Revised grading system of tympanosclerosis

Egyptian Journal of Ear, Nose, Throat and Allied Sciences xxx (2016) xxx–xxx

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Original article

Revised grading system of tympanosclerosis Rauf Ahmad, Zafarullah Beigh ⇑, Tabish Maqbool Department of Otorhinolaryngology and Head Neck Surgery, Government Medical College, Srinagar, Jammu and Kashmir, India

a r t i c l e

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Article history: Received 10 September 2016 Accepted 8 December 2016 Available online xxxx Keywords: Tympanosclerosis Tympanoplasty Ossiculoplasty

a b s t r a c t Introduction: Tympanosclerosis (TS) is a common sequelae of chronic otitis media found in all age groups, this study was conducted to analyze the extent of tympanosclerosis in patients operated for chronic suppurative otitis media in our hospital and have intraoperative findings of tympanosclerosis. Material and method: 165 patients of tympanoplasty who had TS involving ossicular chain, were enrolled in our study. Pre operative air bone gap and operative findings of extent of TS involving ossicles was recorded, time required to mobilize ossicles was also recorded. Post operative air bone gap was documented after 3 months of surgery. Result: This study showed that majority of patients were females from rural area. Most of the patients had grade II tympanosclerosis followed by grade III. There was no statistically significant difference in post operative air bone gap in patients with grade I and grade II TS. Our new grading system for TS removes the overlap between various grading systems for TS developed in past. Conclusion: New grading system for TS helps us to determine time taken for mobilizing ossicular chain, type of ossiculoplasty required and outcome of tympanoplasty surgery. Ó 2016 Egyptian Society of Ear, Nose, Throat and Allied Sciences. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-ncnd/4.0/).

1. Introduction Tympanosclerosis is an anatomoclinical entity which causes thickening and fusion of collagenous fibres into a homogenous mass with final deposition of scatterred intracellular and extracellular calcium and phosphate crystals.The incidence of tympanosclerosis was found to be 35.6% of patients with chronic suppurative otitis media, but 77.8% of these patients had dry ear and the majority of them had hearing loss of the conductive type.1 The relationship between oxygen-derived free radicals and occurrence of TS has been proven in experimental models, and it was also shown that the formation of Tympanosclerosis after experimental myringotomy could be reduced by application of various free radical scavengers.2 TS, depending on its size, site of involvement and ossicular mobility cause severe impeadance to sound transmission and also interferes with satisfactory hearing results following tympanoplasty.

Peer review under responsibility of Egyptian Society of Ear, Nose, Throat and Allied Sciences. ⇑ Corresponding author at: Marouf Colony 90 Feet Road, Bachapora, Srinagar 190020, Jammu and Kashmir, India. E-mail addresses: [email protected] (R. Ahmad), beighzafarullah@yahoo. com (Z. Beigh).

Aim of this study was to develop Grading of the tympanosclerosis depending upon involvement of ossicles, time required to mobilize ossicles and hearing outcome of surgery. 2. Material and method This study was conducted in Department of Otorhinolaryngology and Head-Neck Surgery Government Medical College Srinagar.165 patients of tympanoplasty who had TS involving ossicular chain and operated by same surgeon were enrolled in this study. all operations were done using post aural approach .detailed history was taken and otolaryngological examination was done in all patients. Pure tone audiometery was done in all patients and pre operative air bone gap was calculated using average of air bone gap at 250 Hz, 500 Hz and 1000 Hz. intraoperative finding of extent of TS involving ossicles and time required to mobilize ossicles was also recorded. Post operative air bone gap was documented after 3 months of surgery. Exclusion criteria  Patients with any element of sensory neural hearing loss  Any revision surgery  Ears with any pathology in the external auditory canal  Ears with any pathology requiring mastoid exploration

http://dx.doi.org/10.1016/j.ejenta.2016.12.002 2090-0740/Ó 2016 Egyptian Society of Ear, Nose, Throat and Allied Sciences. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article in press as: Ahmad R., et al. Revised grading system of tympanosclerosis. Egypt J Ear Nose Throat Allied Sci (2016), http://dx.doi.org/ 10.1016/j.ejenta.2016.12.002

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R. Ahmad et al. / Egyptian Journal of Ear, Nose, Throat and Allied Sciences xxx (2016) xxx–xxx

 Immunosuppressed patients or patients taking immunosuppressive medications  Patients with comorbidities like diabetes mellitus or chronic renal disease that could influence wound healing or recovery.

