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ORIGINAL ARTICLE
Year : 2020  |  Volume : 13  |  Issue : 3  |  Page : 229-234  

Pediatric tympanoplasty: Our experiences in a tertiary care teaching hospital of Eastern India


1 Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University (deemed to be), Bhubaneswar, Odisha, India
2 Medical Research Laboratory, IMS and SUM Hospital, Siksha “O” Anusandhan University (deemed to be), Bhubaneswar, Odisha, India

Date of Submission16-Aug-2019
Date of Decision16-Aug-2019
Date of Acceptance15-Oct-2019
Date of Web Publication3-Jun-2020

Correspondence Address:
Santosh Kumar Swain
Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University (Deemed to be), Bhubaneswar, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_111_19

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  Abstract 


Objective: The study objective was to study successful graft uptake and hearing gain by using different graft materials in pediatric tympanoplasty. Materials and Methods: Patients younger than 16 years of age who had undergone tympanoplasty between January 2016 and February 2019 were included in this study. Temporalis fascia or perichondrium was used as the graft material in tympanoplasty. Patient details such as age, sex, side of operated ear, operation technique, audiological profile before and after surgery, and the status of postoperative graft were noted. An intact graft and air–bone gap (ABG) ≤25 dB were considered as successful outcome after postsurgical period. Preoperative audiogram and audiogram after 6 months of surgery were advised for comparison.Results: Thirty-six pediatric patients were included in our study. Temporalis fascia graft was used as the graft material in 22 patients and cartilage graft was used as the graft material in 14 patients. The successful graft uptake was 89% in the temporalis fascia group, whereas it was 96% in the cartilage group. In temporalis fascia group, ABG before surgery was 35.53 dB, ABG after surgery was 17.12 dB, and the postoperative gain was 18.41 dB. In the tragal cartilage group, preoperative ABG was 32.42 dB and postoperative ABG was 15.13 dB, with a postoperative gain of 17.29 dB. The comparison between the temporalis fascia and the tragal cartilage groups was statistically significant for successful graft uptake (P = 0.0119) and hearing outcome (P = 0.0484). Conclusion: Temporalis fascia gives better hearing outcome, whereas tragal cartilage gives better graft uptake in pediatric tympanoplasty.

Keywords: Hearing loss, pediatric, temporalis fascia, tragal cartilage, tympanoplasty


How to cite this article:
Swain SK, Nahak B, Mohanty JN. Pediatric tympanoplasty: Our experiences in a tertiary care teaching hospital of Eastern India. Med J DY Patil Vidyapeeth 2020;13:229-34

How to cite this URL:
Swain SK, Nahak B, Mohanty JN. Pediatric tympanoplasty: Our experiences in a tertiary care teaching hospital of Eastern India. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2020 Jul 5];13:229-34. Available from: http://www.mjdrdypv.org/text.asp?2020/13/3/229/285751




