Effectiveness of nonsurgical office closure of tympanic membrane pars tensa perforations. (Original Article).

Abstract

We report on our experience with nonsurgical office closure of tympanic membrane pars tensa perforations with the little-used but well-established Derlacki method, a procedure that had been in general use before the introduction of tympanoplasty more than a half century ago. We describe our results--including a success rate of 84.2%--in treating 81 perforations during the 6-year span from 1996 through 2001.

Introduction

Although tympanoplasty is the preferred method of treating tympanic membrane perforations, we have achieved consistent success with a little-used but well-established nonsurgical method of closing pars tensa perforations in our office in selected patients. The technique we use was first described in 1944 by Linn, (1) who later demonstrated it to Derlacki. Derlacki modified the technique somewhat and used it extensively in his practice, and in 1953 he reported much success with it. (2) The technique came to be known as the Derlacki method, although Derlacki credited Linn for having originated the procedure. Two decades later, Derlacki reported that he and his colleagues (Shambaugh, Harrison, and Clemis) at Otologic Professional Associates of Chicago had cumulatively treated 1,277 pars tensa perforations between 1953 and 1972 and had successfully healed at least 1,027 of them (80.4%). (3)

Briefly, the method involves four steps:

* First, the margins of the tympanic membrane pars tensa perforation are cauterized with a thin cotton-tipped applicator embedded in a saturated solution of trichloroacetic acid. The acid causes blanching on the rim of the perforation and on approximately 1 mm of the part of the pars tensa that surrounds the perforation.

* Second, antiseptic powder is insufflated over the area being treated.

* Third, the perforated membrane is covered with a pledget of sterile cotton, upon which are instilled a few drops of Euthymol solution (table).

* Fourth, after the procedure, the patient is sent home with a small bottle of Euthymol solution with an eardropper and instructed to instill 2 drops into the treated ear twice a day (morning and evening).

The patient is also given an appointment to return in 10 days for follow-up and another treatment if necessary. About half of the patients in our series required one to three treatments--some as many as 12.

The rationale for the Derlacki method is based on the premise that the acid cauterization breaks up the fibrosis on the perforation's rim and promotes the formation of granulation and the proliferation of new tissue. The Euthymol solution is believed to exert a mild antiseptic effect and to stimulate tissue growth. The cotton pledget prevents crust formation that could halt tissue growth and also acts as a splint to aid in bridging the margins of the perforation. When conditions are deemed favorable, the perforation's rim can be debrided in the manner described by Jeurs. (4) To accomplish this, we use a sterile right-angle hook.

The Derlacki method should be performed on dry ears only. The entire margin of the perforation must be visible, the annulus tendinosus must be intact, and the ear being treated must be free of cholesteatoma. If the ear exhibits any signs of moisture or infection, it must be first treated with a topical or oral antibiotic; treatment can be administered once the ear has remained dry for at least 2 weeks.

Patients and methods

In our office, every ear is examined under the Zeiss operating microscope. Ears that are under consideration for treatment with the Derlacki method also undergo air-bone and speech audiometry, and photographs are taken when feasible. A routine ENT examination is also performed, and particular attention is paid to the nose and nasopharynx. If the history or examination reveals the presence of any allergy, due attention is directed toward managing it. The patency of the eustachian tube is assessed by Valsalva's maneuver and/or politzerization. We also check to determine if the ear is dry and free of cholesteatoma, and to see if the entire margin of the perforation is visible and the annulus tympanicus is intact. Patients whose perforations are characterized by either ossicular disruption or ankylosis are not offered this conservative treatment and are instead assigned to surgery.

Once a patient has satisfied all criteria for treatment eligibility, we perform the procedure as described earlier, except that we do not insufflate the area with antiseptic powder. Patients who exhibit anxiety or who have a low pain threshold can be administered a topical anesthetic; we often use lidocaine 2.5%/prilocaine 2.5% cream. Patients return for regular follow-up visits at 10-day intervals (or as close to 10 days as possible).

During the 6-year span from 1996 through 2001, we treated 81 pars tensa perforations; 75 patients had unilateral perforations, and three patients had bilateral perforations. Patients ranged in age from 11 to 88 years, and the size of their perforations ranged from 2 mm to more than 50% of the surface of the tympanic membrane (several of the largest perforations were bean-shaped and thus larger than 50% of the drum surface). Of the 81 perforations, 51 were associated with otitis media, 15 with tympanoplasty, 10 with trauma, and five with myringotomy and tube placement.

Five patients with unilateral perforations failed to return to the office after their second treatment and were lost to follow-up. Of the remaining 76 perforations, 64 (84.2%) healed and 12 (15.8%) did not. Inmost patients, healing reversed the conductive hearing loss associated with the perforation.

The 64 perforations that healed required between one and 11 treatments. Specifically, 15 perforations healed after only one treatment, 13 required two treatments, 12 required three treatments, five required four treatments, eight required five treatments, four required six treatments, two required eight treatments, three required nine treatments, one required 10 treatments, and one required 11 treatments.

