Abstract
To compare the results of myringoplasty by using operating microscope (postaural) with that of myringoplasty by using endoscope (permeatal). Our study was conducted in Department of ENT of in Chirayu Medical College and Hospital. Total 60 patients of age group 18–60 were taken for study having chronic otitis media or trauma with central perforation. Patients were randomly selected microscopic or endoscopic myringoplasty. 30 patients for Microscopic Myringoplasty and 30 patients for endoscopic Myringoplasty were selected. Out of total 60 patients 35 were females and the 25 were males, 27 were in the age group 15–30 and 23 were in age group 31–45 and only 10 in the age group of 46–60. 18–30 age group cohort was predominant. The average time taken for endoscopic myringoplasty was 65.5 ± 3.45 min and for microscopic myringoplasty 85.7 ± 3.42 min. 26 were having Large central perforation (LCP), of which 13 underwent microscopic and 13 underwent endoscopic myringoplasty. The graft was taken up in situ in 22 patients while 4 patients had small residual central perforation. Out of these four residual perforations 3 were done by endoscopy and 1 by microscopy. 19 (of 60) were having Medium size central perforation (MCP), 10 were operated with endoscope and 9 with microscope. 15 (60) were having Small central perforation (SCP), 7 done with endoscope and 8 with microscope. In all patient graft take up was well. Large central perforation present in maximum patient and had least graft uptake as compared to MCP and SCP. Out of the 30 these endoscopic myringoplasty 27 patients had good graft uptake and 3 had small central residual perforation after 3 months. Out of the 30 microscopic myringoplasty 29 patients had good graft uptake and 1 patient had small central residual perforation after 3 months. In our study pre operative and post operative Air Bone Gaps (ABGs) were 22.05 ± 2.04 and 9.05 ± 1.36 db respectively in endoscopic myringoplasty and 21.81 ± 1.85 and 8.55 ± 1.44 db respectively in microscopic myringoplasty. Microscopic myringoplasty has greater success rate in larger perforations that is LCP and MCP and equal result in SCP. Advantage of microscope is depth perception and both hands are free for procedure which is limitation of endoscopic myringoplasty (need to use endoscope holder). Advantage of endoscopic permeatal myringoplasty is superior visualization, least tissue trauma and better cosmetic outcome, almost equal graft uptake and hearing outcome with less operative time. Endoscope system is portable, so convenient for surgeon where microscope is not available. Also endoscope is a less costly armamentarium. Our study shows better result in myringoplasty can be achieved if both methods of surgery are used in combination.
Electronic supplementary material
The online version of this article (10.1007/s12070-018-1341-4) contains supplementary material, which is available to authorized users.
Keywords: Microscopic myringoplasty, Endoscopic myringoplasty, Pure tone audiometry (PTA), CSOM, Air–Bone–Gap (ABG)
Introduction
The Myringoplasty, is a procedure for repairing or reconstruction the ear drum, using a graft material, without interference with middle ear structures and was initiated by Berthold and was further developed by Wullstein and Zollner [1–5].
Most common cause of damage to the tympanic membrane is chronic ear disease however, damage may be due to trauma, scalds, pressure effects, and head injuries direct physical injury, burns, iatrogenic during insertion of the grommet. Most of these perforations caused by trauma and acute suppurative otitis media heal spontaneously. Long standing,Chronic perforations leading to recurrent ear discharge and needs myringoplasty [6].
There are numbers of techniques of myringoplasty that are described in the literature and these include the underlay technique, [7] overlay technique, [8] “Gelfilm Sandwich” technique [9], “Swinging Door” technique, [10] tipple “C” technique, [11] double breasting technique, [12] fascial pegging technique, [13] anterosuperior anchoring technique, [14] and laser assisted “spot welding” technique [15].
In 1921 Carl Olof Nylenthat (Swedish otologist) used monopolar microscope first time in ear surgery which was soon replaced by a binocular microscope developed in 1922 by Gunnar Holmgren. This microscope also had poor light quality, very short focal length, limited field of vision, and instability. Many new different models came in between which was perfected by Littmann and the Zeiss Company. This model replaced all other models progressively which allowed for the development of tympanoplasties and stapes surgery. The recent developments include the 3-D imaging and navigation system with video output and recording system.
