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Type 1 tympanoplasty with cortical mastoidectomy: results and complications.

INTRODUCTION: Chronic suppurative otitis media is one of the commonest disease processes with which patients present in ENT clinic. The choice of treatment in safe CSOM is tympanoplasty with or without mastoidectomy. Aims of tympanoplasty are to eradicate disease and to improve hearing. There is a lot of controversy around the role of mastoidectomy in repair of tympanic membrane in cases of tubotympanic type of CSOM. Holmquist and Bergstrom first suggested that mastoidectomy improves the chance of successful tympanoplasty for patient with non cholesteatomatous chronic otitis media. They maintained that creation of an aerated mastoid enhances success in patients with poor tubal function or a small mastoid air cell system. (1) While this disease may resolve spontaneously after closure of the middle ear, recurrent suppuration with graft loss will occur in some cases.

After myringoplasty with simple mastoidectomy, however, ears with inflammatory mastoids fared very nearly as well as those without signs of inflammatory changes. Once again, this implies a beneficial effect from mastoidectomy in the compromised mastoid. (2) Exploration of the mastoid with removal of granulations and polypoidal tissues increases the chance of graft uptake and reduces chance of recurrence in the long run. Cortical mastoidectomy with tympanoplasty is a safe procedure but sometimes may present with complications like graft rejection, wound infection, disturbance in taste, vertigo and rarely sensorineural hearing loss.

AIM OF THE STUDY:

I. To study the results of cortical mastoidectomy with type-I tympanoplasty in the treatment of safe CSOM.

II. To study the complications, which may arise in the post-operative period.

MATERIALS AND METHOD: This is a prospective study conducted in the Department of ENT, Tripura Medical College from July 2013 to December 2014.

All the patients who had safe variety of CSOM and have undergone cortical mastoidectomy with type-I tympanoplasty were included in the study.

Detailed history was taken in patients with CSOM with central perforations; clinical examinations were done. After admission in the ward investigations were performed and prepared for surgery under local or general anaesthesia. Post aural incision was made and temporalis fascia was harvested, the same incision was elongated inferiorly and cortical mastoidectomy was done using Zeiss microscope. Margins of the perforation was made raw, posteromeatal skin flap was elevated up to annulus. Middle ear cavity was cleared of granulations and polypoidal tissues if any.

The temporalis fascia graft was placed by underlay technique and it was stabilised with gel foam in the middle ear and external auditory canal. The post aural wound was closed in layers. The stitches were removed after seven days and patients were discharged. Patients were called for check up at the end of 2nd week and 4th week. Audiometry was performed at the end of 2 months. Patients were followed up for at least 6 months.

Inclusion Criteria:

1. Patients with safe variety of CSOM with central perforation

2. Patients who had undergone cortical mastoidectomy and type-I tympanoplasty.

Exclusion Criteria:

1. CSOM with cholesteatoma.

2. Patient who had undergone radical mastoidectomy or MRM.

3. Patient who had undergone tympanoplasty other than type-I.

RESULTS AND OBSERVATION: A total of 42 patients have come with safe CSOM and undergone cortical mastoidectomy with tympanoplasty. Out of 42 patients, number of male patients was 24 and female were 18 with an M: F ratio of 4:3. Age of the patient ranged from 17-52 years. The age are tabulated in the table no 1.

Out of 42 patients small perforations was found in 5 cases, medium perforation was found in 27 cases and subtotal perforation was found in 10 cases which are summarized in table 2.

Of all the patients 12 cases had discharge in ear whereas 30 cases had a dry ear. Out of 42 cases, 7 of them were revision surgeries while the rest 35 were operated for the first time. In the present study it is noted that majority of the patients operated was on the left ear. The data are tabulated as;

The different durations of ear discharge are as shown in the table no 4.

During surgery majority of the cases had underlying disease in the mastoids. The findings are depicted in table no 5.

At the end of 2 month successful graft uptake was found in 38 cases and among the 4 graft rejection cases 3 had partial rejection while 1 had complete rejection.

Among those 36 cases where there was complete graft uptake, audiogram was performed at the end of 2 months. Audiological result has been depicted in table 6. Thirty cases showed satisfactory hearing improvement, three cases showed moderate improvement while two cases showed no improvement in hearing or were worse than preoperative level.

Complications are an integral part of every surgical procedure. In the present study beside 6 cases of graft rejection, there were 4 cases of wound infection, 6 of them had postoperative vertigo, 5 patients suffered from disturbances in taste sensation post operatively and 2 cases had sensorineural hearing loss. No facial nerve palsy was seen postoperatively in this study group.

