Critical analysis of moderate and severe retractions in the pars tensa and pars flaccida of the tympanic membrane,

Abstract Objectives: Analyze the prevalence of retractions in different areas of the Tympanic Membrane (TM), the correlations between the involvement of the Pars Tensa (PT) and Pars Flaccida (PF), and the air-bone gaps. Methods: A cross-sectional study. Patients with moderate and/or severe TM retraction of 2200 consecutive patients with chronic otitis media between August 2000 and January 2019 were included. Ears with previous surgery were excluded. Ears were classified as isolated PF and PT retractions and association of both. The degrees of severity and presence of effusion were evaluated. The data were analyzed using the SPSS Statistics software program. Results: 661 ears were included. The prevalence of isolated atical retractions was 24.9%, of isolated posterior quadrants was 10.6%, and of association of quadrants was 64%. There was no correlation between the retractions in the different areas of the TM (posterior and attic quadrants: r = 0.13; p = 0.041; anterior and posterior quadrants: r = 0.23; p = 0.013, anterior and attic quadrants: r = 0.06; p = 0.043). Effusion was present in 30.7% of the ears. ABG median was lower in ears with PF retraction (6.25 dB HL) than PT retraction, isolated (15 dB HL) or not (13.75 dB HL; p < 0.05); 72% of the ears had an ABG ≤ 20dB HL. For severity of the retraction of PF, the ABG was similar across groups. For the PT, there was a global difference in the medians of ABG in terms of the degree of severity, with a moderate correlation. Conclusion: The prevalence of moderate and severe retractions was 24.5%; 64% of the ears had an association of affected regions. There was no correlation between the retraction in the different areas of the TM. We found a significant correlation between the severity of retraction and the worsening of ABG threshold, only for PT. Evidence level: 4.

Audiological Outcome in Myringoplasties with an Intact Ossicular Chain: Is there a Difference between Chronic Otitis with or without Cholesteatoma?

Abstract Introduction Chronic otitis media (COM) with a central perforation or a concomitant cholesteatoma are both inflammatory lesions, however, with different etiologies. Both entities may present with an intact chain, and the final reconstruction is quite similar. Does it also apply for the hearing outcome? Objectives In a retrospective analysis, we investigated the preoperative hearing and the final hearing outcome of two groups of patients: those with COM and those with cholesteatoma, and compared various factors. Methods Patients operated between 2010 and 2019 were entered prospectively into a research database, and the integrity of the ossicular chain, the extent of the cholesteatoma, and the findings on computed tomography (CT) scans were retrospectively analyzed and correlated to the final hearing outcome. Results Out of 210 tympanoplasties for COM, 162 (80%) presented with an intact chain, and 85 (40%) ears could be analyzed. Out of 283 cholesteatoma surgeries, 53 (19%) ears presented with an intact chain. The preoperative air-bone gap (ABG) was worse in the COM group, but the postoperative ABG over the frequencies of 0.5 kHz and 4 kHz was the same (10 dB to 12 dB) in both groups, and remained within 20 dB in 90% (40 and 78 patients, respectively). The extension of the disease was rather limited in the cholesteatoma group (stages Ch1a and 1b), and better pneumatization and ventilation were beneficial for a good result. Postoperatively, the frequency of 4 kHz had the largest ABG (14 dB and 18 dB). Conclusion Overall, 80% of the patients with COM and less than 20% of those with cholesteatoma had an intact and mobile chain at surgery. Using equivalent surgical techniques for the tympanoplasty, the final outcome was almost the same for both groups, with a mean ABG of 10 dB to 12 dB.

