Abstract
Background
Chronic otitis media treatment has evolved, with microscopic surgeries as the gold standard and endoscopic surgeries as a newer addition.
Materials and Methods
This retrospective study includes 209 patients who underwent type 1 tympanoplasty, utilizing both endoscopic and microscopic techniques, between January 2019 and December 2022 at a tertiary care institute in India. The study aims to compare hearing outcomes, graft uptake, hospital stay, postoperative pain, and cosmesis between the two groups.
Results
Mean AB gap closure was 17.09 + 5.98 dB in the endoscopic group and 16.74 + 5.05 dB in the microscopic group (P = 0.687). The duration of surgery was 79.26 ± 17.37 min in the Endoscopic group and 91.92 ± 15.35 min in the Microscopic group. (P = < 0.00001). The Endoscopic group experienced less post-operative pain, shorter hospital stay (P = < 0.00001, P = 0.0008), and exhibited better cosmetic outcomes (P = 0.00001) compared to the microscopic group.
Conclusion
Endoscopic tympanoplasty is a better alternative to microscopic tympanoplasty, delivering comparable hearing outcomes, shorter surgical duration, improved pain scores, and better cosmesis.
Supplementary Information
The online version contains supplementary material available at 10.1007/s12070-023-04184-4.
Keywords: Endoscopic Tympanoplasty, Microscopic Tympanoplasty, Chronic Otitis Media, Cosmesis, Quality of life
Key Message
Chronic otitis media is a cause of significant morbidity and hearing loss, especially in developing countries like India.
The treatment options have evolved, with microscopic surgeries being the standard and endoscopic surgeries as a newer addition.
The study included 209 patients over 4 years and compared hearing outcomes, graft uptake, postoperative pain, cosmesis, and hospital stay duration between endoscopic and microscopic tympanoplasty.
Results showed similar AB gap closure and successful graft uptake in both groups, indicating comparable hearing outcomes.
Endoscopic tympanoplasty had a significantly shorter duration of surgery, lower postoperative pain scores, and better cosmesis compared to microscopic tympanoplasty.
Endoscopic tympanoplasty offers a better alternative with similar hearing outcomes, improved patient comfort, shorter hospital stay, and better cosmetic outcomes.
Supplementary Information
The online version contains supplementary material available at 10.1007/s12070-023-04184-4.
Introduction
Chronic Otitis Media (COM) describes chronic inflammation of the middle ear and mastoid cavity, which presents with recurrent ear discharge or otorrhoea through a tympanic membrane perforation [1].According to prevalence studies, the global burden caused by COM ranges from 65 to 350 million individuals, with 60% of them experiencing associated hearing loss, resulting in 2 million disability- adjusted life years (DALY). In countries like India, COM is a significant cause of preventable hearing loss, with a prevalence of 7.8%, making it a substantial health issue. The main aim of the treatment is to alleviate symptoms, achieve a dry ear, improve hearing, and prevent complications, particularly in younger patients, as it positively impacts learning, speech, language development, and overall quality of life [2].
The mainstay of management of COM is surgery, where an operating microscope is employed to visualize ear structures. In the early 1950s, Wullstein and Zollner introduced tympanoplasty as the treatment option for COM with the assistance of the operating microscope [3]. The history of ear surgery has evolved over the years and many techniques have been described to improve the outcomes. Microscopic ear surgery despite having certain limitations remains the gold standard.
Ohnsorge at Wurzberg ENT clinic first used an endoscope during ear surgery. Wullstein used an ototympanoscope in 1984 but this device had to be held with two hands and was only used to visualize around the corners. In 1993 Thomassin came up with the proposal for the use of an endoscope for second-look surgery for cholesteatoma. In 1995, Poe used the same technique to inspect the endolymphatic fistula. Tarabichi published 2 case series which included 38 and 165 subjects in 1997 and 1999 respectively, in which endoscopic surgery was performed for tympanic membrane perforation and cholesteatoma surgery [4].
Endoscopic ear surgeries have evolved over the past 20 years as a promising alternative. Unlike microscopes, which offer a straight line of vision, the endoscope provides better visualization of the middle ear cavity directly through the tympanic membrane perforation, especially in individuals with narrow ear canals and anterior tympanic perforations where visualization can be challenging. Additionally, endoscopic surgery avoids external incisions and related complications such as wound infections and keloid formation [5, 6].
However, endoscopic surgeries come with their own set of limitations, including a long learning curve, the need for more expertise, single-handedness during surgery, the requirement for additional equipment, the risk of thermal injury due to the endoscope tip heating up, the need for repeated cleaning during surgery, and obscured vision caused by bleeding [7–12].
