General anaesthetic vs local anaesthetic myringoplasties: a systematic review and meta-analysis.

AIMS: To assess all available data and determine the success rates and tolerability of local anaesthetic myringoplasty in comparison with those undertaken under general anaesthetic myringoplasty. MATERIALS AND METHODS: The study was designed following a PRISMA-P protocol and registered with the PROSPERO database. MEDLINE, Cochrane Library (CDSR/Central), EMBASE and CINHAL-were directly searched for studies, which met the inclusion criteria. OBJECTIVES: Primary objective was to compare perforation closure rates between patients undergoing myringoplasty under local anaesthetic and those under general anaesthetic from all available published data. Secondary outcomes include complications, such as 'any minor complications', infection rates in the first 6 month post-op, facial nerve weakness, dysgeusia and patient satisfaction. RESULTS: 27 studies were included in the final analysis and found that myringoplasty had an overall perforation closure rate of 89%. The pooled proportion of closures after myringoplasty under local anesthesia was 87% and for myringoplasties under general anesthesia was 91%. Analysis of myringoplasty under local anaesthesia focusing on 'in-office' performed procedures only, found a closure rate of 88%. CONCLUSIONS: There is no significant difference in the success rate of myringoplasty surgery when performed under local or general anaesthetic as measured by perforation closure rates. However, there are other factors, which can drive choosing local anaesthetic surgery, such as minimising anaesthetic risks, reducing costs and reducing environmental impact.

Clinical and audiometric outcomes of palisade cartilage myringoplasty under local anesthetic in an office setting.

OBJECTIVE: Assess clinical and functional outcomes of a modified palisade cartilage-perichondrium graft myringoplasty under local in an office setting. STUDY DESIGN: Retrospective case series. SETTING: Tertiary care facility. PATIENTS: Patients with a tympanic membrane perforation presenting between March 2013 and October 2017. Inclusion criteria included age ≥ 7 years, entire perforation margin visualized through a transcanal view, and the ability to lie supine for up to 45 min. Exclusion criteria included a conductive hearing loss larger than expected, and presence of active infection. INTERVENTION: In-office modified myringoplasty technique under local anesthesia without sedation. MAIN OUTCOME MEASURES: Complete perforation closure rate and audiometric outcomes. RESULTS: 250 patients underwent the procedure, of whom 13 had bilateral sequential procedures (total 263 ears). Of those, 197 were primary and 66 revision. Average age was 46.3 years. Perforation sizes were categorized as small (32), moderate (109), large (78), and subtotal (44). Complete perforation closure was evident in 219 of the 250 cases (88%). Preoperative mean air pure tone average (PTA) was 56.7 dB and mean bone PTA was 27.5 dB (pre-operative ABG 29.2 dB). AC-PTA significantly improved to 35.0 dB (p < 0.0001), and ABG to 9.6 dB (p < 0.0001). Only subtotal perforations showed a statistically significant negative relationship with outcome (p = 0.04). CONCLUSION: The modified palisade cartilage-perichondrium graft myringoplasty under local anesthetic is a highly successful procedure well tolerated by adult and pediatric patients with variable perforation sizes. This may have significant potential patient benefits, as well as cost savings to the health care system.

Bacterial cellulose graft versus fat graft in closure of tympanic membrane perforation.

OBJECT: To compare between results of bacterial cellulose graft myringoplasty and fat graft myingoplasty in patients had mild or moderate size safe perforation. METHODS: 120 patients undergoing myringoplasty due to mild or moderate size perforation were divided into 3 groups: group I: 40 patients undergoing myringoplasty with use of bacterial cellulose graft, group II: 40 patients undergoing myringoplasty with use of fat graft, group III: 40 patients undergoing usual myringoplasty with use of temporalis fascia graft (control group). RESULTS: Healing in 20 patients with small perforation and 17 patients with moderate perforation in Group I, Healing in 15 patients with small perforation and 10 patients with moderate perforation in Group II, Healing in 18 patients with small perforation and 12 patients with moderate perforation in Group III. CONCLUSION: Bacterial cellulose graft myringoplasty would be a good, simple, rapid and safe surgery that could be done under local anesthesia in outpatient clinic with shorter time of surgery than fat graft myringoplasty and temporalis fascia graft myringoplasty, with better hearing and healing. SUMMARY AT GLANCE: 120 patients undergoing myringoplasty were divided into 3 groups to compare between results of bacterial cellulose graft myringoplasty, fat graft myringoplasty and temporalis fascia graft myringoplasty.

