A clinical comparison of outpatient and standard myringoplasty.

Abstract

This prospective study compared the surgical outcomes of 35 patients who underwent myringoplasty--16 who were treated as outpatients and 19 who were admitted as inpatients. The outpatient technique involved a free skin graft, with the temporalis fascia placed as an underlay graft. The inpatients underwent the standard myringoplasty procedure.

Postoperatively, 14 of the 16 outpatients (87.5%) and 17 of the 19 inpatients (89.5%) were completely healed within 2 weeks. The results of this study indicate that outpatient myringoplasty with a free skin graft is as safe and effective as standard myringoplasty for most patients.

Introduction

Grafting of the tympanic membrane (myringoplasty) has traditionally been performed as an inpatient procedure in Thailand. Several different methods of grafting have been reported and compared, including those that involve fasciaform grafts, periumbilical superficial fascial grafts, fat grafts, human type IV collagen grafts, xenografts, and heterografts. [1-9]

In standard myringoplasty, a temporalis fascia graft is placed medially to the tympanic membrane remnant or laterally under the tympanomeatal skin flap. [10-11] The technique is rather complicated, and the patient is required to stay in the hospital for 1 or 2 days. The outpatient myringoplasty technique described in this article (figure) is much simpler than the standard procedure.

Patients and methods

This study was carried out in the Department of Otorhinolaryngology at Thammasat and Chulalongkorn Hospital between April 1, 1995, and April 1, 1997. The study involved 35 patients who had permanent perforations of the tympanic membrane that had been present from 3 months to 20 years (mean: 7.9 yr). The most common cause of perforation was chronic otitis media.

Sixteen patients were treated with outpatient myringoplasty, and 19 underwent standard myringoplasty. All patients received an explanation of the techniques, the advantages and disadvantages of each procedure, and possible complications. Audiography was performed pre-and postoperatively. All patients were treated by the author, and all were followed up with periodic postoperative examinations.

Outpatient technique. The ear was sterilized with povidone iodine and draped. The ear canal and the graft site were anesthetized with 4 to 5 ml of lidocaine 2% with adrenaline 1:80,000. A graft was taken from either the tragus (perichondrium) or the supra-auricular area (temporalis fascia), and it was prepared and dried to form a paper-like sheet.

The perforation was measured, and its rim was trimmed and removed with a cupped forceps. The squamous epithelium on the drum remnant was carefully and completely removed with a microcurette ("duckbill" curette) and a small cupped forceps. Care was taken to avoid leaving any squamous epithelial tissue, tearing the membrane fibrous remnant, and injuring the ossicular chain.

A 5 x [5-mm.sup.2] skin graft was taken from the posterior bony ear canal, usually 2 to 3mm below the bony cartilage junction. The graft was preserved in normal saline solution.

Gelfoam impregnated with antibiotic solution was placed into the middle ear cavity so that it filled the space. Excess fluid and blood from the eardrum and middle ear cavity were removed with a small cotton ball at the tip of continuous suction. The fascia graft was cut to its proper size and shape and placed medially to the drum so that it completely covered the perforation.

The skin graft was placed laterally over the fascia and the perforation, and special care was taken to completely unroll the skin edge before packing.

The ear canal packing, including the inner Gelfoam layer and the graft, was splinted with rayon or silk strips or similar material for 2 weeks. Patients were instructed to keep water from entering the ear. They were also told to refrain from nose blowing and air travel for 1 month.

Following surgery, patients were examined every 2 weeks for at least 3 months. Repeat audiography was performed 4 weeks after the operation.

Results

Fourteen of the 16 patients (87.5%) who underwent the outpatient procedure were completely healed within 2 weeks; the remaining two patients had still not healed at 1 month (table). Four weeks after surgery, audiography revealed that 10 of the 14 patients (71.4%) had normal hearing, while the remaining four had a mild hearing loss (10 to 15 dB). The length of the outpatient myringoplasty ranged from 20 to 50 minutes (mean: 31).

Similarly, 17 of the 19 inpatients (89.5%) had healed completely within 2 weeks. The remaining two patients had still not healed at 1 month. Audiography performed 4 weeks after surgery on these 17 patients revealed that 12 (70.6%) had normal hearing and five had a mild hearing loss (10 to 15 dB). The length of the standard myringoplasty procedure ranged from 40 to 90 minutes (mean: 58).

There was no significant difference between the two groups with regard to healing rates and hearing level.

Discussion

The success rates of standard myringoplasty for the treatment of permanent perforations of the tympanic membrane have been reported to range from 80.9 to 91.4%. [10] Two major drawbacks are associated with the standard procedure, especially when the laterally placed graft technique is used. First, a good degree of skill is required to elevate the tympanomeatal skin flap without tearing it. Second, it is difficult for an inexperienced surgeon to reposition the skin flap into the proper location. For these reasons, unsatisfactory outcomes can result when the standard operation is in the hands of a young physician.

The outpatient myringoplasty technique might provide a solution to these problems because it requires no tympanomeatal flap. The surgeon needs only a small free skin graft to cover the fascia graft. Outpatient myringoplasty is easier to perform than standard myringoplasty. Moreover, operating time is shorter and the success rate, at least in this study, is just as high. Outpatient myringoplasty should be a suitable way for a young surgeon to gain experience before undertaking a standard tympanomeatal flap procedure.

The results of this study indicate that outpatient myringoplasty with a free skin graft is as safe and effective as standard myringoplasty for most patients.

From the Department of Otolaryngology, Thammasat University, Bangkok, Thailand.

Reprint requests: Waiphot Chanvimalueng, MD, Department of Otolaryngology, Thammasat University, Bangkok 12120, Thailand.

References

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(4.) Pfleiderer AG, Moffat DA. The fasciaform graft: A technique for the repair of large perforations of the tympanic membrane. Clin Otolaryngol 1988;13:427-34.

(5.) Ajulo SO, Myatt HM, Alusi G. Pen-umbilical superficial fascial graft myringoplasty--a simple alternative. Clin Otolaryngol 1993;18:433-5.

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(7.) Truy E, Disant F, Tiollier J, et al. A clinical study of human type IV collagen as tympanic membrane grafting material: Preliminary noncomparative study. Arch Otolaryngol Head Neck Surg 1994; 120:1329-32.

(8.) Callanan VP, Curran AJ, Gormley PK. Xenograft versus autograft in tympanoplasty. J Laryngol Otol 1993;107:892-4.

(9.) Ensari S, Selampinar F, Akalin Y, et al. The use of molded tympanic heterograft (lamb peritoneum). Ear Nose Throat J 1995;74:487-9.

(10.) Gibb AG, Chang SK. Myringoplasty (A review of 365 operations). J Laryngol Otol 1982;96:915-30.

(11.) Vartiainen E, Nuutinen J. Success and pitfalls in myringoplasty: Follow-up study of 404 cases. Am J Otol 1993;14:301-5.

               Comparison of results with the two techniques
                               Outpatient      Standard
                             myringoplasty  myringoplasty
No. patients                       16             19
Complete healing: n (%)        14 (87.5%)     17 (89.5%)
Operation time: range (mean) 20-50 min (31) 40-90 min (58)
Hearing                         Improved       Improved