Audiological outcome of tympanoplasties a single center experience

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1 Original article Audiological outcome of tympanoplasties a single center experience Selma Hodžić-Redžić*, Lana Kovač-Bilić, Srećko Branica Department of Ear, Nose and Throat and Head and Neck Surgery, University Hospital Center Zagreb Submitted: / Accepted: ABstract Objective: Since the outcome of our operative procedures has not been evaluated, the aim of this study was to evaluate hearing improvement after tympanoplasty indicated for the treatment of chronic suppurative otitis media. Methods: The study included 251 patients of both sexes, who were operated at a tertiary care university hospital during the period of three years. Audiological testing was done prior the surgery and three months later according to the guidelines of the American Speech Language Hearing Association. Results: The median age of patients was 51 (35-62) years, more women (56.97%) than men. Predominant of involvement of the middle ear had 70.92% patients, while 29.08% of them also had of the inner ear involvement. The right ear was affected in 41.43% of patients and left in 40.24% of patients. Both ears were affected in 18.33% of patients. There were 81.67% patients with a dry defect or isolated perforation, while there were 18.33% of patients with additional findings such as cholesteatoma or polyps. Type I tympanoplasty was most common procedure (75.3%), the rarest was type IV (0.8%) tympanoplasty. There was a significant difference in audiological findings preoperatively and postoperatively. The audiological outcome of tympanoplasties was ± db. The audiological outcome in type I tympanoplasty was 17.68±10.66 db, and in type III 16.34±12.59 db, but the difference was not significant. Conclusion: Tympanoplasty is a very effective operative procedure that leads to an excellent improvement of middle ear function in chronic suppurative otitis media, and it is beneficial regardless of tympanoplasty type used. Keywords: tympanoplasty, otitis media, tympanic membrane perforation, hearing loss, middle ear 2016 Folia Medica Facultatis Medicinae Universitatis Saraeviensis. All rights reserved. *Corresponding author Selma Hodžić-Redžić Department of Ear, Nose and Throat and Head and Neck Surgery, University Hospital Center Zagreb, Kišpatićeva 12, Zagreb, Croatia sellhodzic@gmail.com, selmahr@outlook.com tel Introduction Chronic suppurative otitis media represents a persistent inflammation of the middle ear and / or mastoid. It presents with otorrhea, otalgia, hearing loss [1] and represents one of the most common causes of hearing loss in general. The degree of hearing loss depends on the perforation and on the status of the middle ear. Important features of the perforation are its size, location, and length of persistence [2], and hearing loss caused by the perforation in most cases does not exceed 50 db [3,4,5]. If the hearing loss exceeds this value, it is mainly caused by changes in the middle ear, or by the presence of additional pathology: cholesteatoma, granulation tissue or polyps. In most cases, perforation closes spontaneously. If the perforation persists, despite maintaining the ear dry and despite application of antibiotics locally or systemically, tympanoplasty is indicated. Tympanoplasty is a method of treatment of chronic suppurative otitis media [6], which includes the closure of the eardrum defect, eliminating of middle ear disease with or without reconstruction of the ossicular chain [7]. Since it includes the entire spectrum of pathology of the middle ear, facial nerve, Eustachian tube and mastoid, the surgery is not standardized. Surgery technique depends on the individual case [1]. Wullstein and Zollner set the basic principles of tympanoplasty [1] and classified them on the type of reconstruction of the ossicular chain required for restoration of hearing. According to them, five types of tympanoplasty exist. In type I ossicles are intact and mobile; graft is placed on intact maleus. In type II tympanoplasty graft is placed on intact incus. In Type III graft is placed on stapes superstructure, and in type IV it is placed on the basis of the stapes. Type V includes fenestration of the lateral semicircular canal. A good result means improving the hearing for 15 db [1]. Since the outcome of our operative procedures has not been evaluated, the aim of this study was to ascertain 50