A trans-well-based cellular model for the rapid pre-evaluation of tympanic membrane repair materials.

It is important to have a standardized tympanic membrane (TM) perforation platform to evaluate the various myringoplasty materials that have been studied and developed extensively during recent years. However, currently there are no cellular models specifically designed for this purpose, and animal models remain unsatisfactory. The purpose of this study is to propose an inexpensive, readily available, well-controlled, and easy-to-create cellular model as a substitute for use in the evaluation of TM repairing materials. A trans-well model was created using a cell culture insert with a round hole created at the center of the polycarbonate membrane. HaCaT cells were cultured on the fenestrated culture insert, and the desired myringoplasty graft was placed at the center of the window for one week and observed by fluorescent microscopy under vital staining. Under this cellular model, there was notable migration of HaCaT cells onto the positive control graft (rabbit fascia), while only a few cell clusters were observed on the negative control graft (paper). Model validation showed that the cell migration ratio for the PLLA + 1% hyaluronic acid (HA) graft is significantly higher than using myringoplasty paper, poly L-lactide (PLLA), or PLLA + 0.5% HA (p < 0.05). This trans-well-based cellular model might be a useful pre-evaluation platform for the evaluation of TM repairing materials. The model is inexpensive, readily available, easy to create, and standardized for use.

High-speed video analysis of acoustically oscillated guinea pig stapes.

OBJECTIVE: We investigated the ossicular movement in the near-intact middle ear in response to acoustic stimulation using a high-speed video camera and video analysis software program. DESIGN: We have designed a good visual access to the middle ear of the guinea pig by opening the ventral wall of the otic capsule, without injuring the sound-conducting structures, from the external auditory canal to the oval window. The high-speed video camera could record analysable ossicular motion up to 4000 frames per second. RESULTS: The stapes showed reciprocal movement in the same frequency as the stimulating tone, and with an amplitude proportional to the stimulating sound intensity. Injury to the tympanic membrane attenuated the stapedial motion, which was recovered to that of the control level by patch repair of the perforation. CONCLUSION: Our experimental set-up was capable of evaluating the conductive hearing, regardless of the status of the animal's sensorineural hearing or even life. Such a video analysis may provide a powerful tool to investigate the physiology of the middle ear.

Hyaluronic acid fat graft myringoplasty vs fat patch fat graft myringoplasty.

We aim to compare the hyaluronic acid to fat graft myringoplasty (HAFGM) technique to a recently described modified-FGM (M-FGM) in the repair of tympanic membrane perforation (TMP). We also aim to evaluate the hearing level improvement postoperatively. We conducted a prospective study in an adult tertiary care center between 2012 and 2013. Adult patients presenting with simple TMP were operated on randomly using either HAFGM or M-FGM under local anesthesia in outpatients' settings. Success was considered when complete closure is achieved. Audiometric parameters were evaluated pre and postoperatively. Twenty-four patients were included in the study (HAFGM: 10 patients and M-FGM: 14 patients). Complete closure was achieved in 80 % in HAFGM vs 42.8 % in the M-FGM (p = 0.03). The study was abandoned due to the low success rate in first 14 patients of the M-FGM group. The pure tone audiometry was improved postoperatively in the HAFGM only. The study was aborted because of the unsatisfactory obtained results using the MFGM. It also shows the beneficial effect of hyaluronic acid application to FGM for a successful TMP repair.

A Study on Prognostic Factors of Primary and Revision Myringoplasty / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: There is no consensus on the prognostic factors regarding pos-toperative recurrence after myringoplasty. In this study, we investigated the preoperative clinical findings and postoperative results after primary myringoplasty and compared them with those of revision myringoplasty. SUBJECTS AND METHOD: Computerized database of 861 clinical records of last 20 years were analyzed retrospectively for the subjects who underwent myringoplasty at the Department of Otolaryngology, University of Korea. All the surgeries were done under general or local anesthesia by senior surgeons. Primary and revision cases of myringoplasty or type 1 tympanoplasty followed up at least for longer than 3 months were only included in the study. Those other cases of tympanoplasty types, concomitant ossiculoplasty and/or mastoidectomy, or those with the presence of cholesteatoma and those that required repair during exploratory tympanotomy were excluded. RESULTS: 535 primary and 101 revision cases have met our inclusion criteria. Overall, in this study, the failure rates of primary and revision myringoplasty were 11.02% and 5.94%, respectively. Significantly different among the prognostic factors were such as sex, age, anesthesia, surgical approach, the presence of otorreha, size of eardrum perforation, external auditory canal narrowing, valsalva test, degree of pneumatization, graft materials, tympanoplasty type, previous mastoidectomy, the presence of bilateral otitis media influencing on myringoplasty revision, and the presence of otorrhea and sclerotic type of mastoid pneumatization. CONCLUSION: Among various prognostic factors of myringoplasty, poor prognostic factors were preoperative otorrhea and poor pneumatization.