This study includes 209 patients over a comprehensive 4-year period and investigates various aspects such as hearing outcomes, Neotympanum healing, postoperative pain, cosmesis, quality of life, and hospital stay duration.
Aim of the Study
Primary Objective
To Compare the Outcomes of Endoscopic and Microscopic Tympanoplasty in Terms of postoperative improvement in hearing.
Secondary Objectives
To Compare the Outcomes of Endoscopic and Microscopic Tympanoplasty in Terms of Graft Uptake, Operative time, Hospital stay and Postoperative pain using a visual analog scale (VAS), cosmesis by subjective assessment.
Materials and Methods
The retrospective study was conducted at a tertiary care institute in India from January 2019 to December 2022. The records of patients who underwent microscopic and endoscopic tympanoplasty were examined, and a total of 209 eligible patients meeting the inclusion criteria were included in the study. Ethical approval from the Institutional Ethics Committee (IEC) was obtained for conducting the study.
Inclusion criteria:
Cases of chronic otitis media (COM) of mucosal type underwent type 1 tympanoplasty with intact ossicular chain & normal middle ear mucosa.
Exclusion Criteria:
Patients having.
History of past ear surgery/ revision cases.
COM with complication.
Patients below 18 years.
Preoperative Evaluation
Patients were informed regarding the nature of their disease process, treatment options, and the proposed surgical procedure, including expected outcomes, potential risks, and complications. Air conduction (AC), Bone conduction (BC), and Air Bone Gap (A-B Gap) were noted. The preoperative mean pure tone average with postoperative mean pure tone average for 500,1000,2000,4000 Hz was noted in microscopic and endoscopic groups. Perforations involving < 25% of the tympanic membrane were considered as small, 25–50% as medium, and > 50% as large. For microscopic tympanoplasty, shaving was done 1–2 cm above and behind the pinna, and no shaving was done for Endoscopic surgeries but external auditory canal hairs were removed preoperatively. Preoperative antibiotics – Injection amoxicillin + clavulanic acid test dose was given and watched for any allergic reactions. All surgeries were done under local anaesthesia.
Surgical Treatment
Myringoplasty using temporalis fascia graft was done in both endoscopic and microscopic groups.
Surgical Steps of Endoscopic Tympanoplasty
0, 30, and 45-degree endoscopes with diameters of 2.7 and 4 mm are used. The procedure is performed under intramuscular sedation (Pentazocine 30 mg and Promethazine 12.5 mg).
The patient was put in a supine position with the head turned away from the surgeon and the surgical field was painted and draped.
The ear canal is cleaned and debris removed to prevent any entry of debris into the middle ear. The endoscope is used to assess the size, site of perforation, remaining tympanic membrane, and status of middle ear mucosa.
Local anaesthesia is administered in the postauricular region and the four quadrants of the ear canal under endoscopic visualization. Intraoperatively, hemostasis is achieved using cotton balls soaked in a solution of saline and adrenaline (1:1).
A separate horizontal incision of 3 cm was given above the pinna and the temporalis fascia graft is taken.
The margin of perforation is freshened using a straight needle/ sickle knife. [Figure 1 (a)(b)]
Using Rosen’s round knife, from 6 o’clock to 12 o’clock position around 10 mm from the annulus, a semicircular incision is given.
The tympanomeatal flap was elevated with the annulus of the tympanic membrane. [Figure- 1 (c)]
The middle ear is carefully entered, preferably in the posteroinferior quadrant. Pars tensa fibres are separated from the handle of the malleus. [Figure- 1 (d)]
Ossicular chain integrity and mobility are checked.
The harvested temporalis fascia graft is placed carefully on the bare handle of the malleus and tucked under the rim of the remnant tympanic membrane. The tympanomeatal flap is repositioned. [Figure- 1 (e)]
The EAC is packed with medicated gel foam and ribbon pack.
Fig. 1.
(a) endoscopic image of right tympanic membrane perforation (b) freshening of margins (c) elevation of tympano meatal flap (d) checking the ossicular mobility (e) placement of the temporalis fascia graft (f) endoscopic image of healed neotymapnum after 6 months
Surgical Steps of Microscopic Tympanoplasty
A postauricular incision is marked, approximately 5 mm behind the postauricular sulcus.
Local infiltration with xylocaine (2%) with adrenaline (1 in one lac) is given post-aurally and in the external auditory canal using the Four Quadrant technique.
The incision is made and bleeding was controlled with electrocautery.
Musculoperiosteal flaps are elevated at the mastoid tip using a Lempert elevator. The spine of Henle is identified, and a posterior meatotomy is performed using a No. 15 blade.
