Abstract
To study various parameters, including Middle ear risk index (MERI) and their correlation with outcome of middle ear surgery. The study was conducted from September 2015 to May 2017 in Department of Otolaryngology at our institute. It included 185 cases of safe type of chronic suppurative otitis media. These patients were admitted and treated surgically and record was kept for at least 3 months follow-up in postoperated period. The study concluded that a good correlation exist between MERI and result of tympanoplasty.
Keywords: Chronic otitis media, Middle ear risk index, Tympanoplasty, Ossiculoplasty
Introduction
Chronic suppurative otitis media is chronic infection of middle ear cleft i.e. the Eustachian tube, middle ear and mastoid in which permanent perforation and associated otorrhoea is present. It is more common among developing countries and poor rural population due to poor nutrition and lack of education and resources, over-crowding, leading to poor hygiene and frequent upper respiratory tract infections, ignorance, poor access for medical care and lack of adequate treatment [1]. It is common among children and young adults, due to recurrent upper respiratory tract infections, acute otitis media, adenoiditis or as a sequelae of serous otitis media [2]. Chronic suppurative otitis media can lead to extracranial as well as intracranial complications, including, mastoid abscess, hearing loss, facial nerve paralysis, labyrinthitis, lateral sinus thrombosis, meningitis, encephalitis and intracranial abscess [3]. Management aims at early diagnosis with appropriate treatment, whether, medical or surgical, to eradicate the disease or reduce its complications. Treatment can be conservative including regular aural toileting, use of topical or oral antibiotics and the use of hearing aids for rehabilitation or it can be surgical [4].
For the patients opting for surgery, it is necessary to explain the patient about the disease, its severity, treatment options, their outcome and prognosis. The goal of successful tympanoplasty is to create a sound-conducting mechanism in a well-aerated, mucosal-lined middle ear cleft. Various prognostic factors for tympanomastoid surgery have been studied in previous studies. Belluci staged otorrhoea into four parts for prognosis of tympanoplasty. Austin proposed a prognostic stratification based on ossicle status and more recently Kartush developed middle ear risk index (MERI). Becvarovski and Kartush revised and updated MERI in 2001. It involved Belluci’s criteria for otorrhoea, Austin-Kartus classification for ossicular status, middle ear factors, including, tympanic membrane perforation, presence of cholesteatoma, middle ear granulation, previous surgery and smoking [5].
In this study we have studied various parameters prognosticating the results of middle ear surgeries. Also we have used middle ear risk index (MERI) to stratify patient groups according to severity of disease and to evaluate the efficiency of MERI score in predicting the outcome of tympanoplasty (Table 1).
Table 1.
Middle ear risk index
| Risk factor | Risk value | |
|---|---|---|
| 1 | Otorrhoea (Belluci criteria) | |
| Dry | 0 | |
| Occasionally wet | 1 | |
| Persistently wet | 2 | |
| Wet with cleft palate | 3 | |
| 2 | Perforation | |
| Absent | 0 | |
| Present | 1 | |
| 3 | Cholesteatoma | |
| Absent | 0 | |
| Present | 2 | |
| 4 | Ossicular status (Austin/Kartus) | |
| M+I+S+ | 0 | |
| M+S+ | 1 | |
| M+S– | 2 | |
| M–S+ | 3 | |
| M–S– | 4 | |
| Ossicles head fixed | 2 | |
| Stapes fixation | 3 | |
| 5 | Middle ear granulations/effusion | |
| No | 0 | |
| Yes | 2 | |
| 6 | Previous surgery | |
| None | 0 | |
| Staged | 1 | |
| Revision | 2 | |
| 7 | Smoking | |
| No | 0 | |
| Yes | 2 |
According to MERI, risk categories were divided as: score 0 normal; score 1–3 mild disease, score 4–6 moderate disease and score 7–12 severe disease
Aims and Objectives
To observe and evaluate the impact of various prognostic parameters affecting the outcome of middle ear surgeries, namely: age, chronicity of disease, presence of active discharge, duration of inactivity, status of middle ear, presence of bilateral disease, ossicular status and smoking.
To assess the result of surgical treatment of chronic suppurative otitis media and its relation to the MERI (middle ear risk index).
