Release: May 12, 2000
Contact: Kenneth Satterfield, 407-238-4161 (as of 5/12/2000)
TRANSTYMPANIC MYRINGOPLASTY PROVES EFFECTIVE IN TREATING THE PERFORATED EAR DRUM, AT A LOWER COST
Researchers from Ohio State University state that $500 in patient costs can be saved using a new procedure in treating a common pediatric disorder
Orlando, FL -- The repair of chronic tympanic membrane (ear drum) perforations is a common procedure performed in children due to the high incidence of ear infections and trauma involving the placement of inappropriate objects into the ear canal.
Otolaryngologist--head and neck surgeons have a range of options on how to repair the ear drum. Tympanomeatal flap elevation has been the most common conventional procedure, and temporalis fascia and perichondrium are the most widely used graft tissue. This procedure requires an elevation of the tympanomeatal flap in the ear canal and provides improved access to the middle ear space with evaluation of ossicular integrity. Some surgeons use a postauricular incision on all myringoplasty cases. The transtympanic myringoplasty approach has been described recently using fat grafts on selected tympanic membrane perforations without unnecessary exploration of the middle ear. The lifting of the skin in the ear canal is omitted; this relatively new procedure entails a direct surgical approach to the ear drum.
Choosing an appropriate technique is based on the needs of the individual patient. In tympanoplastic surgery, factors to consider in determining the technique include perforation site, size of perforation, amount of rim present, presence of significant conductive hearing loss, and clinical presence of ossicular or mastoid pathology. With selected tympanic membrane perforations, no criteria has been established in determining the best technique to use in terms of success rates and cost effectiveness.
The transtympanic technique is commonly performed at the Columbus Children's Hospital. The procedure is technically expedient and is performed on an outpatient basis. Accordingly, four specialists from the hospital conducted a retrospective review of myringoplasties performed at their hospital during a recent five year period. Their study was limited to tympanic membrane perforations, meeting a strict criteria to provide a comparison of a homogenous population as possible.
Both transtympanic myringoplasty and tympanomeatal flap elevation success rates were compared to each other and to those reported in the literature. Factors that have been suggested to influence outcome were evaluated to determine what relevance they had in our population. Operating room time and a cost analysis of each technique were considered. The authors of the study, "Transtympanic Myringoplasty in Children: A Cost-Effective Technique," are Bryan C. Tagge, MD, Edward E. Dodson, MD, Mary Hart, MD, and Andrew Spector, MD, all from the Columbus Children's Hospital and Department of Otolaryngology-Head and Neck Surgery, Ohio State University, Columbus, Ohio. Their findings were presented before the American Society of Pediatric Otolaryngology, meeting May 16-18 in Orlando, FL.
Methodology: Evaluations were made on the records of pediatric patients who had undergone myringoplasty by seven attending surgeons between January, 1994, and August, 1998. Selection criteria were established for inclusion into the study. These included clean, dry perforations present for a least six months, perforation size not greater than approximately 50 percent of the tympanic membrane, a minimum of two millimeters of drum margin present to the edge of the perforation, conductive hearing loss less than 30 decibels, and clinical absence of ossicular or mastoid pathology.
One hundred and sixty five myringoplasties were performed Ninety-five patients (three to 19 years old) met the inclusion criteria. Forty-seven underwent transtympanic grafting while 48 patients underwent elevation of a tympanomeatal flap. Excluded from the study were procedures performed via a post-auricular approach, revision myringoplasty, and procedures using cartilage for repair of perforations or correction of atelectatic tympanic membranes. Patients were also excluded for insufficient follow up.
Patient characteristics were documented and compared between the two groups. Audiometric testing, including air and bone conduction check were performed under standard conditions. Anesthesia records were evaluated, and beginning and ending surgery times for myringoplasty were documented. Cost analysis was performed by using standard operating room costs and anesthesia charges at their institution. The procedures were performed under general anesthesia.
All patients were discharged on the same day with outpatient follow up scheduled intervals. Patients were followed up for an average 9.7 months (range four to 39 months). Patients in the flap group underwent elevation of a tympanomeatal flap with incision into the canal skin and elevation of the fibrous annulus out of the bony tympanic rim. Ossicles were inspected and documented as normal in all patients. In this group underlay grafting was performed directly via the middle ear. The tympanomeatal flap was then repositioned to its natural position after placement of a graft. Clinical outcomes were assessed by comparing the success rate, defined as closure of the perforation, and the change in the pre-operative to post-operative air bone gap. The frequency and percent of successes were compared using Fisher's Exact test . All procedures with both pre and post-operative air bone gap assessments were compared with respect to the change in air-bone gap.
Results: Success rates for the two groups were 40/48 (83 percent) in the flap group and 42/47 (89 percent) in the transtympanic group respectively. The flap technique averaged 81.1 operative minutes while the transtympanic group averaged 45.4 operative minutes (p-value<0.001) for a savings of $500 to the patient. Audiometric data showed pre-operative conductive hearing loss in 27/31 (87 percent) in the flap group and 19/30 (67 percent) in the transtympanic group. Of these patients, and those with adequate postoperative audiograms, 20/22 (90 percent) of the flap group and 9/12 (75 percent) in the transtympanic group had a decrease in the air bone gap. There were two and three children who did not experience an improvement in the conductive loss in the flap and transtympanic groups respectively. No patients had and increase in the air bone gap.
Conclusions: The study recommends that under certain circumstances, the transtympanic myringoplasty is a safer, more cost-effective procedure for repair of the perforated ear drum, achieving similar results to more conventional surgical procedures.
- end -
RSS