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Chronic otitis media (COM) is a chronic inflammatory disease of the middle ear and mastoid cavity that often results in partial or total loss of the tympanic membrane and ossicles, leading to conductive hearing loss that can range in severity up to 60 - 70 dB [1].
COM--chronic otitis media
COMC--chronic otitis media with cholesteatoma
COMWC--chronic otitis media without cholesteatoma
CWU--canal wall-up
CWD--canal wall-down
ABG--air-bone gap
PTA--pure-tone audiometry
PORP--partial ossicular replacement prosthesis
TORP--total ossicular replacement prosthesis

The aim of the present study was to evaluate preoperative and postoperative functional results using canal wall-up (CWU) and canal wall-down (CWD) techniques of tympanoplasty.

Material and Methods

This retrospective study included 100 patients of both sexes, aged 16 - 84 years, who underwent surgical treatment for COM from 2015 to 2016. The patients were divided into 2 groups based on the presence or absence of cholesteatoma: 50 COM with cholestatoma (COMC) and 50 COM without cholesteatoma (COMWC). The routine clinical and audiometric tests were performed, as well as CWD and CWU techniques of tympanoplasty.

Preoperative and postoperative assessment of puretone audiometry (PTA) screenings were evaluated. The PTA tests were performed 3 months prior to and 6 months after surgery. The tests were performed through air and bone conduction modes. The preoperative and postoperative PTA average was established and evaluated. The PTA scores used in the statistical analysis were based on threshold levels at frequencies of 0.5, 1, 2, and 4 kHz. The air-bone gap (ABG) was calculated from air and bone conduction thresholds of PTA at 0.5 Hz, 1 kHz, 2 kHz at each follow-up.

Audiometric results were interpreted in accordance with the guidelines. We used the criteria recommended by the Japan Clinical Otology Committee for calculation of the hearing improvement using the results of patients with postoperative hearing within 40 dB as the first criterion, hearing gain exceeding 15 dB as the second criterion, and postoperative ABG within 20 dB as the third criterion [2, 3].

Patients of both sexes older than 16 years, with COMC or COMWC diagnosed by preoperative and postoperative audiometry and with indication for middle ear surgery were included. Patients who were younger than 16 years, with bilateral COM, sensorineural hearing loss, malignant middle ear disorders, otitis externa, temporal bone fracture, or previous ear surgery, were excluded from the study.

Data analysis was performed using the Statistical Package for the Social Sciences (SPSS) for Windows Version 16. Statistical analysis was performed with Pearson's chi-square test (% (2)) and T-Test for independent and paired samples. Results were considered significant if the p value was < 0.05.


A total of 100 patients were selected for this study. The average age was 51 years with standard deviation of 16.75, with age ranging from 16 to 84 years. Gender distribution was balanced, with 59 male and 54 female patients. The incidence of male patients was statistically higher (p < 0.05) in the COMC group but there was no statistically significant gender difference between the two groups.

Of the 100 patients who underwent CWD and CWU tympanoplasty for the treatment of COMC and COMWC, the ossicular chain was preserved in 38 cases. Reconstruction of the ossicular chain was performed in 53 patients. In nine patients, ossiculoplasty was not performed due to active ear infection. The modeled autologous incus body (37/53) and partial ossicular replacement prosthesis (PORP) (9/53) were used if a stapes suprastructure was present. The total ossicular replacement prosthesis (TORP) (7/53) was used when the stapes suprastructure was absent. In case of cholesteatoma with eroded incus, we used a remodeling head of malleus (5/37) and mastoid cortex bone (8/37) for the collumela effect.

In the COMC group, 9 (18%) patients underwent a CWU tympanoplasty and 41(82%) a CWD tympanoplasty. In the COMWC group, 46 (92%) patients underwent a CWU tympanoplasty and 4 (8%) a CWD tympanoplasty. When comparing the mean preoperative and postoperative PTA in both groups and no statistically significant differences were found.

A statistically significant difference (p < 0.05) between the mean preoperative and postoperative ABG was found in both groups. However, the difference between the two groups was not statistically significant. In the COMC group, a statistically lower incidence of postoperative ABG < 20 dB was established (p < 0.05), but there was no statistically significant difference between the two groups (Table 1).

