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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 28  |  Issue : 3  |  Page : 166-170

Evaluation of hearing status in pre and post-operative endoscopic type 1 tympanoplasty and its influencing factors


Department of Otorhinolaryngology, Regional Institute of Medical Sciences, Imphal, Manipur, India

Date of Web Publication5-Jan-2015

Correspondence Address:
Moirangthem Niteshore Singh
Changangei Awang Leikai, P.O. Tulihal, Imphal - 795 140, Manipur
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-4958.148502

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  Abstract 

Context: The recent change of using endoscope instead of microscope in performing transcanal type 1 tympanoplasty has encouraged us to compare the results of the surgery. Aims: The aim of this study is to evaluate hearing status in the pre- and post-operative state after endoscopic type 1 tympanoplasty and to correlate the improvement with influencing factors like the age of the patient, site and size of perforation, wet/dry ear, status middle ear mucosa, status of mastoid air cells, and function of Eustachian tube. Settings and Design: An interventional study was carried out in the Department of Otorhinolaryngology, RIMS. Materials and Methods: Thirty cases of diagnosed pars tensa central perforations, aged above 18 years, with a small to subtotal perforation associated with a demonstrable conductive deafness not more than 40 dB was included in the study. Statistical analysis used: Chi-square test. Results: The graft uptake rate in our study is 90% and hearing improvement in terms of airbone (AB) gap within 0-15 dB was achieved in 83.3%. Age, sex, size of perforation, site of perforation, wet/dry ear, and status of the mastoid air cell system were not found to have a significant relation with the successful outcome of endoscopic type 1 tympanoplasty. Presence of mucosal hypertrophy and the nonfunctioning of the Eustachian tube were a significant determinant for the failure of type 1 tympanoplasty. Conclusions: The outcome of endoscopic type 1 tympanoplasty is similar to the outcome of the microscope assisted type 1 tympanoplasty with better cosmesis.

Keywords: Endoscope, Endoscopic type 1 tympanoplasty, Graft uptake, Mucosal hypertrophy, Pure tone audiometry, Temporalis fascia


How to cite this article:
Singh MN, Hamam PD, Lyngdoh NC, Priyokumar OS. Evaluation of hearing status in pre and post-operative endoscopic type 1 tympanoplasty and its influencing factors. J Med Soc 2014;28:166-70

How to cite this URL:
Singh MN, Hamam PD, Lyngdoh NC, Priyokumar OS. Evaluation of hearing status in pre and post-operative endoscopic type 1 tympanoplasty and its influencing factors. J Med Soc [serial online] 2014 [cited 2020 Nov 24];28:166-70. Available from: https://www.jmedsoc.org/text.asp?2014/28/3/166/148502


  Introduction Top


The recent change of using endoscope instead of microscope in performing transcanal type 1 tympanoplasty has encouraged us to compare the results of the different approach of type 1 tympanoplasty surgery. In this study, the main aim is to evaluate hearing status in the preoperative state and compare it with the postoperative state after performing endoscopic type 1 tympanoplasty and to correlate the improvement with influencing factors like the age of the patient, site and size of perforation, wet/dry ear, middle ear mucosal status, status of mastoid air cells, and function of  Eustachian tube More Details using various parameters like tuning fork test, pure tone audiometry, impedance audiometry, etc.


  Materials and Methods Top


It is an interventional and observational study. The study was conducted with prior approval from Ethical Committee of Regional Institute of Medical Sciences, Imphal, Manipur. The procedure and data collection were carried out for 1.5 calendar years; with effect from the month of September, 2010. Thirty patients suffering from pars tensa perforation of tympanic membrane [Figure 1] aged above 18 years with demonstrable conductive deafness not more than 40 dB with complaint of decrease in hearing associated with tympanic membrane perforation without history of previous operation or a revision operation, tympanosclerosis, acute exacerbation of chronic otitis media (COM) or purulent otorrhea, cholesteatoma, ossicular discontinuity, sensorineural hearing loss, cancer of head and neck affecting the function of middle or internal ear, or chronic cough or chronic obstructive pulmonary disease (COPD). Descriptive statistics and analysis were carried out using statistical test like paired t-test, chi-square test, etc.
Figure 1: Pre-operative tympanic membrane perforation

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The patients' hearing levels in decibel are assessed with a biologically calibrated Advanced Digital Audiometer AD 2100 at frequencies 250; 500; 1,000; 2,000; 4,000; and 8,000 Hzin an acoustically treated sound proof boot. Pre-andpostoperative pure tone average (PTA) and airbone (AB) gap were calculated and compared by taking the averages of bone conduction and air conduction at the frequencies of 500, 1,000 and 2,000 Hz. Endoscopic tympanoplasty istypically performed via transcanal approach. Inspection of the ear canal and middle ear is performed using a 4 or 2.7 mm 0° endoscope. Any abnormalities of the ear canal and tympanic membrane is examined and noted. The age of the patient, site and size of perforation, wet/dry ear, middle ear mucosal status, status of mastoid air cells, and function of Eustachian tube are duly recorded.

