 (76.25%) and that with unsafe CSOM was
19(23.75%). The patients were aged between 14 and 74 years In our study average pre-operative hearing loss in 80cases
(mean age: 32.2years). The number of male and female patients of CSOM was 33.58 dB. Postoperatively, at first follow-up
was 48 (60.00%) and 32 (40.00%) (M:F=1.5:1.0), respectively. of 10weeks, average hearing loss in 80cases was 26.35dB.
Hence, postoperatively at 10weeks an average gain of 7.23dB
The primary complaints of the patients were ear discharge in 80 was seen.
(100%) cases and hearing loss in 74 (92.50%) cases. The duration
of ear discharge ranged from 6 months to 50 years. Maximum A total of 53cases were in Group-A (tympanoplasty) where
number of patients, that is, 30 (37.50%) cases, had duration of average hearing loss pre-operatively was 31.98 dB and
ear discharge of 10-15 years. Duration of hearing loss complaint postoperatively at 10weeks average hearing loss was 24.18dB.
was present from 6 months to 30 years. Maximum number of Hence, an average gain of 7.8dB was noticed in Group-A.
patients, that is, 34 (42.50%) cases, complained of hearing loss
from 1 to 5 years, whereas 6 (07.50%) cases had no hearing loss. A total of 4 cases were in Group-B (CWU mastoidectomy with
tympanoplasty) where average hearing loss pre-operatively
Based on intra-operative findings, the patients were was 30.00 dB and postoperatively at 10 weeks average hearing
reclassified into safe CSOM(53(66.25%)) and unsafe CSOM loss was 26.5dB. Hence, an average gain of 3.5dB was noticed
cases (27 (33.75%)). Intra-operatively, eight (10.00%) cases, in Group-B.

Indian Journal of Otology | October 2013 | Vol 19 | Issue 4 | 165

 Kabdwal, etal.: Post operative hearing in CSOM

A total of 23cases were in Group-C (CWD mastoidectomy with Table 3: Hearing evaluation at 6 months (second
tympanoplasty) where average hearing loss pre-operatively follow-up)
was 37.91 dB and postoperatively at 10weeks average hearing Pre-op hearing Post-op hearing Gain Loss
loss was 31.30 dB. Hence, an average gain of 6.61 dB was Total(30cases) 32.64 24.1 8.54 -
noticed in Group-C. Group-A(15cases) 28.4 18.13 10.27 -
Group-B(4cases) 30.00 31.5 - 1.5
Overall, postoperatively at 10 weeks an average gain of Group-C(11cases) 35.63 29.54 6.09 -
11.76dB and an average loss of 6.94dB was seen in all 80cases
of CSOM.
Table 4: Comparison
Comparison of pre- and postoperative hearing Study Tympanoplasty Tympanoplasty with
mastoidectomy
at second follow-up of 6 months [Table 3] Pre-op Post-op Pre-op Post-op
A total of 30 (37.50%) patients were examined at second ABG ABG ABG ABG
follow-up of 6 months, of which 15 had safe CSOM and Present study(2011) 31.98 24.18 36.74 30.59
15patients had unsafe CSOM. 10weeks
Present study(2011) 28.4 18.13 34.13 30.06
6months
On second follow-up at 6 months, average pre-operative Saha etal.(2006) 29.83 23.33 32.5 29.3
hearing loss in 30cases of CSOM was 32.64dB and average ABG: Airbone gap
hearing loss in 30 cases was 24.1 dB. Postoperatively, at
months, an average gain of 8.54dB was observed.
Table 5: Comparison between group-A and group-B
In this study all 15 cases of safe CSOM underwent type-I Study Group A Group B
tympanoplasty. Pre-operative average hearing loss in 15cases Pre-op Post-op Pre-op Post-op
ABG ABG ABG ABG
diagnosed as safe CSOM intra-operatively was 28.4 dB,
Present study(2011), 31.98 24.18 30.00 26.5
whereas postoperatively at second follow-up of 6 months at 10weeks
average hearing loss in cases of safe CSOM was 18.13 dB. Present study(2011), 28.4 18.13 30.00 31.5
Hence, postoperatively an average hearing gain of 10.27dB at 6months
was seen in patients of safe CSOM[Table4]. Goyal(2010)[13] 28.42 14.42 25.45 17.52
ABG: Airbone gap