Graft uptake and hearing assessment in revision myringoplasty in a tertiary centre

Background:The revision myringoplasty surgery is done for the graft failure after myringoplasty. The surgeons’ make use of the temporalis fascia or cartilage as the graft material. Some surgeons opt for the revision myringoplasty with cortical mastoidectomy as well.Methods:This study is a retrospective, observational study done in the Department of ENT and Head and Neck Surgery, Tribhuvan University Teaching Hospital from December 2015 to 2019. Dataof all the patients undergoing revision myringoplasty with or without cortical mastoidectomy were collected from the record section and included in the study. Post-operatively, the patients were assessed for graft uptake and hearing assessment after six weeks of surgery. Total uptake of the graft was taken as the successful graft uptake. The hearing was assessed by air conduction threshold (AC threshold) and air-bone gap status postoperatively.Results:Total of 42 patients were analysed with the graft uptake of 86%. There was no significant difference in the graft uptake on using the temporalis fascia or tragal cartilage. Regarding the hearing assessment, the average pre-operative and post-operative AC threshold was 37.95±5.68 dB and 29.36±6.28dB. The average pre and postoperative AB gap was 29.97±8.16dB and 21.85±6.68dB. The improvement in the hearing threshold was significant (p value<0.05).Conclusions:The graft uptake rate for revision surgery in our centre was comparable to other studies in the literature. There was significant hearing improvement pre and postoperatively after revision myringoplasty.

Study of Preoperative Indicators of Ossicular Defect in Mucosal Type of Chronic Suppurative Otitis Media.

Ossicular defect is although more common in squamosal type of chronic suppurative otitis media, it can also occur in mucosal type of the disease. Its preoperative knowledge not only helps surgeon to plan for ossicular reconstruction in a better way but also to counsel the patient accordingly. We wanted to determine the prevalence of ossicular chain defect and preoperative identification of clinical and audiological factors as indicators of ossicular defects in patients with Mucosal CSOM.METHODSThis is a hospital based cross sectional study of 2 years. Patients 15 to 60 years of age, having inactive mucosal type of Chronic Suppura­tive Otitis Media, posted for Tympanoplasty were included in the study. Findings on history, clinical, audiological and intraoperative otomicroscopic examination were recorded and analysed.RESULTSOssicular necrosis was noted in 21 (23.33%) of total 90 patients. On statistical analysis, patients of age >30 years (p=0.019, duration of ear discharge >10 years (p=0.003), those having large and subtotal perforation (p<0.001), adhesion of tympanic membrane edges to promontory (p=0.04), incudostapaedial joint area exposure (p=0.01) and air-one gap >40 dB (p <0.001) were found to be statistically significantly associated with ossicular erosion.CONCLUSIONSAll patients of mucosal type of chronic suppurative otitis media should be assessed in detail so as to get a clue of ossicular defects to be prepared for its repair and will not come as a surprise during surgery.

Role of preoperative air-bone gap in tinnitus outcome after tympanoplasty for chronic otitis media with tinnitus / Papel do gap aéreo-ósseo pré-operatório no desfecho do zumbido após timpanoplastia para otite média crônica com zumbido

Abstract Introduction Previous reports indicated that middle ear surgery might partially improve tinnitus after surgery. However, until now, no influencing factor has been determined for tinnitus outcome after middle ear surgery. Objective The purpose of this study was to investigate the association between preoperative air-bone gap and tinnitus outcome after tympanoplasty type I. Methods Seventy-five patients with tinnitus who had more than 6 months of symptoms of chronic otitis media on the ipsilateral side that were refractory to medical treatment were included in this study. All patients were evaluated through otoendoscopy, pure tone/speech audiometer, questionnaire survey using the visual analog scale and the tinnitus handicap inventory for tinnitus symptoms before and 6 months after tympanoplasty. The influence of preoperative bone conduction, preoperative air-bone-gap, and postoperative air-bone-gap on tinnitus outcome after the operation was investigated. Results and conclusion The patients were divided into two groups based on preoperative bone conduction of less than 25 dB (n = 50) or more than 25 dB (n = 25). The postoperative improvement of tinnitus in both groups showed statistical significance. Patients whose preoperative air-bone-gap was less than 15 dB showed no improvement in postoperative tinnitus using the visual analog scale (p = 0.889) and the tinnitus handicap inventory (p = 0.802). However, patients whose preoperative air-bone-gap was more than 15 dB showed statistically significant improvement in postoperative tinnitus using the visual analog scale (p < 0.01) and the tinnitus handicap inventory (p = 0.016). Postoperative change in tinnitus showed significance compared with preoperative tinnitus using visual analog scale (p = 0.006). However, the correlation between reduction in the visual analog scale score and air-bone-gap (p = 0.202) or between reduction in tinnitus handicap inventory score and air-bone-gap (p = 0.290) was not significant. We suggest that the preoperative air-bone-gap can be a predictor of tinnitus outcome after tympanoplasty in chronic otitis media with tinnitus.

