Tubotympanic Type Research Articles

English

OBJECTIVE: To assess ossicular defects in patients with tubo-type of CSOM in relation to size of tympanic membrane perforation and its associated hearing loss. SETTING: This study was carried out in department of Oto-rhino-laryngology, Vinayaka Mission Medical College, Karaikal. (Tertiary Care hospital). METHODS: The study included 150 patients who attended ENT OPD from May 2012 to May 2013. The patients underwent ossiculoplasty and were diagnosed to have tubo- tympanic type of CSOM. The parameters studied were size of perforation of tympanic membrane, pre-operative hearing levels and intra-operative ossicular defects. RESULTS: Incus was the commonest ossicle affected especially the long process of incus. In some cases the entire incus was absent. Involvement of the incus was seen was highly evident in patients with subtotal perforation of the tympanic membrane. Majority of patients had conductive hearing loss between 39.40 to 59.60 dB in patients having either single or multiple ossicular involvements. CONCLUSIONS: Ossicular defects and associated hearing loss may occur in tubo-tympanic type of CSOM. Ossicular defects were more common in sub-total perforation of tympanic membrane than central perforation. Knowledge gained from this study could be utilized by ENT surgeons in efficient management of

Clinical Application of a Microbiological Study on Chronic Suppurative Otitis Media

Our prospective study conducted over a period of 9 months includes 100 samples of ear discharge collected from 90 patients suffering from tubo-tympanic type of chronic suppurative otitis media (CSOM). The ear discharge which is collected with sterile swabs is subjected to Gram’s staining and culture of the causative organism. Antibiotic sensitivity test of cultured bacterial growth is undertaken to know the susceptibility of the causative organism. Of the 100 samples, 62 were culture positive where Pseudomonas aeruginosa was the most common pathogen followed by Staphylococcus aureus. Most of the cultured organisms in our study were sensitive to drug Ciprofloxacin. The outcome of our study enabled us to set an empirical medical treatment for an early resolution of ear discharge and inflammation in our patients with CSOM as we could understand the aetiological pathogens and their susceptibility pattern. Effective medical treatment in obtaining a discharge free ear prior to surgical treatment led us to improve the surgical outcome in our patients with CSOM.

A Comparative Study of Temporalis Fascia Graft and Vein Graft in Myringoplasty

To compare the surgical outcome of temporalis fascia graft (TFG) and vein graft (VG) in myringoplasty. This prospective study was carried out over 60 patients with inactive tubotympanic type of chronic suppurative otitis media, with small to moderate size central perforation in Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry from November 2009 to March 2011. Patients were equally randomized into two groups; TFG group and VG group according to the graft material used for myringoplasty. After routine investigations, X-ray mastoid and paranasal sinuses and pure tone audiometry, all cases were operated under local anesthesia using underlay technique. Patients were followed at 2week, 1 and 3month postoperatively. Graft uptake, audiological improvement, degree of hearing improvement, and complications were studied during follow up. In TFG group, graft uptake rate was 80% and hearing improvement was present in 66.7% whereas in VG group graft uptake rate was 83.3% and hearing improvement was present in 70%. No patient had deterioration in hearing, sensory neural hearing loss or any other complications postoperatively. Difference between the preoperative and postoperative air bone (AB) gap was considered as degree of hearing improvement. Postoperative AB gap was <10dB in 60 % and 66.7% of patients of TFG group and VG group respectively. The difference in graft uptake rate and hearing improvement between two groups was not statistically significant. Both TFG and VG are equally effective in terms of graft uptake and hearing improvement in myringoplasty.