In 15 cases diagnosed as unsafe CSOM, the majority of

the 11 (36.66%) underwent CWD mastoidectomy with
Table 6: Group C result
tympanoplasty. Average hearing loss in these 15 cases was
Study CWD mastoidectomy with tympanoplasty
34.13 dB pre-operatively, which at second follow-up of Pre-op ABG Post-op ABG Net gain
6months was 30.06dB. Thus an average gain of 4.07dB was Present study(2011), 37.91 31.30 6.61
observed. at 10weeks
Present study(2011), 35.63 29.54 6.09
A total of 15 cases were in Group-A (tympanoplasty) at 6months
where average hearing loss pre-operatively was 28.4 dB and Shrestha(2008)[14] 37.8 29.8 8.0
ABG: Airbone gap, CWD: Canal wall down
postoperatively at 6months average hearing loss was 18.13dB,
Hence, an average gain of 10.27dB was noticed in Group-A.
Table 7: Comparison between CWU and CWD
A total of 4cases were in Group-B(CWU mastoidectomy with Study CWU CWD
tympanoplasty) where average hearing loss pre-operatively Pre-op Post-op Pre-op Post-op
was 30.00dB and postoperatively at 6months average hearing ABG ABG ABG ABG
loss was 31.5dB. Hence, an average loss of 1.5dB was noticed Present study(2011), 30.00 26.5 37.91 31.30
in Group-B[Table5]. at 10weeks
Present study(2011), 30.00 31.5 35.63 29.54
at 6months
Overall, postoperatively at 6 months an average gain of
Varshney(2009)[16] 31.04 20.55 33.94 26.37
12.55dB and an average loss of 9.83dB were seen[Table6]. ABG: Airbone gap, CWD: Canal wall down, CWU: Canal wall up

A total of 11cases were in Group-C(CWD mastoidectomy with

tympanoplasty) where average hearing loss pre-operatively DISCUSSION
was 35.63dB and postoperatively at 6months average hearing
loss was 29.54dB. Thus, an average gain of 6.09dB was noticed In this work we studied a total of 80 patients of CSOM to
in Group-C [Table7]. compare pre-and postoperative hearing status.

