Abstract
Myringoplasty is the surgical treatment for the repair of tympanic membrane (TM) perforations. It is indicated for treatment of recurrent ear discharge, improving conductive hearing loss, and preventing future infections, especially in high risk groups. In this case-based review, the normal anatomy and physiology of the ear is described, followed by the way conductive and sensorineural hearing loss are differentiated through a detailed history, examination and investigations, including audiometry and tympanometry. The anatomy of the TM is explored and the causes, presentation and diagnosis of TM perforations, which are a cause of conductive hearing loss, are described
This review focuses on how myringoplasty is used to repair TM perforations, and what factors affect its success, relating the findings to four patients who have undergone myringoplasty. The underlay technique is used more frequently, yielding better results with fewer side-effects, especially for posterior perforations, whereas overlay is shown to be better for anterior perforations due to a better view of the TM, but has higher risks for graft lateralisation and blunting. Over-underlay is similar to underlay in success, but can only be applied where the handle of malleus is intact.
TM repair was shown to be independent of age, sex and timing of antibiotic administration, although chronic perforations take longer to heal. The effect of size on the surgical outcome is debatable, with different studies showing opposite results. Side-effects, alternative treatment options and potential biases in the studies are discussed, as well as the limitations of the information obtained from the cases.
The conclusion is that there is no “one-fits-all” procedure or graft that is suitable for the repair of all TM perforations, and each patient should be assessed on an individual basis, taking into consideration their own needs and wishes.
References
Tortora G.J. (2011) Principles of anatomy and physiology. 13th ed. Hoboken, NJ.: Wiley, 2011.
Kumar PJ, Clark ML. Kumar and Clark’s clinical medicine. 8th ed. Edinburgh: Churchill Livingstone, 2012.
Drake RL, Vogl AW, Mitchell AWM. Gray’s anatomy for students. 2nd ed. Philadelphia, PA.: Churchill Livingstone, 2009.
Lim EKS, Loke YK, Thompson AM. Medicine and surgery : an integrated textbook. Edinburgh: Churchill Livingstone, 2007.
NHS Choices. Hearing loss – causes. Available from: http://www.nhs.uk/Conditions/Hearing-impairment/Pages/Causes.aspx.
Encyclopaedia Britannica. Transmission of sound by bone conduction. Available from: http://www.britannica.com/EBchecked/topic/175622/human-ear/65049/Transmission-of-sound-by-bone-conduction.
American Speech-Language-Hearing Association. Types of hearing loss. Available from: http://www.asha.org/public/hearing/Sensorineural-Hearing-Loss/.
Clarke R. Lecture notes: diseases of the ear, nose and throat. Chichester: Wiley-Blackwell, 2014.
Oktem F, Toprak M, Yener M, et al. Vibration characteristics of grafts for the tympanic membrane. Advances in Therapy 2007;24(1):81-90. Available from: https://doi.org/10.1007/BF02849995
Howard ML. Middle ear, tympanic membrane, perforations. MedScape; [updated 14/07/2014 20/03/15]; Available from: http://emedicine.medscape.com/article/858684-overview.
Kenny T. Perforated eardrum. Patient.co.uk; [updated 04/11/13 20/03/15]; Available from: http://www.patient.co.uk/health/perforated-eardrum.
Aggarwal RS, Saeed SR, Green KJM. Myringoplasty. J Laryngol Otol. 2006;120(6):429-32. Available from: https://doi.org/10.1017/S0022215106000697
Kenny T. Ear infection (Otitis Media). Patient.co.uk; [updated 13/12/1220/03/15]; Available from: http://www.patient.co.uk/health/ear-infection-otitis-media.
Bristol ENT Partnership. Eardrum perforations. 2010 [20/03/15]; Available from: http://www.entbristol.co.uk/otoscopy.php.
Kohn FE, Feijen J, Feenstra L. New perspectives in myringoplasty. Int J Artif Organs 1984;7(3):151-62.
Bluestone CR. Surgical atlas of pediatric otolaryngology 2nd ed. BC Decker; 2002.
ENT for medical students. 2013 [20/03/15]; Available from: http://ent4students.blogspot.co.uk/2013/05/ent-pictures-ear.html.