A study of graft uptake rate of myringoplasties in Bir Hospital

Chronic suppurative otitis media-tubotympanic type is one of the commonest ear diseases in the practice of otolaryngology. It mainly occurs in the people with poor socio-economic conditions hence, its magnitude is immense in remote areas of Nepal where poverty prevails the most and in people who do not have access to health facilities. The main features of this disease are ear discharge lasting more than three months, hearing loss, and perforation of the tympanic membrane. The aim of this study is to evaluate the graft uptake rate of patients who underwent Myringoplasties for Chronic Suppurative otitis media tubotympanic type. The total number of patients in the study was 129. Age of the patients varied from 13 to 45 years. Myringoplasties were performed on these patients. They were followed up at one week for stitch and ear pack removal, and then at four weeks to see for graft uptake. The graft uptake rate was found to be 81.4 %. There were no significant complications, except that few patients complained of pain at the site of incision for harvesting the graft. This study showed that myringoplasty has good success rate./7 and can be carried out safely for closure of tympanic membrane perforation in cases of chronic suppurative otitis media tubo-tympanic type. DOI: http://dx.doi.org/10.3126/jcmsn.v7i1.5969 JCMSN 2011; 7(1): 24-27

Evaluation of Eustachian tube function in chronic suppurative otitis media (tubotympanic type) with reference to its treatment outcome

Aims and Objectives: To assess the eustachian tube function (ETF) and to evaluate the treatment outcome of chronic suppurative otitis media (CSOMtubotympanic type) in relation to eustachian tube dysfunction. Materials and Methods: Prospective study for a period of 2 years; the study comprises of 100 patients diagnosed to have CSOM (tubotympanic type). ETF was assessed by Toynbee's test. Patients with normal ETF were taken up for myringoplasty. Patients with totally impaired ETF irrespective of middle ear mucosal status (dry or wet) were taken up for cortical mastoidectomy with tympanoplasty. Patients with partially impaired ETF, with dry middle ear mucosa were taken up for myringoplasty and those with wet middle ear were taken up for cortical mastoidectomy with tympanoplasty. Results and Analysis: The ETF in these patients was analyzed and graft uptake was assessed clinically in reference to ETF status. The results are tabulated and analyzed using Chi-square test using number cruncher statistical system (NCSS) software. In our study, preoperative ETF had a highly significant P value = 0.0005. Conclusion: Methodology of treatment adapted for CSOM patients based on ETF proves that the eustachian tube plays a major role in the uptake of graft.

Prevalence of cholesteatoma in chronic suppurative otitis media with central perforation

Introduction: Chronic suppurative otitis media (CSOM) is a long-standing infection of middle ear cleft having a permanent perforation in the tympanic membrane with or without discharge. This is usually classified into two main groups: tubotympanic and atticoantral disease. The atticoantral type is called unsafe type because of the associated complications due to granulations and cholesteatoma which may be life-threatening. Tubotympanic type with central perforation is usually not associated with major complications such as cholesteatoma formation. Materials and Methods: This study has been conducted in the Department of ENT, Alluri Sita Rama Raju Academy of Medical Science, Eluru, A.P., India. Study group includes 210 patients having CSOM with central perforations in the tympanic membranes who underwent different types of procedures in our department. Preoperatively, all the patients were evaluated with otoscopy, microscopy, pure-tone audiometry, and some patients with computed tomography scan. All the patients had been evaluated peroperatively for confirmation of preoperative findings under microscope. Results: Surprisingly, seven patients with central perforations were having cholesteatoma, confirmed by biopsy. Conclusion: This study suggests that no perforation in CSOM is safe. Any patient coming for medical advice having CSOM with any type of perforation should be evaluated properly to exclude the underlying pathology like cholesteatoma which may be dangerous later on if not identified.