166 Indian Journal of Otology | October 2013 | Vol 19 | Issue 4 |

 Kabdwal, etal.: Post operative hearing in CSOM
The most commonly affected age group was between 21 and
30 years, as observed by various other studies as well.[1,7,8]
This early presentation may be due to increased awareness to
health issues and difficulty in hearing affecting work efficiency,
leading patients and parents to seek early medical intervention.
The ratio of male to female patients was 1.50:1.00. Similar
findings have been reported by several other authors.[3,9,10]
The duration of ear discharge ranged from 6 months to
50 years. A total 30 (37.50%) cases had duration of ear
discharge between 10 and 15years. The duration of disease in
unsafe cases was generally seen to be longer. This particular
finding may be a result of conversion of safe type of disease
into unsafe disease over time.[11]
The duration of hearing loss was in all cases found to be lesser
than duration of ear discharge. This may be attributed to
difficulty in appreciating minor degrees of hearing loss by the
patient. Hearing loss would be noticed only when the disease
had progressed sufficiently to cause significant impairment of
hearing by perforation or ossicular destruction.
In our study, on average postoperative hearing gain was
seen in all three surgical categories and these findings are
consistent with those of Saha, et al.[12] who also witnessed
hearing gain postoperatively in all cases undergoing type-I
tympanoplasty (Group-I) and simple mastoidectomy with
tympanoplasty(Group-II).[12]
Goyal found an average hearing gain in both Group-A(type-I
tympanoplasty) and Group-B(type-I tympanoplasty with cortical
mastoidectomy), which was also similar to the findings of our study
in Group-A(tympanoplasty) and Group-B(CWU mastoidectomy
with tympanoplasty) at first follow-up of 10weeks. On second
follow-up at 6months similar results were seen as compared with
Goyal. But an average hearing loss of 1.5dB was seen, which could
be because of displacement of graft in Group-B.[13]
Shrestha, et al. noticed a net gain of 8.0 dB in patients
[14]
undergoing CWD mastoidectomy with tympanoplasty, which
was also in accordance with our study where a net gain of 6.61dB
was noticed at 10weeks and a gain of 6.09dB at 6months in
Group-C(CWD mastoidectomy with tympanoplasty).
Varshney, et al. compared the hearing results by the CWU
versus CWD procedure and found postoperative hearing
gain in both groups similar with the hearing results of both
these groups in our study at first follow-up of 10weeks, but
a postoperative hearing loss of 1.5 dB was seen at second
follow-up of 6months in the CWU group in our study.[16]
Mathai noticed a definitive improvement of hearing in all
cases that underwent myringoplasty(in the range of 20 to
30 dB) with closure or narrowing of ABG except in three
cases where CHL persisted. This was in accordance with our
study where definitive improvement was seen in 46(86.8%)
Indian Journal of Otology | October 2013 | Vol 19 | Issue 4 |
out of 53cases who underwent tympanoplasty. Cases in which
maximum gain in hearing was seen were in the < 25-dB
group, followed by the 26- to 40-dB group, at both first and
second follow-up.[15]
Shrestha and Sinha also noticed maximum improvement
in hearing in the 0- to 10-dB group in all cases undergoing
myringoplasty at all postoperative follow-ups. Our study also
revealed maximum improvement in hearing in the< 25-dB
group at both follow-ups of 10weeks and 6months.[1]
CONCLUSION
In this study we found that postoperative hearing results were
better in the case of safe CSOM as compared with unsafe
CSOM and of tympanoplasty as compared with tympanoplasty
with mastoidectomy.
REFERENCES
1. Shrestha S, Sinha BK. Hearing results after myringoplasty.
Kathmandu Univ Med J 2006;4:455-9.
2. Gupta A, Gupta. A study of prevalence of complications
of suppurative otitis media in rural area of Loni. Ind J Otol
1996;2:177-83.
3. Akinpelu OV, Amusa YB, Komolafe EO, Adeolu AA, Oladele AO,
Ameye SA. Challenges in management of chronic suppurative otitis
media in a developing country. J Laryngol Otol 2008;122:16-20.
4. Gulati SP, Sachdeva OP, Kumar A. Audiological prole in chronic
suppuartive otitis media. Ind J Otol 2002;8:24-8.
5. Slattery WH. Pathology and clinical course of inammatory
diseases of the middle ear. In: Glasscock ME, Gulya AJ, editors.
Glasscock-Shambaugh Surgery of the Ear. 5th ed. New Delhi:
Reed Elsevier India Pvt. Ltd; 2003. p. 428-9.
6. Slattery WH. Pathology and clinical course of inammatory
diseases of the middle ear. In: Glasscock ME, Gulya AJ, editors.
Glasscock-Shambaugh Surgery of the Ear. 5th ed. New Delhi:
Reed Elsevier India Pvt. Ltd; 2003. p. 403.
7. Singh RK, Safaya A. Middle ear hearing restoration using
autologous cartilage graft in canal wall down mastoidectomy.
Indian J Otol 2005;11:10-4.
8. Ajalloueyan M. Experience with surgical management
of cholesteatomas. Arch Otolaryngol Head Neck Surg
2006;132:931-3.
9. Chandra R, Mishra R. Some observations on the total and subtotal
perforations of the tympanic membranes. Ind J Otolaryngol
1964;16:3-20.
10. Rupa V, Raman R. Chronic suppurative otitis media:
Complicated versus uncomplicated disease. Acta Otolaryngol
1991;111:530-5.
11. El-Sayed Y. Bone conduction impairment in uncomplicated chronic
suppurative otitis media. Am J Otolaryngol 1998;19:149-53.
12. Ashok SK, Munshi DM, Ghosh SN. Evaluation of improvement of
hearing in type I tympanoplasty and its inuencing factors. Ind
J Otol Head Neck Surg 2006;58:253-7.
13. Goyal R. Role of cortical mastoidectomy in type I tympanoplasty.
Ind J Otol 2010;16:8-12.
14. Shrestha BL, Bhusal CL, Bhattarai H. Comparison of pre and
post-operative hearing results in canal wall down mastoidectomy
167
 Kabdwal, etal.: Post operative hearing in CSOM

with type III tympanoplasty. JNMA J Nepal Med Assoc
2008;47:224-7.
15. Mathai J. Myringoplasty with temporalis fascia: Analysis of
200 cases. Ind J Otol Head Neck Surg 1999;51:9-12.
16. Varshney PK, Gupta R. Canal wall up versus canal wall down
procedure: Comparative evaluation. Ind J Otol. 2009;15:20-2.
How to cite this article: Kabdwal N, Varshney S, Bist SS, Bhagat
S, Mishra S, Agarwal V. Pre and post operative evaluation of hearing
in chronic suppurative otitis media. Indian J Otol 2013;19:164-8.
Source of Support: Nil. Conict of Interest: None declared.

168 Indian Journal of Otology | October 2013 | Vol 19 | Issue 4 |

Copyright of Indian Journal of Otology is the property of Medknow Publications & Media
Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv
without the copyright holder's express written permission. However, users may print,
download, or email articles for individual use.