- Email: [email protected]
Bilateral same-day endoscopic tympanoplasty
Journal Pre-proof Bilateral same-day endoscopic tympanoplasty
Engin Dursun, Emine Demir, Suat Terzi, Zerrin Özergin Coşkun, Metin Çeliker, Özlem Çelebi Erdivanlı PII:
S0196-0709(19)31156-1
DOI:
https://doi.org/10.1016/j.amjoto.2020.102397
Reference:
YAJOT 102397
To appear in:
American Journal of Otolaryngology--Head and Neck Medicine and Surgery
Received date:
10 December 2019
Please cite this article as: E. Dursun, E. Demir, S. Terzi, et al., Bilateral same-day endoscopic tympanoplasty, American Journal of Otolaryngology--Head and Neck Medicine and Surgery(2018), https://doi.org/10.1016/j.amjoto.2020.102397
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
© 2018 Published by Elsevier.
Journal Pre-proof
Engin Dursun
2.
Emine Demir
3.
Suat Terzi
4.
Zerrin Özergin Coşkun
5.
Metin Çeliker
6.
Özlem Çelebi Erdivanlı
Recep Tayyip Erdogan University of Medicine, Department of Otorhinolaryngology
na
lP
re
1-6
-p
1.
ro of
Bilateral same-day endoscopic tympanoplasty
Corresponding Author: Emine Demir, Recep Tayyip Erdogan University of Medicine,
ur
Department of Otorhinolaryngology, Sehitler Street, No:74, Rize/ Center, Pin code: 53020, Phone: 904642130491, Fax: 904642130364, e-posta: [email protected], ORCID
Jo
ID: 0000-0003-4087-432X
Journal Pre-proof
Abstract
Purpose: Although bilateral same-day tympanoplasty is a faster and more comfortable procedure for patients, it is rarely performed due to its theoretical risks. The present study aims to evaluate the results of patients who underwent bilateral same-day endoscopic tympanoplasty. Materials and Methods: In this study, 26 patients and 52 ears were evaluated. Postoperative anatomic success rate, pre- and postoperative hearing test results, hearing gains and
ro of
postoperative complications were recorded.
Results: Postoperative anatomic success rate was 92.3% (48/52). Audiological tests revealed the preoperative air-bone gap (ABG) as 19.1±8.8 (7-35) dB and postoperative ABG as
-p
9.8±5.7 (5-25) dB. Postoperative ABG decreased significantly (p: <0.001) and 9.2±4.6 (2-23) dB hearing gain was obtained. We did not observe any significant complications.
re
Conclusion: Bilateral same-day endoscopic tympanoplasty is a feasible surgical procedure with good anatomic and functional outcomes, low complication rate and good postoperative
lP
patient comfort.
Jo
ur
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Key words: Bilateral tympanoplasty; same-day tympanoplasty; endoscopic tympanoplasty.
Journal Pre-proof
Introduction Tympanoplasty is the closure of the perforated tympanic membrane (TM) due to chronic otitis media and is one of the most common surgical procedures performed by otosurgeons. Until today, several graft materials and surgical techniques have been described for tympanoplasty 1-4. The prevalence of bilateral chronic otitis media is not clearly known; however, data suggests that 25-50% of all chronic otitis media patients has bilateral involvement 5. Until
ro of
now, bilateral same-day tympanoplasty application has been controversial. Altough bilateral same-day tympanoplasty has low cost, short surgical time, good functional and anatomical results, the otosurgeons prefer traditional approach, which is to perform the operation in
sensorineural hearing loss (SNHL)
6,7
-p
different sessions. Surgeons avoid bilateral surgery because of the risk of iatrogenic . Therefore, there exists very limited data in the
re
literature regarding same-day bilateral tympanoplasty 6.
The purpose of this study is to the evaluate anatomic and functional results of patients
na
Materials and Methods
lP
who underwent bilateral same-day endoscopic tympanoplasty.
This study was conducted in accordance with the ethical standards stated in the
Patients
Jo
2019/181).
ur
‘Declaration of Helsinki’, and was approved by the local ethics committee (protocol number:
Patients who underwent same-day bilateral tympanoplasty/myringoplasty between June 2014 and April 2019 were evaluated. Patients with a follow-up period of at least 6 months and only TM intervention were included in the study. Patients with interference of ossicular chain during operation, patients who underwent atticoantrotomy or mastoidectomy due to suspicion of mastoid or tympanum pathology, patients who did not have sufficient follow-up period and the patients who underwent revision surgery were not included in the study. The demographic data of the patients, follow-up periods according to the last visit, dimensions of the TM perforation (perforation; small if less than 1/3 of TM; medium if between 1/3 and 2/3 of TM; and large if bigger than 2/3 of TM) and surgical procedures (type
Journal Pre-proof 1 tympanoplasty, butterfly myringoplasty, fat myringoplasty) were recorded. Air-bone gap (ABG) was calculated using the differences at 4 frequencies (0.5, 1, 2, and 4 kHz) of air conduction and bone conduction averages. In addition, hearing gains were calculated from the differences between pre- and postoperative ABG results. Postoperative graft status was evaluated at the 6th month follow-up; presence of dry ears, ears with no perforation, and no graft lateralization and medialization were considered as anatomically successful.
