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Decision making in patients with natural myringostapediopexy: a study of the contralateral ear.

Abstract

Naturally occurring myringostapediopexy frequently results in minimal hearing loss and is asymptomatic. Management decisions in such ears, however, often hinge on an appraisal of evolution toward cholesteatoma. The study of the contralateral ear has been used by our research team to infer the progression of chronic otitis media. This cross-sectional, comparative study describes the clinical findings of the contralateral ear in a series of patients with myringostapediopexy. This study included a historical and current sample of 46patients divided into a pediatric ([less than or equal to] 18 years) and an adult group. Patient distribution according to sex was similar (52.2% male), and 56.5% were adults. Mean conductive hearing loss ranged from 14.1 to 21.2 dB in ears with myringostapediopexy and from 16.0 to 26.6 dB in the contralateral ears according to the frequency assessed. The contralateral ear was normal in only 19.6% of the cases of myringostapediopexy. Central tympanic membrane perforation was found in 6.5% of the cases; perforation-retraction, in 17.4%; moderate or severe retraction, in 28.3%; and cholesteatoma, in 28.3%. The prevalence of cholesteatoma in the contralateral ear in the pediatric and adult groups was not significantly different (p = 0.5; [Chi square] test). The presence of significant abnormalities, particularly cholesteatoma, in the contralateral ears suggests a probable unfavorable progression in cases of myringostapediopexy and may influence management decisions.

Introduction

The treatment of tympanic membrane (TM) retractions is one of the most challenging topics in clinical otology. Several questions associated with this abnormality are based on the difficulty to understand the physiopathology behind the structural changes of the TM leading to diffuse or localized atrophy, progressive retractions and, eventually, loss of self-cleaning properties with cholesteatoma formation. Controversy is based on the fact that patients may be asymptomatic during the earlier phases of the process and hearing loss may be minimal, even in the presence of erosion of the long process of the incus. (1-4)

A previous study conducted by our group found that 53% of the patients with myringostapediopexy (defined by Costa et al (5) as a retraction limited to the postero-superior region, in which there is erosion of the long process of the incus and fixation of the affected TM to the head of the stapes) presented with an air-bone gap [less than or equal to] 25 dB at all frequencies. (6) This finding suggests that such a condition may mimic a surgical type III tympanoplasty in which the TM is repaired and advanced to the head of the stapes. (7) As such, surgical intervention in this case with the sole purpose of a hearing gain is generally not justifiable.

Still, the decision of how, and especially when, to intervene surgically in a patient with a dry myringostapediopexy should take into consideration at least three important clinical aspects, and the functional result is only one of them. The degree of disease progression and the associated self-cleaning capacity are the other two factors, equally relevant in the evaluation of these patients since it is well known that progressive TM retractions are the main path to cholesteatoma formation. (8)

In real-life practice, it is impossible to predict if, when, and in which direction these retractions will progress. It has been shown that a meticulous analysis of the contralateral ear (CLE) may offer important clues in this regard. (9,10) We have studied the behavior of the CLE in chronic otitis media (COM) through a series of studies focusing on (1) the cellular-level histology (histopathology of 170 human temporal bones with COM) (9); (2) the anatomic-clinical picture (middle ear findings of 500 patients with COM) (10); and (3) the physiology-function (the quantification of the air-bone gap in the CLE of 463 patients with COM). (11)

We believe our findings helped to shed some light on three key aspects of the disease process: Where did it come from (etiology)? What is the current condition (established pathology)? And, more importantly, how fast and in which direction is the disease marching (natural history)? The insight gained from this perspective can inform decision making in the clinical care of TM retraction.

With these concepts in mind, the objective of the present study is to describe the clinical findings in the CLE in a series of patients with myringostapediopexy.

Patients and methods

This cross-sectional, comparative study enrolled a historical and current sample among patients followed up in the Chronic Otitis Media Clinic of Hospital de Clinicas de Porto Alegre (HCPA), Porto Alegre, Brazil, from August 1,2000, to February 28, 2011. Patients were included if they had a natural myringostapediopexy detected via video-otoscopy (figure 1). The condition was defined as severe, limited retraction to the posterosuperior quadrant of the TM with erosion of the long process of the incus and fixation of the affected tympanic segment to the head of the stapes in at least one ear.

