Hearing im prove ment is com monly used as discriminant

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1 /STRU^NI RAD UDK DOI /ACI S A multivariate anal y sis of chronic otitis re lated prog nos tic fac tors in de ter min ing hear ing im prove ment in tympanoplasty... Slobodan Spremo 1, Sanja Špiri} 1, Dmitar Travar 1, Predrag Špiri} 1, Mira Spremo 2 1 Uni ver sity clinic Cen ter Banja Luka, De part ment for OtorhinolaryngologyBanja Luka, Bosna i Hercegovina 2 Med i cal fac ulty, Uni ver sity Banja Luka, Banja Luka, Bosna i Hercegovina OB JEC TIVE: The aim of this study was to eval u - ate which fac tors are best pre dic tors of hear ing im prove ment af ter tympanoplasty and to eval u - ate best func tional out come in dif fer ent forms of pa thol ogy in the tym panic cav ity and mas toid in chronic otitis me dia. METH ODS: Pro spec tive study in cluded 120 pa - tients who were op er ated for chronic sup pu ra tive otitis me dia and cholesteatoma in the ENT De part - ment Uni ver sity Clinic Cen ter Banja Luka from 2006 to Mul ti ple lin ear re gres sion anal y sis was used to mea sure which fac tors pre dict better hear ing im - prove ment. MAIN OUT COME MEA SURES: A model that eval u - ates fac tors re lated to chronic otitis me dia: ossicular chain in teg rity, tym panic tube func tion, tym panic membrane perforation, type of surgery and condition of tym panic and mas toid walls was used to pre dict postoperative hearing improvement. Hearing outcome was mea sured com par ing pre op er a tive to post op er a - tive pure-tone average (PTA) and postoperative air-bone gap (ABG). RE SULTS: Out of 120 op er ated pa tients, we per - formed pri mary sur gery in 106 and re vi sion sur gery in 9 cases due to re cur rent cholesteatoma. We ob - served high correlation and statistically significant contribution of ossicular chain pathology ( =-0.310, t=-3.01, p<0.05), and mas toid bone ero sion or de fects ( =2.05, t=2.05, p<0.05), on the vari ance of PTA. The same vari ables were highly cor re lated with ABG clo - sure: ossicular chain pa thol ogy ( =-0.230, t=-2.14, p<0.05), and mas toid bone ero sion or de fects ( = 2.05, t=2.08, P<0.05). Vari ance of pre op er a tive to post op - er a tive PTA dif fer ence ex plained by the model as a whole was 24,7%, F(8,119)=4.54, p<0.01. Vari ance of pre op er a tive to post op er a tive ABG dif fer ence ex - plained by the model as a whole was 18,3% rezime F(8,119)=3.1, p<0.01. The pre dic tive model in this study in cluded 8 vari ables re lated to mid dle ear pa - thol ogy proved to be su pe rior to an a lyz ing each vari - able sep a rately. CON CLU SION: A model that eval u ates fac tors re - lated to chronic otitis me dia: ossicular chain in teg rity, tympanic tube function, tympanic membrane perfora - tion, type of sur gery and con di tion of tym panic and mastoid walls has significant predictive value for hearing assessment in tympanoplasty. Key words: tympanoplasty, cholesteatoma, hear ing loss sur gery INTRODUCTION Hearing im prove ment is com monly used as discriminant fac tor for eval u a tion of tympanoplasty suc - cess in sur gery for chronic sup pu ra tive otitis me dia (CSOM). The suc cess of tympanoplasty can be mea sured by the post op er a tive in teg rity of the tym panic re con struc - tion and hear ing im prove ment 1. Some au thors sug gested that form of chronic otitis 1-3, pa thol ogy on the ossicular chain and bony walls of the tym panic cav ity 3,4 pre op er a - tive du ra tion of in flam ma tion and ear dis charge 4,5 and type of sur gery are the most im por tant fac tors in flu enc ing de ter min ing hear ing im prove ment. The ob jec tives of the study was to an a lyze which fac tors are best pre dic tors of hear ing im prove