Resumo Introdução Relatos anteriores indicaram que a cirurgia no ouvido médio pode melhorar parcialmente o zumbido após a cirurgia. No entanto, até agora, nenhum fator influenciador foi determinado para o resultado do zumbido após cirurgia de ouvido médio. Objetivo O objetivo deste estudo foi investigar a associação entre o gap aéreo-ósseo pré-operatório e o desfecho do zumbido após timpanoplastia do tipo I. Método Setenta e cinco pacientes com zumbido, com mais de 6 meses de sintomas de otite média crônica no lado ipsilateral que eram refratários ao tratamento médico foram incluídos nesse estudo. Todos os pacientes foram avaliados através de otoendoscopia, audiometria tonal/vocal, questionário utilizando a escala visual analógica e o questionário tinnitus handicap inventory para sintomas de zumbido antes e 6 meses após a timpanoplastia. A influência da condução óssea pré-operatória, gap aéreo-ósseo pré-operatório e pós-operatório sobre o desfecho do zumbido após a operação foi analisada. Resultados e conclusão Os pacientes foram divididos em dois grupos com base na condução óssea pré-operatória de menos de 25 dB (n = 50) ou mais de 25 dB (n = 25). A melhora do zumbido pós-operatória em ambos os grupos mostrou significância estatística. Pacientes com gap aéreo-ósseo pré-operatório inferior a 15 dB não apresentaram melhora no zumbido pós-operatório utilizando a escala visual analógica (p = 0,889) e o tinnitus handicap inventory (p = 0,802). Entretanto, pacientes com gap aéreo-ósseo pré-operatório maior do que 15 dB apresentaram melhoria estatisticamente significante no zumbido pós-operatório com a escala visual analógica (p < 0,01) e o tinnitus handicap inventory (p = 0,016). A mudança pós-operatória no zumbido mostrou significância em comparação com o zumbido pré-operatório usando a escala visual analógica (p = 0,006). No entanto, a correlação entre a redução no escore da escala visual analógica e gap aéreo-ósseo (p = 0,202) ou entre a redução no escore do tinnitus handicap inventory e gapaéreo-ósseo (p = 0,290) não foi significativa. Sugerimos que o gapaéreo-ósseo pré-operatório possa ser um preditor de desfecho do zumbido após timpanoplastia em otite média crônica com zumbido.

A Comparative Study of Temporalis Fascia versus Tragal Peri-chondrium as Graft in Repair of Tympanic Membrane Perforation

The perforations of the tympanic membrane may be of traumatic origin or due to chronic suppurative otitis media. If the perforations fail to heal conservatively, they require surgical closure. Autologous graft materials have stood the test of time in repairing tympanic membrane perforations. In our tertiary care institution, we conducted a prospective randomised control trial on 20 subjects to evaluate the comparative efficacy of temporalis fascia and tragal perichondrium as grafting material in underlay tympanoplasty. In this study, surgical success was evaluated in terms of intact drum membrane and minimal complications during the follow-up period. Temporalis fascia achieved a graft uptake of 90% and a satisfactory hearing improvement in 76% of the patients with minimal postoperative complications. Tragal perichondrium achieved a success rate of 80% graft uptake and 75% hearing gain. The rates are comparable with no statistical significance of difference between them.