Myringoplasty in simple chronic otitis media: critical analysis of long-term results in a 1,000-adult patient series.

OBJECTIVES: Investigate the recurrence of chronic otitis media after primary and revision myringoplasty, compare long-term anatomic and audiologic results of underlay and overlay myringoplasty, and examine the prognostic factors. STUDY DESIGN: Retrospective study. PATIENTS: Approximately 1,040 adult patients with chronic simple otitis media undergoing a myringoplasty (overlay and underlay) by different surgeons at a single institution (ENT Department of Bergamo Ospedali Riuniti) between May 1999 and March 2009. METHODS: The cumulative recurrence rate of chronic otitis media during 10-year follow-up period was calculated using a Kaplan-Meier survival analysis. A multivariate analysis was used to evaluate different prognostic factors based on long-term outcome in myringoplasty. RESULTS: The overall 10-year graft success rate was 78% in 1,040 patients. The 10-year recurrence rate of chronic otitis media was 15% in overlay myringoplasty and 26% using the underlay technique (p < 0.05). In revision myringoplasty, the overlay technique showed a better success rate than underlay (p < 0.05). Significant recovery was observed in the air conduction thresholds and air-bone gaps in both groups with no statistical difference between techniques (p = 0.1). Multivariate analysis demonstrated that the underlay myringoplasty technique, a pathologic contralateral ear and an anterior or subtotal perforation, using a perichondrial graft or age of surgery younger than 40 years were statistically significant (p < 0.01) factors that negatively influenced the myringoplasty outcomes. CONCLUSION: More successful outcomes in primary and revision surgery for chronic otitis media occurred using overlay myringoplasty, although there were more minor postoperative complications. Both clinical and technical variables affected the success rate of myringoplasty.

Myringotomy and ventilation tube insertion with minims tetracaine drops.

We present a novel and safe technique for insertion of ventilation tubes under local anaesthetic which we feel improves the patient's experience and shortens the overall procedural time.

Resolved effusion on myringotomy: a study of dry tap without general anesthesia.

OBJECTIVES: Finding a resolution of middle ear effusion using myringotomy, or dry tap (DT), is relatively common, but its clinical outcome is confounded by general anesthesia (GA). The confounding effect of GA and a time delay can be removed because laser myringotomy can be completed under topical anesthesia, which is a routine procedure for otitis media with effusion (OME) before GA in our clinic. DT without GA would clarify the clinical outcome, and the percentage of recurrence for OME after DT would be clinically relevant. The objectives of the present study are (1) to clarify the clinical nature of DT without including the confounding effect of GA and a time delay and (2) to determine if OME recurs when a ventilation tube (VT) is not used for DT. METHODS: The control group consisted of 308 children who received an unilateral myringotomy due to a natural resolution in the contralateral ear. The experimental group consisted of 296 children who had a bilateral myringotomy, and a ventilation tube was not inserted for DTs after laser myringotomy under topical anesthesia. The rate of DT and the recurrence rate of OME without tube insertion was the main outcome measure. RESULTS: In the control group, which showed a natural resolution, the rate of DT was 16.9% (52/308) of patients, and DT was more common in non-B tympanometry, which only had a recurrence rate of 17.3% (9/52). In the study group, 3.7% of patients showed unilateral DT (UDT) with contralateral positive effusion, and 5.4% of patients showed bilateral DTs (BDTs). BDT showed a non-B tympanometry pattern and a low rate of recurrence (25.0%), which was similar to the control group. UDT showed a B-type tympanometry in 81.8% of the patients, and the recurrence rate was significantly higher (68.2%; 15/22) than the BDT and control patients. BDT or DT with signs of natural resolution showed a low rate of OME recurrence regardless of tympanometry, and thus, patients do not need a VT. CONCLUSIONS: DT was not rare even without GA and the associated time delay, and DT was more common in the children that showed a natural resolution. However, microscopy and tympanometry was imperfect to predict dry tap, and thus, the surgeon needs to be prepared for individualized management of DT. UDT with B-type tympanometry and contralateral persistent effusion frequently recurred without tubes, and thus, VT for UDT appeared to be necessary.