ment af ter tympanoplasty and to eval u ate best func tional out come in dif fer ent forms of pa thol ogy in tym panic cav ity and mas toid in chronic otitis me dia. The sur gery aims ei ther to im prove hear ing thresh old or to close air bone gap 5-7. Dif fer ent pa thol ogy con di tions af fect ing the mid dle ear mu cosa, tubal func tion, tym - panic bony walls and ossicular chain de mands for cre - ative re con struc tion of the ossicular chain tym panic walls and tym panic mem brane. Af ter hear ing gain the sta tus of the tym panic graft, post op er a tive in fec tion or cholesteatoma re cur rence rate are con sid ered as good pre dic tors

2 48 S. Spremo et al. ACI Vol. LX for tympanoplasty suc cess as sess ment Angeli 11 and Choi 12 found that patho logic con di tions in the mid dle ear and mas toid cav ity are im por tant prog nos tic fac tors for pre dict ing the func tional re sults of tympanoplasty. In this study we an a lyzed value of 8 vari ables re lated to mid dle ear pa thol ogy in pre dict ing hear ing gain: ossicular chain in teg rity, tym panic tube func tion, tym panic membrane per fo ra tion, type of sur gery and con di tion of tym - panic and mas toid walls. PA TIENTS AND METH ODS In the pro spec tive study we fol lowed up 120 pa tients with chronic sup pu ra tive otitis me dia (CSOM) who were op er ated be tween 2005 and 2011, in the Otorhinolaryngology de part ment Uni ver sity Clinic Cen ter Banja Luka by the same sur geon. The fol low up pe riod was from one to five years. The in clu sion cri te ria for study were chronic sup pu ra tive otitis me dia (CSOM) and mid dle ear cholesteatoma. All pa tients were sub ject to otological ex - am i na tion us ing the oto-mi cro scope and pre op er a tive as - sess ment of the clin i cal data that in cluded: eval u a tion of the tym panic tube func tion, tym panic mem brane and ossicular chain in teg rity, pa thol ogy in tym panic and mas - toid cav ity. The mean out come mea sures: Hear ing out come was mea sured com par ing pre op er a tive to post op er a tive puretone av er age (PTA) and post op er a tive air-bone gap (ABG). We cre ated a set of fac tors re lated to chronic otitis me - dia as: ossicular chain in teg rity, tym panic tube func tion, tym panic mem brane per fo ra tion, type of sur gery and con - di tion of tym panic and mas toid walls was used to pre dict post op er a tive hear ing im prove ment. The op er a tion was per formed un der gen eral an es the sia, by retroauricular ap - proach. In re gard to the ex tent of the pa thol ogy in the mid dle ear, pa thol ogy on the ossicular chain we per - formed dif fer ent types of tympanoplasty as clas si fied by Tos 7. For re con struc tion we used autologous bone chips taken from mas toid cor tex. Type I tympanoplasty was per formed when the ossicular chain was mo bile and un - dam aged. We used free temporalis mus cle fas cia graft for clos ing tym panic mem brane per fo ra tion. In cases with incus ero sion usu ally on the long pro cess or incudo-stapedial joint, type II tympanoplasty was per - formed. When both malleus and incus were miss ing, and the sta pes was pres ent we per formed type III tympanoplasty. This was usu ally ob served in cholesteatoma cases with ossicular ero sion. If all os si cles: malleus, incus, sta pes were miss ing we im ple mented type IV Tympanoplasty. In cases with large or re cur rent cholesteatoma, re cur rent CSOM and pres ent otological com pli ca tions we per formed tympanomastoidectomy. All pa tients were op er ated by one sur geon. De mo graphic and clin i cal data are pre sented in Ta ble 1. Mean age at time of sur gery was 46.6 years (range: 9-78 years, SD=16.1). Upon clin i cal re view there was 59 (%) cholesteatoma and 