Surgical Procedure Surgery for bilateral tympanoplasty was routinely performed under general anesthesia,
ro of
starting the side with larger perforation. Each ear was prepared separately for surgery just before the surgical procedure. The same surgical tray was used for both ears. For endoscopic ear surgery, camera head (Storz) and 0o, 14- and 18-cm, and 3- and 4-mm endoscopes (Karl
-p
Storz, Tuttlingen, Germany) connected to a high-resolution monitor were used. The surgical technique was determined depending on the location and the size of perforation, and
re
preference of the physician performing the surgery. In our clinic, fat myringoplasty or butterfly myringoplasty is usually used in small perforations, butterfly myringoplasty is
lP
performed in medium perforations and type 1 tympanoplasty with tympanomeatal flap
Statistical Analysis
na
elevation is preferred in large perforations.
ur
Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) version 20.0 (SPSS Inc.; Chicago, IL, USA). Frequency analysis and t-test were used
Results
Jo
to evaluate the data. Statistical significance level was taken as p<0.05.
Twenty-six patients and 52 ears were included in the study. Fourteen patients (60.7%) were female and 12 (39.3%) were male. The mean age was 34.3±12.4 (16-54) years. The mean follow-up period was 19.2±9.4 (7-42) months. Fat myringoplasty was performed for 6 ears, butterfly myringoplasty for 30 ears and type 1 tympanoplasty for 16 ears. Post-operative anatomic success rate was 92.3%. The dimensions of TM perforation, surgical techniques, and anatomic success rates are presented in Table 1.
Journal Pre-proof
Table 1: Anatomical success rate of the ears according to tympanic membrane perforation size, and surgical techniques. Medium perforation 2/2 (100%) 19/20 (95%) 21/22 (95.4%)
Large perforation 13/14 (92.7%) 5/6 (83.3%) 18/20 (90%)
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Small perforation Type 1 tympanoplasty Butterfly myringoplasty 4/4 (100%) Fat myringoplasty 5/6 (83.3%) Total 9/10 (90%)
Total 15/16 (93.7%) 28/30 (93.3%) 5/6 (83.3%) 48/52 (92.3%)
-p
Considering pure tone audiometry tests, preoperative ABG decreased from 19.1±8.8 (7-35) dB to 9.8±5.7 (5-25) dB postoperatively (p <0.001). Mean hearing gain was 9.2±4.6
re
(2-23) dB. The ears were also evaluated separately as right and left. Preoperative ABG of the
lP
right ear decreased from 18.7±8.3 (8-35) dB to 9.1±5.4 (5-22) dB postoperatively (p <0.001). Mean hearing gain was 9.6±4.4 (2-20) dB. Preoperative ABG of the left ear lessened from 19.6.3±9.4 (7-35) dB to 10.8±6 (5-25) dB postoperatively (p <0.001). Mean hearing gain was
na
8.7±4.9 (2-23) dB. No complications including postoperative SNHL, tinnitus, significant
Jo
Discussion
ur
disturbing taste problem and facial paralysis were observed in any patient.
We obtained 92.3% anatomic success rate and significant postoperative hearing gain in patients who underwent bilateral same-day endoscopic tympanoplasty in our study. We found that bilateral same-day endoscopic tympanoplasty is feasible having satisfactory surgical results without complications. Bilateral chronic tympanic membrane perforation carries difficulties for ear surgeons in their decision of treatment. One of these worries is about performing the surgery on the same day. The risk of postoperative iatrogenic SNHL, which may occur especially during ossicular chain injury or manipulation, averts surgeons from performing bilateral same-day tympanoplasty 8,9. The rate of iatrogenic hearing loss following tympanoplasty is between 1.24.5% 9. In our study, SNHL was not observed in any patient. It is thought that tinnitus due to peroperative ossicular manipulations and taste disturbance due to chorda tympani damage of bilateral ears may cause more discomfort in
Journal Pre-proof patients undergoing bilateral same-day tympanoplasty. In addition, the need for wound care lasting up to postoperative 1 month and hearing difficulties in the postoperative period due to the presence of bilateral dressings may become obstacles for bilateral same-day surgery 8,10,11. However, Caye-Thomasen and coworkers
12
revealed that patients with same-day bilateral
myringoplasty application tolerated postoperative hearing discomfort caused by packing in the external auditory canal. They also revealed bilateral same-day surgery as advantageous because of reduced postoperative clinical visits and follow-up processes. No significant discomfort was observed in any of our patients due to dressing. We think that endoscopic application of tympanoplasty to our patients presents a significant advantage in this regard.