Table 2 Grading of tympanosclerosis. Grade

Operative findings

Grade I

Tympanosclerosis fixing Maleus and/or Incus from lateral surface Tympanosclerosis fixing Maleus or Incus from lateral surface Tympanosclerosis fixing Maleus and Incus from lateral surface Tympanosclerosis fixing Maleus and/or Incus from medial surface with or without findings of Grade I Tympanosclerosis fixing Maleus or Incus from medial surface Tympanosclerosis fixing Maleus and Incus from medial surface Tympanosclerosis fixing Stapes superstructure and/or Stapes Footplate with or without findings of Grade I and II Tympanosclerosis involving Stapes superstructure and/or Stapes Footplate, Stapes Mobile/fixed stapes initialy but surgeon able to mobilize Tympanosclerosis involving Stapes Footplate, Stapes fixed and surgeon not able to mobilize Tympanosclerosis causing Obliteration of Oval window with or without finding of Grade I, II and III

3. Results

Ia Ib

Results are given in Tables 1–4. New Grading of tympanosclerosis is given in Table 2.

Grade II IIa IIb

4. Discussion

Grade III

there have been many classifications put forward by various authors depending upon histological nature of tympanosclerosis, anatomical location and on the basis of surgical outcome. All of these classification systems are debatable. we proposed new Grading for tympanoseclerosis depending upon our experience at Government medical college hospital Srinagar, J&K India. This grading is based on anatomical location of tympanoseclerosis in middle ear causing ossicular fixation, time required to remove this TS and out come of surgery. In our study majority of the patients were females from rural area. Most common age group was 36–45 years with 40% of patients (Table 1). In our study majority of the patients had TS involving Medial surface of Maleus and/or Incus (54 patients) followed by Tympanosclerosis involving Stapes superstructure and/ or Stapes Footplate (46 patients), these two groups were assigned as Grade II and Grade III. Patients who had Tympanosclerosis involving lateral surface of Maleus and/or Incus was assigned Grade I TS and patients who had Tympanosclerosis causing Obliteration of Oval window was assigned Grade IV TS. Our Grading system alloted different grades to patients with TS on lateral and medial surface of maleus and incus, this gave advantage to our Grading system over previously proposed grading system by Wieling and Kerr3, which assign patients in these two groups in one group according to wieling and kerr,the group I – the process affects pars tensa intacta or perforated tympanic membranes, the group II – the process fixes the incudomalleolar complex while the stapes is mobile, the group III – fixed or absent stapes and the mobile incudomalleolar complex if there is one, and the group IV – a completely fixed ossicular chain. Our Grading system also separates patients with movable stapes from patients with fixed stapes and patients with obliterated oval window. Tos et al.4 suggest in case of fixed plate and intact ossicular chain to keep it along with mobilization of the stapes. They approve stapes ligaments resection in case of uneasy approach to the oval niche during removal the plaques, but with no fenestration of the plate nor its removal. In case of the stapes suprastructures absence and if the plaques fix the plate they recommend stapedoplasaty in 2 acts in act 1 to remove plaques from

Table 1 Demographics of patients. Criteria

Number of patients

Percentage

Sex Male Female

73 92

44.2 55.7

Age 15–25 years 26–35 years 36–45 years >45 years

22 34 66 43

13.33 20.60 40.0 26.06

Residence Rural Urban

102 63

61.81 38.18

IIIa

IIIb Grade IV

Table 3 Mean time required to mobilize ossicles. Grade Grade Grade Grade Grade

I II III IV

Number of patients

Time required to mobilize ossicles

39 54 46 26

92 min 118 min 136 min Second stage

Table 4 Pre and postoperative mean air Bone gap. Grade Grade Ia Ib Grade IIa IIb Grade IIIa IIIb Grade

I

II

III

IV

N

Pre op ABG

Post op ABG

39 22 17 54 25 29 46 38 08 26

34 dB 32 dB 36 dB 40 dB 38 dB 42 dB 52 dB 51 dB 54 dB 56 dB

<10 dB <10 dB <10 dB 12 dB 10 dB 14 dB 16 dB 16 dB 56 dB 60 dB

the plate, and in act 2 to do stapedotomy and stapedoplasty. Numerous authors share the same opinion, advocating mobilization, too, agreeing with Tos et al.4 that its highest advantage is one act performance, while Smyth5 disagrees with that, thinking that the possibility of damaging the inner ear during mobilization either with hydric blast or perilymphatic fistula is very great, leading together to sensorineural hearing damage. This Grading system solves this difference in opinion by allocating different grades to patients in which stapes was movable and in those patients who had not movable stapes (Grade IIIa and IIIb). Grade IV was allotted to that group of patients in which no attempt to mobilize stapes was made due to obliteration of oval window due to extensive tympanoseclrosis in that area.Patients in Grade I had TS fixing maleus and/or incus on lateral surface (Ia/Ib), this group of patient had mobile/uninvolved stapes, so maleus and/or incus was mobilized after dislocating incudostapedial joint. Time required to mobilize the ossicles was dependent upon whether only maleus or incus was involved or both hence Graded accordingly (Ia and Ib). it was difficult to examine and remove disease from medial surface of maleus and incus (fixing maleus and/or incus medialy),in such patients (IIa and IIb) incudostapedial joint was first dislocated as in group I patients to prevent dislocation of stapes and injury to