Comparison of Short- and Long-term Hearing Outcomes of Successful Inlay Cartilage Tympanoplasty Between Small and Large Eardrum Perforations

OBJECTIVES: To compare the short- and long-term hearing outcomes after successful inlay cartilage tympanoplasty between patients with small ( or =50%) eardrums perforations. METHODS: This is a retrospective case series study conducted in a tertiary referral center. Twenty-five patients who underwent 27 procedures were enrolled. Their mean age was 60.26 years (range, 42 to 76 years). The mean follow-up time was 18.86 months (range, 12.30 to 35.83 months). The preoperative, initial postoperative, and long-term hearing results in patients with total repair of the eardrum were analyzed. RESULTS: In the small size group, the average (+/-standard deviation) air-bone gap (ABG) closure was 1.08+/-7.53 dB in the short-term and 2.33+/-11.56 dB in the long-term hearing examinations. There was no difference between short- and long-term ABG closure (P=0.689). In the large size group, the average ABG closure was 9.77+/-9.40 dB in the short-term and 16.25+/-6.01 dB in the long-term hearing examinations. There was a significant difference between short- and long-term ABG closure (P=0.029). CONCLUSION: Patients with large perforations have continuous hearing improvement and ABG closure for more than one year. In contrast, the short- and long-term postoperative ABGs are almost the same in patients with small perforations. More long-term postoperative follow-up of hearing results is necessary for large perforations.

AudioIogicaI Characteristics of Large VestibuIar Aqueduct Syndrome / 听力学及言语疾病杂志

Objective To study the audiological characteristics of large vestibular aqueduct syndrome (LVAS)and provide evidence for early diagnosis and prevention.Methods Tympanometry,Otoacoustic emission , auditory brainstem response (ABR),auditory steady-state response(ASSR)were performed on the 49 cases of LVAS which were diagnosed by CT scanning from May,2010 to October,2013.Among them,23 cases(46ears)were examined by pure tone andiometry at the same time.ResuIts Pure tone andiometry showed that 33 ears were mixed hearing loss in the 23 cases(46 ears),the air-bone gap was larger at low frequencies than that of at high frequen-cies,15 ears were senserineural hearing loss with no air-bone gap;96 ears were type A tympanogram.Acoustic re-flex were present in 5 ears ;34 cases (68 ears)of LVAS group were detected with ASNR in 3 -4 ms by the ABR testing,the positive rate was 70.8%.ConcIusion Our study indicates that for confirmed LAVS,if the pure tone andiometry shows significant air-bone gaps at low frequencies with the normal tympanograms,and ASNR is e-voked during the routine ABR testing.

Manual stapedotomy still holds good in the era of laser.

Context: In the present era of stapedotomy, there is an inevitable role for laser. But the conventional technique with manual burr still has its own merits in various settings such as usage in resource poor setting in developing countries and avoidance of laser hazards. AIMS: To evaluate the audiometric outcomes after manual stapedotomy. Settings and Design: The present study was retrospective record-based study. Patients who have been diagnosed otosclerosis and those who were not willing for surgery with laser, but gave consent for manual stapedotomy were included for the study. Materials and Methods: Preoperatively, and at each subsequent post-operative follow-up visits, patients were required to undergo a pure-tone audiogram. The air-bone gaps at the end of 6 months were used for final analysis. Statistical Analysis Used: Data was analyzed with using Statistical Package for Social Sciences (SPSS) version 12 (Chicago, IL, USA). Descriptive frequency distributions, mean, standard deviation of audiometric data were calculated. The paired t test was done to see the improvement in the air bone gap post-operatively. Results: The mean age of presentation is 32.2 years. Overall, the male:female ratio was found to be 1:1.2. Post-operative air bone closure to 15 decibels was obtained in 80% of patients. There was no significant correlation between the pre-operative hearing loss and post-operative gain, age, and gender of distribution of focus. Conclusions: The post-operative hearing after stapedotomy has been remarkable in all the patients even with manual burr. There were no major vestibular complications in any of these patients. The study has shown that the significant post-operative hearing results can be still achieved with meticulous surgery by an experienced surgeon with manual burr in the present laser era.