2 hearing improvement after tympanoplasty indicated for the treatment of chronic suppurative otitis media. Material and Methods Patients The study was retrospective and included patients with chronic otitis media who had tympanoplasty performed at a tertiary care university hospital during the period of three years. From 311 patients who underwent surgery, 251 had the necessary data and were included in the study. The study included patients of both sexes. Indications for surgery were chronic otitis media with a discharge that does not respond to therapy, persistent perforation, a persistence of retraction pockets and cholesteatoma. The retroauricular approach was primarily used; transmeatal and endaural approaches were used in isolated cases. Tympanoplasty was done under general anesthesia. Materials used to close the perforations were temporal fascia graft, tragal perichondrium graft, cartilage and graft consisted of cartilage and perichondrium. Additionally, cholesteatoma was removed, and the ossicular chain was reconstructed. Methods According to preoperative otomicroscopic finding, patients were divided into two groups: those with perforation alone, and those with additional finding of cholesteatoma or polyps. Audiological testing was done prior the surgery and three months later. It was accomplished with a Clinical Audiometer AC40 and transducers that meet the applicable specifications of ANSI S [8]. Hearing testing was performed according to the guidelines of the American Speech Language Hearing Association (ASHA) [8]. Air-conduction threshold assessment was made at 250, 500, 1000, 2000, 3000, 4000, 6000, and 8000 Hz and when there was a low-frequency hearing loss, the hearing threshold at 125 Hz was also measured. When there was a difference of 20 db or more between the threshold values at any two adjacent octave frequencies from 500 to 2000 Hz, interoctave measurements was made. The better ear was tested first. The initial test frequency was 1000 Hz and was followed by 2000, 3000, 4000, 6000, and 8000 Hz, followed by a retest of 1000 Hz before testing 500, 250, and 125 Hz [8]. Bone conuction thresholds were obtained at octave intervals from 250 to 4000 Hz and at 3000 Hz. The initial frequency tested was 1000 Hz followed by 2000, 3000, and 4000 Hz followed by a retest of 1000 Hz before testing 500 and 250 Hz [8]. The air-bone gap was measured at four frequencies 500, 1000, 2000 and 4000 Hz, which are speech frequencies and a mean of these four frequencies was the main audiological outcome. According to dominant, patients were divided into two groups. One group consisted of patients who had only of middle ear involvement, such as previously discharging ear and hearing loss. The second group consisted of patients who, besides of middle ear, had also the of inner ear involvement, such as vertigo, tinnitus and sensorineural hearing loss. Also, according to the intraoperative finding of cholesteatoma, patients were divided into two groups, those with cholesteatomatous chronic otitis media, and those with non-cholesteatomatous chronic otitis media. Statistical analysis Data were analysed using Medcalc Statistical Software version 15.8 (MedCalc Software bvba, Ostend, Belgium). Preoperative and postoperative audiograms were analysed using paired t-test. P value less than 0.05 was considered statistically significant. Results The study included 251 patients, aged years. The median age was 51 (35-62) years. The study included % of patients older than 51 years and % of them were women (Table 1). Table 1: Age and gender distribution of the patients Characteristic N % <30 years Age years >51 years Gender Male Female Dominant were middle ear (70.92%) which included discharging ear and hearing loss, but only % of patients had additional preoperative otomicroscopic findings, such as cholesteatoma or polyps (Table 2). Table 2: Clinicopathologic characteristics of patients Dominant Affected ear Preoperative otoscopic finding Cholesteatoma Characteristic N % Middle ear Middle and inner ear Right Left Both Dry ear Additional finding Yes No