The edges of the perforation are freshened using a straight needle following which the tympanomeatal flap is elevated from the 6 o’clock to 12 o’clock position to the fibrous annulus.
The annulus together with the drum is elevated from its sulcus.
Ossicular status (integrity and mobility) is confirmed by eliciting a round window reflex using a pick.
The graft is placed medial to the tympanic annulus. The middle ear is packed with medicated gel foam. The tympanomeatal flap is repositioned.
Postoperative Care & Outcome Measures
Postoperatively injectable antibiotics are administered for one day along with antihistamines and paracetamol 1 gram thrice daily for analgesia. On postoperative day 1, the mastoid dressing is removed, and the incision site is examined for hematoma. If no complications are present, Patients are discharged on postoperative day 1 on oral antibiotics and antihistamines.
Follow-up
Patients are called for the first follow-up on postoperative day 10 in the out patient department for ear pack and suture removal. Subsequently, they are called for follow-ups in the 2nd week, 2 months,3 months, and 6 months.
During each follow-up, graft uptake and the presence of any complications were checked. Successful graft uptake was defined as complete healing without any residual perforation for at least 6 months postoperatively. In the sixth month, pure tone audiometry is done, and the results are compared with preoperative values.
Statistical Analysis
Statistical analysis was done using IBM-SPSS (International Business Machines Corporation- Statistical Package for the Social Sciences) version 22. The Parametric (continuous) data like age, duration of disease, and hearing loss are expressed as mean and standard deviation. Dichotomous data like gender are expressed as a proportion. Quantitative data in patient and control groups like hearing gain (in dB) are compared using an unpaired or independent sample t-test. The comparison between the categorical variables like graft uptake done by the Chi-square test. Duration of surgery and VAS scores analyzed with Wilcoxon Mann Whitney test. For all statistical tests, p < 0.05 is considered statistically significant.
Results
A total of 209 patients were included in the study, with 103 underwent endoscopic tympanoplasty and 106 underwent microscopic tympanoplasty.
The mean age of patients in the endoscopic tympanoplasty group was 29.5 ± 8.44 years and the microscopic tympanoplasty group was 31.6 ± 9.76 years. Mean age, Male-female ratio, duration of discharge, and duration of hearing loss were similar in both groups preoperatively without any statistically significant difference (P = 0.098, 0.240,0.275 respectively) (Table 1).
Table 1.
Comparison of complications between the two groups
| Complications | ENDOSCOPIC TYMPANOPLASTY GROUP (ET) | MICROSCOPIC TYMPANOPLASTY GROUP (MT) |
|---|---|---|
| Altered taste sensation | 0 | 0 |
| Post-operative infection | 0 | 2 |
| Hematoma | 0 | 1 |
| Wound dehiscence | 0 | 1 |
| Hypertrophic scar | 0 | 1 |
| Residual/reperforation | 5 | 7 |
| Sensorineural hearing loss | 0 | 0 |
In the endoscopic group, 68 patients had large perforation,18 had moderate perforation and 17 had small perforation. On the other hand, in the microscopic group, 69 had large central perforation, 24 had moderate central perforation and 13 had small central perforation. There was no statistically significant difference between 2 groups in terms of pre-operative ear findings (P = 0.507) Table 2.
Table 2.
Demographic details
| ENDOSCOPOIC TYMPANOPLASTY GROUP (ET) (N = 103) | MICROSCOPIC TYMPANOPLASTY GROUP(MT) (N = 106) |
P VALUE | |
|---|---|---|---|
| Age(years) | 29.5 ± 8.44 | 31.6 ± 9.76 | 0.098 |
| Male: female ratio | 48/55 | 58/48 | 0.240 |
| Duration of ear discharge(years) | 6.78 ± 5.47 | 7.7 ± 6.63 | 0.275 |
| Duration of hearing loss(years) | 4.78 ± 5.01 | 5.35 ± 5.75 | 0.446 |
|
Perforation size Large |
68 | 69 | 0.507 |
| Medium | 18 | 24 | |
| Small | 17 | 13 | |
| Pre-operative Air Conduction (dB) | 36.70 ± 4.75 | 35.95 ± 5.39 | 0.29 |
| Pre-operative Bone Conduction (dB) | 11.68 ± 4.14 | 11.49 ± 2.62 | 0.69 |
| Pre-operative Air-Bone Gap(dB) | 25.02 ± 9.03 | 24.27 ± 6.00 | 0.48 |
The mean preoperative air conduction average in the endoscopic group was 36.70 ± 4.75 dB, and in the microscopic group, it was 35.95 ± 5.39 dB. Postoperatively, the air conduction average in the endoscopic and microscopic groups was 27.99 ± 6.65 dB and 26.94 ± 5.14 dB, respectively. The postoperative air conduction levels did not show a statistically significant difference between the two groups (P = 0.205) in Table 3.