It is important to note that patients with eroded, but still connected, incudostapedial joints were excluded from this study. Other exclusion criteria were previous surgical otologic treatment (except myringotomy for ventilation tube insertion), accumulation of epithelial debris in the tympanic retraction or TM perforation; otorrhea; and conditions clearly associated with eustachian tube dysfunction, such as craniofacial malformations and rhinopharyngeal tumors.

[FIGURE 1 OMITTED]

During the first visit, the patient's clinical history (age, sex, ethnicity, and clinical otologic symptoms) was collected and, after that, the two ears were cleaned (if necessary) and examined under the microscope and with the aid of a 4-mm, 0[degrees] endoscope. Every case was video-recorded, with the images being captured with a digital recorder and stored on a compact disc. The same senior otologist performed the video-otoscopy in all patients.

All patients underwent pure-tone and speech audiometry to define hearing thresholds and the degree of perception and recognition of speech. The tests were conducted in the Audiology Section of the Otolaryngology Service of HCPA using an AD27 audiometer (Interacoustics; Eden Prairie, Minn).

Pure-tone audiometry was performed at 1,000,2,000, 3,000,4,000,6,000,8,000,500, and 250 Hz frequencies, tested in this order. The values of air conduction at 250 to 8,000 Hz and of bone conduction at 500 to 4,000 Hz were recorded. Conductive hearing loss (CHL) was calculated by subtracting the air-conduction value from the bone-conduction value at each frequency. The mean conductive hearing loss was measured, and the mean value of the conductive hearing loss at all frequencies (500 to 4,000 Hz) and the pure-tone average (speech recognition zone) was calculated as the mean of CHL at 500, 1,000, and 2,000 Hz.

The CLE was evaluated and classified as normal or abnormal. Patients in the group with normal CLE had a normal-appearing TM, neotympanum, limited plaques of tympanosclerosis, and mild retractions (according to a modified Sade classification: medial displacement of the pars flaccida and/or pars tensa, without contacting the ossicular chain and without signs of bony erosion). (10)

When abnormal, the CLE was classified as chronic otitis media with cholesteatoma or without cholesteatoma employing the following criteria:

* cholesteatoma: any signs of accumulation of keratin debris in the middle ear;

* central perforation: TM perforation with all margins under direct view (360 degrees);

* perforation-retraction: TM perforation associated with at least two of the following findings: medial displacement of the malleus handle, adherence of the remaining TM to the promontory, or rests of the remaining TM lying over the promontory;

* moderate to severe retraction; medial displacement of the pars tensa contacting the promontory or the pars flaccida touching the neck of the malleus associated or not associated with ossicular erosion.

For comparisons, patients were divided into a pediatric group, which included patients ages 0 to 18 years, 11 months, and 30 days (n = 20), and an adult group, in which patients were [greater than or equal to] 19 years of age (n = 26).

Data were stored in an Excel (Microsoft; Redmond, Wash.) database. For the statistical comparison of the air-bone gap between the myringostapediopexy and the CLE, the Student t test was used. A chi-square ([chi square]) test and a simple frequency table were used to evaluate the prevalence of cholesteatoma in the CLE between groups. The Statistical Package for the Social Sciences (SPSS 10.0 for Windows) was employed for statistical analyses.

All tests were two-tailed, and the level of significance was set at p < 0.05.

Patient consent forms were signed for the anonymous use of patient data. Treatment was not affected regardless of whether patients provided or refused informed consent. This study was approved by the Ethics Committee of the Group of Research and Graduate Studies of FICPA, under no. 11-0003. As this study also used historical data for analysis, all authors signed a form for the confidential use of data.

Results

Of a population of 1,169 patients with chronic otitis media, 46 (3.9%) were identified as having a natural myringostapediopexy. In 1 patient the finding was bilateral, resulting in a total of 47 ears. Patient distribution according to sex was similar (24 [52.2%] were male), and 26 (56.5%) were adults.

The overall mean age with standard deviation ([+ or -] SD) at the time of the first visit was 30.8 [+ or -] 20.8, ranging from 6 to 81 years. The mean age in the pediatric group was 12 [+ or -] 2.9, and 44.8 [+ or -] 16.9 in the adult group.