There was no statistically significant difference in the proportion of patients achieving hearing with postoperative improvement in PTA >15 dB between the two groups (Table 2). There was a statistically lower incidence of patients with a postoperative PTA < 40 dB (p < 0.05) in the COMC group, but the difference between the two groups was not statistically significant (Table 3).

In the COMC group, CWD tympanoplasty was statistically more frequent (p < 0.05), while the CWU tympanoplasty was statistically more frequent in the COMWC group (p < 0.05). The CWU tympanoplasty was statistically more effective (p < 0.05) when analyzing the mean postoperative PTA and ABG in the study patients (Table 4).


The aim of this study was to compare preoperative and postoperative hearing results in two groups of patients (COMC and COMWC), who underwent CWU or CWD tympanoplasty. There are various prognostic factors that could have a potential impact on functional outcomes of surgical treatment of the middle ear. Poor preoperative hearing, open technique, younger age, bilateral cholesteatoma, oscillatory chain erosion and revision surgery, which are in direct correlation with poor functional hearing results after surgical treatment [4, 5].

Our results showed that there were no statistically significant differences in the main preoperative and postoperative PTAs and ABGs in the two groups. While analyzing the proportion of patients who gained postoperative hearing improvement in PTA >15 dB, we did not find a statistically significant difference between the two groups. A similar finding was also noted by Azevedo AF et al. (2013), who observed that there had been no statistically significant preoperative or postoperative differences in PTA at 500 Hz, 1-2 kHz between CWD and CWU techniques in COM surgical treatment. Kim MB et al. (2010) reported that the proportion of patients with an ABG < 20 dB was 58.6% of CWD patients and 68.4% of CWU patients (P = 0.25). The authors concluded that the type of mastoid surgery (CWU and CWD) did not affect the hearing results of chronic suppurative otitis media patients [6, 7].

Our results, however, differ from Shrestha BL et al. (2008), who reported that results after evaluation of the type III tympanoplasty had varied widely, showing statistically significant improvement in mean postoperative PTA-ABG in the range of 15 - 61.2 dB [8]. We noted that in the COMC group a statistically lower incidence of postoperative ABG < 20 dB (p < 0.05) was found. Furthermore, there was a statistically lower frequency of patients with postoperative PTA < 40 dB (p < 0.05). However, the difference between the two groups was not statistically significant regarding the presence of cholesteatoma.

The choice of surgical technique remains controversial and it is usually decided based on the presence or the absence of cholesteatoma, its location, the state of the middle ear mucosa and auditory thresholds [6]. Both techniques have specific advantages and disadvantages. The CWD technique is superior to the CWU technique, especially in patients with cholesteatoma. In our study, CWD tympanoplasty was statistically more frequent in the COMC group, whereas the CWU tympanoplasty was statistically more frequent in the COMWC group. Our study showed that hearing improvement was possible following surgery with CWU tym-panoplasty and ossicular chain reconstruction.

The results of the study demonstrated that there was a statistically significant difference between preoperative and postoperative PTA values and ABG in both groups. Uyar M et al. revealed that postsurgical ABG value was < 20 dB in 27% of CWU patients, and 7.7% of CWD patients. Mean hearing gain of patients with active squamous disease was 3.8 dB in CWU group and 11.9 dB in CWD group (p < 0.5) [9]. Lesinskas E et al. (2004) reported that the ABG on pure tone audiogram, 12 months following the surgery, was less than 25 dB in 38.46% of cases after closed tympanoplasty, while there was no hearing improvement after modified radical mastoidectomy [10]. Wilson KF et al. (2012) revealed that closed technique showed better initial hearing results and less morbidity, but a higher recurrence rate, up to 40% [11].

Moreover, other studies have reported no significant differences in hearing outcomes in association with the two techniques. Minovi et al. evaluated the audiometric results after using open cavity tympanomastoidectomy in advanced attic cholesteatoma [12]. A postoperative ABG < 20 dB was achieved in 42.9% of the operated ears, whereas 9.3% (n = 15) of the operated ears showed a postoperative ABG > 30 dB. The authors reported that although most cholesteatomas nowadays could be eradicated with the CWU technique, in far advanced cholesteatomas, the CWD technique may be applied with acceptable postoperative hearing results. Cook JA et al. reported that modified radical mastoidectomy provided relatively safe surgical access for the removal of chronic middle ear and mastoid disease and gave reproducible results [13]. However, it has been suggested that hearing may not be as good as that after "intact canal wall mastoidectomy". The surgery should be tailored regarding the clinical stage and intraoperative findings in each case [12-15].