Table 3.
Comparison of postoperative outcomes between the two groups
| ENDOSCOPOIC TYMPANOPLASTY GROUP (ET) | MICROSCOPIC TYMPANOPLASTY GROUP(MT) | P VALUE | |
|---|---|---|---|
| Post-operative AC threshold (dB) | 27.99 ± 6.65 | 26.94 ± 5.14 | 0.205 |
| Post-operative BC threshold (dB) | 10.93 ± 3.38 | 10.24 ± 3.94 | 0.170 |
| Post-operative AB Gap (dB) | 17.09 ± 5.98 | 16.74 ± 5.05 | 0.687 |
| Duration of surgery (minutes) | 79.26 ± 17.37 | 91.92 ± 15.35 | < 0.00001 |
| VAS score on postoperative day 1 | 5.48 ± 1.26 | 6.92 ± 0.91 | < 0.00001 |
| Graft uptake | 98/103(95.1%) | 99/106(93.3%) | 0.295 |
| Hospital stay (days) | 1 | 1.1 | 0.0008 |
|
Cosmesis Excellent Satisfactory Poor |
98 4 1 |
22 61 23 |
0.00001 |
The preoperative air-bone gap was 25.02 ± 9.03 dB in the endoscopic tympanoplasty group and 24.27 ± 6.00 dB in the microscopic tympanoplasty group. After surgery, the air-bone gap improved to 17.09 ± 5.98 dB and 16.74 ± 5.05 dB, respectively, in the two groups. This change was significant in both groups, but there was no statistically significant difference between the post-operative AB gaps (P = 0.687).
The mean duration of surgery in endoscopic tympanoplasty was 79.26 ± 17.37 min, while in the microscopic group, it was 91.92 ± 15.35 min. There was a significant difference in operative time between the two groups, with the mean operating time being significantly lower in the endoscopic tympanoplasty group (P < 0.00001).
The graft uptake at the 6-month follow-up period in the endoscopy group was 95.1% and in the microscopic group was 93.3% which was not found to be statistically significant. (P = 0.295). In the microscopic group, 2 patients had post-operative wound infection, 1 had hematoma, and 1 had hypertrophic scar whereas in the endoscopic group, none had any complications.
The mean duration of hospital stay in the endoscopic group was 1 day and in the microscopic group was 1.1 days. This was statistically significant (p = 0.0008).
While comparing cosmesis subjectively, 98 patients in the endoscopic group reported excellent cosmesis, 4 were satisfactory, and 1 reported a poor response. However, in the microscopic group, 22 reported excellent, 61 reported satisfactory, and 23 reported poor cosmesis. This difference was statistically significant (P < 0.00001).
Discussion
COM and its treatment have been described from the time of Egyptian healers [3]. Over the years, numerous studies have been conducted to improve surgical outcomes and enhance hearing after surgery. Various techniques and modifications were suggested by different surgeons to achieve optimal results. Microscopic surgery has been the standard of care for a significant period, while endoscopic surgeries are a more recent addition. The primary objective of surgery is the complete eradication of the underlying disease and the attainment of maximum functional and hearing outcomes. Additionally, the social disability caused by the disease is a concern that needs to be addressed.
In this study, we compared the hearing outcomes, graft uptake along with postoperative pain score on a postoperative day one, cosmesis, and duration of hospital stay which is also an important aspect of the treatment. Many times, the surgery may be successful but may result in a visually nonappealing scar or keloid in the postauricular area, or persistent pain in the site of incision in the post aural region.
Outcomes Analysis in Tympanoplasty
The preoperative mean pure tone average with postoperative mean pure tone average for 500,1000,2000,4000 Hz was noted in microscopic and endoscopic groups. Preoperative audiological parameters like air conduction level, bone conduction level, and air-bone gap were not significantly different between the two groups. Postoperatively AB gap closure was similar in both groups without statistically significant difference.
In previous studies by Pal et al., Gulsen et al., Kim et al., and Zhang et al. the postoperative air conduction and post-operative AB gap between the study groups were found to be insignificant. In terms of hearing outcomes in tympanoplasty, our study has similar results to the previous studies with no statistically significant difference between the two groups [13–16].