A supraauricular scalp incision [Figure 2] of 2 cm is made about 1 cm above hairline to harvest temporalis fascia. In this study, only the underlay technique was performed to provide similar ground for comparability. Antibiotics are given, along with a mild pain reliever. Water entry in the operated ear is strictly prohibited, and nose blowing is discouraged. Patients are seen at 2-3 weeks to remove the packing from the external auditory canal and to ensure that adequate healing has begun. It is then determined whether or not the graft has fully taken. They are seen [Figure 3] at 6 weeks to evaluate complete healing; however, final postoperative evaluation was made after an interval of 6 months.
Figure 2: Supra-auricular incision

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Figure 3: Post-operative tympanic membrane

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  Results Top


Hearing impairment: In this study, hearing impairment indicates the patients with demonstrable conductive deafness not more than 40 dB.

Successful outcome: An intact mobile tympanic membrane with closure of AB gap less than or equal to 15 dB at 6months after the operation is considered successful outcome.

According to the criteria of success, 25 (83.3%) had a successful outcome and five (16.7%) patients had an unsuccessful outcome [Table 1].
Table 1: Success rate


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The study failed to show any association with the site of perforation and success rate of the procedure (P-value of 0.235).

Hearing result

The preoperative air conduction had a mean of 35.3 ± 2.78 dB and the preoperative bone conduction had a mean of 6.61 ± 2.71 dB. The postoperative air conduction had a mean of 22.27 ± 5.45 dB and the postoperative bone conduction value was 7.5 ± 2.17 dB.

There was a gain of 14dB postoperatively. Twenty-nine patients showed AB gap improvement; whereas, one patient showed a worsened AB gap of 3.33 dB. This patient had unsuccessful graft intake with displacement of the graft laterally postoperatively.

Complications

There were two cases of graft displacement, two cases of reperforation, one facial nerve paresis which recovered with conservative treatment, three cases of significant vertigo, and one case of infection postoperatively.

Cosmetic result

All the cases had an excellent cosmetic outcome.


  Discussion Top


In the present study, a total of 30 cases diagnosed as pars tensa central perforations, aged above 18 years, with a demonstrable conductive deafness not more than 40 dB and consented to participate in the study procedure underwent endoscopic type 1 tympanoplasty. The patients were followed for a period of 6 months. The graft uptake rate, audiometric outcome, and hearing gains of the patient were analyzed with the help of software Statistical Package for Social Sciences (SPSS) version 19. The age of the patient, site and size of perforation, wet/dry ear, status of middle ear mucosal, status of mastoid air cells, and function of Eustachian tubeear that may affect the improvement of hearing after endoscopic type 1 tympanoplasty operationwere recorded.

The mean age of the patients is 29.4 ± 9 years. The sex distribution in the study has no statistically significant association in the outcome of the surgery [Table 2] and [Table 3]. This finding is also similar to the studies of Sharma et al., [1] Aich et al., [2] and Shaikh et al. [3]
Table 2: Sex distribution



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Table 3: Age distribution of the patients


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Size of perforation [Table 4] and [Table 5], site of perforation [Table 6], and wet/dry ear [Table 7], were not found to have a significant relation with the successful outcome of endoscopic type 1 tympanoplasty. This finding is also similar to the studies of Sharma et al., [1] and Shaikh et al. [3]
Table 4: Perforation size


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Table 5: Size-success rate


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Table 6: Site of perforation


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However, there is a significant negative influence of middle ear mucosal hypertrophy [Table 8] on the surgical outcome of the patients. This finding is consistent with the reported value of Sharma et al., [1] Aich etal., [2] Shaikh et al., [3] Landsberg et al., [4] and Tos et al. [5]
Table 7: Dry/wet ear: Success rate


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Table 8: Status of middle ear mucosa: Success rate


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Nonfunctioning Eustachian tube was found in two (6.6%) cases and a functioning Eustachian tube was found in 28 (93.4%) cases [Table 9]. All the cases with a blocked Eustachian tube had a failure rate of 100%. This finding shows a significant relationship between the nonfunctioning Eustachian tube and failure rate of the surgery. This finding is in agreement with the findings of Chopra et al., [6] and Collins et al. [7] However, Tos et al., [5] reported that Eustachian tube function seemed to have no importance for reperforation.
Table 9: Eustachian tube patency: Success rate


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Status of the mastoid air cell system [Table 10] were not found to affect the outcome of the surgery.