The teaching of otology surgeries during the otolaryngologist’s training period is traditionally done with the use of microscopes. Microscope provides binocular vision and both the hands of surgeon are free for operative work. Major demerit of operating microscope is that it provides a magnified image along a straight line [16].
In the last decade, there has been increased use of endoscopes in otologic surgery, not just with combination of microscope, but exclusively. Even in cases of over hanged external auditory canal by virtue of availability of endoscopes with different angles this method has the potential to allow “around the corner” visualization of small recesses, through narrow spaces, without the need for canal-plasty,
Advantages of endoscope are it provides an excellent magnified image with a good resolution, with minimal effort it can be used to visualize the middle ear cavity and antero- inferior recess of external auditory canal can be visualized using an endoscope, great magnification can be achieved by just getting the endoscope closer to the surgical field, even difficult areas to visualize under microscopy like sinus tympani can easily be examined using an endoscope.
Disadvantage of endoscope are lack of binocular vision, single handed technique, as surgeon holds the endoscope in one hand which can be compensated by using endoscope holder [17, 18].
Materials & Methods
This prospective study was conducted in Department of ENT of Chirayu Medical College and Hospital from January 2016 to December 2016. Total 60 patients of age group 18-60 were taken for study that had chronic otitis media or trauma with central perforation. Patients were randomly selected for endoscopic or microscopic myringoplasty. 30 patients for endoscopic and 30 patients for microscopic myringoplasty. Patients were admitted 1 day before surgery. Detailed history, physical and clinical examination of ear, nose and throat was done. Informed written consent was taken. Pre-Operative medication given. All procedure were done under general anesthesia. Temporalis facia graft was taken in both groups. Endoscopic myringoplasty done by using 0, 30, 45, and 70 degree Hawks Rigid endoscope 4 mm diameter, 100 mm length with camera and Monitor via permeatal route and microscopic myringoplasty was done by using Ziess microscope via post aural William wilde’s incision. Middle ear mucosa, ossicular chain integrity, eustechian tube opening, and round window reflex was confirmed in both groups, Graft placed as underlay technique in both groups. Patient was discharged on next day after surgery. Post operative pain was analyzed by Wong–Baker FACES pain rating scale till the date of discharge. Patients were called for follow up after 1 week for suture removal and after 1 month for assessment of graft uptake, PTA was done at 3rd month to evaluate hearing improvement and final review after the 6th month.
Inclusion Criteria
CSOM with inactive mucosal disease (dry perforations)
Patients above 18 years of age
Exclusion Criteria
CSOM with active mucosal disease (discharging years)
CSOM with squamosal disease
Patients with associated systemic diseases
Patients with sensory neural hearing loss and mixed hearing loss
Analysis and Statistical Aspects
In our study out of total 60 patients 25 were males and the 35were females. Out of 60 Patients 27 were in the age group 18–30 and 23 were in age group 31–45 and only 10 in the age group of 46–60. 18–30 age group cohort was predominant. The average time taken for endoscopic myringoplasty was 65.5 ± 3.45 min and for microscopic myringoplasty 85.7 ± 3.42 min. Out of 60 patient 26 were having large central perforation (LCP). Of which 13 underwent microscopic and 13 underwent endoscopic myringoplasty. The graft was in situ in 22 patients while 4 patients had small residual central perforation. Out of these four residual perforations 3 were done by endoscopy and 1 by microscopy.
19 out of 60, were having medium size central perforation (MCP), 10 were operated with endoscope and 9 with microscope, 1 patient had small residual perforation which was performed with endoscopic method. Out of 60 patients 15 were having small central perforation (SCP), 7 done with endoscope and 8 with microscope. In all patient graft take up was well. Large central perforation present in maximum patient and had least graft uptake as compared to MCP and Small central perforation (SCP). Out of 30 patients of endoscopic myringoplasty 27 patients had good graft uptake and 3 had small central residual perforation after 3 months. Out of the 30 microscopic myringoplasty 29 patients had good graft uptake and 1patient had small central residual perforation after 3 months.