Among the 15 perforations that were incidental to tympanoplasty (five had been operated on elsewhere), two were noticed on the third postoperative visit. One of these two patients, a 47-year-old woman, had a perforation that involved the anterosuperior pars tensa and which failed to heal despite 12 treatments. The other patient, a 30-year-old man, had a smaller perforation that involved the anterior pars tensa and which healed after one treatment.

Among the 10 perforations that had been occasioned by trauma were those caused by a firecracker explosion, a slap, a spill of hot slag, and injuries incurred while water-skiing, scuba diving, and improper self-cleaning of the ear. Four of the 10 trauma patients had been seen within a few hours of their accident. For these four patients, we omitted the first treatment step (cauterization and blanching); when possible, we also attempted to evert the retracted and ruptured membrane with a right-angle hook and/or suction. These four perforations all healed after only one treatment. The other six traumatic perforations were not treated until weeks had passed. Four of the six patients required two treatments, and the other two required three.

The five patients whose perforations had been caused by myringotomy with tube insertion were not seen until months after their tubes had extruded. One of these patients had two distinct perforations of the anterior pars tensa, both of which healed after the fourth treatment.

We found that in most cases, the smaller the perforation was, the fewer treatments were required. For example, an 81-year-old woman whose perforation was roughly 6mm healed after six treatments (figure 1). In contrast, a 74-year-old woman with a 4-mm perforation required only two treatments (figure 2). Even so, perforations of similar size can require a larger or smaller number of treatments.

All healed membranes were re-examined 1 month after the final treatment. It was at this follow-up visit that we discovered that six healed perforations had reopened. Treatment was reinstituted, and four of these six perforations healed after four additional treatments; these patients were included in the 64 treatment successes. The other two patients failed to heal despite protracted treatment (12 additional applications), and each was classified as one of the 12 treatment failures.

Discussion

Predicting a priori how many treatments are needed to heal a given perforation is difficult. In our practice, we have established two cutoff points to guide us in determining if we should stop treatment. First, if no granulation tissue has developed around the rim of the perforation and no evidence of new tissue growth is noted by the seventh application, we stop treatment (sequential photographs and accurate notes are helpful in documenting the progress of healing or lack thereof). If the patient is showing signs of progress, we continue treatment for as many as 12 visits, but if no closure has occurred by then, we usually stop treatment. We realize that these cutoff points are more or less arbitrary, but they are rooted in experience. Prolonging conservative treatment when experience suggests that it is futile is a misuse of resources and only delays the initiation of definitive surgery.

Once a perforation has healed, we schedule patients for a follow-up examination 1 month later. Thereafter, we see them every 3 months for 1 year. The purpose of these visits is to monitor healing and to look for any reopening or recurrence of the perforation.

Overall, we have found that the Derlacki method is a reliable means of healing pars tensa perforations in properly selected patients. The procedure is simple, rapid, convenient, and virtually risk-free. Moreover, the economic advantage to patients and insurance carriers is considerable. We recommend this method highly, and we agree with Derlacki and Jeurs that every practicing otolaryngologist should be familiar with it.

Table.

Selected characteristics of ingredients in 1 L of Euthymol otic solution

Ingredient              Amount   Pharmacologic property

Eucalptol               0.40 ml  Minor germicidal; skin
                                 irritant; odor masker

Methylsalicylate        0.22 ml  Rubefacient with analgesic
                                 properties; counterirritant

Thymol                  0.078 g  Antifungal

Menthol                 0.091 g  Stimulator of nervers that
                                 perceive cold; depressor of
                                 nerves that perceive pain

Oil of orange           0.24 ml  Mild antiseptic

Sodium borate           4.05 g   Antiseptic with cleansing
 (powdered and sifted)           properties

Boric acid              4.05 g   Mild anti-inflammatory and
 (powdered)                      antiseptic

Ethyl alcohol 95%       12.0 ml  Germicidal; preservative

Sterile water            ~1 L

References

(1.) Linn EG. Closure of tympanic membrane perforations. Eye, Ear, Nose, and Throat Monthly 1944;23:185-7.

(2.) Derlacki EL. Repair of central perforations of tympanic membranes. Arch Otolaryngol 1953;58:405-20.

(3.) Derlacki EL. Office closure of central tympanic membrane perforations: A quarter century of experience. Trans Am Acad Ophthalmol Otolaryngol 1973;77:53-66.

(4.) Jeurs AL. Office closure of tympanic membrane perforations: A new approach. Laryngoscope 1958;68:1207-15.

From Century Ear, Nose, and Throat, Orland Park, Ill.

Reprint requests: Louis F. Scaramella, MD, Century Ear, Nose, and Throat, 16001 S. 108th Ave., Orland Park, IL 60467. Phone: [phone]; fax: [phone].