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We conclude that endoscopic tympanoplasty minimizes postoperative discomfort in bilateral same-day operations due to no head bandage application, less requirement of frequent dressing, and lack of postauricular incision. In addition, same-day surgery may be more
-p
comfortable since the patients experience this process only once rather than repeating the same procedure twice and get rid of the disease in both ears at once. We did not observe
re
tinnitus or any taste problem in our patients. We think that careful manipulations of the tympanic cavity during surgery can prevent the tinnitus and minimize taste problems. On the
lP
other hand, in endoscopic ear surgery, unlike traditional ear surgeries, do not require postauricular incision, postoperative wound care, and dressing which leaves a small incision
na
in the area where the graft is removed. This is an important advantage in bilateral same-day application. We think that informing the patient in the preoperative period that external ear
ur
canals will be kept closed bilaterally during postoperative healing period will increase the patient’s adaptation to the postoperative period.
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Some researchers argue that complication rates increase with same-day bilateral TM perforation repair 8. In our study, no complications were observed. This might be related to bilateral tympanoplasty procedure only. In other words, longer procedures such as ossiculoplasty and mastoidectomy may lead to fatigue and attention problems in the surgeon, leading to increased complication rates and lower success rates. Contrary to these researchers according to some authors, as in our study, bilateral same-day tympanoplasty has low complication rates
6,8
. However, as far as we know, there are no studies that present
comparative data on unilateral and bilateral same-day tympanoplasty. Suzuki et al. 13 reported that long-term anaesthesia in tympanoplasty surgery might increase early local wound complications. Therefore, we think that prolonged surgical time in bilateral same-day tympanoplasty might adversely affect wound healing. This can be evaluated by comparative future studies that presenting the results of unilateral and bilateral same-day tympanoplasty.
Journal Pre-proof There are a limited number of studies on bilateral same-day tympanoplasty in the literature and these studies report successful anatomical and functional outcomes
8,10,14
. Kim
et al.8 and Yu et al.10 reported good functional and anatomical outcomes for the patients who underwent bilateral middle ear surgery in the same session. Daneshi and coworkers
14
presented the results of 9 patients who underwent bilateral endoscopic cartilage tympanoplasty. Evaluating the anatomical and functional results, they stated that bilateral tympanoplasty was feasible. In our study, bilateral same-day endoscopic tympanoplasty was performed in 26 patients and anatomic success rate was 92.3%, in addition to a significant decrease in preoperative ABG in the postoperative period, and satisfactory hearing gain. If
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there is no gelfoam placed in the middle ear after tympanoplasty, the patients will reach the hearing level to communicate socially comfortable shortly after the removal of the pack in the external auditory canal, and if any, at the latest after the 6th week. However, permanent
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hearing loss which especially if the pathology is bilateral, can be a serious cause of morbidity at after surgery. Therefore, we routinely recommend conventional hearing aids for patients
re
with bilateral hearing loss after surgery in our clinic. If patients do not benefit from this, we suggest that bone conduction hearing aids for hearing rehabilitation.
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Various graft materials such as fascia, perichondrium, cartilage, and fat can be used to closure of the tympanic perforation. Several factors such as the surgeon’s experience, size of
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the perforation, middle ear pressure, and revision of the surgery are decisive for the material to be preferred 15,16. In our clinic, we usually prefer cartilage grafts for medium and large size
ur
perforations, while we use fat grafts for small size perforations. However, in our study, we achieved over 90% graft anatomical success rate in patients we used cartilage grafts, whereas
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this rate was 83.3% for the patients we used fat grafts. According to these results, suggesting that fat myringoplasty can be performed only as an office procedure for the repair of small tympanic membrane perforations. However, we think that, if we perform bilateral same-day tympanoplasty under general anaesthesia, the closure of the tympanic membrane perforation by cartilage can be considered a more correct option for patients. Bilateral same-day tympanoplasty has been reported to have lower cost and shorter surgical time than staged surgery 5. In our study, we did not present a staged surgery group, so we could not evaluate the cost and duration comparatively. However, we think that the duration of surgery can not be significantly affected and only anaesthesia time can be shortened. In addition, using the same surgical tray for both ears can reduce costs. Performing two-sided cochlear implants in a single surgical procedure is called ' simultaneous bilateral cochlear implantation’
17
. In the literature, implementing bilateral
Journal Pre-proof tympanoplasty in a single surgical procedure is referred to as ‘bilateral same-day tympanoplasty’
10,14
. We think that the term ‘simultaneous bilateral tympanoplasty’ can be
used for the expression of ‘bilateral same-day tympanoplasty’, as in cochlear implant. It is appropriate to perform ossicular chain manipulations as carefully as possible to prevent hearing loss and tinnitus in ear surgeries. Particularly, same-day application of bilateral surgery poses a greater risk for complications. Therefore, we believe that in the hands of an experienced surgeon, this risk may not cause serious problems. In addition, all patients who are planned to undergo bilateral tympanoplasty should be informed regarding the complications of the procedure and that only one ear might be operated during surgery.
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Because, in case of a damage in the ossicular chain in the first operated side, or an opening in the oval or round window membrane, the surgeon can stop the surgery by completing one side without performing the operation for the other side.
-p
Our study has some limitations. Firstly, our study includes a small group of patients. Secondly, we did not enroll a patient group who underwent microscopic surgery. Lastly, our
re
study is retrospective and our results should be reviewed accordingly. Comparison of the results of endoscopic surgery in different patient groups having bilateral same-day
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Conclusion
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tympanoplasty with microscopic application may provide important information.