In our study pre operative and post operative Air–Bone–Gaps (ABGs) were 22.05 ± 2.04 and 9.05 ± 1.36 db respectively in endoscopic myringoplasty and 21.81 ± 1.85 and 8.55 ± 1.44 db respectively in microscopic myringoplasty.
Independent t-test value for surgical outcome is t-1.373 with P value of 1.752 there is no significant difference in both groups with good hearing improvement.
In our study post operative pain was analyzed by Wong–Baker FACES pain rating scale till the date of discharge patient were asked for post operative pain 1 day after surgery, in endoscopic procedure there is mild pain or almost no pain but in patient in microscopic procedure with post aural route there is significant irritating pain (Tables 1, 2).
Table 1.
Results of endoscopic and microscopic assisted myringoplasty
| Variable | Group A Endoscopic myringoplasty |
Group B Microscopic myringoplasty |
P value |
|---|---|---|---|
| Age (mean) | 29.8 years | 34.3yreas | |
| Sex | Male-22 | Male-10 | |
| Female-08 | Female-20 | ||
| Tympanic membrane perforation[%] | LCP–13 patient (43.33%) | LCP–13 patient (43.33%) | |
| MCP-10 patient (33.33%) | MCP = -09 patient (30%) | ||
| SCP- 07 patient (23.33%) | SCP -08 patient (26.66%) | ||
| Graft success rate [After 3 Month] | 90% (27out of 30) | 96.67% (29 out of 30) | |
| Cosmetic out come | Better | Good | |
| Pain scale [Post operative] | Mild | Significant irritating pain | |
| Average time taken Mean ± SD | 65.5 mts ± 3.45 | 85.7 mts ± 3.42 |
P value < 0.001 T value-22.775 (significant) |
|
Pure tone audiometry [Air bone gap] Mean ± SD Preoperative Post operative |
22.05 ± 2.04 db 9.05 ± 1.36 db |
21.81 ± 1.85 db 8.55 ± 1.44 db |
P value = 1.752 e |
Table 2.
Success rate of endoscopic and microscopic assisted myringoplasty
| Graft up take | Graft failure | Success % [After 3 Month] | P Value | |||
|---|---|---|---|---|---|---|
| At 1 month | ||||||
| Endoscope assisted | LCP-10 | 26 | 3 | 4 | 86.67 |
Chi Square value 1.96 P value = 0.16 > 0.05 Non-significant |
| MCP-9 | 1 | |||||
| SCP-7 | 0 | |||||
| Microscope assisted | LCP-12 | 29 | 1 | 1 | 96.67 | |
| MCP-09 | 0 | |||||
| SCP-08 | 0 | |||||
| Total (N = 60) | 55 | 5 | ||||
| At 3 months | ||||||
| Endoscope assisted | LCP-10 | 27 | 3 | 3 | 90 |
Chi Square value 1.07 P value = 0.30 > 0.05 Non-significant |
| MCP-10 | 0 | |||||
| SCP-7 | 0 | |||||
| Microscope assisted | LCP-12 | 29 | 1 | 1 | 96.67 | |
| MCP-09 | 0 | |||||
| SCP-08 | 0 | |||||
| Total (N = 60) | 56 | 4 | ||||
| At 6 months | ||||||
| Endoscope assisted | LCP-10 | 27 | 3 | 3 | 90 |
Chi Square value 1.07 P value = 0.30 > 0.05 Non-significant |
| MCP-10 | 0 | |||||
| SCP-7 | 0 | |||||
| Microscope assisted | LCP-12 | 29 | 1 | 1 | 96.67 | |
| MCP-09 | 0 | |||||
| SCP-08 | 0 | |||||
| Total (N = 60) | 56 | 4 | ||||
Discussion
Myringoplasty is operative procedure to repair tympanic membrane perforation which is common procedure in otorhinolaryngology practice. The aim of our study was to compare advantages and disadvantages of endoscopic myringoplasty with that of microscopic myringoplasty in term of operative time, cosmetic outcome, graft uptake and audiological improvement.