The mean conductive hearing loss ranged from 14.1 to 21.2 dB in ears with myringostapediopexy and from

16.0 to 26.6 dB in the CLEs according to the frequency assessed (table). The pure-tone average was 18.4 [+ or -] 8.8 dB in ears with myringostapediopexy and 23.3 [+ or -] 16.5 dB in the CLEs. Although the mean CHL is slightly more severe at most frequencies in the CLE, there was no statistically significant difference in the mean CHL between the ears with myringostapediopexy and the CLEs.

The evaluation of the CLE in cases of myringostapediopexy revealed that 19.6% were normal, 6.5% had central perforations of the TM, 17.4% had perforation-retractions, 28.3% had moderate to severe retractions, and 28.3% had cholesteatoma. The prevalence of cholesteatoma in the CLEs in the pediatric and adult groups was not significantly different (p = 0.5; [chi square] test) (figure 2).

The evaluation of the cholesteatoma growth patterns in the CLEs in cases of myringostapediopexy revealed that 46.2% were posterior mesotympanic cholesteatomas (pars tensa), 30.8% were epitympanic (pars flaccida), and in 23.1% the growth patterns could not be defined. Among the CLEs with retraction, the prevalence of pars tensa (PT) retraction was 84.6%, pars flaccida (PF) 7.7%, and both (PF and PT retraction) 7.7%.

========== Discussion

Moderate and severe TM retractions reflect poor ventilation of the middle ear cleft and mastoid pneumatic system. They represent a late stage of a sequence that includes eustachian tube dysfunction followed by negative pressure and, frequently, effusion. The scenario includes the development of TM retractions, which may become stable over time or may progress to more severe stages, eventually leading to cholesteatoma formation. This series of events is the basis of the otitis media pathogenesis model known as "the continuum," which was developed by the Paparella group from Minneapolis. (12) The main premise of this theory is that all subtypes of otitis media represent different phases of the same process. The continuum has been reproduced in a series of elegant animal studies and demonstrated in human temporal bone histopathology. (12)

TM retractions (and specifically myringostapediopexy) are perplexing conditions that pose an intriguing dilemma. Whereas they may present as an incidental finding or with minimal symptoms, clearly they represent irreversible tissue pathology (TM atrophy and ossicular erosion) and a potential for cholesteatoma formation.

The clinical dilemma for the otologic surgeon is to be appropriately conservative (in most cases) but to carefully choose an opportunity to intervene where intervention would prevent progression of this destructive disease. What is the threshold for intervention? Intervention has the goal of reinforcement of the TM and introduction of a ventilation tube (a minimally invasive procedure but not devoid of complications!). What is the risk of not intervening, with the prospect of advancing disease requiring more invasive surgery and lower chances for functional restoration?

The decision-making process would be supported if we could collect enough clues to predict with some degree of certainty the progression of a given retraction to a cholesteatoma. Unfortunately, the lack of prospective studies, and especially individual variability, make prediction of the natural history of a TM retraction difficult. The observations of the CLE may be a valuable factor in estimating an individual's potential for progression.

In the present study, we observed that 28.3% of patients with natural myringostapediopexy had cholesteatoma in the CLE. Is this, therefore, a high-risk group for progression? It would seem important to segregate this group for more careful clinical observation if not early intervention. We also observed 28.3% of patients that had moderate to severe retraction in the CLE. This group, too, may deserve high-risk status.

According to Sade, most cases of mild retraction of the TM may resolve spontaneously or remain stable for many years. (13) In contrast, once the TM adheres to the promontory, the ossicles, or other middle ear structures, there is no evidence of reversibility of the pathologic process. (14) Cassano and Cassano found that there is a trend toward progression of tympanic retraction in 65% of the cases and spontaneous resolution or no progression in 35%. (15)

In adults, retraction may be stable for many years. In children, however, it usually progresses into erosion of the ossicular chain and cholesteatoma formation. (16) The prevalence of TM retraction in pediatric patients has not been clearly defined in the literature. In our sample, 43.5% of the patients with myringostapediopexy belonged to the pediatric group.