The results of our study suggest that bilateral same-day endoscopic tympanoplasty is a
ur
feasible surgical procedure with satisfactory anatomic and functional results, low
Jo
complication rates and post-operative patient comfort. Acknowledgements: The authors thank Professor M. Emre Durakoğlugil, M.D. for editorial supervision.
Financial Disclosure: None Conflict of Interest: None
Journal Pre-proof
References 1- Yegin Y, Çelik M, Koç AK, Küfeciler L, Elbistanlı MS, Kayhan FT. Comparison of temporalis fascia muscle and full-thickness cartilage grafts in type 1 pediatric
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tympanoplasties. Braz J Otorhinolaryngol. 2016;82(6):695–701. 2- Şen A, Özdamar K. Endoscopic tympanoplasty with limited tympanomeatal flap elevation in pediatric cases: comparison of anatomic and audiological results of grafts.
-p
Eur Arch Otorhinolaryngol. 2019 Sep;276(9):2427-2432.
3- Lee S, Cho HH. Transcanal Endoscopic Tympanoplasty for Pediatric Patients Under
doi: 10.21053/ceo.2019.00318.
re
15 Years of Age with Chronic Otitis Media. Clin Exp Otorhinolaryngol. 2019 Aug 3.
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4- Demirci S, Tuzuner A, Karadas H, Acıkgoz C, Caylan R, Samim EE. Comparison of temporal muscle fascia and cartilage grafts in pediatric tympanoplasties. Am J
na
Otolaryngol. 2014 Nov-Dec;35(6):796-799. 5- Olusesi AD, Oyeniran O. Outcome and cost analysis of bilateral sequential same-day
ur
cartilage tympanoplasty compared with bilateral staged tympanoplasty. J Laryngol Otol. 2017 May;131(5):399-403.
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6- Rai AK, Singh GB, Sahu R, Singh S, Arora R. Evaluation of simultaneous bilateral same day tympanoplasty type I in chronic suppurative otitis media. Auris Nasus Larynx. 2014 Apr;41(2):148-152. 7- Kazikdas KC, Onal K, Yildrim N. Sensorineural hearing loss after ossicular manipulation and drill-generated acoustic trauma in type 1 tympanoplasty with and without mastoidectomy: a series of 51 cases. Ear Nose Throat J. 2015;94:378–398. 8- Kim CW, Lee JS, Park CH, Kwon SY, Kim DK, Lee JH. Comparison of sequential same-day middle ear surgeries: bilateral mastoidectomy, unilateral mastoidectomy with
contralateral
tympanoplasty,
and
bilateral
tympanoplasty.
Eur
Arch
Otorhinolaryngol. 2015;272:1395-1402. 9- Tos M, Lau T, Plate S. Sensorineural hearing loss following chronic ear surgery. Ann Otol Rhinol Laryngol. 1984;93:403-409.
Journal Pre-proof 10- Yu MS, Yoon TH. Bilateral same-day surgery for bilateral perforated chronic otitis media: inlay butterfly cartilage myringoplasty. Otolaryngol Head Neck Surg. 2010;143:669-672. 11- Guinand N, Just T, Stow NW, Van HC, Landis BN. Cutting the chorda tympani: not just a matter of taste. J Laryngol Otol. 2010;124(9):999–1002. 12- Caye-Thomasen P, Nielsen TR, Tos M. Bilateral myringoplasty in chronic otitis media. Laryngoscope. 2007;117(5):903–906. 13- Suzuki S, Yasunaga H, Matsui H, Fushimi K, Yamasoba T. Factors associated with prolonged duration of post-tympanoplasty local treatment in adult chronic otitis media
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patients: A retrospective observational study using a Japanese inpatient database. Auris Nasus Larynx. 2016;43:377–81
14- Daneshi A, Jahandideh H, Daneshvar A, Safdarian M. Bilateral same-day endoscopic
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transcanal cartilage tympanoplasty: initial results. Braz J Otorhinolaryngol. 2017 Jul Aug;83(4):411-415.
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15- Wasson JD, Papadimitriou CE, Pau H. Myringoplasty: impact of perforation size on closure and audiological improvement. J Laryngol Otol. 2009;123(9):973-7.
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16- Eldaebes MMAS, Landry TG, Bance ML. Repair of subtotal tympanic membrane perforations: A temporal bone study of several tympanoplasty materials. PLoS One.
na
2019 Sep 19;14(9):e0222728.
17- Cheng LJ, Soon SS, Wu DB, Ju H, Ng K. Cost-effectiveness analysis of bilateral
ur
cochlear implants for children with severe-to-profound sensorineural hearing loss in
Jo
both ears in Singapore. PLoS One. 2019 Aug;14(8):e0220439.