62 (%) CSOM cases. Post op er a tive fol low up was taken in 6 months and 1 year fol low ing TABLE 1 DEMOGRAPHIC AND CLINICAL DATA Number of patients 120 Age at surgery (years): mean, SD, (range) Type of surgery sur gery when pa tients were ex am ined in ref er ence to the: con di tion of the tym panic mem brane and hear ing sta tus. Hearing assessment 46.6; 16.1; (9-78) Primary 106 Revision 14 Chronic otitis me dia type CSOM (%) 61(50.8) Cholesteatoma (%) 59(49.2) PTA: (db) mean; SD; (range) Preoperative 62.1; 14.5; (33-95) Postoperative 48.6; 15.8 (20-95) ABG:(dB)mean; SD; (range) Preoperative 32.1; 6.5; (11-48) Postoeprative 20.3; 7.8; (5-47) * PTA: Pure tone av er age in deci bels; ABG: Air-bone gap in deci bels For hear ing as sess ment we cal cu lated Pure Tone Av er - age (PTA) for bone and air con duc tion as a mean of hear ing thresh old on the 0,5 khz, 1 khz, 2 khz and 4 khz. The Air Bone Gap (ABG) was cal cu lated as the dif - fer ence of PTA on air and bone con duc tion on 1kHz ac - cord ing to ac cepted guide lines 6. We used pre op er a tive and the 6 months post op er a tive audiogram for the anal y - sis of ABG clo sure and PTA hear ing im prove ment. Pure tone audiometry was per formed pre op er a tively and 6 months post op er a tively. Sta tis ti cal anal y sis We cal cu lated de scrip tive sta tis tics: fre quen cies of de - mo graph ics and clin i cal data, mean, and stan dard de vi a - tion of post op er a tive PTA and ABG val ues in cor re la tion to the sur gi cal pro ce dures. For hear ing as sess ment we cal cu lated mean, SD and vari ance for PTA and ABG. Univariate anal y sis of group dif fer ences on nom i nal vari - ables was per formed to ex plore dif fer ences be tween groups on PTA and ABG us ing stu dent T test.

3 Br. 4 A multivariate anal y sis of chronic otitis re lated prog nos tic fac tors in de ter min ing hear ing 49 im prove ment af ter tympanoplasty TABLE 2 TYMPANOPLASTY PERFORMED IN CORRELATION TO THE TYPE OF CSOM Type of CSOM Tympanoplasty Type Type I Type II Type III Type IV Tympanomastoidectomy Total Cholesteatoma Tubotimpanal CSOM Aticoanthral CSOM Total TABLE 3 POSTOPERATIVE ABG IMPROVEMENT: RESULTS OF UNIVARIATE ANALYSIS OF GROUP DIFFERENCES ON MIDDLE EAR PATHOLOGY VARIABLES Chronic otitis type Variable N *Mean ABG diff (db) SD(dB) F p value CSOM * Cholesteatoma Tympanic tube orifice Open * Obstructed Tympanic membrane perforation Central, anterior * Posterior, attic, total Type of sur gery Pri mary * Revision Attic Pathology Lat eral at tic in tact ossicular chain * Medial attic, ossicular chain disruption Mesotympanic pathology Anterior tympanum * Oval window, sinus tympani, Ossicular chain Intact or immobile * Discontinued, missing ossicles Mastoid bone erosion or defects No Yes

4 50 S. Spremo et al. ACI Vol. LX TABLE 4 POSTOPERATIVE ABG DIGGERENCE OF 120 PATIENTS WITH CSOM Postoperative ABG difference in db Cholesteatoma: N(%) CSOM type CSOM Tubotimpanal: N(%) CSOM Aticoanthral: N(%) Total <0 4 (3.3) 0 (0) 0 (0) 4 (3.3) (10.8) 1 (0.8) 5 (4.2) 19 (15.8) (8.3) 2 (1.7) 5 (4.2) 17 (14.2) (13.3) 8 (6.7) 17 (14.2) 41 (34.2) (10.8) 6 (5.0) 16 (13.3) 35 (29.2) (2.5) 0 (0) 1 (0.8 ) 4 (3.3) Total 59 (49.2) 17 (14.2) 44 (36.7) 120 (100) TABLE 5 RESULTS OF MULTIPLE LINEAR REGRESSION ANALYSIS OF POSTOPERATIVE ABG IMPROVEMENT IN 120 CASES WITH CSOM B SE t p (Constant) CSOM type Tympanic tube orifice Tympanic membrane perforation Type of surgery Attic walls Mesotympanic walls Ossicular chain * Lateral semicircular canal fistula * TABLE 6 RESULTS OF MULTIPLE LINEAR REGRESSION ANALYSIS OF POSTOPERATIVE PTA IMPROVEMENT IN 120 CASES WITH CSOM B SE t p (Constant) CSOM type Tympanic tube orifice Tympanic membrane perforation Type of surgery Attic walls