Antioxidant effect of pomegranate extract in reducing acute inflammation due to myringotomy.

OBJECTIVE: To assess the effect of pomegranate extract on acute inflammation due to myringotomy. DESIGN: Prospective, randomised study. SUBJECTS: Thirty Sprague-Dawley rats were divided into three groups. Group one constituted controls. Group two underwent myringotomy. Group three underwent myringotomy and also received 100 µl/day pomegranate extract, via gavage, one day before and two days after surgery. Following sacrifice 48 hours after myringotomy, the animals' right ears were used to determine the concentration of reactive oxygen species, using the chemiluminescence method; left ears were used for histological study. RESULTS: Reactive oxygen species levels were significantly decreased in group three compared with group two (p < 0.01). The density of inflammatory cells in group three was significantly less than that in group two (p < 0.01). Lamina propria thickness and vessel density were also significantly decreased in group three compared with group two (p < 0.01). CONCLUSION: Our results indicate that oral pomegranate extract decreases reactive oxygen species concentration and acute inflammation in the tympanic membrane after myringotomy.

Comparison of Myringoplasty for the Chronic Small Tympanic Membrane Perforations: Fat versus Perichondrium / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: There are several techniques to perform myringoplasty for tympanic membrane perforations as an outpatient procedure. The aim of this study is to compare the results of fat and perichondrium myringoplasty for the treatment of chronic small tympanic membrane perforations. SUBJECTS AND METHOD: This investigation included 46 patients with chronic tympanic membrane perforations smaller than 3 mm. The patients were equally divided into 2 main groups according to surgical procedures. The patients underwent fat, or perichondrium myringoplasty without skin incision via transcanal approach under local anesthesia. The healing results of perforation and hearing improvement were investigated. RESULTS: Closure rates of the perforations in the fat, perichondrium myringoplasty groups were all the same as 87% (20/23). There were no significant differences between techniques in tympanic membrane closure rates with regard to size and location and in hearing improvement. However, the recovery time was a little faster in perichondrium myringoplasty during follow up. CONCLUSION: Conservative myringoplasty using fat and perichondrium is a feasible procedure that can be perfomed on outpatient basis for chronic small tympanic membrane perforations.

Bivalve cartilage inlay myringoplasty: an office-based procedure for closing small to medium-sized tympanic membrane perforations.

OBJECTIVE: To determine whether bivalve inlay cartilage-perichondrium myringoplasty (BCM) is successful in closing tympanic membrane perforations in an office setting. STUDY DESIGN: Retrospective case review. SUBJECTS AND METHODS: Adult patients with chronic perforations underwent BCM under local and topical anesthesia. Success was defined as complete closure of perforation at follow-up of at least 1 month. Predictors of success were identified by comparing the success and failure groups on pre- and postoperative pure tone average (PTA), patient demographics (age, gender), and characteristics of the perforations (size, location, duration, etiology). RESULTS: A total of 145 procedures were performed and the patients were followed for 1 to 78 months. The success rate for perforations smaller than 4 mm was 75 percent. Size of the perforation, and pre- and postoperative PTAs were significantly different between the two groups. The only significant predictors of success were preoperative PTA and size of perforation. CONCLUSIONS: BCM is a viable option for closure of small and medium-sized perforations in an office setting.

Effects of ciprofloxacin-dexamethasone on myringotomy wound healing.

OBJECTIVE: To evaluate the effects of the ciprofloxacin-dexamethasone (CDX) combination ototopical treatment after myringotomy on tympanic membrane (TM) healing in ears with eustachian tube obstruction (ETO) and unobstructed ears. STUDY DESIGN: Prospective, randomized, masked, controlled. METHODS: ETO was created in the left ear of 30 rats to induce a model of otitis media with effusion (OME). After 3 weeks, bilateral myringotomy was performed (day 0). Animals were randomized into three groups to receive no treatment or bilateral once daily ototopical treatment with balanced salt solution (BSS, vehicle) or CDX for 13 days. Bilateral otomicroscopy was performed on days 7, 14, and 28. On day 14, five randomly selected animals per group were humanely euthanized and the TM harvested for histology. Three additional rats provided normal negative control ears for histologic comparisons. RESULTS: On day 14, TM perforation healing rates were 100% in all ears of untreated and BSS-treated animals, 89% (8/9) in CDX-treated obstructed ears, and 30% (3/10) in CDX-treated unobstructed ears (P < .05 vs. BSS). On day 28, 100% (5/5) of the CDX-treated unobstructed ears and 80% (4/5) of the CDX-treated obstructed ears were healed. Histology showed initial TM thickening postmyringotomy in all ears but no significant qualitative differences between groups on day 28. CONCLUSION: Myringotomy healing was transiently modulated by treatment with CDX but proceeded normally after CDX discontinuation. This early modulation might enhance middle ear drainage and middle ear concentrations of CDX when tympanostomy tube surgery is performed in patients with active OME and ETO, thus potentially reducing otorrhea and preventing or treating infection. It would not be expected to increase the risk of premature tube extrusion or adversely affect normal healing of the TM after usual spontaneous extrusion.

