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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 28  |  Issue : 4  |  Page : 310-313

Is endoscopic tympanoplasty an alternative to microscopic tympanoplasty for small central perforations? A study


1 Department of ENT, Air Force Hospital, Jaisalmer, Rajasthan, India
2 Department of ENT, 151 Base Hospital, Guwahati, Assam, India
3 Department of ENT, Gauhati Medical College and Hospital, Guwahati, Assam, India

Date of Submission08-Jun-2022
Date of Decision01-Nov-2022
Date of Acceptance07-Nov-2022
Date of Web Publication29-Dec-2022

Correspondence Address:
Dr. Tejpal Singh Bedi
Department of ENT, 151 Base Hospital, Guwahati, Assam
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/indianjotol.indianjotol_93_22

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  Abstract 


Introduction: Traditional approaches to tympanoplasty involve the use of a microscope. However, with the advent of endoscopes and HD cameras, endoscopic tympanoplasty has appeared as an alternative to microscopic tympanoplasty. Our study was aimed at assessing the success rates of endoscopic tympanoplasty in small dry central perforations of pars tensa. Materials and Methods: 49 patients were enrolled in this study for undergoing endoscopic tympanoplasty and the surgical outcome was analyzed in terms of graft uptake and postoperative air-bone gap closure for 6 months. Results: Among the study population, 45 participants (91.84%) had an intact neotympanum at the end of 6 months, two participants (4.08%) had residual perforation, and two (4.08%) had recurrent perforations due to upper respiratory tract infection. The mean preoperative air-bone gap (AB gap) was 23.63 dB ± 3.9 dB in the study population with a minimum of 16 dB and a maximum of 31 dB (95% confidence interval [CI] 22.43–24.83), whereas the mean postoperative AB gap was 13.84 dB ± 2.79 dB, minimum being 8 dB and maximum being 20 dB (95% CI 12.98–14.69). The difference between the preoperative and postoperative air-bone gap was statistically significant (P < 0.001). Conclusions: We conclude that the endoscopic myringoplasty is an attractive alternative to conventional microscopic myringoplasty in terms of surgical outcomes, graft uptake, and air-bone gap closure.

Keywords: Endoscopic tympanoplasty, microscopic tympanoplasty, surgical outcomes


How to cite this article:
Rajguru R, Bedi TS, Rajguru G. Is endoscopic tympanoplasty an alternative to microscopic tympanoplasty for small central perforations? A study. Indian J Otol 2022;28:310-3

How to cite this URL:
Rajguru R, Bedi TS, Rajguru G. Is endoscopic tympanoplasty an alternative to microscopic tympanoplasty for small central perforations? A study. Indian J Otol [serial online] 2022 [cited 2023 Feb 5];28:310-3. Available from: https://www.indianjotol.org/text.asp?2022/28/4/310/365967




  Introduction Top


Chronic otitis media (COM) is an inflammatory disorder of the middle ear cleft effecting 65–330 million people worldwide, leading to hearing impairment in about 50% of the affected population.[1] COM is the result of an initial episode of acute otitis media, negative middle ear pressure, or otitis media with effusion. Depending on the disease activity, COM is classified as healed, mucosal, or squamous type. It is an important cause of hearing loss, particularly in the developing world. The management options for COM mucosal type are topical antibiotic drops, surgery, a hearing aid, or no treatment, depending on the symptomatology and the patient's choice. In patients with a history of intermittent activity, surgery to close the perforation is indicated to minimize future activity and reduce the patient's hearing disability.[2]

Tympanoplasty refers to any surgery involving the reconstruction of the tympanic membrane and/or the ossicular chain after eradicating disease from the middle ear. Myringoplasty is a tympanoplasty without ossicular reconstruction.[3]

The traditional approaches to tympanoplasty involve the use of a microscope as the binocular nature of vision and availability of both hands for surgery makes the microscopic technique a widely preferred one technique. However, microscope gives a magnified image in a straight line. Hence, while performing microscopic tympanoplasty, it is difficult to visualize certain areas such as retrotympanum, attic, and hypotympanum.[4] Furthermore, in the presence of anterior or posterior canal wall overhang, sometimes even the edges of perforation may not be visualized completely, and the surgeon has to frequently adjust either the microscope or the patient's head.[5] This leads to discomfort for the patient and increase in the duration of the surgery. With the advent of endoscopy and better cameras, endoscopic tympanoplasty has appeared as an alternative to microscopic tympanoplasty and is gaining popularity in the recent years. It is less invasive, with a wider field of vision and shorter operating time.[6]