Tympanometry, a Prognostic Indicator of Myringoplasty with Assessment of Eustachian Tube Function

Objective: To determine Eustachian tube function in tubotympanic type of chronic ear disease and to correlate Eustachian tube function with pathological change in middle ear mucosa. Materials and Methods: A prospective study of the cases of tubotympanic type of chronic suppurative otitis media was undertaken. Patients were subjected to clinical examination followed by audiometry tests and impedence audiometry to determine eustachian tube functions. Patients were then subjected to myringoplasty and eustachian tube function were then reassessed post operatively. Results: In our study, out of 30 cases who underwent myringoplasty, 21 cases had successful surgical outcome and 9 cases were failed. Out of 24 cases of good Eustachian tube function, 21 cases had successful surgical outcome intends of taking up graft, absence of otorrhea and improvement in hearing. In remaining 3 cases, there was recurrence of otorrhea with central perforation. All the 6 cases with poor Eustachian tube function had surgical failure. Conclusion: The prognosis of the middle ear reconstructive surgery has direct correlation with Eustachian tube functions and Eustachian tube function tests should be a routine investigation in all the cases planned for surgical reconstruction of the middle ear.

Pre-Operative and Post-Operative Assessment of Hearing following Tympanoplasty.

Tympanoplasty is one of the ever evolving surgical procedures mainly aimed at restoring the hearing loss and eradication of middle ear disease. We have made an attempt to assess the hearing improvement of various types and techniques of tympanoplasty. A prospective observational study was done on 50 cases of CSOM, of which 45 cases were tubotympanic type, and 5 cases were attico-antral. Patients of only pure conductive component with good cochlear reserve and good Eustachian tube function were considered for the study. This study aims at assessing the hearing improvement with various types of tympanoplasty.

Middle Ear Cleft in Chronic Otitis Media: A Clinicohistopathological Study

Chronic mucosal diseases of middle ear cleft or chronic suppurative otitis media has been traditionally defined as a chronic inflammation of the middle ear and mastoid usually associated with perforation of the tympanic membrane and otorrhoea. Understanding the pathology and pathogenesis of chronic suppurative otitis media is important in predicting the management, prognosis and sequelae of the disease. The present prospective study was conducted to evaluate the clinical, intraoperative and histopathological changes in middle ear cleft. 100 patients diagnosed with CSOM who underwent surgery were taken. The mucosa and granulation tissue was removed along with ossicles wherever indicated and sent for histopathological examination. On clinical examination, 72 cases were found to be of tubotympanic type and 28 cases of atticoantral variety. However, intraoperatively, of the tubotympanic cases 8 were found to be of unsafe type which was also proven histologically. Stratified squamous epithelium was revealed in most of the cases accompanied by changes in the submucosa. Ossicular chain was involved in 40 cases with incus being the commonest bone to be eroded.

Using Middle Ear Risk Index and ET Function as Parameters for Predicting the Outcome of Tympanoplasty

Otitis media is an important and a highly prevalent disease of the middle ear and poses serious health problem world wide especially in developing countries where large percentage of the population lack specialized medical care. With a large number of patients frequently undergoing tympanoplasty for tubotympanic type of CSOM, it's important to assess the severity of the disease and predict the outcome of the surgical management whenever done. A normally functioning eustachian tube is an equally essential physiologic requirement for a healthy middle ear and normal hearing. In this study we have used the middle ear risk index (MERI) developed by Kartush which generates a numeric indicator of the severity of the middle ear disease to stratify patient groups according to the severity of the disease and to evaluate the efficiency of MERI score in predicting the outcome of tympanoplasty.

Otitis media: Does the onus lie on sinonasal pathology?

Background: Although most of the literature refers to sinusitis and upper respiratory tract as causative factor of otitis media (OM), only few articles refer to actual nasal pathologies that can lead to it. Objective: To study the influence of sinonasal disease on the middle ear condition (OM). Material and Methods: 200 patients of otitis media attending ENT Services of teaching institution in Central India were included.In 340 ears detailed ENT examination was carried out. Results: Of the 200 patients of otitis media 50% had chronic suppurative otitis media tubotympanic type, 41% had retraction and remaining had cholesteatoma and otitis media with effusion. Sinonasal evaluation revealed deviated nasal septum in 80%, sinusitis in 13.5% and polyp in 10.5% patients. Multiple sinonasal pathologies were present in some patients. On treatment of sinonasal disease significant improvement of middle ear disease was found in 79.31% ears after septal correction (Wilcoxon Signed rank test, P<0.05), 82.35% ears after treatment of sinusitis and in 76.92% ears after polypectomy. Conclusion: On the basis of these results we recommend evaluation and treatment of sinonasal disease before surgical treatment of ear disease is undertaken.