The preoperative air conduction had a mean value of 35.3 ± 2.78 dB and the preoperative bone conduction was 6.61 ± 2.71 dB. The postoperative air conduction had a mean value of 22.27 ± 5.45 dB and bone conduction mean value of 7.5 ± 2.17 dB. The preoperative AB gap was 28.72 ± 3.65 dB and the postoperative AB gap was 14.72 ± 5.88 dB. There was an average hearing gain of 14 dB postoperatively [Table 11] and [Table 12]. Twenty-nine (96.7%) patients had an improvement in hearing; however, one patient had worsening of hearing by −3.33 dB. This patient who had a worsened hearing had an unsuccessful graft uptake with displacement of the graft laterally postoperatively.
Table 10: X-ray mastoid: Success rate


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Table 11: Pre- and postoperative airbone gap


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Table 12: Paired sample statistics


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The improvement in AB gap and hearing within 15 dB is statistically significant as shown by the paired t-test value of 10.77 and P-value of 0.000 with a degree of freedom of 29 [Table 11]. As the successful outcome criteria include graft uptake with improvement in hearing <15 dB, 27(90%) had a successful graft uptake and 25(83.3%) had an AB gap <15 dB.

As the data suggested, the overall success rate is 83.3% in this study. The overall success rate and the graft uptake ratesare comparable to the values given in some literature. Aich and coworkers [2] reported an overall graft take rate of 84%. The mean pre- and post-operative air conduction threshold in the successful cases was 35.2 and 24.1 dB, respectively, with a mean audiological improvement of 11.1 dB and airbone gap improvement was 12.4 dB. Yadav et al., [8] had an overall success rate of 80%. The successful outcome rate of Haruqop et al., [9] (82% endoscopic vs 86% microscopic) are comparable to the outcome of this study. The graft uptake rate of 90% in our study is comparable to the success rate as reported by Shaikh et al., [3] (81%) and Raj and Meher [10] (90% for endoscopic vs 85% in microscopic group) [Table 13].
Table 13: Status of ear at 6 months


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The issue of cosmesis is one of the major concerns of the patients. Another advantage of endoscopic type 1 tympanoplasty is the excellent cosmetic outcome. There was no retro auricular incision or endaural incision. The harvesting of temporalis fascia graft is done by giving a 2 cm incision in the scalp 2 cm above the pinna or 1cm above the hairline in the supraauricular region. The resultant scar is well hidden by the hair and is not visible as the incision is not given in the exposed part of the skin.


  Acknowledgement Top


We are indebted to our teachers who guided us in the study as ear surgeons and ENT consultants. Thanks are also due to the local audiometry assistants and staff in the department of Otorhinolaryngology that took part in this study.

 
  References Top

1.
Sharma D, Singh S, Sohal B, Singh B. Prospective study of myringoplasty using different approaches. Indian J Otolaryngol Head Neck Surg 2009;61:297-300.  Back to cited text no. 1
    
2.
Aich ML, Alam ABMK, Talukder DC, Harun AA, Abdullah M. Outcome of myringoplasty. Bangladesh J Otorhinolaryngol 2009;15:40-4.  Back to cited text no. 2
    
3.
Shaikh AA, Farrukh MS, Mutiullah S, Rafi T, Onali MA. Audiological results of Type I Tympanoplasty by underly technique with temporalis fascia graft. Pak J Otolaryngol 2009;25:30-1.  Back to cited text no. 3
    
4.
Landsberg R, Fishman G, DeRowe A, Berco E, Berger G. Fat graft myringoplasty: Results of a long-term follow-up. J Otolaryngol 2006;35:44-7.  Back to cited text no. 4
    
5.
Tos M, Stangerup SE, Orntoft S. Reasons for reperforation after tympanoplasty in children. Acta Otolaryngol Suppl 2000;543:143-6.  Back to cited text no. 5
    
6.
Chopra H, Gupta S, Munish M. Correlation between eustachian tube functions and result of myringoplasty. Indian J Otolaryngol Head Neck Surg 1994;3:149-51.  Back to cited text no. 6
    
7.
Collins WO, Telischi FF, Balkany TJ, Buchman CA. Pediatric Tympanoplasty: Effect of contralateral ear status on outcomes. Arch Otolaryngol Head Neck Surg 2003;129:646-51.  Back to cited text no. 7
    
8.
Yadav SP, Aggarwal N, Julaha M, Goel A. Endoscope-assisted myringoplasty. Singapore Med J 2009;50:510-2.  Back to cited text no. 8
    
9.
Haruqop A, Mudhol R, Godhi RA. A comparative study of endoscope assisted myringoplasty and microscope assisted myringoplasty. Indian J Otolaryngol Head Neck Surg 2008;60:298-302.  Back to cited text no. 9
    
10.
Raj A, Meher R. Endoscopic transcanal myringoplasty-A study. Indian J Otolaryngol Head Neck Surg 2001;5:47-9.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13]


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