Journal Pre-proof Author statement Engin Dursun: Supervision, Writing - Review & Editing Emine Demir: Conceptualization, Writing - Original Draft Suat Terzi: Methodology, Software Zerrin Özergin Coşkun: Resources, Validation Metin Çeliker: Data Curation, Formal analysis
Jo
ur
na
lP
re
-p
ro of
Özlem Çelebi Erdivanlı: Visualization, Conceptualization
Engin Dursun, Emine Demir, Suat Terzi, Zerrin Özergin Coşkun, Metin Çeliker, Özlem Çelebi Erdivanlı PII:
S0196-0709(19)31156-1
DOI:
https://doi.org/10.1016/j.amjoto.2020.102397
Reference:
YAJOT 102397
To appear in:
American Journal of Otolaryngology--Head and Neck Medicine and Surgery
Received date:
10 December 2019
Please cite this article as: E. Dursun, E. Demir, S. Terzi, et al., Bilateral same-day endoscopic tympanoplasty, American Journal of Otolaryngology--Head and Neck Medicine and Surgery(2018), https://doi.org/10.1016/j.amjoto.2020.102397
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
© 2018 Published by Elsevier.
Journal Pre-proof
Engin Dursun
2.
Emine Demir
3.
Suat Terzi
4.
Zerrin Özergin Coşkun
5.
Metin Çeliker
6.
Özlem Çelebi Erdivanlı
Recep Tayyip Erdogan University of Medicine, Department of Otorhinolaryngology
na
lP
re
1-6
-p
1.
ro of
Bilateral same-day endoscopic tympanoplasty
Corresponding Author: Emine Demir, Recep Tayyip Erdogan University of Medicine,
ur
Department of Otorhinolaryngology, Sehitler Street, No:74, Rize/ Center, Pin code: 53020, Phone: 904642130491, Fax: 904642130364, e-posta: [email protected], ORCID
Jo
ID: 0000-0003-4087-432X
Journal Pre-proof
Abstract
Purpose: Although bilateral same-day tympanoplasty is a faster and more comfortable procedure for patients, it is rarely performed due to its theoretical risks. The present study aims to evaluate the results of patients who underwent bilateral same-day endoscopic tympanoplasty. Materials and Methods: In this study, 26 patients and 52 ears were evaluated. Postoperative anatomic success rate, pre- and postoperative hearing test results, hearing gains and
ro of
postoperative complications were recorded.
Results: Postoperative anatomic success rate was 92.3% (48/52). Audiological tests revealed the preoperative air-bone gap (ABG) as 19.1±8.8 (7-35) dB and postoperative ABG as
-p
9.8±5.7 (5-25) dB. Postoperative ABG decreased significantly (p: <0.001) and 9.2±4.6 (2-23) dB hearing gain was obtained. We did not observe any significant complications.
re
Conclusion: Bilateral same-day endoscopic tympanoplasty is a feasible surgical procedure with good anatomic and functional outcomes, low complication rate and good postoperative
lP
patient comfort.
Jo
ur
na
Key words: Bilateral tympanoplasty; same-day tympanoplasty; endoscopic tympanoplasty.
Journal Pre-proof
Introduction Tympanoplasty is the closure of the perforated tympanic membrane (TM) due to chronic otitis media and is one of the most common surgical procedures performed by otosurgeons. Until today, several graft materials and surgical techniques have been described for tympanoplasty 1-4. The prevalence of bilateral chronic otitis media is not clearly known; however, data suggests that 25-50% of all chronic otitis media patients has bilateral involvement 5. Until
ro of
now, bilateral same-day tympanoplasty application has been controversial. Altough bilateral same-day tympanoplasty has low cost, short surgical time, good functional and anatomical results, the otosurgeons prefer traditional approach, which is to perform the operation in
sensorineural hearing loss (SNHL)
6,7
-p
different sessions. Surgeons avoid bilateral surgery because of the risk of iatrogenic . Therefore, there exists very limited data in the
re
literature regarding same-day bilateral tympanoplasty 6.
The purpose of this study is to the evaluate anatomic and functional results of patients
na
Materials and Methods
lP
who underwent bilateral same-day endoscopic tympanoplasty.
This study was conducted in accordance with the ethical standards stated in the
Patients
Jo
2019/181).
ur
‘Declaration of Helsinki’, and was approved by the local ethics committee (protocol number:
Patients who underwent same-day bilateral tympanoplasty/myringoplasty between June 2014 and April 2019 were evaluated. Patients with a follow-up period of at least 6 months and only TM intervention were included in the study. Patients with interference of ossicular chain during operation, patients who underwent atticoantrotomy or mastoidectomy due to suspicion of mastoid or tympanum pathology, patients who did not have sufficient follow-up period and the patients who underwent revision surgery were not included in the study. The demographic data of the patients, follow-up periods according to the last visit, dimensions of the TM perforation (perforation; small if less than 1/3 of TM; medium if between 1/3 and 2/3 of TM; and large if bigger than 2/3 of TM) and surgical procedures (type
Journal Pre-proof 1 tympanoplasty, butterfly myringoplasty, fat myringoplasty) were recorded. Air-bone gap (ABG) was calculated using the differences at 4 frequencies (0.5, 1, 2, and 4 kHz) of air conduction and bone conduction averages. In addition, hearing gains were calculated from the differences between pre- and postoperative ABG results. Postoperative graft status was evaluated at the 6th month follow-up; presence of dry ears, ears with no perforation, and no graft lateralization and medialization were considered as anatomically successful.