  Introduction Top


Chronic suppurative otitis media is a global disease, seen in all the continents having different socioeconomic and environmental background. It is most commonly seen in developing countries where our region is no exception. Malnutrition, poverty, crowding, and recurrent upper respiratory tract infections are the root causes for the development of chronic otitis media. The overall prevalence of chronic otitis media in pediatric age group is around 3%.[1] Perforation of the tympanic membrane is a known sequel of chronic otitis media in children, which is often associated with hearing loss, recurrent infection, and frequent visits to the physician and cause significant discomfort and morbidity. Hence, tympanoplasty or repair of tympanic membrane causes eradication of the infections from the middle ear and improves the hearing of children with chronic otitis media.[2] Tympanoplasty in the pediatric population is a controversial theme.[3] It was reported that the success of tympanoplasty in pediatric patients ranges from 35% to 94%.[4] This wide range of success is attributed to different selection criteria and definition of successful outcome. The successful outcome is measured by postoperative integrity of the graft material.[5] Success of pediatric tympanoplasty is poorer in comparison to the adult tympanoplasty due to numerous factors such as recurrent upper respiratory tract infection, narrow external auditory canal, unpredictable  Eustachian tube More Details status, low immunity, and difficult postoperative care. Nevertheless, the present data showed that pediatric tympanoplasty is successful as similar to adult tympanoplasty.[6] The aim of tympanoplasty is to eradicate the diseases from the middle ear cleft and reconstruct the hearing mechanism. Temporalis fascia, cartilage, vein, fascia lata, perichondrium, and autografts such as duramater have been used since the description of the initial tympanoplasty. At present, temporalis fascia is the most commonly used graft material in tympanoplasty due to the neighborhood of the donor site to the surgical field. Occasionally, retraction and decrease in the size of graft occur in temporalis fascia due to the presence of irregular elastic fibers and fibrous connective tissue.[7] Cartilage grafts are usually resistant to retraction and infection when compared to temporalis fascia. However, the rigidity of the cartilage graft gradually decreases by time.[8] There are numerous studies on tympanoplasty in adult groups, but they are limited in the pediatric population. Comparison between temporalis fascia and tragal cartilage in pediatric tympanoplasty is a unique and rare study in our region. Here, we compared the success rate of temporalis fascia and hearing gain in comparison to tragal cartilage in pediatric tympanoplasty.


  Materials and Methods Top


Thirty-six patients under 16 years of age who had undergone tympanoplasty in our otorhinolaryngology department during January 2016–February 2019 were included in the study. This study was approved by our Institutional ethics committee (IEC) with reference number IMS/CRL/IEC/94/14.10.2015. The detailed data were retrospectively analyzed. All the patients had a central perforation in the tympanic membrane present since 1 year before the surgery. Patients with atelectasis, cholesteatoma, or very small perforation (<25% size) were excluded from the study. All the patients those included in this study were divided into two groups on the basis of graft materials used for tympanoplasty. In the first group, temporalis fascia [Figure 1] was used in 22 patients, whereas in the second group, tragal cartilage [Figure 2]a was used among 14 patients. All the tympanoplasties were performed by senior otologists under general anesthesia with postaural approach. Computed tomography (CT) scan and pure-tone audiogram were done in all patients before surgery. In our study, age, sex, operation side, perforation size, used graft material, surgical approach, pre- and postoperative hearing profile, and status of the graft after surgery were documented in both groups of patients. In the first group of patients, the dried temporalis fascia was kept over the malleus with an overlay-underlay technique and the graft material was supported by gelfoam in both sides. In the second group of patients, the tragal cartilage was prepared as a chondroperichondrial graft [Figure 2]b, placed over the malleus fitted with a split made in the cartilage [Figure 3] overlay-underlay technique and the middle ear was filled with gelfoam. All the patients attended the otorhinolaryngology outpatient department for checkup at the postoperative 1st week and 1st month. Postoperative hearing assessment with pure-tone audiogram was done on the 1st, 3rd, and 6th months after the operation. The clinical and demographic data of the two groups were compared statistically. The preoperative and postoperative air–bone gaps (ABGs), hearing gains, and successful postoperative graft uptake were compared within the groups as well as between the groups. The successful graft uptake, the tympanic perforation size, and the side of ear undergone surgery were investigated. Postoperative success was considered as an intact graft without any retraction or lateralization with an ABG < 25 dB. In our study, the significance of intergroup difference was analyzed by Chi-square test. The result was significant when P < 0.05.
Figure 1: Harvesting temporalis fascia for use in tympanoplasty as the graft material

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Figure 2: (a and b): Harvesting tragal cartilage for use in tympanoplasty as the graft material

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Figure 3: Intraoperative picture of cartilage tympanoplasty showing the placement of tragal cartilage