[A new model for training in tympanoplasty]. / Entwicklung eines Tympanoplastik-Trainingsmodells.

BACKGROUND: Functional simulation of middle ear reconstruction is a valuable tools for training in otosurgery. We introduce a new experimental model which provides a direct acoustic feedback of the functional quality of ossicular chain reconstruction. METHOD: In this model the tympanic membrane and the ossicular chain have to be reconstructed for proper sound transmission to an artificial inner ear receptor. The received signal is converted into acoustic information and consecutively provided via headphone. RESULTS: Any changes in the reconstruction (e. g. tilting the prosthesis) can be experienced online and immediately optimized by the surgeon or a trainee. CONCLUSION: The experimental model can be used for demonstration and training in otosurgery. This model is also suitable for comparing measurements of transfer functions in a calibrated version and can be applied to development and critical evaluation of middle ear prostheses.

Simple underlay myringoplasty.

OBJECTIVE: To introduce simple underlay myringoplasty which is widely performed in Japan. PATIENTS: 391 ears with perforated eardrum underwent simple underlay myringoplasty from 2000 to 2004, and which were followed up for more than six months after surgery. METHODS: After removing the margin of the perforation by a transcanal approach under local anaesthesia, a connective tissue graft was inserted through the perforation and lifted to contact the edge. Fibrin glue was dropped on the contact area. There was no packing in the canal or in the middle-ear cavity. If the perforation remained, re-closure was attempted using the patient's frozen tissue. RESULTS: The rate of closure after the initial attempt was 304/391 (77.7 per cent), and that after re-closure for unsuccessful cases was 70/87 (80.5 per cent). The overall rate was 374/391 (95.7 per cent). There were no serious complications such as sensorineural hearing loss. CONCLUSIONS: Simple underlay myringoplasty is a simple and minimally invasive procedure employing fibrin glue and has led to a high closure rate of the eardrum.

Tympanic reperforation in myringoplasty: evaluation of prognostic factors.

OBJECTIVES: The most frequent failure in myringoplasty is reperforation. This complication appears at a rate of 7% to 27%. The aim of this study was to evaluate the importance of the principal prognostic factors to the risk of reperforation. METHODS: This is a study of prognosis based on an inception cohort. The prognostic factors considered in the study refer to clinical and surgical aspects; follow-up ranged from 5 to 7 years (mean, 68 months). The study was performed on 212 patients with or without otorrhea who underwent operation for tympanic perforation. All subjects underwent myringoplasty by means of an underlay or overlay technique depending on the size and site of the perforation. RESULTS: Healing of the tympanic perforation was obtained in 182 cases (86%). Age, otorrhea, status of the contralateral ear, and conductive hearing loss did not significantly affect the outcome of surgery. On the other hand, time from surgery, the site of perforation, the type of anesthesia, the approach, the surgical technique, and the type of graft were significantly related to the outcome. CONCLUSIONS: In the analysis of our results, the surgical approach proved to be the principal prognostic factor in the anatomic outcome of myringoplasty. The results obtained suggest that the principal factors influencing the outcome of myringoplasty are technical and not clinical.

Fat Myringoplasty Trimmed with CO2 Laser / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Fat myringoplasty is a simple and safe method for repairing tympanic membrane perforation. The purpose of this study was to investigate the effect of fat myringoplasty accompanied by CO2 laser treatment for the trimming of perforation. MATERIALS AND METHOD: Twenty-one patients diagnosed with the following tympanic membrane perforations were used: 1) Traumatic perforation, 2) Chronic otitis media without active inflammation, 3) Re-perforation after middle ear surgery. The procedure was performed at OPD under local anesthesia while operating a microscope that was adapted to the CO2 laser. RESULTS: The overall success rate was 81 percent (17/21). CONCLUSION: Fat myringoplasty can be recommended for repairing tympanic membrane perforation in traumatic, chronic otitis media and re-perforation after middle ear surgery. Fat myringoplasty was simple and effective on only small perforations (