3 Tympanoplasty type I was the most common procedure, which was performed in 75.3 % patients (Table 3). Table 3: Number of patients treated with different types of tympanoplasties Tympanoplasty type Number of patients % Type I Type II Type III Type IV The general audiological outcome, regardless of the tympanoplasty type, amounted ± db (p<0.001) (Table 4). Type I and type III of tympanoplasties were the most common procedures done (98 % of all cases) and audiological outcomes of these two types are shown in table 5. Discussion Tympanoplasty eliminates abnormalities of the middle ear, restore the function of the Eustachian tube, preserve or reconstruct the ossicular chain, and thus renew the transmission of the sound to the inner ear [9]. So, it closes the eardrum perforation and improves the hearing. From 251 patients included in this study, % of them had more than 51 years, which is a consequence of the fact that chronic otitis media is most often in this age group. There was a mild predominance of women (56.97 %) while in most cases, women are generally more concerned about their health, even though there are studies in which there is a predominance of men [1,10,11,12]. The right ear was affected in 41.3% of patients, left was affected in 37.68% of patients and both ears were affected in 21.1% patients. In a study of Shetty et al.[1], in 42% of patients right ear was affected, in 42% patients left ear was affected while in 16% of patients both ears were affected. The distribution is very similar to this study. In the study of Gupta et al. [11], 36% of patients had the cholesteatoma, as opposed to 18.12% in this study. Hearing loss was the dominant symptom, and was presented in all patients (100%). The same result was found in other studies. In this study, 75.3 % patients underwent type I tympanoplasty, compared to 74 % in the study of Shetty et al. [1]. 16 % of patients in named study underwent type II tympanoplasty compared to 1.2 % of patients in this study % of patients underwent type III tympanoplasty in this study compared to 10% of patients in the study of Shetty et al [1]. Type IV was performed in 0.8% of cases in this study, and in the named study of Shetty et al. [1], this type of tympanoplasty was not done. In the study of Oleusesi et al. [10], type I tympanoplasty was performed in 91.11% of patients and type III in 8.88% of patients. In this, and also in other studies, type I was the most frequent type of tympanoplasty, and it is followed by type III of tympanoplasty. This is due the fact that eardrum perforation gives the permanently, and people visit the doctor as soon as possible. So the first type of tympanoplasty is the most frequent type. On the other hand, due the fact that incus has not its own blood supplement and it necrotizes first, type III is the second most frequent type. Type II and type IV are really rare, while rare are people who wait so long to need a type IV of tympanoplasty. Such results in frequency are found here, too. Hearing gain in this study amounted db while in the study of Gupta et al. [11] this improvement amounted 6.3 db. Mishra et al. [13] announced improvement of db at 95% of their cases. Accord- Table 4: General audiological outcome, regardless of the tympanoplasty type Finding Mean ±SD Audiological gain (mean± SD) p* value Preoperative 45.13±19.07 Postoperative 28.73± ± P< * Paired samples t-test Table 5: Hearing gain in type I and type III tympanoplasties Tympanoplasty type Preoperative finding (mean ±SD) Postoperative finding (mean ±SD) Hearing gain (mean±sd) Type I 44.54± ± ± Type III 46.78± ± ± * Independent samples t-test. Difference between hearing gain in two groups. **Hearing gain for at least 15 db % of success** P * value P>

4 ing to a study of Kolo et al. [14] hearing improvement amounted db. Inodorewala et al. [15] published hearing improvement of db, and Shetty et al. [1] published improvement of 22.9 db. So, audiological outcomes are very similar to result found in this study. Hearing improvement in type I tympanoplasty amounted db. In the study of Shetty et al. [1], this improvement amounted 18.8 db. In type III tympanoplasty the improvement was db, compared to db in the named study [1]. Improvement in type I tympanoplasty is very similar, but there was a slightly better result of type III tympanoplasty in this study. While the audiological gain of 15 db is considered as a good result, our operations lead to very good audiological outcomes. The main deficiency of this study is the fact that there were not enough patients in all tympanoplasty groups for sufficient statistical analysis. With the type II and the type IV, there were, in sum, only five patients. On the other side, there were enough patients in the tympanoplasty I and III groups, which are, accordingly to other studies also the most often. Due to this fact, those results are still important while they cover the most types of tympanoplasties at all. So to provide a good functional outcome in tympanoplasties, all steps of the treatment process must be respected; preoperatively the status of the middle ear [16, 17], intraoperatively type of surgery as well as surgeon ability and postoperatively, anatomical, physiological and pathological events in the middle ear [1,15,18,19]. Conclusion Tympanoplasty is a very effective operative procedure that leads to an excellent improvement of middle ear function in chronic suppurative otitis media, and it is beneficial regardless of tympanoplasty type used. Declaration of interest Authors declare no conflict of interest. 53

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