Cortical mastoidectomy in surgery of tubotympanic disease. Are we overdoing it?

Background and purpose of the study The role of cortical mastoidectomy in the surgical treatment of tubotympanic type of otitis media has remained controversial especially when there is no evidence of active infection. Though literature is replete with studies for and against the requirement of mastoidectomy, there is a paucity of prospective studies in this regard. A randomized controlled trial was conducted to assess the impact of mastoidectomy in the management of mucosal chronic otitis media. Methods 62 patients with uncomplicated mucosal chronic otitis media were randomly allotted to two groups of 31 each. Patients in group A underwent tympanoplasty with mastoidectomy and group B underwent tympanoplasty without mastoidectomy. All the patients were followed up for a minimum of three months and results were assessed in terms of graft uptake, hearing improvement and need for repeat procedure. Results No significant difference in outcome was observed between the two groups in all parameters compared. The residual air-bone gap was 12.55 ± 12.98 in group A and 12.71 ± 11.54 in group B. Graft uptake rate was 93.55% in group A and 96.775% in group B. 2 patients in group A and one patient in group B underwent repeat procedures. Conclusions There is little evidence in favour of cortical mastoidectomy in surgery of tubotympanic disease.

Sutureless tympanoplasty using acellular dermis

Objective A prospective randomized unblinded controlled trial was conducted by comparing acellular dermis with temporalis fascia as graft materials in tympanoplasty (type 1) in terms of operative time, postoperative pain, graft success rate, and audiologic outcome. Study design Forty-two patients with (inactive) chronic suppurative otitis media of tubotympanic type were randomized, matched, and divided equally into 2 groups of 21 each. One group underwent tympanoplasty (type 1) via transcanal route using temporalis fascia graft and the other using acellular dermis. Both groups were compared for operative time, postoperative pain, graft success rate, and audiologic improvement in hearing. Results There was a statistically significant reduction in operative time ( P < .05) and postoperative pain ( P < .05) in the acellular dermis group. However, there was no statistical difference in graft success rate ( P > .05) and hearing improvement ( P > .05) between both the groups. Conclusion Results of tympanoplasty using acellular dermis as graft material are comparable to that using temporalis fascia in terms of graft uptake and hearing improvement. However, tympanoplasty using acellular dermis has the advantage of shorter operative time and lesser postoperative pain.

Prospective study of myringoplasty using different approaches

Myringoplasty is one of the various surgical techniques for the management of chronic supurative otitis media of tubotympanic type (CSOM-TT). The presence of a perforation of tympanic membrane with intermittent discharge and hearing loss of conductive nature are the indications of myringoplasty. Myringoplasty can be performed by any of the three approaches, i.e. permeatal, endaural, or post-aural. It is a beneficial procedure done for closing tympanic membrane perforation and improving hearing. The aim of this study was to evaluate and compare different approaches of myringoplasty and various factors influencing surgical outcome. Myringoplasty was done in 90 cases of tympanic membrane perforation with temporalis fascia graft by underlay or onlay technique through one of the three approaches, i.e. permeatal, endaural and post-aural. The overall success rate in this study was 81.11% with majority of patients had improvement in hearing. Statistically there was no significant difference in results with different approaches. Age, sex, site, size and duration of disease had no bearing on graft take in this study. In repairing tympanic membrane perforations similar success rates are achieved with postaural or endaural approaches. A permeatal approach is most limited in the exposure obtained. What is important in choosing the appropriate approach is the location and size of the perforation and size of external auditory canal.