Mesotympanic walls Ossicular chain * Lateral semicircular canal fistula * Mul ti ple lin ear re gres sion anal y sis was used to mea sure which fac tors pre dict better hear ing im prove ment in terms of post op er a tive PTA and ABG clo sure. The vari - ables in cluded in the mul ti ple lin ear re gres sion were: chronic otitis me dia type (CSOM or cholesteatoma), tym panic tube or i fice (open or ob structed), tym panic mem brane per fo ra tion (cen tral, an te rior or pos te rior, at - tic, to tal), type of sur gery (pri mary or re vi sion), at tic pa - thol ogy (lat eral at tic, in tact ossicular chain or me dial at - tic, ossicular chain dis rup tion), mezotympanum pa thol - ogy (an te rior tym pa num or oval win dow, si nus tympani), ossicular chain (in tact, im mo bile or dis con tin ued, missing os si cles), mas toid bone ero sion or de fects (no or yes). Sta tis ti cal anal y sis was per formed with SPSS ver 19 for Win dows. P val ues of < 0,05 were con sid ered sig nif i cant. RE SULTS Pa tients de mo graphic data and de scrip tive sta tis tic of pre op er a tive and post op er a tive PTA and ABG are re - ported in Ta ble 1. Out of 120 op er ated pa tients, we per - formed pri mary sur gery in 106 and re vi sion sur gery in 9 cases due to re cur rent cholesteatoma and 5 for re cur rent ef fu sion and tym panic per fo ra tion. The range of pa tients age was 9 to 78 years, me dian age was 46.6 years.

5 Br. 4 A multivariate anal y sis of chronic otitis re lated prog nos tic fac tors in de ter min ing hear ing 51 im prove ment af ter tympanoplastybr. TABLE 7 MODEL SUMMARY FOR REGRESSION Regression ANOVA R R Square Adjusted R Square F p ABG improvement * PTA difference.497 a * The hear ing post op er a tively for a whole sub group of 61 CSOM and 59 cholesteatoma cases im proved in terms of PTA, and ABG clo sure. Mean PTA dif fer ence was 13.5 db and ABG dif fer ence was 11.8 db. Hear ing re sults and Univariate anal y sis of ABG clo sure, for all in de pend - ent vari ables are pre sented in ta ble 2. Sig nif i cantly better post op er a tive hear ing re sults were achieved in chronic sup pu ra tive otitis com pared to cholesteatoma cases (p=0.01) and in pri mary com pared to re vi sion sur gery (p=0.04). Hear ing im prove ment com monly rep re sented by gain of hear ing thresh old and air bone gap clo sure as the sta - tus of the tym panic graft, post op er a tive in fec tion or cholesteatoma re cur rence rate are con sid ered as pre dic - tive vari ables for tympanoplasty suc cess. Post op er a tive PTA and ABG val ues were sig nif i cantly af fected by the ossicular chain pa thol ogy. In the chronic otitis me dia and cholesteatoma group, two pa ram e ters were de tected to be sig nif i cantly cor re lated with post op er a tive hear ing out - come: ossicular dis con ti nu ity and osteitis or mas toid bone ero sion or de fects. De fects on the incudo-stapedial joint, sta pes and bod ies on the incus and malleus were sig nif i cantly cor re lated to post op er a tive ABG and PTA. We per formed pri mary osiculoplasty in all cases with ossicular chain dis con ti nu ity. Com mon find ing were long pro cess of incus or incudo-stapedial joint de fect. For the osiculoplasty incus was re moved and shaped to the capitulum of the sta pes on one side and placed in con tact with long pro cess of the malleus on the other side or be - low the malleus trans posed in a way that new ossicular chain was formed. In cases when the cholesteatoma perimatrix was ad her ent to en tire incus body or ex ten sive osteitis was found on incus, autologous bony collumela was used to void the gap be tween the sta pes and malleus han dle. The osiculoplasty con trib uted to the sig nif i cant im prove ment in both hear