  Materials and Methods Top


We conducted a descriptive study for 2 years from December 2018 to December 2020, at the ENT department of our tertiary care academic medical hospital to assess the success rates of endoscopic tympanoplasty in small dry central perforations of pars tensa with an objective to evaluate the efficacy of endoscopic myringoplasty by analyzing the take-up rate of temporalis fascia graft and postoperative audiometric results.

A sample size of 49 patients attending the ENT outpatient department with tympanic membrane perforation consenting to undergo endoscopic tympanoplasty was considered the study population. Patients included in the study were cases of COM mucosal type with dry small central perforations of pars tensa, in the age group of 18–60 years. Patients with chronic Eustachian tube dysfunction, those with perforations of <3 months, smokers, patients with comorbidities such as tuberculosis, syphilis, or HIV-positive status, those on immunosuppressives or with compromised immunity, diabetics, and those on ototoxic drugs were excluded from this study. Patients with underlying otosclerosis, suspected ossicular discontinuity, narrow or abnormal external ear canal, those having COM with any complication, or those with COM squamous type were also excluded from our study.

All patients were operated under local anesthesia with lignocaine 4% in 1/80,000 adrenaline. Injections were done in four points inside the canal at the bony-cartilaginous junction. A wide-angle Storz Otoendoscope “0” degree (2.7 mm diameter) connected to Storz camera and an LED light source of 300 W were used. The camera was connected to a monitor with a video recording system. After cleaning and draping, the external auditory canal was cleaned with saline, and the endoscope was introduced through the canal to examine the perforation and insinuated in the middle ear to visualize its cavity as well as ossicles [Figure 1]. Margins and the undersurface of the perforation were then freshened [Figure 2]. Temporalis fascia graft was harvested by a separate incision in the supra-aural region after infiltration with the local anesthesia. Tympanomeatal flap was elevated by taking 12 o'clock to 6 o'clock incision till the annulus, and the middle ear mucosa so visualized was incised to enter the middle ear [Figure 3]. The handle of malleus was bared, and the graft was placed by underlay technique [Figure 4]. Tympanomeatal flap was reposited, and gel foam pieces were placed in the middle ear and external auditory canal.
Figure 1: Endoscopic view of small central perforation

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Figure 2: Edges of perforation freshened

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Figure 3: Middle ear mucosa seen after elevating tympanomeatal flap

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Figure 4: Graft in situ

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The patients were then reviewed weekly for the first 3 weeks and monthly subsequently for 6 months. A repeat pure-tone audiometry was performed at the end of 6 months. The patients' pre- and postoperative audiograms were compared and analyzed.

Statistical analysis

IBM SPSS version 22 (International Business Machines, SPSS, Armonk, New York, USA) was used for statistical analysis. Categorical variables at different time periods of follow-up compared using McNemar's test. The change in the quantitative parameters, before and after the intervention, was assessed by paired t-test. Descriptive analysis was carried out by the mean and standard deviation for quantitative variables, frequency, and proportion for categorical variables.

Ethical clearance

Ethical approval for this study with proposal number 500/AC/28 was granted by Institutional Ethical Committee - Institute of Naval medicine on 04 Sep 2018. The same was accepted by the Maharashtra University of Health Sciences vide letter number MUHS/Medical/MUHS-013529/2019 dated 05/02/2019.


  Results Top


A total of 49 patients were included in the final analysis. The mean age of the patients was 38.04 years ± 11.85 years, with the youngest being 18 years, and the oldest patient of the cohort was 57 years of age.

The cohort had an almost equal gender distribution, with 25 male and 24 female patients. Only small central perforations were included in the study; we had two anterosuperior perforations, 18 posteroinferior perforations, 15 central perforations, and 14 anteroinferior perforations.

The average time taken for a surgery was around 1.25 h with a standard deviation of 0.14 h.