This study is not without limitations, as it has focused on comparing short-term hearing results following middle ear surgery. Due to a short-time frame, we were not able to follow up potential occurrences of the residual/recurrent cholesteatoma.


In the group of patients with chronic otitis media with cholesteatoma, a statistically significant lower incidence of postoperative air-bone gap < 20 dB (p < 0.05) was found. The difference between the two groups was statistically significant (p < 0.05). When analyzing the mean postoperative pure tone audi-ometry and air-bone gap values, the canal wall-up tympanoplasty was found to be statistically more effective than the canal wall-down tympanoplasty.

Various pathomorphological and pathophysiological changes in the middle ear, the presence of extensively different forms of cholesteatomas, the choice of surgical procedures and poor preoperative hearing are in direct correlation with postoperative hearing.


[1.] Merchant SN, McKenna MJ, Rosowski JJ. Current status and future challenges of tympanoplasty. Eur Arch Otorhi-nolaryngol. 1998;255(5):221-8.

[2.] Monsell EM. New and revised reporting guidelines from the Committee on Hearing and Equilibrium. American Academy of Otolaryngology-Head and Neck Surgery Foundation, Inc. Otolaryngol Head Neck Surg. 1995;113(3):176-8.

[3.] Sato S, Suzuki R, Ohno T, Yoshida A, Wakisaka H, Ohba S, et al. Evaluation of hearing after tympanoplasty for pars tensa cholesteatoma according to Japan Otological Society guidelines. Otology Japan. 2015;25(1):19-24.

[4.] Stankovic MD. Audiologic results of surgery for cholesteatoma: short- and long-term follow-up of influential factors. Otol Neurotol. 2008;29(7):933-40.

[5.] Stankovic M. Follow-up of cholesteatoma surgery: open versus closed tympanoplasty. ORL J Otorhinolaryngol Relat Spec. 2007;69(5):299-305.

[6.] Azevedo AF, Soares AB, Garchet HQ, Sousa NJ. Tym-panomastoidectomy: comparison between canal wall-down and canal wall-up techniques in surgery for chronic otitis media. Int Arch Otorhinolaryngol. 2013;17(3):242-5.

[7.] Kim MB, Choi J, Lee JK, Park JY, Chu H, Cho YS, et al. Hearing outcomes according to the types of mastoidectomy: a comparison between canal wall up and canal wall down mastoidectomy. Clin Exp Otorhinolaryngol. 2010;3(4):203-6.

[8.] Shrestha BL, Bhusal CL, Bhattarai H. Comparison of pre and post-operative hearing results in canal wall down mastoidectomy with type III tympanoplasty. JNMA J Nepal Med Assoc. 2008;47(172):224-7.

[9.] Uyar M, Acar A, Kilinc SB, Boynuegri S, Kaya A, Qavusoglu F, et al. Hearing outcomes after suppurative chronic otitis media surgery. Kulak Burun Bogaz Ihtis Derg. 2015;25(3):131-6.

[10.] Lesinskas E, Vainutiene V. Closed tympanoplasty in middle ear cholesteatoma surgery. Medicina (Kaunas). 2004;40(9):856-9.

[11.] Wilson KF, Hoggan RN, Shelton C. Tympanoplasty with intact canal wall mastoidectomy for cholesteatoma: long term surgical outcomes. Otolaryngol Head Neck Surg. 2013;149(2):292-5.

[12.] Minovi A, Dombrowski T, Shahpasand S, Dazert S. Audiometric results of open cavity tympanomastoidectomy in advanced attic cholesteatoma. ORL J Otorhinolaryngol Relat Spec. 2015;77(3):180-9.

[13.] Cook JA, Krishnan S, Fagan PA. Hearing results following modified radical versus canal-up mastoidectomy. Ann Otol Rhinol Laryngol. 1996;105(5):379-83.