ing re lated vari ables: Air-bone gap clo sure and hear ing thresh old im prove ment. Ero sions or de fects on the mas toid bone, es pe cially lab y rin thine fis tula, and fa cial ca nal dehiscence, were sec ond good pre dic tor of post op er a tive hear ing suc cess. Mas toid osteitis was in versely cor re lated to ABG and PTA post - op er a tive im prove ment. Ex ten sive pa thol ogy in the mas - toid bone re quired ex ten sive sur gi cal ap proach: wall down tympanoplasty or tympanomastoidectomy op er a - tions re sult ing in poor hear ing im prove ment. Other chronic otitis re lated vari ables: CSOM type, tym - panic tube func tion, size and po si tion of tym panic mem - brane per fo ra tion, type of sur gery, con di tion of at tic or mezotympanum walls did not con trib ute sig nif i cantly to the pre dic tive value of the whole model, al though we ob - served that post op er a tive PTA and ABG clo sure was di - rectly re lated to the range of pa thol ogy found intraoperatively. Osiculoplasty and at tic wall re con struc - tion con trib uted most to hear ing im prove ment re sult ing in ABG gain for more than db in 66.7% op er ated pa tients, and for db gain in 32.5% pa tients. This re sult im plies that patho logic con di tions in the mid dle ear and mas toid cav ity are sig nif i cant pre dic tors of post op er - a tive hear ing out come and over all suc cess. Ozbek 8 re viewed 54 pa tients op er ated for CSOM us ing the pal i sade car ti lage tympanoplasty. He found that post - op er a tive ABG was less than 20 db in 71% pa tients, rec - om mend ing pro ce dure in re gard to func tional re sults. Angeli 11 re ported that pre op er a tive ABG and sta tus of malleus han dle had a greater prog nos tic value on post op - er a tive ABG then form of chronic otitis, age and sta pes and tym panic an nu lus sta tus which is con sis tent with our find ings. The pre dic tive model in this study in cluded 8 vari ables re lated to mid dle ear pa thol ogy proved to be su pe rior to an a lyz ing each vari able sep a rately. We sug gest sur geons to quan tify the prog nos tic fac tors in each pa tient prior to sur gery to better un der stand prob a bil ity of hear ing gain. This also can serve as an ob jec tive pa ram e ter pre sented to the pa tient in the pre and post op er a tive eval u a tion. CON CLU SION A model that eval u ates fac tors re lated to chronic otitis me dia: ossicular chain in teg rity, tym panic tube func tion, tym panic mem brane per fo ra tion, type of sur gery and con di tion of tym panic and mas toid walls has sig nif i cant pre dic tive value for hear ing as sess ment in tympanoplasty. SA@ETAK Cilj ovog rada je bio da se proceni koji faktori su najbolji prediktori poboljšanja sluha posle tim panoplastike i evaluacija funkcionalnih rezultata u korelaciji sa razliè~itim oblicima patološkog nalaza u bubnoj duplji i mastoidu kod hroniè~nog otitisa.

6 52 S. Spremo et al. ACI Vol. LX METODE: Prospektivnom studijom je analizirano 120 bolesnika koji su operisani zbog hroniè~nog gnojnog otitisa i holesteatoma u Univerzitetskom kliniè~kom centru Banja Luka od 2006 do Višestruka linearna regresiona analiza je koriš}ena za merenje faktora koji predvidjaju stepen poboljšanja sluha. Model kojim se procenjuju faktori povezani sa hroniè~nim otitisom uklju~èuje evaluaciju: integriteta lanca slušnih košè~ica, funkciju tube tim pani, perforacija bubne opne, tip operacije i patološki proces u šupljini srednjeg uva, koriš}en je za predvidjanje postoperativnog poboljšanja sluha. Rezultati promene sluha pre i nakon operacije su mereni razlikom praga sluha (PTA) i razlikom vazdušno-koštane pukotine (ABG). REZULTATI: Od 120 operisanih pacijenata, primarnu operaciju smo uradili kod 106 a revizione