Surgical Procedure Surgery for bilateral tympanoplasty was routinely performed under general anesthesia,
ro of
starting the side with larger perforation. Each ear was prepared separately for surgery just before the surgical procedure. The same surgical tray was used for both ears. For endoscopic ear surgery, camera head (Storz) and 0o, 14- and 18-cm, and 3- and 4-mm endoscopes (Karl
-p
Storz, Tuttlingen, Germany) connected to a high-resolution monitor were used. The surgical technique was determined depending on the location and the size of perforation, and
re
preference of the physician performing the surgery. In our clinic, fat myringoplasty or butterfly myringoplasty is usually used in small perforations, butterfly myringoplasty is
lP
performed in medium perforations and type 1 tympanoplasty with tympanomeatal flap
Statistical Analysis
na
elevation is preferred in large perforations.
ur
Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) version 20.0 (SPSS Inc.; Chicago, IL, USA). Frequency analysis and t-test were used
Results
Jo
to evaluate the data. Statistical significance level was taken as p<0.05.
Twenty-six patients and 52 ears were included in the study. Fourteen patients (60.7%) were female and 12 (39.3%) were male. The mean age was 34.3±12.4 (16-54) years. The mean follow-up period was 19.2±9.4 (7-42) months. Fat myringoplasty was performed for 6 ears, butterfly myringoplasty for 30 ears and type 1 tympanoplasty for 16 ears. Post-operative anatomic success rate was 92.3%. The dimensions of TM perforation, surgical techniques, and anatomic success rates are presented in Table 1.
Journal Pre-proof
Table 1: Anatomical success rate of the ears according to tympanic membrane perforation size, and surgical techniques. Medium perforation 2/2 (100%) 19/20 (95%) 21/22 (95.4%)
Large perforation 13/14 (92.7%) 5/6 (83.3%) 18/20 (90%)
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Small perforation Type 1 tympanoplasty Butterfly myringoplasty 4/4 (100%) Fat myringoplasty 5/6 (83.3%) Total 9/10 (90%)
Total 15/16 (93.7%) 28/30 (93.3%) 5/6 (83.3%) 48/52 (92.3%)
-p
Considering pure tone audiometry tests, preoperative ABG decreased from 19.1±8.8 (7-35) dB to 9.8±5.7 (5-25) dB postoperatively (p <0.001). Mean hearing gain was 9.2±4.6
re
(2-23) dB. The ears were also evaluated separately as right and left. Preoperative ABG of the
lP
right ear decreased from 18.7±8.3 (8-35) dB to 9.1±5.4 (5-22) dB postoperatively (p <0.001). Mean hearing gain was 9.6±4.4 (2-20) dB. Preoperative ABG of the left ear lessened from 19.6.3±9.4 (7-35) dB to 10.8±6 (5-25) dB postoperatively (p <0.001). Mean hearing gain was
na
8.7±4.9 (2-23) dB. No complications including postoperative SNHL, tinnitus, significant
Jo
Discussion
ur
disturbing taste problem and facial paralysis were observed in any patient.
We obtained 92.3% anatomic success rate and significant postoperative hearing gain in patients who underwent bilateral same-day endoscopic tympanoplasty in our study. We found that bilateral same-day endoscopic tympanoplasty is feasible having satisfactory surgical results without complications. Bilateral chronic tympanic membrane perforation carries difficulties for ear surgeons in their decision of treatment. One of these worries is about performing the surgery on the same day. The risk of postoperative iatrogenic SNHL, which may occur especially during ossicular chain injury or manipulation, averts surgeons from performing bilateral same-day tympanoplasty 8,9. The rate of iatrogenic hearing loss following tympanoplasty is between 1.24.5% 9. In our study, SNHL was not observed in any patient. It is thought that tinnitus due to peroperative ossicular manipulations and taste disturbance due to chorda tympani damage of bilateral ears may cause more discomfort in
Journal Pre-proof patients undergoing bilateral same-day tympanoplasty. In addition, the need for wound care lasting up to postoperative 1 month and hearing difficulties in the postoperative period due to the presence of bilateral dressings may become obstacles for bilateral same-day surgery 8,10,11. However, Caye-Thomasen and coworkers
12
revealed that patients with same-day bilateral
myringoplasty application tolerated postoperative hearing discomfort caused by packing in the external auditory canal. They also revealed bilateral same-day surgery as advantageous because of reduced postoperative clinical visits and follow-up processes. No significant discomfort was observed in any of our patients due to dressing. We think that endoscopic application of tympanoplasty to our patients presents a significant advantage in this regard.