Although the prevalence of cholesteatoma in the CLE in our sample was similar between adults and children, the greatest incidence of disease progression over time in children suggests that conservative treatment in such cases may not be the best therapeutic strategy. (16)

Abnormalities in the CLE were also studied by Couloigner et al in the analysis of 56 children (60 ears) with severe retraction of the posterosuperior quadrant. (17) In their series, although it included patients with cleft palates and rhinopharyngeal tumors, the CLE had abnormalities in 39 of 60 ears (65%); 38% had tympanic retraction, 15%, otitis media with effusion, 7%, TM perforation and 5%, cholesteatoma. With these findings in mind, we use the following guidelines when making decisions regarding the management of myringostapediopexy:

1. If there is a PT cholesteatoma in the CLE that has been operated on with a stable outcome and good hearing, surgical intervention should be seriously considered to attempt to thwart progression in the subject ear.

2. Children withmyringostapediopexy in thesubjectear and PT cholesteatoma or severe retraction in the CLE are given the strongest recommendation for intervention. The family should always be included in the decision making.

Although our data cannot provide a definitive recommendation for treatment in cases of cholesteatoma or severe retraction in the CLE, they do highlight the role the CLE can play to inform clinical decision making. Since symptoms and audiometry are frequently disproportionate with the extent of pathology and frequently unable to predict future clinical progression, the CLE becomes a strong relative factor in selecting therapy. We also recommend video-otoscopy to enable the clinician to detect changes and identify progressive disease.

Our research group has studied the changes in the CLE in patients with chronic inflammatory diseases of the middle ear since 2000, and our findings stress the disease's tendency to affect both ears. (18,19) Our histologic study in human temporal bones showed a prevalence of 77% of significant alterations in the CLE. (9) Granulation tissue was found in 81 %, TM retraction in 35%, and cholesteatoma in 8%. (9) In our clinical series of 500 patients, we found TM retractions in 38% of CLEs, perforations in 26%, and cholesteatoma in 5%. (10)

Costa et al (10) reminded us of the importance of studying diseased ears in pairs to understand the dynamic pathologic process. Therefore, the maxim "You will be in my shoes tomorrow," is used by those authors to stress that the ears should be analyzed as an intrinsically related pair and not as an isolated unit. Frequently, the most affected ear can predict the future status of the ear on the contralateral side.

Conclusion

The presence of significant disease in the CLE, particularly cholesteatoma, suggests unfavorable progression in cases of natural myringostapediopexy. The status of the CLE appears to be a valuable element in the pursuit of appropriate management decisions and may suggest the likelihood of progression of the disease.

References

(1.) Pfaltz C. Retraction pocket and development of cholesteatoma in children. Adv Otorhinolaryngol 1988;40:118-23.

(2.) Dornhoffer JL. Surgical management of the atelectatic ear. Am J Otol 2000; 21(3):315-21.

(3.) Dornhoffer J. Cartilage tympanoplasty: Indications, techniques, and outcomes in a 1,000-patient series. Laryngoscope 2003;113(11):1844-56.

(4.) Elsheikh MN, Elsherief HS, Elsherief SG. Cartilage tympanoplasty for management of tympanic membrane atelectasis: Is ventilatory tube necessary? Otol Neurotol 2006;27(6):859-64.

(5.) Costa SS, Ruschel C, Cruz OL, Paparella MM. Otites medias--aspectos gerais. In: Cruz OL, Costa SS (eds). Otologia Clinica e Cirurgica. 1st ed. Rio de Janeiro: Revinter; 2000:137-61.

(6.) Schmidt VB, da Costa SS, Rosito LP, et al. Myringostapediopexy: Is it a natural type III tympanoplasty? OtolNeurotol 2013;34(l):79-82.

(7.) Costa SS, Cruz OL, Kluwe LHS, Smith MM. Timpanoplastias. In: Cruz OL, Costa SS (eds). Otologia Clinica e Cirurgica. 1st ed. Rio de Janeiro: Revinter; 2000:245-70.

(8.) Jackler RK. The surgical anatomy of cholesteatoma. Otolaryngol Clin North Am 1989;22(5):883-96.

(9.) Rosito LP, da Costa SS, Schachern PA, et al. Contralateral ear in chronic otitis media: A histologic study. Laryngoscope 2007;117(10):1809-14.