Regarding the successful graft uptake, it was noted that 95.1% had successful graft uptake in the endoscopic group and 93.3% had successful graft uptake and the difference between the two groups is not statistically significant. (P = 0.295). A literature review and meta-analysis by Tseng et al. noted that the tympanic membrane closure, results are similar in both endoscopic and microscopic tympanoplasties [17]. In Other studies the healing of the tympanic membrane after endoscopic tympanoplasty is between 80 and 100% of cases and microscopic tympanoplasty is between 83 and 100% [18, 19].
The mean duration of surgery in endoscopic tympanoplasty was 79.26 + 17.37 min, while in the microscopic group was 91.92 + 15.35 min. There is a significant difference in operative time between the two groups which was found to be statistically significant, with the mean operating time being lowest in the endoscopic tympanoplasty group. The absence of the need for a postauricular incision, soft tissue dissection, and suturing in endoscopic tympanoplasty may be the reason for this time difference. In our study, we experienced time loss in microscopic tympanoplasty due to frequent manipulation of the head position while placing the graft to visualize all the edges. However, in endoscopic tympanoplasty, we were able to assess the adequacy of graft placement by moving the endoscope in and out and zooming to visualize around the corners. A study by Rashmi et al. also reported a statistically significant difference in the mean duration of surgery between endoscopic and microscopic tympanoplasty (63.2 ± 13 min vs. 83.8 ± 22.7 min, respectively), which is consistent with our findings [13–16, 20].
Post-operative pain scores were measured on postoperative day one using a visual assessment scale. The endoscopic tympanoplasty group had a pain score of 5.48 ± 1.26, while the microscopic tympanoplasty group had a pain score of 6.92 ± 0.91. Both surgeries were conducted under local anaesthesia, but there was a significant difference between the two groups in terms of VAS, with the highest pain score observed in the microscopic tympanoplasty group. This difference was found to be statistically significant (P = 0.0328).
In a similar study by Choi et al., when pain scores were compared at 3, 6 h, and 1 day postoperatively, the pain scores were not significantly different between the groups immediately up to 6 h post-surgery. However, on postoperative day 1, the pain scores were significantly lower in the endoscopic group. These observations align with the findings of our study [16, 21, 22].
The mean duration of hospital stay was less in the endoscopic group compared to the microscopy group. All patients of the endoscopic tympanoplasty group were discharged on postoperative day 1, but the increased pain, hematoma, and wound infection caused the late discharge of a few patients in the microscopic group. By reducing the duration of hospital stays, there is a potential to alleviate the financial burden linked to extended hospitalizations and subsequent healthcare costs.
While comparing cosmetic outcomes also, the endoscopic group had a better cosmesis compared to the microscopic group. (P = 0.00001) In a similar study by Lakpathi et al. 100% of patients in the endoscopic group rated the cosmesis result as excellent compared to 30% of patients in the microscopic group who rated the cosmesis as excellent and 50% as satisfactory [23]. A study by Hargoup et al. had similar results [24]. In endoscopic tympanoplasty we can harvest the temporalis fascia by a 2 cm separate incision behind the hairline avoiding a postauricular incision and scar and patients were more satisfied in the endoscopic group. The presence of a healed Neotympanum and the absence of a visible postauricular scar significantly enhances an individual’s self-confidence, empowering them to embrace a social life akin to their pre-disease state and also allows them to engage fully in social interactions and activities without the burden or stigma of their previous condition.
In this study conducted in our institute comparing microscopic and endoscopic tympanoplasty, the hearing outcomes and graft uptake are comparable between the two groups. However, the endoscopic group has a lesser duration of surgery, less post-operative pain, less hospital stay, and better cosmesis. None of the endoscopic tympanoplasties needed conversion to microscopic tympanoplasty for any reason in our series. Proper infiltration of local anesthetic and the use of adrenaline-soaked cotton pledgets helped in achieving good hemostasis. The light intensity was kept below 50% to avoid any thermal injury [25, 26].
In our experience, endoscopic tympanoplasty has revolutionized the treatment for the mucosal type of chronic otitis media (COM) in this era of minimally invasive surgery. Based on our observations, it has become the preferred approach for patients and surgeons alike, offering enhanced outcomes with reduced invasiveness.
Conclusion
Endoscopic tympanoplasty is a better alternative to microscopic tympanoplasty, providing comparable hearing outcomes and graft uptake while significantly reducing postoperative pain, hospital stay, and delivering impressive cosmetic results.
Electronic Supplementary Material
Below is the link to the electronic supplementary material.
Funding
This study was not funded by any organization.
Declarations
Conflict of Interest
The authors don’t have any conflicts of interest among them.
Ethical Approval
Ethical committee approval was taken by the institutional review board and written informed consent was taken from all patients participated in the study.
Institutional review
Institutional review board approval was obtained for the study.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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