Please cite this article in press as: Ahmad R., et al. Revised grading system of tympanosclerosis. Egypt J Ear Nose Throat Allied Sci (2016), http://dx.doi.org/ 10.1016/j.ejenta.2016.12.002

R. Ahmad et al. / Egyptian Journal of Ear, Nose, Throat and Allied Sciences xxx (2016) xxx–xxx

inner ear. Then TS was first removed from lateral aspect of ossicles if present and then maleus and incus were removed so as to clear the TSP from medial surface of ossicles and adjacent areas of middle ear. After clearing all the disease, reshaped incus (interposition) was used to place over stapes superstructure and grafting of the tympanic membrane perforation done. Time required to remove disease process in this group of patients was more than in group I patients (Table 3). In patients with TSP involving Stapes superstructure and/or Stapes Footplate (Grade III), Grade IIIa with movable stapes (stapes fixed initially but surgeon was able mobilize stapes safely after removing TS patches), ample time required to remove TS and mobilize stapes hence Graded accordingly. In grade IIIa patients, during removal of TS from stapes footplate area and fallopian canal area it was observed that involved bone was invariably thinned out. removing TS patches from these areas required lot of patience and fine instrumentation to prevent injury to fallopian canal (dehiscent facial canal) and stapes footplate, Patients in Grade IIIb and Grade IV had fixed stapes, second stage surgery (stapedectomy/stapedotomy) was needed. We did not include patients with isolated myringosclerosis in our study as was done by Milanko Milojevic´ et al.6 And atic tympanosclerosis was classified into Grade I and II depending on site of TS. There was not much difference in hearing outcome after 3 months of surgery in Grade I,II and IIIa group of patients, patients in group IIIb and IV required second stage surgery (Table 3) this was in accordance with various researchs done previously comparing mobilization with interposition e.g. Albu et al.7

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5. Conclusion tympanosclerosis is very common entity in chronic suppurative otitis media patients and must be dealt with at the time of tympanoplasty, depending on extent of tympanosclerosis grading system helps us to determine time taken for mobilizing ossicular chain,type of ossiculoplasty required and outcome of tympanoplasty surgery.

References 1. Wu Y, Yin S, Zhu H, Zhang S. Tympanosclerosis incidence among patients with chronic suppurative otitis media. Lin Chuang Er Bi Yan Hou Ke Za Zhi.. 2006;20 (22):1016–1017. 2. Ozcan C, Görür K, Cinel L, Talas DU, Unal M, Cinel I. The inhibitory effect of topical N-acetylcysteine application on myringosclerosis in perforated rat tympanic membrane. Int J Pediatr Otorhinolaryngol. 2002;63(3):179–184. 3. Wielinga EW, Kerr AG. Tympanosclerosis. Clin Otolaryngol Allied Sci. 1993;18 (5):341–349. 4. Tos M, Lau T, Arndal H, Plate S. Tympanosclerosis of the mid-dle earlate results of surgical treatment. J Laryngol Otol. 1990;104(9):685–689. 5. Smyth GDL. Tympanomastoid disease. In: Gibb AG, Smith MFW, eds. Otology. London: Butterworths; 1982:3–18. 6. Prognostic significance of tympanosclerotic plaques localization and their morphological and histologicalcharacteristics for the outcome of surgical treatment Milanko Milojevic´⁄, Dragoslava Djeric´, Dušan Bijelic´⁄. VOJNOSANITETSKI PREGLED 201269(2)190–4, Volume 69, Broj 2, UDC616.284/ .287-089.17, DOI:10.2298/VSP100815005M. 7. Albu S, Babighian G, Trabalzini F. Surgical treatment of tympa-nosclerosis. Am J Otol. 2000;21(5):631–635.

Please cite this article in press as: Ahmad R., et al. Revised grading system of tympanosclerosis. Egypt J Ear Nose Throat Allied Sci (2016), http://dx.doi.org/ 10.1016/j.ejenta.2016.12.002