Surgical Repair of Perforated Eardrum Still Viable Option
Embargo expired: 19-Sep-2003 12:00 PM EDT
Source Newsroom: American Academy of Otolaryngology Head and Neck Surgery (AAOHNS)
Newswise — A perforated eardrum, or middle ear, often resolves on its own or with the aid of antibiotics. But there are circumstances when surgery to repair the perforated eardrum may be necessary to control infection, or it may be performed to protect the middle ear or to restore hearing. Tympanoplasty is a microsurgical procedure that uses a patient's own tissues (autologous grafts), to reconstruct the tympanic membrane. Grafts may be taken from different areas, including (in order of most frequent use) loose connective tissue, temporalis fascia, tragal perichondrum, and the periosteum.
The prognostic factors that influence whether the graft is accepted without rejection and the positive success on hearing may include age of the patient. Researchers have attempted to establish the role of age on the fastening of the tympanic grafts, analyzing the results of the surgery on children and adults. In connection with elderly adults there is scarce bibliography defining whether there are more anatomic or functional failures in this age group.
Past research has placed a greater importance on the existence of concurrent illnesses and the state of the patients' general health, as these factors might negatively influence morbidity and mortality . As to effect on hearing, some research has demonstrated that the procedure has a positive effect on patients over 60 years old., although it is quite acceptable: in one study there was a gap closure within 20 dB on 70 percent of the patients over 60 years, in comparison with a 90 percent closure in patients between 50 and 59 years old, and 100 percent between 20 and 49 years of age.
The advances on anesthetic and surgical techniques have led to an increasing number of tympanoplasties being performed on patients that presented limitations due to decompensated base pathologies, or patients who due to their advanced age would not tolerate a surgery. To examine whether such a procedure is a prudent move for the aging population, two Chilean surgeons set out to determine the anatomic and audiological results of primary tympanoplasties on patients over 50 years of age and to determine whether age and type of grafting have an influence on the anatomic and functional success.
The authors of "Tympanoplasty In Patients Over Fifty Years" are M.Pia Vallejos MD and Luis Dentone MD, both from the Hospital Barros Luco Trudeau, San Bernardo, Chile. Their findings are to be presented at the American Academy of Otolaryngology--Head and Neck Surgery Foundation http://www.entnet.org Annual Meeting & OTO EXPO, Orlando, FL, September 21-24, 2003.
Methodology: A retrospective descriptive study (chart review) was made, examining the data in the clinical files. All primary tympanoplasties made on patients over 50 years old, without cholesteatoma or mastoid draining performed at the otolaryngology service of Barros Luco Trudeau Hospital between September 1990 and September 2000, were included. Some 146 files were recovered of which only 118 had full data.
The two researchers examined the results of 118 tympanoplasties. The average age of the group was 56.7 years, varying between 50 and 73 years of age. Approximately 75.2 percent of the surgeries were performed on female patients. In terms of age, 74.6 percent (n=88) corresponds to patients between 50 and 59 years and 25.4 percent to patients between 60 and 73 years old. Surgery average follow-up time was three to four months.
Within the study group, 65.2 percent of the patients carried a unilateral perforated ear drum while 34.8 percent had a bilateral damaged middle ear (in the latter group only one ear was operated on). The greater number of perforations were central in location. In relation to surgical technique, 67 ears were approached retro-auricularly and 51 endo-aural . The graft was placed lateral to the eardrum in 102 cases and on 16 patients it was placed medially to it. On 57.6 percent of the ears temporal fascia graft was used, tragal perichondrium graft on 271 percent and on 15.3 percent, a graft composed by tragal cartilage-perichondrium. The most frequent operation performed was myringoplasty (without ossiculoplasty), (n=91). Fourteen type 1 tympanoplasties were conducted, 12 type III-A tympanoplasties (10.2 percent) and one III-B tympanoplasty. The operations were practiced by residents and doctors of the otolaryngology service of Barros Luco Trudeau Hospital.
Results: The key findings of this research were:
"¢ There is a tendency not to operate patients over 60 years (only 25 percent of the sample was 60 years or more. A lower rate of fastening is assumed, which was not wholly demonstrated until now, but also a higher prevalence of medical pathologies was added in this age group, which might contraindicate an elective surgery, adding higher perioperatory morbidity/mortality.
"¢ Anatomic success in patients over 60 years of age (67 percent) is significantly lower than in younger patients (84 percent between 50 and 59 years old).
"¢ The type of perforation or the surgical technique utilized does not have a major influence on the anatomic result of the tympanoplasty. The type of graft, however, does show that the graft composed by cartilage and perychondrium produces the best long term results and the perychondrium graft, the lowest fastening frequency. The temporal fascia graft does not loose its efficiency. These percentages tend to be lower in the age group over 60 years. The composed graft seems to have better stability, which allows a better fastening.
"¢ The improvement of hearing appeared to be lower in older age patients. There was an auditive improvement in almost 40 percent of the sample, where this is slightly better (42 percent) in patients between 50 and 59 years old. Only 22 percent of the patients over 60 years of age showed an auditive improvement over 10 dB. This could be due to the longer time of evolution of the pathology, which causes greater damage to the ossicle chain and hampers its repair.
Conclusions: The researchers concluded that the anatomic and functional result of tympanoplasties decreases after the age of 60. However, the success rate of the graft and audiological response still recommends this procedure as a viable option for the elderly patient.