Clinical characterization of audiometrics and vestibular evoked myogenic potentials in patients with large vestibular aqueduct syndrome / 临床耳鼻咽喉头颈外科杂志

Objective:To investigate the clinical and diagnostic characteristics of audiometric findings and vestibular-evoked myogenic potentials in patients with large vestibular aqueduct syndrome (LVAS).Method:Thirty LVAS subjects(60 ears) recruited received pure tone audiometry, acoustic immittance, auditory brain stem responses (ABRs), distortion-product otoacoustic emission(DPOAE), Vestibular evoked myogenic potentials(VEMP) and caloric test, and the diagnostic significance of the results was analyzed.Result:All 30 cases(60 ears) showed progressive and fluctuating hearing loss, while 16 cases experienced dizziness when hearing fluctuated. Most of our cases showed sensorineural hearing loss, and 47 ears(94.0%) showed air-bone gap in the low frequencies, with mean gaps of (43±17)dB HL at 250 Hz, (33±18 )dB HL at 500 Hz, in which the middle ear function showed normal. The acoustically evoked short latency negative response(ASNR) with medium latency(3.06±0.52)ms was elicited from 18 ears(64.3%). The mean amplitude of vestibular evoked myogenic potentials(VEMP) of 42 ears was (147.10± 107.55)μv,and the threshold of VEMP of 19 ears was 75 dB nHL,of 7 ears was 65 dB nHL.Conclusion:Characteristics of hearing performance, such as progressive and fluctuating hearing loss, air-bone gap at the low frequencies with normal middle ears, the ASNR, and increased amplitude and decreased threshold of the VEMPs, will help clinicians make initial diagnosis of LVAS ,and provide a reference for further imaging examination.

Relationship of pure tone audiometry and ossicular discontinuity in chronic suppurative otitis media

Background: Pure tone audiometry is routinely used to determine conductive and sensorineural hearing status. Ossicular discontinuity is usually assessed intra-operatively. If ossicular discontinuity can be predicted by pure tone audiometry, perhaps the operative procedure of choice and prognosis for hearing can also be anticipated. Objective: To determine the predictive value of preoperative pure tone audiometry on the presence of gross ossicular discontinuity in chronic otitis media. Methods: Records of 205 patients, 7 to 75 years of age undergoing their first operation for chronic otitis media were reviewed. Preoperative audiograms and operative records for tympanomastoidectomy were evaluated. A total of 162 patients meeting inclusion criteria were included in the study. Likelihood ratios for positive and negative ossicular discontinuity for frequency-specific air-bone gap cut-offs were determined. Multiple logistic regression analysis for pure tone audiometry and operative findings to predict ossicular discontinuity was performed and a model for predicting ossicular discontinuity using logistic regression obtained. Results and Conclusion: Frequency-specific air bone gap (ABG) cut-off values can predict ossicular discontinuity in chronic suppurative otitis media namely: 50 dB ABG at 500 Hz, >30 dB ABG at 2 KHz, and > 50 dB ABG at 4 KHz best predict the presence of ossicular discontinuity in general. In the absence of cholesteatoma, the air bone gaps of 50 dB at 500 Hz, >20 dB at 2 KHz and >40 dB at 4 KHz increase the probability of ossicular discontinuity from 32.97 percent to 85.9 percent. These findings suggest that ossicular exploration may not be necessary for the former while an evaluation of the ossicular chain may be mandatory for the latter in the setting where cholesteatoma is not present or suspected. Presence of cholesteatoma, granulation tissue and size of tympanic membrane perforation are important factors to consider in predicting ossicular discontinuity. (Author)