Sarkar S. A review on the history of tympanoplasty. Indian J Otolaryngol Head Neck Surg. 2013;65(Suppl 3):455-60. Available from: https://doi.org/10.1007/s12070-012-0534-5
Zhang ZG, Huang Q., Zheng YQ, Sun W, Chen YB, Si Y. Three autologous substitutes for myringoplasty: a comparative study. Otol Neurotol. 2011;32(8):1234-8. Available from: https://doi.org/10.1097/MAO.0b013e31822f0ba7
Yung M, Vivekanandan S, Smith P. Randomized study comparing fascia and cartilage grafts in myringoplasty. Ann Otol Rhinol Laryngol. 2011;120(8):535-41. Available from: https://doi.org/10.1177/000348941112000808
Ozgursoy OB, Yorulmaz I. Fat graft myringoplasty:a cost-effective but underused procedure. J Laryngol Otol. 2005;119(4):277-9. Available from: https://doi.org/10.1258/0022215054020377
Hakuba N, Hato N, Okada M, Mise K, Gyo K. Preoperative factors affecting tympanic membrane regeneration therapy using an atelocollagen and basic fibroblast growth factor. JAMA Otolaryngol Head Neck Surg. 2015;141(1):66. Available from: https://doi.org/10.1001/jamaoto.2014.2613
Singh BJ, Sengupta A, Das S. K, Ghosh D, Basak, B. A comparative study of different graft materials used in myringoplasty. Indian J Otolaryngol Head Neck Surg. 2009;61(2):131-4. Available from: https://doi.org/10.1007/s12070-009-0051-3
Sergi B, Galli J, De Corso E, Parrilla C, Paludetti G. Overlay versus underlay myringoplasty: report of outcomes considering closure of perforation and hearing function. Acta Otorhinolaryngol Ital.2011;31(6):366-71.
Rogha M, Berjis N, Taherinia A, Eshaghian A. Comparison of tympanic membrane grafting medial or lateral to malleus handle. Adv Biomed Res. 2014;3:56. Available from: https://doi.org/10.4103/2277-9175.125804.
Singh M, Rai A, Bandyopadhyay S, Gupta SC. Comparative study of the underlay and overlay techniques of myringoplasty in large and subtotal perforations of the tympanic membrane. J Laryngol Otol. 2003;117(6):444-8. Available from: https://doi.org/10.1258/002221503321892262
Doyle PJ, Schleuning AJ, Echevarria J. Tympanoplasty: should grafts be placed medial or lateral to the tympanic membrane. Laryngoscope.1972;82(8):1425-30. Available from: https://doi.org/0.1288/00005537-197208000-00005
She W, Dai Y, Chen F, Qin D, Ding X. [Comparative evaluation of over-under myringoplasty and underlay myringoplasty for repairing tympanic membrane perforation]. Lin Chuang Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 2008;22(10):433-5.
Kartush JM, Michaelides EM, Becvarovski Z, LaRouere MJ. Over-under tympanoplasty. Laryngoscope. 2002;112(5):802-7. Available from: https://doi.org/10.1097/00005537-200205000-00007
Hung T, Knight JR, Sankar V. Anterosuperior anchoring myringoplasty technique for anterior and subtotal perforations. Clini Otolaryngol Allied Sci, 2004;29(3):210-4. Available from: https://doi.org/10.1111/j.1365-2273.2004.00805.x
Westerberg J, Harder H, Magnuson B, Westerberg L, Hyden D. Ten-year myringoplasty series: does the cause of perforation affect the success rate? J Laryngol Otol. 2011;125(2):126-32. Available from: https://doi.org/10.1017/S0022215110002069
Derby Hospitals NHS Foundation Trust. Myringoplasty/Tympanoplasty – Patient information.2010 [20/03/15]; Available from: https://www.derbyhospitals.nhs.uk/easysiteweb/getresource.axd?assetid=2990&type=0&servicetype=1.
Albera R, Ferrero V, Lacilla M, Canale A. Tympanic reperforation in myringoplasty: evaluation of prognostic factors. Ann Otol Rhinol Laryngol. 2006;115(12):875-9. Available from: https://doi.org/10.1177/000348940611501202
Vos JD, Latev MD, Labadie RF, etval. Use of AlloDerm in type I tympanoplasty: a comparison with native tissue grafts. Laryngoscope. 2005;115(9):1599-602. Available from: https://doi.org/10.1097/01.mlg.0000172042.73024.ad
Levin B, Redmond SL, Rajkhowa R, et al. Preliminary results of the application of a silk fibroin scaffold to otology. Otolaryngol Head Neck Surg. 2010;142(3 Suppl 1):S33-5. Available from: https://doi.org/10.1016/j.otohns.2009.06.746
Karela M, Berry S, Watkins A, Phillipps JJ. Myringoplasty: surgical outcomes and hearing improvement: is it worth performing to improve hearing? Eur Arch Otorhinolaryngol. 2008;265(9):1039-42. Available from: https://doi.org/10.1007/s00405-007-0570-z.
Lee P, Kelly G, Mills RP. Myringoplasty: does the size of the perforation matter? Clin Otolaryngol Allied Sci. 2002;27(5):331-4. Available from: https://doi.org/10.1046/j.1365-2273.2002.00590.x