DISCUSSION: Many authors have recommended mastoidectomy in conjunction with tympanic membrane grafting to increase graft success in tympanoplasty. The primary argument in favour of mastoidectomy has been an improvement in the middle ear and mastoid environment through clearance of diseased mucosa and through the ventilatory mechanisms of an open mastoid system. Opponents of mastoidectomy argue that the mastoid air cell system is thought to function, at least in part, as a buffer to the changes in pressure within the middle ear. The functional advantage of a large aerated mastoid was first suggested by Holmquist and Bergstrom, (3) and, later, was substantiated by Sade et al. (4,5) It is theorized that when an aerated mastoid communicates well with the middle ear, it acts as a buffering system to reduce the impact of pressure changes experienced by the middle ear.

The presence of a pneumatized mastoid greatly increases the volume of the middle ear and mastoid system, which, in accordance with Boyle's law, can moderate pressure changes in the middle ear cleft.

In our study on exploration, the mastoid was normal in 35.71%, polypoidal changes were found in 16.66% and granulations in 47.62%. Anita Krishnan et al, (6) found polypoidal tissues in antrum after exploration in 58% of normal looking middle ear during operation whereas the antral mucosa showed similar changes at the rate of 100% in accordance with the middle ear disease.

It was found in the study that the graft uptake rate was 85.7%. Albu S et al, (7) showed success rate of 82.8% in tympanoplasty with cortical mastoidectomy. Our results are comparable to that in the study conducted by McGrew et al, (8) where they had a graft take-up rate of 91.6% in patients who had tympanoplasties with mastoidectomy. They found a better clinical outcome in patients who had tympanoplasty with cortical mastoidectomy. These patients had shown absence of disease progression along with reduction in the number of patients requiring subsequent procedures was noted. Mishiro Y et al. (9) obtained a graft success rate of 90.5% in tympanoplasty with cortical mastoidectomy. Vikas kakkar et al. (10) found success rate of graft uptake in cortical mastoidectomy with tympanoplasty to be 90%

It was found that the duration of disease had no influence on the uptake of graft. Sizes of the perforation have no relation with outcome of surgery. The post-operative air conduction was within 25 dB in 73.8% of cases and within 40dB in 7.1% of cases. Mishiro Y et al, (9) showed the rates of postoperative AB gap within 20 dB was 90.4%. Vikas Kakkar et al, (10) found in their study hearing improvement of more than 10 dB in 82.5% cases and hearing improvement of more than 20 dB in 25% cases.

In our study we got complications like graft rejection (14.3%), disturbance in taste (11.9%), vertigo (14.3%), wound infection (9.5%), SN hearing loss (4.8%). P. J. D. Dawes. (11) reported wound infection occurred in six per cent of cases, Twenty-six per cent of patients reported symptoms consistent with chorda tympani trauma, vertigo in 10 per cent of patients in a study of 145 cases of tympanomastoid surgery. E H Sham et al (12) found in his study that 50% of the cases had possible injury to chorda tympani nerve, however no patients complained of altered taste or dry mouth.

CONCLUSION: It is a good practice to open up mastoid and look for any disease process in type-I tympanoplasty. Opening up of mastoid eradicates disease process and lowers graft rejection. Cortical mastoidectomy also increases the air reserve of the middle ear cleft and improves the middle ear physiology in the long run. Cortical mastoidectomy with type-I tympanoplasty gives high success rate and gives rise to few complications.

DOI: 10.14260/jemds/2015/2040

REFERENCES:

(1.) Holmquist J, Bergstrom B. The mastoid air cell system in ear surgery. Arch Otolaryngol 1978; 104:127-9.

(2.) Jackler RK, Schindler RA, Francisco S. Role of the mastoid in tympanic membrane reconstruction. Laryngoscope 1984; 94:495-500.

(3.) Holmquist J, Bergstrom B. The mastoid air cell system in ear surgery. Arch Otolaryngol 1978;104:127-9.

(4.) Sade J. The correlation of middle ear aeration with mastoid pneumatization. The mastoid as a pressure buffer. Eurn Arch Otorhinolaryngol 1992;249:301-4.

(5.) Cinamon U, Sade J. Mastoid and tympanic membrane as pressure buffers: A quantitative study in a middle ear cleft model. Otol Neurotol 2003;24:839-42.

