Bilateral same day surgery for bilateral perforated chronic otitis media

Bilateral same day surgery for bilateral perforated chronic otitis media

Auris Nasus Larynx 27 (2000) 35 – 38 www.elsevier.com/locate/anl Bilateral same day surgery for bilateral perforated chronic otitis media M. Sakagam...

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Auris Nasus Larynx 27 (2000) 35 – 38 www.elsevier.com/locate/anl

Bilateral same day surgery for bilateral perforated chronic otitis media M. Sakagami a,*, Y. Mishiro b, K. Tsuzuki a, T. Seo a, M. Sone a a b

Department of Otolaryngology, Hyogo College of Medicine, 1 -1 Mukogawa, Nishinomiya City, Hyogo 663 -8501, Japan Department of Otolaryngology, Osaka Uni6ersity Medical School, 2 -2 Yamadaoka, Suita City, Osaka 565 -0871, Japan Received 11 December 1998; received in revised form 1 February 1999; accepted 12 March 1999

Abstract Objecti6e: Bilateral same day surgery has been performed rarely because of the risk of postoperative sensorineural hearing loss following conventional myringoplasty or tympanoplasty (CMT). Simple underlay myringoplasty (SUM) through the ear canal has been developed by Yuasa R, Saijo S, Tomioka Y, et al. Office closure of eardrum perforation with fibrin glue (in Japanese), Otolaryngol Head Neck Surg (Tokyo) 1989;61:1117–1122, which has little risk of sensorineural hearing loss. We tried bilateral same day surgery using this technique and evaluated its outcome. Methods: Of 86 cases with bilateral perforated chronic otitis media that we treated between 1995 – 1997, 25 cases underwent bilateral same day surgery. Bilateral SUMs was performed on seven patients, SUM and CMT on 16 patients, and bilateral CMTs on two patients. Results: Closure of perforation was successful in 18 patients (72%) on both sides and in seven patients (28%) on one side. Postoperative air–bone gap of less than 20 dB was achieved in 15 cases (60%) on both sides and in 23 cases (92%) on one side. Conclusion: Bilateral same day surgery for bilateral perforated chronic otitis media is possible if the operative indications are considered. © 2000 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Bilateral chronic otitis media; Sensorineural hearing loss; Bilateral same day surgery; Tympanic perforation

1. Introduction When patients had bilateral perforated chronic otitis media and requested ear surgery on both sides by same day surgery, ear surgeons hesitated to operate on both sides because of the risk of postoperative sensorineural hearing loss [1–3]. Recently, Yuasa et al. have developed simple underlay myringoplasty (SUM) through the ear canal which has very little risk of sensorineural hearing loss and a high percentage of successful closure of tympanic perforation [4 – 6]. In Japan, a few reports of bilateral same day surgery were presented using this technique. Few cases have so far been treated and the trials were considered to be pilot studies. 

The present study was partly presented at the 21st Annual Meeting of Politzer Society at Antalya, Turkey, on 8–11 June, 1998. * Corresponding author. Tel.: +81-798-456493; fax: + 81-798418976. E-mail address: [email protected] (M. Sakagami)

In the present study, we reviewed the results of bilateral same day surgery for perforated chronic otitis media and discussed its indications.

2. Subjects and methods Two hundred and ninety-seven cases of perforated chronic otitis media underwent tympanoplasty or myringoplasty at the hospitals of Hyogo College of Medicine and Osaka University Medical School between 1995 and 1997. Cholesteatoma, adhesive otitis media, and cholesterin granuloma were excluded. Eighty-six cases (29.0%) had bilateral chronic otitis media with tympanic perforation. In the present series, 25 cases were treated by bilateral same day surgery according to the following operative indications: (1) positive hearing gain after closure of the perforation by paper patch; (2) small or middle-sized perforation; (3) dry ear at operation; (4) wide/straight external ear

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surgery by SUM/SUM in seven cases, SUM/CMT in 16 cases, and CMT/CMT in two cases. Thus, SUM was performed in 29 ears and CMT in 21 ears (Table 1). The CMT/CMT cases were children and they had narrow external ear canals. However, as their parents strongly requested bilateral same day ear surgery, we performed bilateral CMTs although CMT had a risk of sensorineural hearing loss. The postoperative hearing was assessed at least 6 months after surgery and audiography was performed at the final examination.

3. Results Fig. 1. Schematic drawing of cutting and removal of the margin of the perforation.

Fig. 2. Schematic drawing of simple underlay myringoplasty (SUM). A subcutaneous connective tissue obtained from the retroauricular region is underlaid and fixed with a few drops of fibrin glue.

canal. The patients were six males and 19 females, and their mean age was 48.8 years old (7 – 78 years old). Surgery was performed by two techniques. One was conventional myringoplasty or tympanoplasty (CMT) through retroauricular incision, which is routinely done all over the world. The other was SUM through the ear canal, developed by Yuasa et al. (1989) [4]. The remnant of the perforated ear drum was locally anesthetized, and the margin of the perforation was cut and removed with a fine pick (Fig. 1). Then, connective tissue or temporal fascia, obtained from the retroauricular region, was inserted through the perforation. The stretched graft was gently lifted to make reliable contact with the edge of the perforation, and then, a few drops of fibrin glue were applied to the contact area. The fixation of the graft took a few minutes. There was no packing in the external ear canal (Fig. 2). According to the above mentioned indications and patients’ requests, we performed bilateral same day