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We conclude that endoscopic tympanoplasty minimizes postoperative discomfort in bilateral same-day operations due to no head bandage application, less requirement of frequent dressing, and lack of postauricular incision. In addition, same-day surgery may be more
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comfortable since the patients experience this process only once rather than repeating the same procedure twice and get rid of the disease in both ears at once. We did not observe
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tinnitus or any taste problem in our patients. We think that careful manipulations of the tympanic cavity during surgery can prevent the tinnitus and minimize taste problems. On the
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other hand, in endoscopic ear surgery, unlike traditional ear surgeries, do not require postauricular incision, postoperative wound care, and dressing which leaves a small incision
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in the area where the graft is removed. This is an important advantage in bilateral same-day application. We think that informing the patient in the preoperative period that external ear
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canals will be kept closed bilaterally during postoperative healing period will increase the patient’s adaptation to the postoperative period.
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Some researchers argue that complication rates increase with same-day bilateral TM perforation repair 8. In our study, no complications were observed. This might be related to bilateral tympanoplasty procedure only. In other words, longer procedures such as ossiculoplasty and mastoidectomy may lead to fatigue and attention problems in the surgeon, leading to increased complication rates and lower success rates. Contrary to these researchers according to some authors, as in our study, bilateral same-day tympanoplasty has low complication rates
6,8
. However, as far as we know, there are no studies that present
comparative data on unilateral and bilateral same-day tympanoplasty. Suzuki et al. 13 reported that long-term anaesthesia in tympanoplasty surgery might increase early local wound complications. Therefore, we think that prolonged surgical time in bilateral same-day tympanoplasty might adversely affect wound healing. This can be evaluated by comparative future studies that presenting the results of unilateral and bilateral same-day tympanoplasty.
Journal Pre-proof There are a limited number of studies on bilateral same-day tympanoplasty in the literature and these studies report successful anatomical and functional outcomes
8,10,14
. Kim
et al.8 and Yu et al.10 reported good functional and anatomical outcomes for the patients who underwent bilateral middle ear surgery in the same session. Daneshi and coworkers
14
presented the results of 9 patients who underwent bilateral endoscopic cartilage tympanoplasty. Evaluating the anatomical and functional results, they stated that bilateral tympanoplasty was feasible. In our study, bilateral same-day endoscopic tympanoplasty was performed in 26 patients and anatomic success rate was 92.3%, in addition to a significant decrease in preoperative ABG in the postoperative period, and satisfactory hearing gain. If
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there is no gelfoam placed in the middle ear after tympanoplasty, the patients will reach the hearing level to communicate socially comfortable shortly after the removal of the pack in the external auditory canal, and if any, at the latest after the 6th week. However, permanent
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hearing loss which especially if the pathology is bilateral, can be a serious cause of morbidity at after surgery. Therefore, we routinely recommend conventional hearing aids for patients
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with bilateral hearing loss after surgery in our clinic. If patients do not benefit from this, we suggest that bone conduction hearing aids for hearing rehabilitation.
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Various graft materials such as fascia, perichondrium, cartilage, and fat can be used to closure of the tympanic perforation. Several factors such as the surgeon’s experience, size of
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the perforation, middle ear pressure, and revision of the surgery are decisive for the material to be preferred 15,16. In our clinic, we usually prefer cartilage grafts for medium and large size
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perforations, while we use fat grafts for small size perforations. However, in our study, we achieved over 90% graft anatomical success rate in patients we used cartilage grafts, whereas
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this rate was 83.3% for the patients we used fat grafts. According to these results, suggesting that fat myringoplasty can be performed only as an office procedure for the repair of small tympanic membrane perforations. However, we think that, if we perform bilateral same-day tympanoplasty under general anaesthesia, the closure of the tympanic membrane perforation by cartilage can be considered a more correct option for patients. Bilateral same-day tympanoplasty has been reported to have lower cost and shorter surgical time than staged surgery 5. In our study, we did not present a staged surgery group, so we could not evaluate the cost and duration comparatively. However, we think that the duration of surgery can not be significantly affected and only anaesthesia time can be shortened. In addition, using the same surgical tray for both ears can reduce costs. Performing two-sided cochlear implants in a single surgical procedure is called ' simultaneous bilateral cochlear implantation’
17
. In the literature, implementing bilateral
Journal Pre-proof tympanoplasty in a single surgical procedure is referred to as ‘bilateral same-day tympanoplasty’
10,14
. We think that the term ‘simultaneous bilateral tympanoplasty’ can be
used for the expression of ‘bilateral same-day tympanoplasty’, as in cochlear implant. It is appropriate to perform ossicular chain manipulations as carefully as possible to prevent hearing loss and tinnitus in ear surgeries. Particularly, same-day application of bilateral surgery poses a greater risk for complications. Therefore, we believe that in the hands of an experienced surgeon, this risk may not cause serious problems. In addition, all patients who are planned to undergo bilateral tympanoplasty should be informed regarding the complications of the procedure and that only one ear might be operated during surgery.
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Because, in case of a damage in the ossicular chain in the first operated side, or an opening in the oval or round window membrane, the surgeon can stop the surgery by completing one side without performing the operation for the other side.
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Our study has some limitations. Firstly, our study includes a small group of patients. Secondly, we did not enroll a patient group who underwent microscopic surgery. Lastly, our
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study is retrospective and our results should be reviewed accordingly. Comparison of the results of endoscopic surgery in different patient groups having bilateral same-day
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Conclusion
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tympanoplasty with microscopic application may provide important information.