Pattern of ear diseases in rural school children: Experiences of free health camps in Nepal

Objective This study was done to find out the prevalence of different types of ear disease in rural school children of Nepal. Material and methods This is a prospective cross-sectional study among 2000 children aged between 5 and 13 years. Children those attending free health camps in rural places of six districts of Nepal were included. These free health camps were organized either by Healthy Human Society (non-governmental organization run by doctors of Nepal) or in association with other organizations. All these children were interviewed and examined otoscopically from January 2006 to December 2008. Informed consent was taken from guardians to participate in this study. Results are expressed in numbers and percentages. Results Out of 2000 children, 64.2% were male and 35.8% female children. The most common ear diseases were wax (62.0%), followed by chronic suppurative otitis media (7.6%) and otitis media with effusion (4.7%). In CSOM, there was 83.0% tubotympanic type. Both the wax and CSOM were common in 5–7 years age group. Overall ear diseases were present in 81.6% children. Conclusion Wax followed by chronic suppurative otitis media and otitis media with effusion were the most common ear diseases in rural school children of Nepal. Improvement of socioeconomic status and health care facilities, such as repetitions of free health camps will be helpful in reducing the prevalence of ear diseases.

Frequency Dependence of Hearing Loss with Perforations

This cross-sectional study was conducted in different sizes of pars tensa perforation in patients with chronic suppurative otitis media (CSOM) tubo-tympanic type undergoing myringoplasty. A total of 50 patients were recruited from the outpatient Department of Otorhinolaryngology - Head and Neck Surgery in TU Teaching Hospital from June 2003 to May 2004. Cases of CSOM tubo-tympanic type with dry central perforation, conductive type of hearing loss were subjected to myringoplasty. Preoperative audiometric evaluations were done. While operating under microscope diameter of perforations were measured and perforations were grouped according to the size. This study showed that the hearing loss was found to be more at lower frequencies and less as the frequencies increased. Hearing loss is more marked at lower frequencies as compared to higher frequencies, irrespective any size or location of perforation of pars tensa.

Correlation of hearing impairment with site of tympanic membrane perforation

Objective: This prospective study was done to assess the level of preoperative hearing impairment in different sites of pars tensa perforation in patients with chronic suppurative otitis media (CSOM) tubo-tympanic type undergoing myringoplasty. Materials and Methods: A total of 50 patients were recruited from the outpatient Department of Otorhinolaryngology and Head and Neck Surgery from June 2003 to May 2004. Cases of CSOM tubo-tympanic type with dry central perforation, with conductive type of hearing loss were subjected to myringoplasty. Preoperative audiometric evaluations were done. Just prior to operation, examination under microscope was performed. Exact site of perforation was noted. During operation, those found to have ossicular discontinuity or fixation were excluded from this study. Results: It was observed that the greatest hearing loss was found in big central (45dB) and posterior central (43dB); whereas least in those of anterior central (31dB) and central malleolar (34dB) perforations. The average hearing loss at 500Hz, 1000Hz and 2000Hzwas 46.40 dB, 30.90 dB and 31.9 dB respectively. This showed that the hearing loss is maximum at the lowest frequencies and minimum as the frequencies increase. Conclusion: This study shows that the posterior-central perforations cause more hearing loss than anterior-central ones. The hearing loss is maximum at the lowest frequencies and minimum as the frequencies increase. Journal of Institute of Medicine Vol.27(2) 2005