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  Results Top


In our study, 36 tympanoplasties were conducted in the pediatric age group. There were 22 boys and 14 girls. The age ranges of the patients those included in our study were between 6 and 16 years (mean 12 years). The characteristics of the temporalis fascia and tragal cartilage groups are summarized in [Table 1]. The age, sex, operative side, surgery type, and size of perforation in tympanic membrane were almost similar in two groups with P > 0.05 [Table 1]. In our study, the successful graft uptake was higher among boys (98%) than girls (72%) (P < 0.0001). The age of the patient, perforation size, operative technique, and presence of tympanosclerosis were not significantly related to successful graft uptake. Successful graft uptakes were not significantly related with mastoidectomy. In the temporalis fascia group, the preoperative mean ABG was 35.13 dB and postoperative ABG was 17.12 dB, with a postoperative gain of 18.41 dB. The success of temporalis fascia graft uptake [Figure 4] in the first group was 89% [Table 2]. In the tragal cartilage group, the preoperative ABG was 32.42 dB and postoperative ABG was 15.13 dB, with a postoperative gain of 17.29 dB. The success and failure rates of tragal cartilage graft uptake [Figure 5] were 96% and 4%, respectively [Table 2]. The success rate of graft uptake in tragal cartilage group (96%) was better than that of the temporalis fascia group (89%), and the difference was statistically significant (P = 0.0119). The preoperative and postoperative ABG comparison in both temporalis fascia and tragal cartilage groups was statistically significant (0.0484). When comparing between the temporalis fascia and tragal cartilage groups, the mean hearing gain and ABG were statistically insignificant. The postoperative ABG was 25 dB or better in 16 (72.72%) patients in the temporalis fascia group, whereas postoperative ABG was 25 dB or better in 9 (64.28%) patients. Calculating the ratio of the patients with postoperative ABG with ≤25 dB among the two groups showed significant outcome [Table 3].
Table 1: Clinical profile of pediatric patients in the temporalis fascia and the tragal cartilage groups

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Figure 4: Postoperative picture of temporalis fascia uptake in pediatric tympanoplasty

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Table 2: Preoperative and postoperative auditory status

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Figure 5: Postoperative picture of tragal cartilage uptake in pediatric tympanoplasty

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Table 3: Comparing success rate in temporalis fascia and cartilage groups