Visualization of margin of perforation after refreshing edges in large and subtotal perforation is good in endoscopic procedure also Eustachian tube orifice, IS joint round window is best seen here as endoscope easily negotiated through curvy EAC. Frequent adjustment of Microscope and head is required in microscopic myringoplasty. Canaloplasty and curettage is not required in endoscopic procedure but it is required in microscopic procedure if overhang causes difficult visualization of ossicular chain. In our study canaloplasty is done in 2 patients and curettage in 2 patients. Similar observations were found in research of Patel Jaimin et al. and Ahmad aftab et al. [19, 20].
In endoscopic myringoplasty perforation closure rate is good in SCP but it is lesser in MCP and LCP as compares to microscopic. One reason may be 2-dimensional vision, contact of edges of perforation with graft is better due to 3-dimension vision in microscopic procedure. Endoscopic myringoplasty procedure is based on 2D images hence depth perception is difficult so surgeon has to be very careful whether the graft is sufficiently lifted to make contact with edge of perforation. This limitation is minimized by full high definition camera system. One of main disadvantages with an endoscopic myringoplasty is that it is one-handed surgery. The surgeon has to use one hand to hold the endoscopic system and the other hand for doing surgery which make a bit difficult to perform surgery. In study of Kmar et al. [21] the overall success rate for medium central perforations was 85.7%. A small perforation recurred in 4 years (11.4%). One case lost during follow up period. After 1st week of surgery: 25 patients out of 35 had intact ear drum. 4th weeks after surgery: 30 patients out of 35 had intact ear drum.
Hearing improvement is very impotent factor after myringoplasty which not only signify success of surgery but also improves quality of life of patient who came with primary complaint of hearing loss. There are many of studies which shows hearing gain post operatively. In study of Dundar et al. [22]. the preoperative and postoperative ABGs were 20.40 and 8.12 dB, respectively, in the endoscopic tympanoplasty group and 21.34 and 8.13 dB, respectively, in the microscopic tympanoplasty group. In our study pre operative and post operative ABGs were 22.05 ± 2.04 and 9.05 ± 1.36 db respectively in endoscopic myringoplasty and 21.81 ± 1.85 and 8.55 ± 1.44 db respectively in microscopic myringoplasty.
Operative time is less in endoscopic myringoplasty as compared to microscopic as there is no need of postaural soft tissue work, shorten operative time and lesser surgical trauma, leads to fast post operative recovery. The average operative duration in Group 1 was 65.5 ± 3.45 min, and that in Group 2 was 85.7 ± 3.42 min. The operative duration in Group 1 was significantly lower than that in Group 2 according to an independent-samples t test (P < 0.001) similar result was also found in study of Dundar et al. [22]. On the other hand in study of Kojima et al. [23] operating time was compared between the microscopic group (41 years) and the endoscopic group (15 years), the mean operating time was 54.1 and 53.0 min, respectively, showing no significant difference between the two groups.
In endoscopic procedure there is mild pain or almost no pain requiring analgesic for 1 or 2 days but in patient in microscopic procedure with post aural route there is significant irritating pain, patient has to take analgesics compulsorily, also endoscopic myringoplasty has excellent cosmetic outcome as no post aural scar mark, less post surgical pain.
Advantages of microscopic myringoplasty are that there is no overcrowding of instrument in External auditory canal as in endoscopic surgery, both hands are free so bleeding control during surgery as well as elevation of tympanomeatal flap is also better and magnification is of great advantage of microscopic procedure. In our study graft take up rate is more as compared to endoscopic one.
Conclusion
Microscopic myringoplasty has more success rate in Large Central Perforation and Medium Central Perforation and equal results in Small Central Perforation. Advantages of microscope are depth perception and both hands are free for procedure which is limitation of endoscopic myringoplasty, if not using endoscope holder. Advantage of endoscopic permeatal myringoplasty is superior visualization, least tissue trauma, and better cosmetic outcome, almost equal graft uptake and hearing outcome with less operative time. Endoscope system is portable so convenient for surgeon where microscope is not available. Also endoscope is a less costly armamentarium. Our study shows better result in myringoplasty can be achieved if both methods of surgery are used in combination.
Electronic supplementary material
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Compliance with Ethical Standards
Conflict of interest
All authors declare that they have no conflict of interest
Ethical consideration
Both microscopic and endoscopic myringoplasty are established method of treatment. There is no ethical conflict.
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