(10.) da Costa SS, Rosito LP, Dornelles C, Sperling N. The CLE in chronic otitis media: A series of 500 patients. Arch Otolaryngol Head Neck Surg 2008;134(3):290-3.

(11.) Silveiro Netto LF, da Costa SS, Sleifer P, Braga ME. The impact of chronic suppurative otitis media on children's and teenagers' hearing. Int J Pediatr Otorhinolaryngolol 2009;73(12):1751-6.

(12.) Paparella MM, Hiraide F, Juhn SK, Kaneko Y. Cellular events involved in middle ear fluid production. Ann Otol Rhinol Laryngol 1970;79(4):766-79.

(13.) Sade J. Secretory Otitis Media and its Sequelae. New York: Churchill Livingstone; 1979:214-16.

(14.) Danner CJ. Middle ear atelectasis: What causes it and how is it corrected? Otolaryngol Clin North Am 2006;39(6): 1211-19.

(15.) Cassano M, Cassano P. Retraction pockets of pars tensa in pediatric patients: Clinical evolution and treatment. Int J Pediatr Otorhinolaryngol 2010;74(2):178-82.

(16.) Borgstein J, Gerritsma TV, Bruce IA. Erosion of the incus in pediatric posterior tympanic membrane retraction pockets without cholesteatoma. Int J Pediatr Otorhinolaryngol 2008;72(9):1419-23.

(17.) Couloigner V, Molony N, Viala P, et al. Cartilage tympanoplasty for posterosuperior retraction pockets of the pars tensa in chidren. Otol Neurotol 2003;24(2):264-9.

(18.) Scheibe B, Smith M, Schmidt L, et al. Estudo da orelha contralateral na otite media cronica: "Efeito Orloff." Rev Bras Otorrinolaringol 2002;68(2):245-59.

(19.) Dornelles CC. Colesteatomas adquiridos: Analise comparativa da perimatriz entre pacientes pediatricos e adultos. Disserta^ao de Mestrado. Porto Alegre: Faculdade de Medicina da Universidade Federal do Rio Grande do Sul, UFRGS; 2004.

Viviane Bom Schmidt, MD; Sady Selaimen da Costa, MD, PhD; Leticia Petersen Schmidt Rosito, MD; Neil Sperling, MD; Rodrigo Gonsalves Dias, MD

From the Department of Otolaryngology-Head and Neck Surgery, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil (Dr. Schmidt, Dr. da Costa, Dr. Rosito, and Dr. Dias); and the Department of Otolaryngology, State University of New York Downstate Medical Center, Brooklyn (Dr. Sperling).

Corresponding author: Viviane Bom Schmidt, Department of Otolaryngology-Head and Neck Surgery, Ramiro Barcelos, 2350, Porto Alegre, Rio Grande do Sul, Brazil. Email: viviboms@gmail.com
Table. Mean conductive hearing loss at each frequency in the ears
with natural myringostapediopexy and in the contralateral ears

Frequency (Hz)    Mean CHL ([+ or -]          Mean CHL         p Value
                  SD) in the ears w/    ([+ or -] SD) in the
                 myringostapediopexy     contralateral ears

500              21.2 [+ or -] 11.9     26.6 [+ or -] 18.5      0.17
1,000            19.8 [+ or -] 10.5     24.5 [+ or -] 18.3      0.25
2,000            15.6 [+ or -] 9.7      18.2 [+ or -] 14.6      0.49
3,000            14.1 [+ or -] 8.9      16.0 [+ or -] 13.1      0.42
4,000            19.1 [+ or -] 11.1     18.2 [+ or -] 11.4      0.66

Key: CHL = conductive hearing loss; SD = standard deviation.

Figure 2. Graph illustrates the prevalence of cholesteatoma in the
contralateral ears in adult vs. pediatric patients, according to the
[chi square] test.

Cholesteatoma

Pediatric group   35%
Adult group       23.1%

Note: Table made from bar graph.
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Title Annotation:ORIGINAL ARTICLE
Author:Schmidt, Viviane Bom; da Costa, Sady Selaimen; Rosito, Leticia Petersen Schmidt; Sperling, Neil; Dia
Publication:Ear, Nose and Throat Journal
Article Type:Report
Geographic Code:3BRAZ
Date:Sep 1, 2016
Words:3504
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