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  Discussion Top


Chronic suppurative otitis media is a long-standing infection of the part or whole of the middle ear cleft, characterized by otorrhea, permanent perforation in the tympanic membrane, and impaired hearing. Corrective surgery such as tympanoplasty is helpful to offer dry ear with improvement in hearing. Tympanoplasty is a common operation performed in the middle ear. Over the years, continued efforts have been made by otologists to attain successful outcome. The common causes of tympanic perforations among pediatric age groups are complicated otitis media, traumatic perforation, and perforation due to previous use of myringotomy tubes. If ear drum perforation does not resolve, tympanoplasty is needed. Significant hearing loss may be due to a large perforation of tympanic membrane, which may affect speech and language development. The speech and language are badly affected if hearing loss occurs in very young age of life.[9] An important cause for performing tympanoplasty in pediatric patients is to prevent the formation of cholesteatoma due to migration of the squamous epithelium cells into the middle ear cleft and provide speech and hearing. The argument for performing tympanoplasty in children is highly appreciated for preventing complications and preserving the hearing, speech, and language. It was thought that the success of tympanoplasty is determined by multiple factors such as age of the patient, size and site of the perforation, status of middle ear and contralateral ear, graft materials used, surgical technique, surgical skill of the surgeon, and preoperative hearing status.[2] Tympanoplasty in the pediatric population is controversial as there are no fixed criteria for patient age, surgical approach, and patient selection. The age, sex, site, size of the tympanic membrane perforation, surgical technique, presence of ear discharge, status of the opposite ear, and the functional status of Eustachian tube are different parameters responsible for the success of the tympanoplasty. One study showed younger age as the only criterion for poor outcome in tympanoplasty surgery.[10] Cochlear function is usually excellent in children which probably helps for the restoration and preservation of hearing among pediatric patients.[11] In the pediatric age group, the success of tympanoplasty surgery is less when compared to that of adults. Eustachian tube dysfunction and the higher incidence of recurrent otitis media are the main reasons for the poor outcome of tympanoplasty in the pediatric age group than adults. Previously underwent adenoidectomy children show lower incidence of recurrent otitis media. The success of pediatric tympanoplasty is higher in those who had undergone adenotonsillectomy previously.[12] In medical literature, one study compared temporalis fascia and cartilage in pediatric tympanoplasty where success rate is higher in palisade cartilage tympanoplasty and the hearing gain was similar in both groups.[13] There are a number of studies comparing different materials in adults, whereas in the pediatric population, they are rare. The graft success rate was 96% in tragal cartilage group and 89% in the temporalis fascia group, and the difference was statistically significant in our study. The difference between the preoperative and postoperative ABG was statistically significant on intragroup comparison [Table 2], whereas the difference was also statistically significant when comparing between the two groups [Table 3]. Vartiainen and Vartiainen reported higher success rate for graft uptake in girls,[14] whereas Emir et al. documented that there was statistically significant difference between the male gender and graft uptake.[15] In our study, success rate is higher among boys than girls. Numerous graft materials are used in tympanoplasty. Among them, temporalis fascia is most commonly used; however, cartilage is a better graft material as it is resistant to infections and retraction.[16],[17] In one study, 96% of the pediatric and adult patients those who underwent tympanoplasty with cartilage as the graft material showed significant hearing gain.[18] Dornhoffer et al. and Zwierz A et al. compared temporalis fascia and cartilage for hearing outcomes but did not find any significant difference between these two graft materials.[18],[19] In another study of pediatric type-1 tympanoplasty, cartilage graft provided successful outcome in long-term follow-up where long-term hearing results of primary type-1 cartilage tympanoplasty were better than short-term hearing outcome.[20] Both temporalis fascia and tragal cartilage perichondrium are suitable graft materials for tympanoplasty in the pediatric age group with 83.3% of graft uptake.[21] Tragal cartilage perichondrium may be the better choice of graft material due to its higher success rates. In our study, hearing outcome and graft uptake showed statistically significant outcome when temporalis fascia and tragal cartilage were compared in pediatric tympanoplasty. The hearing outcome is superior in pediatric type-1 tympanoplasty than type-2 and type-3.[22] One study was in concordant with our result where the butterfly cartilage tympanoplasty provided excellent graft success rates and improved hearing along with lesser operating time to postaural or transcanal approach tympanoplasty.[23]

As the sample size of our study is the main limitation, it is necessary to cover a greater range of patient for evaluation and prognostic index. According to Haynes et al.,[24] it is always preferable to quantify the success of a therapeutic intervention while explaining the procedure or technique as calculated value gives them more objective data by which a decision can be made for an intervention.


  Conclusion Top


Tympanoplasty is an ideal treatment modality for tympanic membrane perforation in the pediatric age group. Tympanoplasty can be done at any age group. Graft uptake and hearing outcomes are important criteria for successful pediatric tympanoplasty. Both types of grafts can be used in children those who undergo tympanoplasty. However, hearing outcome was better in temporalis fascia and graft uptake was better in cartilage group in our study. Nowadays, pediatric tympanoplasty for tympanic membrane perforation by using temporalis fascia or cartilage graft results offers excellent outcomes similar to adult tympanoplasty.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Wakode PT, Joshi SV, Gawarle SH. Chronic suppurative otitis media in school going children. Indian J Otolaryngol Head Neck Surg 2006;58:152-5.  Back to cited text no. 1
    
2.
Uyar Y, Keles B, Koc S, Ozturk K, Arbag H. Tympanoplasty in pediatric patients. Int J Pediatr Otorhinolaryngol 2006;70:1805-9.  Back to cited text no. 2
    
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Pignataro L, Grillo Della Berta L, Capaccio P, Zaghis A. Myringoplasty in children: Anatomical and functional results. J Laryngol Otol 2001;115:369-73.  Back to cited text no. 3
    