The results of our study suggest that bilateral same-day endoscopic tympanoplasty is a
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feasible surgical procedure with satisfactory anatomic and functional results, low
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complication rates and post-operative patient comfort. Acknowledgements: The authors thank Professor M. Emre Durakoğlugil, M.D. for editorial supervision.
Financial Disclosure: None Conflict of Interest: None
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References 1- Yegin Y, Çelik M, Koç AK, Küfeciler L, Elbistanlı MS, Kayhan FT. Comparison of temporalis fascia muscle and full-thickness cartilage grafts in type 1 pediatric
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tympanoplasties. Braz J Otorhinolaryngol. 2016;82(6):695–701. 2- Şen A, Özdamar K. Endoscopic tympanoplasty with limited tympanomeatal flap elevation in pediatric cases: comparison of anatomic and audiological results of grafts.
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Eur Arch Otorhinolaryngol. 2019 Sep;276(9):2427-2432.
3- Lee S, Cho HH. Transcanal Endoscopic Tympanoplasty for Pediatric Patients Under
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15 Years of Age with Chronic Otitis Media. Clin Exp Otorhinolaryngol. 2019 Aug 3.
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4- Demirci S, Tuzuner A, Karadas H, Acıkgoz C, Caylan R, Samim EE. Comparison of temporal muscle fascia and cartilage grafts in pediatric tympanoplasties. Am J
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Otolaryngol. 2014 Nov-Dec;35(6):796-799. 5- Olusesi AD, Oyeniran O. Outcome and cost analysis of bilateral sequential same-day
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cartilage tympanoplasty compared with bilateral staged tympanoplasty. J Laryngol Otol. 2017 May;131(5):399-403.
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6- Rai AK, Singh GB, Sahu R, Singh S, Arora R. Evaluation of simultaneous bilateral same day tympanoplasty type I in chronic suppurative otitis media. Auris Nasus Larynx. 2014 Apr;41(2):148-152. 7- Kazikdas KC, Onal K, Yildrim N. Sensorineural hearing loss after ossicular manipulation and drill-generated acoustic trauma in type 1 tympanoplasty with and without mastoidectomy: a series of 51 cases. Ear Nose Throat J. 2015;94:378–398. 8- Kim CW, Lee JS, Park CH, Kwon SY, Kim DK, Lee JH. Comparison of sequential same-day middle ear surgeries: bilateral mastoidectomy, unilateral mastoidectomy with
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tympanoplasty,
and
bilateral
tympanoplasty.
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Arch
Otorhinolaryngol. 2015;272:1395-1402. 9- Tos M, Lau T, Plate S. Sensorineural hearing loss following chronic ear surgery. Ann Otol Rhinol Laryngol. 1984;93:403-409.
Journal Pre-proof 10- Yu MS, Yoon TH. Bilateral same-day surgery for bilateral perforated chronic otitis media: inlay butterfly cartilage myringoplasty. Otolaryngol Head Neck Surg. 2010;143:669-672. 11- Guinand N, Just T, Stow NW, Van HC, Landis BN. Cutting the chorda tympani: not just a matter of taste. J Laryngol Otol. 2010;124(9):999–1002. 12- Caye-Thomasen P, Nielsen TR, Tos M. Bilateral myringoplasty in chronic otitis media. Laryngoscope. 2007;117(5):903–906. 13- Suzuki S, Yasunaga H, Matsui H, Fushimi K, Yamasoba T. Factors associated with prolonged duration of post-tympanoplasty local treatment in adult chronic otitis media
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patients: A retrospective observational study using a Japanese inpatient database. Auris Nasus Larynx. 2016;43:377–81
14- Daneshi A, Jahandideh H, Daneshvar A, Safdarian M. Bilateral same-day endoscopic
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transcanal cartilage tympanoplasty: initial results. Braz J Otorhinolaryngol. 2017 Jul Aug;83(4):411-415.
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15- Wasson JD, Papadimitriou CE, Pau H. Myringoplasty: impact of perforation size on closure and audiological improvement. J Laryngol Otol. 2009;123(9):973-7.
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16- Eldaebes MMAS, Landry TG, Bance ML. Repair of subtotal tympanic membrane perforations: A temporal bone study of several tympanoplasty materials. PLoS One.
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2019 Sep 19;14(9):e0222728.
17- Cheng LJ, Soon SS, Wu DB, Ju H, Ng K. Cost-effectiveness analysis of bilateral
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cochlear implants for children with severe-to-profound sensorineural hearing loss in
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both ears in Singapore. PLoS One. 2019 Aug;14(8):e0220439.
Journal Pre-proof Author statement Engin Dursun: Supervision, Writing - Review & Editing Emine Demir: Conceptualization, Writing - Original Draft Suat Terzi: Methodology, Software Zerrin Özergin Coşkun: Resources, Validation Metin Çeliker: Data Curation, Formal analysis
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Özlem Çelebi Erdivanlı: Visualization, Conceptualization