(6.) Anita Krishnan 1, E. K. Reddy 2, C. Chandrakiran 3, K. M. Nalinesha 4, P. M. Jagannath 5 Tympanoplasty with and without cortical mastoidectomy--a comparative study Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 54 No. 3, July - September 2002. pp 195-198.

(7.) Albu S, Trabalzini F, Amadori M, Usefulness of cortical mastoidectomy in myringoplasty OtolNeurotol. 2012 Jun; 33 (4):604-9.doi:10.1097/MAO.0b013e31825368f2..

(8.) McGrew BM, Jackson CG, Glasscock ME 3rd. Impact of mastoidectomy on simple tympanic membrane perforation repair. Laryngoscope 2004;114:506-11.

(9.) Mishiro Y, Sakagami M, Takahashi Y, Kitahara T, Kajikawa H, Kubo T. Tympanoplasty with and without mastoidectomy for non-cholesteatomatous chronic otitis media. Eur Arch Otorhinolaryngol 2001;258:13-5.

(10.) Vikas Kakkar, Chandni Sharma, Sunil Garg, S. Bishnoi, A. Gulati, P. Malik Role of cortical mastoidectomy on the results of tympanoplasty in tubotympanic type of chronic suppurative otitis media National Journal of Otorhinolaryngology and Head & Neck Surgery, Vol. 2(11) No. 3, December 2014.

(11.) P. J. D. Dawes Early complications of surgery for chronic otitis media, The Journal of Laryngology & Otology The Journal of Laryngology & Otology / Volume 113 / Issue 09 / September 1999, pp 803-810.

(12.) E H Sham, MBBS, N Prepageran, FRCS, R Raman, MS, K F Quek Chorda Tympani Nerve Function after Myringoplasty. Med J Malaysia Vol 62 No 5 December 2007. pp361-363.

Vikramjit Singha [1], Amlan Debbarma [2]

AUTHORS:

[1.] Vikramjit Singha

[2.] Amlan Debbarma

PARTICULARS OF CONTRIBUTORS:

[1.] Assistant Professor, Department of ENT, Tripura Medical College.

[2.] Post Graduate Trainee, Department of ENT, Tripura Medical College.

FINANCIAL OR OTHER COMPETING INTERESTS: None

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Vikramjit Singha, Assistant Professor, Department of ENT, Tripura Medical College, Hapania-799014, Agartala.

E-mail: amlandebbarma@gmail.com

Date of Submission: 28/09/2015.

Date of Peer Review: 29/09/2015.

Date of Acceptance: 01/10/2015.

Date of Publishing: 10/10/2015.

Table 1: Age Distribution

Age Groups      No. of Cases   Percentage %

 0-10 years          0             0
 11-20 years         5           11.9%
 21-30 years         20          47.6%
 31-40 years         10          23.8%
 41-50 years         6           14.2%
 51-60 years         1            2.3%

Table 2: Size of Perforation

Small perforation     5 cases    11.9%
Medium perforation    27 cases   64.2%
Subtotal perforation  10 cases   23.8%

Table 3: Side Affected

Side Affect   No. of Cases   Percentage (%)

Left              24            57.1%
Right             18            42.9%

Table 4: Duration of Discharge

    Duration       No. of Cases   Percentage

6 months--1 year        3           7.2 %
1 year--2 years         7           16.6%
2 years -3 years        20          47.6%
3 years and more        12          28.5%

Table 5: Intra Operative Findings of Mastoids

     Findings        No. of Cases   Percentage

Normal                   15          35.7%
Polypoidal tissues       7           16.7%
Granulations             20          47.6%

Table 6: Graft Uptake Rate

Graft Uptake      No. of Cases   Percentage

Positive uptake       36          85.7%
Graft rejected        6           14.3%

Table 7: Audiological results in successful cases-Postoperative
air conduction threshold

Post op A.C (dB)   No. of Cases   Percentage

0-25 dB               31           73.8%
26-40 dB              3             7.1%
>40 dB                2             4.7%

Table 8: Complications

Complications            Number of Patients   Percentage

Graft rejection                  6              14.3%
Disturbance in taste sensation   5              11.9%
Vertigo                          6              14.3%
Wound infections                 4               9.5%
S.N hearing loss                 2               4.8%
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Title Annotation:ORIGINAL ARTICLE
Author:Singha, Vikramjit; Debbarma, Amlan
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Clinical report
Date:Oct 12, 2015
Words:2128
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