Chronic Suppurative Otitis Media: A Clinical Profile in Sokoto, Nigeria

This is a retrospective study of sixty eight cases of chronic suppurative otitis media seen in the Ear, Nose and Throat (ENT) Department of Usmanu Danfodiyo University Teaching Hospital Sokoto from June 1998 to May 1999. It was commonest in the paediatric age group (68.82%). The commonest symptom at presentation was ear discharge (100%), ear ache (26.47%), hearing loss (22.46%) and itchiness (10.29%). The commonest signs were ear discharge (100%) and tympanic membrane perforation (100%). All patients had the tubotympanic type of chronic suppurative otitis media. Pseudomonas aeruginosa and staphylococcus aureus were the most commonly cultured organisms (28.5% each). Cultures were sensitive to gentamicin and peflacine in most cases. Chronic suppurative otitis media is a public health problem affecting mainly the paediatrics age group with attendant learning impairment, caused by some degree of hearing loss and frequent hospital visitation for treatment. Therefore, prevention is stressed to reduce the morbidity of the disease. Key words: Chronic suppurative otitis media, pseudomonas aerugi nosa, hearing loss. Sahel Med. J. Vol.6(3) 2003: 75-78

Eustachian tube mucociuary transport in chronic suppurative otitis media

Eustachian tube dysfunction is one of the well-known factors leading to development of chronic suppurative otitis media. Tube mucociliary transport is important for elimination of the inflammation products from the middle ear enabling recovery of the affected mucosa of the middle ear, local circulation and restoration of normal air pressure in the middle ear. The study was aimed at determining: 1. whether perforation site on the tympanic membrane influences tube mucociliary transport time in individuals with traumatic rupture of the eardrum; 2. possible time difference of tube mucociliary transport between group of patients with chronic suppurative otitis media and group of patients with traumatic rupture of the tympanic membrane; 3. possible time difference of tube mucociliary transport between chronic tubotympanic type of suppurative otitis media, so called tubotympanic otitis media and atticoantral type of chronic suppurative otitis media, the so called atticoantral otitis; 4. the association between the degree of defect of the tympanic membrane mucosa and time of tube mucociliary transport in each individual type of chronic suppurative inflammation of the middle ear. Eustachian tube mucociliary transport was studied in 16 patients with tubotympanic otitis, in 13 patients with atticoantral otitis and in 9 patients with traumatic rupture of the eardrum (control group of patients). All patients were treated at the Institute of Otorhinolaryngology and Maxillofacial Surgery, Clinical Centre of Serbia in Belgrade during 2002. Tube mucociliary transport was studied upon instillation of 10 microl 5% sterile saccharine solution through the existing eardrum perforation in the course of preoperative preparation of the patient for surgical intervention. The time interval from the moment of sterile saccharine solution application till perception of the sweet taste in the mouth and pharynx was measured in studied patients. The obtained results were analyzed using the methods of descriptive and analytical statistics (t-test for small independent samples). The mean time of tube mucociliary transport in patients with traumatic rupture of the tympanic membrane was 7.6 minutes. The mean time of tube mucociliary transport in tubotympanic otitis with normal mucosa of the tympanic cavity promontorium was 15 minutes, while mean time of tube mucociliary transport in tubotympanic otitis with polypoid changes of the promontory mucosa was 24 minutes (t = 5.218; p < 0.01). Mean time of tube mucociliary transport in atticoantral otitis with normal promontory mucosa of the tympanic cavity was 35.5 minutes, while mean time of mucociliary tube transport in atticoantral otitis with polypold changes of promontory mucosa was 48 minutes (t = 6.99; p < 0.01). In the irreversibly changed tympanic cavity mucosa, tube clearance saccharine test was negative even after one hour. The results of our study indicate the possibility that prolonged mucociliary tube transport has greater influence to development of atticoantral otitis rather than to development of tubotympanic otitis. The association between the degree of mucosal defect and time of mucocillary transport was evidenced in both types of chronic suppurative inflammation of the middle ear.

Reliability of conventional ear swabs in tubotympanic CSOM

Conventional external ear swab cultures were compared with cultures obtained from the middle ear, in 25 cases of tubotympanic type ('safe'), chronic suppurative otitis media. These cultures were identical in 22 of the 25 cases. Anaerobic organisms were isolated in only one case. Mixed infections of both gram-positive and gram-negative organisms were seen in nine cases (36 per cent). Staphylococcus aureus was the commonest single agent isolated (16 cases). Multidrug resistance was seen in 12 of these isolates.