Among the study population, 45 participants (91.84%) had an intact neotympanum at the end of 6 months, two participants (4.08%) had residual perforation, and two (4.08%) had recurrent perforations due to upper respiratory tract infection. The recurrent perforations were managed with Trichloro Acetic Acid (TCA) cauterization and silastic sheet application.

The mean preoperative air-bone gap (AB gap) was 23.63 dB ± 3.9 dB in the study population, with a minimum of 16 dB and maximum of 31 dB (95% confidence interval [CI] 22.43–24.83), whereas the mean postoperative AB gap was 13.84 dB ± 2.79 dB, minimum being 8 dB and maximum being 20 dB (95% CI 12.98–14.69). The difference between the preoperative and postoperative air-bone gap was statistically significant (P < 0.001).


  Discussion Top


Since the introduction of tympanoplasty in the 1950s, a variety of surgical techniques have been developed, though the conventional microscopic technique through a postaural incision is the most popular one.[7]

The problems with this technique are primarily related to the postaural scar and vision in a straight field which many a times requires canal wall drilling. Postaural incision leads to increased tissue handling and tissue dissection, thus causing an increased incidence of pain, paresthesia, or hypoesthesia around the incision and pinna.

However, with the advent of endoscopes and better visualization, endoscopic tympanoplasty is fast becoming an attractive option. The endoscopic technique is a minimally invasive surgery that offers unique set of advantages like quicker operating time, easily maneuverable field of view with a good visualization, better cosmesis, as well as the availability of angled visualization and less tissue dissection. However, space constraints, the use of one hand to maneuver, the endoscope, and constant fogging/smearing of the tip lead to a steeper learning curve for endoscopic tympanoplasty.[6]

Operational success in cases of tympanoplastyis usually described on the basis of graft uptake and AB gap closure. Graft success rates as elicited by various studies for endoscopic groups vary from 79% to 100%. In our study, we achieved a success rate of 91.84%. Furthermore, Lade et al., Harugop et al., Tseng et al., Kuo and Wu, Jyothi et al., Guler and Özcan, and Mokbel et al. in their respective studies found that the graft uptake for endoscopic tympanoplasty gives comparable or even better results when measured against microscopic tympanoplasty.[4],[5],[7],[8],[9],[10],[11]

The AB gap gain was used as the other standard measure to ascertain the surgical outcome of endoscopic tympanoplasty in our study. We had used temporalis fascia as the graft material. We found that the mean preoperative air-bone gap was 23.63 ± 3.9, whereas the postoperative air-bone gap was 13.84 ± 2.79, and this was statistically significant (P < 0.001). Our results are corroborated by other studies which also claim a favorable and significant difference in the AB gap closure in endoscopic tympanoplasty. Thus, eliciting the fact that the endoscopic tympanoplasty leads to a significant closure of AB gap compared to preoperative levels.[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14]

The use of the endoscope comes with its own sets of advantages and challenges; however, the skill set is adaptable; plus, with the advent of endoscopic suites, the setup is readily available at most ENT centers to which an otoendoscope can be easily added. Although not a part of our study, we made some observations that the postoperative cosmesis is much better since the postauricular scar is avoided. Thus, endoscopic tympanoplasty aids in increasing patient satisfaction.[15],[16],[17] Endoscopic tympanoplasty also doubles up as an excellent teaching tool for middle ear anatomy. The use of angled endoscopes allows one to easily demonstrate and access the anatomy of the so-called hidden areas of the ear such as the sinus tympani, hypotympanum, and retrotympanum at the same time giving a close-up view of the middle ear with excellent details.[18]


  Conclusions Top


At the end of our study, we were able to ascertain that the endoscopic tympanoplasty offers good success rates and leads to a significant hearing improvement and thus forms a lucrative option to microscopic tympanoplasty.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
World Health Organization. Chronic Suppurative Otitis Media: Burden of Illness and Management Options. Geneva: World Health Organization; 2004.  Back to cited text no. 1
    
2.
World Health Organization. Chronic suppurative otitis media : burden of illness and management options. World Health Organization;2004.  Back to cited text no. 2
    