operacije kod 9 pacijenata. Utvrdili smo visok stepen korelacije i statisti~èki zna~èajan doprinos patologije lanca slušnih košè~ica (â =-0,310, t=-3.01, p<0,05), kao i patoloških promena u srednjem uvu i mastoidu (â =2,05, t =2.05, p<0,05), u odnosu na PTA. Koeficijenti korelacije istih varijabli u odnosu na promenu ABG su (â =-0,230, t =-2.14, p <0,05), a za faktore patologije u mastoidu (â = 2,05, t=2,08, p<0,05). Model u celini je statisti~èki znaè~ajan prediktor poboljšanja sluha, F (8,119) = 4,54, p<0,01. Prediktivni model sa 8 faktora posmatranih zajedno pokazao se boljim u odnosu na analizu za svaku promenljivu posebno. ZAKLJUÈ^AK: Model kojim smo procenili patološke promene srednjeg uva kod hroni~ènog otitisa: integritet lanca slušnih koš~èica, funkcija timpanalne tube, perforacija bubne opne, tip operacije i patološke promene u srednjem uvu, ima znaè~ajnu prognosti~èku vrednost za procenu poboljšanja sluha nakon timpanoplastike. Kljuè~ne re~èi: timpanoplastika, holesteatom, nagluvost i gubitak sluha 6. Com mit tee on Hear ing and Equi lib rium guide lines for the eval u a tion of re sults of treat ment of con duc tive hear ing loss. Otolaryngol Head Neck Surg. 1995;113(3): Tos M. Car ti lage tympanoplasty meth ods: pro posal of a clas si fi ca tion. Otolaryngol Head Neck Surg. 2008; 139(6): Ozbek C, CiftçI O, Tuna E, Yazkan O, Ozdem C. A com par i son of car ti lage pal i sades and fas cia in type 1 tympanoplasty in chil dren: an a tomic and func tional results. Otol Neurotol. 2008;29(5): Mishiro Y, Sakagami M, Kondoh K, Kitahara T, Kakutani C. Long-term out comes af ter tympanoplasty with and with out mastoidectomy for per fo rated chronic otitis me dia. Eur Arch Otorhinolaryngol. 2009;266(6): Moon IS, Song MH, Kim HN, Chung MH, Lee WS, Lee HK. Hear ing re sults af ter ossiculoplasty us ing Polycel pros the sis. Acta Otolaryngol. 2007;127(1): Angeli SI, Ku lak JL, Guzmán J. Lat eral tympanoplasty for to tal or near-to tal per fo ra tion: prognostic fac tors. La ryn go scope. 2006;116(9): Choi HG, Lee DH, Chang KH, Yeo SW, Yoon SH, Jun BC. Fre quency-spe cific hear ing re sults af ter sur gery for chronic ear dis eases. Clin Exp Otorhinolaryngol. 2011;4(3): Spremo S, Udovèiæ B. Acute mas toid i tis in chil dren: sus cep ti bil ity fac tors and man age ment. Bosn J Ba sic Med Sci. 2007;7(2): Spremo S, Stupar Z. Char ac ter is tics of sensorineural hear ing loss sec ond ary to in ner ear acous tic trauma. Srp Arh Celok Lek. 2008;136(5-6): REF ER ENCES 1. Boronat-Echeverría NE, Reyes-García E, Sevilla-Delgado Y, Aguirre-Mariscal H, Mejía-Aranguré JM. Prog nos tic fac tors of suc cess ful tympanoplasty in pe - di at ric pa tients: a co hort study. BMC Pediatr. 2012;12:67 2. Onal K, Uguz MZ, Kazikdas KC, Gursoy ST, Gokce H. A multivariate anal y sis of otological, sur gi cal and pa - tient-re lated fac tors in de ter min ing suc cess in myringoplasty. Clin Otolaryngol. 2005;30(2): Pinar E, Sadullahoglu K, Calli C, Oncel S. Eval u a - tion of prog nos tic fac tors and mid dle ear risk in dex in tympanoplasty. Otolaryngol Head Neck Surg. 2008; 139 (3): Jeng FC, Tsai MH, Brown CJ. Re la tion ship of pre - op er a tive find ings and ossicular dis con ti nu ity in chronic otitis me dia. Otol Neurotol. 2003;24(1): P J D Dawes. Tympanoplasty - re port ing hear ing re - sults and "hear ing ob jec tive". Clin Otolaryngol Al lied Sci. 2004;29(6):612-7 AC KNOWL EDGE MENTS The re sults pre sented in the ar ti cle are col lected through sci en tific and daily sur gi cal prac tice of the au thor in the Uni ver sity Clinic Cen ter Banja Luka. DEC LA RA TION OF IN TER EST The au thors de clare that they do have no con flicts of in ter est with re - spect to au thor ship and the pub li ca tion of article.