[14.] Zhang X, Chen Y, Liu Q, Han Z, Xu A, Ding Y. Longterm results analysis of mastoidectomy for chronic otitis media. Lin Chuang Er Bi Yan Hou Ke Za Zhi. 2005;19(19):870-2.

[15.] Cruz OL, Kasse CA, Leonhart FD. Efficacy of surgical treatment of chronic otitis media. Otolaryngol Head Neck Surg. 2013;128(2):263-6.

Dalibor VRANJES, Sanja SPIRIC, Slobodan SPREMO, Dmitar TRAVAR, Predrag SPIRIC and Mirjana GNJATIC

University Clinical Center of the Republic of Srpska, Ear, Nose and Throat Clinic

University of Banja Luka, Faculty of Medicine, Bosnia and Herzegovina

Corresponding Author: Dr Dalibor Vranjes, Klinika za bolesti uha, grla i nosa, Univerzitetski klinicki centar Republike Srpske, 78000 Banjaluka, 12 beba bb, Bosna i Hercegovina, E-mail:
Table 1. The proportion of patients with a postoperative air-bone gap
within 20 dB
Tabela 1. Deo bolesnika sa postoperativnim vazdusno-kostanim zjapom
unutar 20 dB

                        Yes/Da  No/Ne  Total/Ukupno

Group/Grupa   COMC   N  12      38      50
                     %  24(*)   76     100
                     N  26      24      50
                     %  52      48     100
Total/Ukupno         N  38(*)   62     100
                     %  38      62     100

Legend/Legend: COMC - chronic otitis media with cholesteatoma hronicni
otitis medija sa holesteatomom; COMWC - chronic otitis media without
cholesteatoma/hronicni otitis medija bez holesteatoma; (*) p<0,05

Table 2. The proportion of patients with a postoperative improvement in
PTA >15 dB
Tabela 2. Deo bolesnika sa postoperativnim poboljsanjem prosecnog praga
sluha > 15 dB

Group/Grupa             PTA>15 dB
                        Yes/Da     No/Ne  Total/Ukupno

              CCOM   N   3         47(*)   50
                     %   6         94     100
              COMWC  N   8         42(*)   50

                     %  16         84     100
Total/Ukupno         N  11         89     100
                     %  11         89     100

Legend/Legend: COMC - chronic otitis media with cholesteatoma/hronicni
otitis medija sa holesteatomom; COMWC - chronic otitis media without
cholesteatoma/hronicni otitis medija bez holesteatoma; (*) p<0,05

Table 3. The proportion of patients with a postoperative PTA<40 dB
Tabela 3. Deo bolesnika sa postoperativnim prosecnim pragom sluha < 40

Group/Grupa             PTA<40 dB
              CCOM      Yes/Da     No/Ne  Total/Ukupno

                     N  12(*)      38      50
                     %  24         76     100
                     N  20         30      50
                     %  40         60     100
Total/Ukupno         N  32         68     100
                     %  32         68     100

Legend/Legend: CCOM - chronic otitis media with cholesteatoma hronicni
otitis medija sa holesteatomom; COMWC - chronic otitis media without
cholesteatoma/hronicni otitis medija bez holesteatoma; (*) p<0,05

Table 4. The mean postoperative of PTA and ABG in regard to surgical
Tabela 4. Srednja postoperativna vrednost PTA i ABG u odnosu na
hirurske tehnike

                        Surgical   N   Average value  Standard
                        technique                     deviation

The mean postoperative  CWU        55  46,038(*)      20,1037
Srednja postoperativna  CWD        45  65,533         24,9242
vrednost PTA
The mean postoperative  CWU        55  20,715(*)      12,7538
Srednja postoperativna  CWD        45  27,551         14,2958
vrednost ABG

Legend/Legenda: PTA - pure tone average/prosecan prag sluha; ABG -
air-bone gap/vazdusno-kostani zjap; (*) p<0,05, CWV - canal
wall-up/ocuvan zid kanala; CWD - canal wall-down/uklonjen zid kanala
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Author:Vranjes, Dalibor; Spiric, Sanja; Spremo, Slobodan; Travar, Dmitar; Spiric, Predrag; Gnjatic, Mirjana
Publication:Medicinski Pregled
Date:Mar 1, 2018

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