Closure of the ear drum on both sides was successful in five patients of SUM/SUM (71%), 12 patients of SUM/CMT (75%), and two patients of CMT/CMT (100%). Closure of the ear drum on one side was obtained in all patients (Fig. 3). The rate of closure of the ear drum was 23/29 (76%) in the SUM series and 19/21 (90%) in the CMT series. The preoperative air conduction hearing level was 48.6919.5 dB in the SUM series and 48.4 9 19.4 dB in the CMT series. The preoperative bone conduction hearing level was 28.4917.6 and 18.79 12.3 dB, and the postoperative air conduction hearing level was 36.89 18.9 and 36.19 19.2 dB, respectively. The hearing gain was the same in both series (11.8 9 9.4 dB). The postoperative air–bone (A–B) gap was less than 20 dB in 24/29 (83%) of the SUM series and in 15/21 (71%) of the CMT series (Table 1). We examined the postoperative hearing levels in both ears (Fig. 4). The A–B gap was less than 10 dB in 6/25 (24%) on both sides and in 17/25 (68%) on one side. This gap was less than 20 dB in 15/25 (60%) and in 23/25 (92%), respectively. The air conduction hearing level was less than 20 dB in 3/25 (12%) on both sides and in 10/25 (40%) on one side; less than 30 dB in 7/25 (28%) and in 14/25 (56%); and less than 40 dB in 10/25 (40%) and in 21/25 (84%), respectively. A typical case of bilateral perforated chronic otitis media is shown in Fig. 5. After bilateral same day surgery, hearing was improved bilaterally and the A–B gap almost disappeared. Table 1 The pre- and postoperative hearing results in the SUM and CT series

Pre a.c. Pre b.c. Post a.c. Gain A–B gapB20 dB

SUM (dB) (n =29)

CMT (dB) (n= 21)

48.6 9 19.5 28.4 9 17.6 36.8 9 18.9 11.8 9 9.4 24/29 (83%)

48.49 19.4 18.79 12.3 36.1 9 19.2 11.8 9 9.4 15/21 (71%)

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Fig. 3. The rate of closure of the ear drum in each procedure.

4. Discussion Many attempts have been reported on the closure of tympanic perforation by means other than CMT. The transplanted grafts included vein graft [7], fat [8], micropore tape [9,10], etc. However, the results were not satisfactory when compared with the conventional methods since the graft was not stably fixed and should be supported by a material inserted into the middle ear cleft. Fibrin glue has been employed to ear surgery since the 1980s [11]. Yuasa et al. [4] developed SUM, a new simple method by fixing the graft securely to the freshened margin of the perforation with fibrin glue without any packing at all. This method has achieved success rate for closure of the ear drum and postoperative hearing level almost similar to those of the conventional method without damage to the inner ear [5,6]. In the present study, we applied this technique to bilateral ear surgery for bilateral perforated chronic otitis media because it had very little risk of postoperative sensorineural hearing loss. Yuasa’s operative indi-

Fig. 5. A typical case of bilateral same day surgery. The patient is a 47-year-old female who suffered from bilateral perforated chronic otitis media. She had central perforations on both sides. The left ear was operated on by CMT and then the right ear by SUM. After surgery, the A – B gap has almost disappeared.

cation is dry ear regardless of the size of perforation [5,6]. Since we have not been so skillful in this technique, our indications have some limitations: (1) dry ear; (2) small to middle-sized perforation; (3) wide and straight ear canal. Although performing SUM on both sides achieved ideal results, we performed CMT on one side in the following cases: (1) when no hearing gain after the paper patch test was obtained; (2) when it was difficult to operate through the ear canal. If either ear could not attain some hearing gain after the paper patch test, we gave up bilateral ear surgery on the same day, and operated on one side by CMT followed by an operation on the other side at least 6 months later. The rate of closure of the ear drum by SUM was 23/29 (76%) in the present study, which was lower than

Fig. 4. The postoperative hearing results in terms of air–bone (A – B) gap (left) and air conduction hearing level (a.c.) (right).

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that of the previous report ( 90%)[6]. The rate of closure on both sides was 5/7 (71%) in SUM/SUM and in 12/16 (75%) in SUM/CMT. The reason why closure of the ear drum failed is our unskillfull technique of SUM. Yuasa recommended several equipments to improve SUM technique. These are a smooth jaw forceps to lift the stretched graft, a pick with smooth tip, and a suction tube which can control pressure. He also suggested using strong local anesthesia including narcotic drug (personal communication). If our technique of SUM is improved, the success rate of bilateral closure could reach 90%. Concerning the postopeative hearing results, the A–B gap was less than 20 dB in 24/29 (83%) of SUM series and in 15/21 (71%) of CMT series. A – B gap of less than 20 dB on both sides was obtained in 15/25 (60%). The reason why the postoperative hearing did not improve even with closure of the perforation was as follows. Reviewing the patients’ charts and operation records pointed out that we performed SUM technique even in the ears in which the paper patch test did not completely close A–B gap. In such cases, CMT should be recommended although bilateral ears are not operated upon on the same day. The air conduction hearing level on both sides was less than 20 dB in 3/25 (12%), less than 30 dB in 7/25 (28%), and less than 40 dB in 10/25 (40%). Since the preoperative bone conduction hearing level was mostly 20 – 30dB, we obtained these unsatisfactory results. Our previous data showed that bone conduction hearing level deteriorated with the duration of chronic otitis media under long-term observation of individual patients [12]. If we can operate chronic otitis media at the early stage, we can obtain good hearing results for both ears. In conclusion, bilateral same day surgery was possible for bilateral perforated chronic otitis media with the SUM technique if appropriate operative indications were considered. Furthermore, the success rate will be improved as surgeons become more skillful in the SUM technique.

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Acknowledgements The authors express their hearty thanks to Dr Yuasa, Sendai Middle Ear Surgery Center, for his helpful suggestions concerning the operative techniques.

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