3.
Kumar M, Kanaujia SK, Singh A. A comparative study of endoscopic myringoplasty versus conventional myringoplasty. Otorhinolaryngol Clin 2015;7:132-7.  Back to cited text no. 3
    
4.
Guler İ, Özcan M. A comparison of endoscopic and microscopic techniques for the repair of tympanic membrane perforations. ENT Updates 2019;9:166-171.  Back to cited text no. 4
    
5.
Jyothi AC, Shrikrishna BH, Kulkarni NH, Kumar A. Endoscopic myringoplasty versus microscopic myringoplasty in tubotympanic CSOM: A comparative study of 120 cases. Indian J Otolaryngol Head Neck Surg 2017;69:357-62.  Back to cited text no. 5
    
6.
Garcia Lde B, Moussalem GF, Andrade JS, Mangussi-Gomes J, Cruz OL, Penido Nde O, et al. Transcanal endoscopic myringoplasty: A case series in a university center. Braz J Otorhinolaryngol 2016;82:321-5.  Back to cited text no. 6
    
7.
Mokbel KM, Moneir W, Elsisi H, Alsobky A. Endoscopic transcanal cartilage myringoplasty for repair of subtotal tympanic membrane perforation: A method to avoid postauricular incision. J Otolaryngol Rhinol 2015;1:004.  Back to cited text no. 7
    
8.
Lade H, Choudhary SR, Vashishth A. Endoscopic versus microscopic myringoplasty: A different perspective. Eur Arch Otorhinolaryngol 2014;271:1897-902.  Back to cited text no. 8
    
9.
Harugop AS, Mudhol RS, Godhi RA. A comparative study of endoscope assisted myringoplasty and micrsoscope assisted myringoplasty. Indian J Otolaryngol Head Neck Surg 2008;60:298-302.  Back to cited text no. 9
    
10.
Tseng CC, Lai MT, Wu CC, Yuan SP, Ding YF. Comparison of the efficacy of endoscopic tympanoplasty and microscopic tympanoplasty: A systematic review and meta-analysis. Laryngoscope 2017;127:1890-6.  Back to cited text no. 10
    
11.
Kuo CH, Wu HM. Comparison of endoscopic and microscopic tympanoplasty. Eur Arch Otorhinolaryngol 2017;274:2727-32.  Back to cited text no. 11
    
12.
Harugop AS, Mudhol RS, Godhi RA. A comparative study of endoscope assisted myringoplasty and microscope assisted myringoplasty. Indian J Otolaryngol Head Neck Surg 2008;60:298-302.  Back to cited text no. 12
    
13.
Mohanty S, Manimaran V, Umamaheswaran P, Jeyabalakrishnan S, Chelladurai S. Endoscopic cartilage versus temporalis fascia grafting for anterior quadrant tympanic perforations – A prospective study in a tertiary care hospital. Auris Nasus Larynx 2018;45:936-42.  Back to cited text no. 13
    
14.
Lou ZC. Endoscopic myringoplasty: Comparison of double layer cartilage-perichondrium graft and single fascia grafting. J Otolaryngol Head Neck Surg 2020;49:40.  Back to cited text no. 14
    
15.
Chozhan P, Subramanian MS, Kannathal D, Malarvizhi R. Comparative study between endoscopic cartilage myringoplasty and endoscopic temporalis fascia myringoplasty. Int J Otorhinolaryngol Head Neck Surg 2018;5:24.  Back to cited text no. 15
    
16.
Taneja V, Milner TD, Iyer A. Endoscopic ear surgery: Does it have an impact on quality of life? Our experience of 152 cases. Clin Otolaryngol 2020;45:126-9.  Back to cited text no. 16
    
17.
Kanona H, Virk JS, Owa A. Endoscopic ear surgery: A case series and first United Kingdom experience. World J Clin Cases 2015;3:310-7.  Back to cited text no. 17
    
18.
Anschuetz L, Siggemann T, Dür C, Dreifuss C, Caversaccio M, Huwendiek S. Teaching middle ear anatomy and basic ear surgery skills: A qualitative study comparing endoscopic and microscopic techniques. Otolaryngol Head Neck Surg 2021;165:174-81.  Back to cited text no. 18
    


    Figures

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



 

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