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Eisenbeis JF, Herrmann BW. Areolar connective tissue grafts in pediatric tympanoplasty: A pilot study. Am J Otolaryngol 2004;25:79-83.  Back to cited text no. 4
    
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Sckolnick JS, Mantle B, Li J, Chi DH. Pediatric myringoplasty: Factors that affect success-a retrospective study. Laryngoscope 2008;118:723-9.  Back to cited text no. 5
    
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Collins WO, Telischi FF, Balkany TJ, Buchman CA. Pediatric tympanoplasty: Effect of contralateral ear status on outcomes. Arch Otolaryngol Head Neck Surg 2003;129:646-51.  Back to cited text no. 6
    
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Indorewala S. Dimensional stability of the free fascia grafts: An animal experiment. Laryngoscope 2002;112:727-30.  Back to cited text no. 7
    
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Demirci S, Tuzuner A, Karadas H, Acıkgoz C, Caylan R, Samim EE, et al. Comparison of temporal muscle fascia and cartilage grafts in pediatric tympanoplasties. Am J Otolaryngol 2014;35:796-9.  Back to cited text no. 8
    
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Sheahan P, O'Dwyer T, Blayney A. Results of type 1 tympanoplasty in children and parental perceptions of outcome of surgery. J Laryngol Otol 2002;116:430-4.  Back to cited text no. 9
    
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Friedman AB, Gluth MB, Moore PC, Dornhoffer JL. Outcomes of cartilage tympanoplasty in the pediatric population. Otolaryngol Head Neck Surg 2013;148:297-301.  Back to cited text no. 10
    
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Société FD. Surgical treatment of tympanic perforation in children. Arch Peidiatr 2005;12:372.  Back to cited text no. 11
    
12.
Ribeiro JC, Rui C, Natercia S, Jose R, Antonio P. Tympanoplasty in children: A review of 91 cases. Auris Nasus Larynx 2011;38:21-5.  Back to cited text no. 12
    
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Ozbek C, Ciftçi O, Tuna EE, Yazkan O, Ozdem C. A comparison of cartilage palisades and fascia in type 1 tympanoplasty in children: Anatomic and functional results. Otol Neurotol 2008;29:679-83.  Back to cited text no. 13
    
14.
Vartiainen E, Vartiainen J. Tympanoplasty in young patients: The role of adenoidectomy. Otolaryngol Head Neck Surg 1997;117:583-5.  Back to cited text no. 14
    
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Emir H, Ceylan K, Kizilkaya Z, Gocmen H, Uzunkulaoglu H, Samim E, et al. Success is a matter of experience: Type 1 tympanoplasty: Influencing factors on type 1 tympanoplasty. Eur Arch Otorhinolaryngol 2007;264:595-9.  Back to cited text no. 15
    
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Schuknecht HF, Shi SR. Surgical pathology of middle ear implants. Laryngoscope 1985;95:249-58.  Back to cited text no. 16
    
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Zhan KY, Rawlins KW, Mattingly JK, Malhotra PS, Adunka OF. Pediatric lateral graft tympanoplasty A review of 78 cases. Int J Pediatr Otorhinolaryngol 2019;119:166-70.  Back to cited text no. 17
    
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Dornhoffer J. Cartilage tympanoplasty: Indications, techniques, and outcomes in a 1,000-patient series. Laryngoscope 2003;113:1844-56.  Back to cited text no. 18
    
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Zwierz A, Haber K, Sinkiewicz A, Kalińczak-Górna P, Tyra J, Mierzwiński J. The significance of selected prognostic factors in pediatric tympanoplasty. Eur Arch Otorhinolaryngol 2019;276:323-33.  Back to cited text no. 19
    
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21.
Çayir S, Kayabaşi S. Type 1 tympanoplasty in pediatric patients: Comparison of fascia and perichondrium grafts. Int J Pediatr Otorhinolaryngol 2019;121:95-8.  Back to cited text no. 21
    
22.
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23.
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24.
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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