Hearing evaluation after myringoplasty

Bangladesh J Otorhinolaryngol 2010; 16(1): 23-28 Original Article Hearing evaluation after myringoplasty Sudhangshu Shekhar Biswas1, Md. Anwar Hossain2, Md. Monjurul Alam3, Md. Taufiq Atiq2, Zaheer Al-Amin4 Abstract: This study was carried out to assess the graft take rate as well as hearing improvement after myringoplasty with temporal fascia graft by underlay technique. Study was done in department of ENT and Head-Neck Surgery of BSMMU, Dhaka Medical College Hospital and BIRDEM from July 2006 to June 2007. Sixty (60) patients were included prospectively for this work. In this study graft take rate was 85% (51 out of 60) and graft failure was 15% (9 out of 60). The age range of the patients was 10 to 50 years. Highest number of patients was in the age group of 21 to 30 years and graft take was also maximum in this age group. Graft take rate of small size perforation (100%) and medium size perforation (93.23%) had more than subtotal perforation (77.77%). Success rate of posterior perforation was maximum (93.75%) followed by anterior perforation (88.23%). In case of approach of operation postaural approach had maximum success rate (88.09%) followed by endaural (75%) and transcanal approach (80%). In this study the mean pre and postoperative air conduction threshold in the successful cases were 34 dB and 24 dB respectively, with a mean audiological improvement of 10 dB. Improvement of mean air bone gap was 11 dB. Of the successful cases hearing was improved in 31 patients (60.78%) and 20 patients (39.21%) showed no significant hearing improvement. From this study it can be concluded that myringoplasty is a valid treatment modality for tympanic membrane perforation. Keywords: Myringoplasty,Graft take rate, Hearing improvement. Introduction: In Bangladesh like all developing countries the incidence of chronic suppurative otitis media (CSOM) is very high because of poor socioeconomic standard, over crowding, poor nutrition and lack of health education1. 1. Registrar, ENT-Head & Neck Surgery Dept, BIRDEM, Dhaka, Bangladesh. 2. Medical Officer, ENT-Head & Neck Surgery Dept, BSMMU, Dhaka, Bangladesh. 3. Associate Professor, ENT-Head & Neck Surgery Dept, BSMMU, Dhaka, Bangladesh. 4. Professor, ENT-Head & Neck Surgery Dept, BIRDEM, Dhaka, Bangladesh. Address of Correspondence : Dr. Sudhangshu Shekar Biswas, Registrar, ENT-Head & Neck Surgery Dept, BIRDEM, Dhaka, Bangladesh. Among the two types of chronic suppurative otitis media. Tubotympanic variety is the commonest and is called safe variety as the risk of developing complications are less and the name tubotympanic indicate disease of Eustachian tube and tympanic cavity1. Tubotympanic disease is always charac-terized by central perforation involving the pars tensa of varying size and shape but with a narrow margin of intact annulus and usually with part or all of the membrane of the malleus remaining2. The perforation of the tympanic membrane is associated with aural discharge and hearing loss. Aural discharge is always mucoid or mucopurulent and varies with upper respiratory tract infection. Discharge is usually intermittent recurring whenever there is a fresh head cold or water enters in to the ear2. Bangladesh J Otorhinolaryngol Hearing loss in tubotympanic disease is usually conductive in nature but a few case of sensorineural hearing loss is found3 . Hearing loss with intact ossicular chain is approximately 10-30 dB4,5. But more when ossicular chain is disrupted. Myringoplasty is the operation specially designed to repair or reconstruct the tympanic membrane. The earliest reported successful myringoplasty was done by Berthold in 1978, using full thickness skin graft3. Since then, myringoplasty has gone through many changes in technique and materials. Shea in 1960, first introduced underly technique for myringoplasty but using vein graft3. And autologus temporal fascia used as graft material firstly by Heerman in 19603. The surgical outcome of myringoplasty is influenced by many factors. The reported success rate of myringoplasty is therefore variable, partly because of differences in the inclusion and exclusion criteria, In a study overall success rate of myringoplasty was 86%. Posterior and inferior perforations had a 98% success rate for repair compaired to only 67% of anterior perforation. The success rate of subtotal perforation closure was (92.5%)6 . But the poorer results were in younger patients. A study found better success with advancing age7. This is due to lower incidence of upper airway infection and better Eustachian tube function in later age and the relative immaturity of system in younger children, Lorenzo Pignataro found better success rate in underlay technique than overly technique8. The success rate was 82.3% in the former and 79.1% in the later. At present, myringoplasty is a common operation in the Otolaryngology Department, having microsurgical facilities. The present study aims to evaluate the surgical and audiological outcome of myringoplasty using underlay technique with temporal fascia 24 Vol. 16, No. 1, April 2010 graft in selected patients with tympanic membrane perforation and to assess the factors potentially influencing those outcomes. Methods : This prospective study was carried out in the department of ENT and Head- Neck surgery of BSMMU, Dhaka Medical college hospital and BIRDEM from July 2006 to June 2007. Sixty (60) cases were selected for this study who underwent myringoplasty using underlay temporal fascia graft. The assessment of the patients was established on the basis of history, clinical examination and audiometric test per operative assessment and post operative followup was done. Inclusion criteria: (a) CSOM- Tubo tympanic type with dry central perforation for at least 3 months but with no other external ear, middle ear or inner ear diseases. (b) No evidence of cholesteatoma. (c) uncomplicated. (d) Age between 11 to 50 year. Exclusion criteria: (a) Evidence of cholesteatoma. (b) Previous tympanic surgery. (c) Traumatic perforation. (d) Severe Tympanosclerosis . (e) Only hearing ear. (f) Chronic otitis externa. (g) Systemic diseases : Diabetes Mellitus, Tuberculosis. The patients were post operatively followed up at weekly interval for 1st month and Then at the period of three month interval for 1st year. At the follow up examination, result of surgery was regarded as successful if ear was dry and the tympanic membrane intact and mobile. Audio metric test (PTA and Impedence) were performed after three months and hearing gain or loss was compaired with pre-operative test. Hearing evaluation after myringoplasty Sudhangshu Shekhar Biswas et al Results: Table-I show that overall graft taken in 51 cases (85%) and graft failure in 9 cases (15%), amongst which complete failure of graft was in 4 patients (1.66%), medialization in one patient (1.66), residual perforation in 3 patient (5%) and re- perforation in one patient (1.66%). In this study maximum patients wer (...truncated)