Materials and methods
The study was conducted from September 2015 to May 2017 in our institute. 185 cases of safe type of chronic suppurative otitis media with adequate cochlear reserve were included in the study. These patients were admitted and treated surgically and record was kept for at least 3 months follow-up in postoperated period.
Tympanoplasty is defined as successful when the graft is accepted and intact after 3 months. Delayed failure was defined as perforation or atelectasis that occurred after 3 months.
Selection of patients for study
Inclusion criteria
Patients of all age groups, above 10 years.
Patients with mucoid type of chronic suppurative otitis media.
Presence of conductive hearing loss with no sensorineural hearing loss.
Good general physical condition.
Exclusion criteria
Patients with age less than 10 years.
Patients with acute suppurative otitis media and otitis externa.
Patients with squamous type of chronic suppurative otitis media.
Patients with sensorineural hearing loss.
Congenital deformity for ear, nose or throat.
Severe systemic disease.
Results
185 cases of safe type of chronic suppurative otitis media were included in the study. The patients ranged in age from 11 to 60 years; maximum number of cases were in age group 21–30 years (43.2%), 102 were female (55.1%) and 83 were male (44.9%), most of them belonged to rural areas 147 (79.5%) and were from lower socioeconomic group 122 (66%). 26 (14%) of them were smokers. Common presenting symptoms were ear discharge in 182 (98.4%), decreased hearing in 165 (89.2%), tinnitus in 46 (24.9%) and earache in 16 (8.7%) cases. Out of them, 68 cases (36.8%) cases had bilateral disease while 117 cases (63.2%) had unilateral disease. Most of them had ossicular chain intact and mobile and underwent type 1 tympanoplasty (159 cases, 86.0%), incus or lenticular process of incus was eroded in 15 cases (8.1%), malleus was eroded in 8 cases (4.3%), all ossicles except stapes footplate were absent in 3 cases (1.6%) while ossicles were fixed in 1 case (0.5%).
In our study, overall graft acceptance rate was 80.5%. Various factors which were found to be significantly associated with graft uptake rate were socioeconomic status (χ2 = 8.255; p = 0.016), smoking (χ2 = 13.75; p = 0.0002), middle ear mucosa (χ2 = 8.275; p = 0.004), duration of inactivity (χ2 = 12.523; p = 0.028). Whereas, size of perforation (χ2 = 6.643; p = 0.156) and duration of disease (χ2 = 6.018; p = 0.304) were found to have no association with graft uptake rate (Tables 2, 3, 4, 5, 6, 7).
Table 2.
Socioeconomic status versus graft uptake
| Socioeconomic status | Graft failure | Graft accepted | Total |
|---|---|---|---|
| Lower | 31 (25.4) | 91 (74.6) | 122 |
| Middle | 3 (6.7) | 42 (93.3) | 45 |
| Upper | 2 (11.1) | 16 (88.9) | 18 |
| Total | 36 (19.5%) | 149 (80.5%) | 185 |
Table 3.
Smoking versus graft uptake
| Smoking | Graft failure | Graft accepted | Total |
|---|---|---|---|
| No | 24 (15.1%) | 135 (84.9%) | 159 |
| Yes | 12 (46.1%) | 14 (53.9%) | 26 |
| Total | 36 (19.5%) | 149 (80.5%) | 185 |
Table 4.
Middle ear mucosa versus graft uptake
| Middle ear mucosa status | Graft failure | Graft accepted | Total |
|---|---|---|---|
| Normal | 25 (15.9%) | 132 (84.1%) | 157 |
| Unhealthy | 11 (39.3%) | 17 (60.7%) | 28 |
| Total | 36 (19.5%) | 149 (80.5%) | 185 |
Table 5.
Duration of disease versus graft uptake
| Duration of disease | Graft rejected | Graft accepted | Total |
|---|---|---|---|
| No discharge | 2 (50.0%) | 2 (50.0%) | 4 |
| < 5 years | 14 (22.6%) | 48 (77.4%) | 62 |
| 6–10 years | 5 (17.9%) | 23 (82.1%) | 28 |
| 11–15 years | 1 (8.3%) | 11 (91.7%) | 12 |
| 16–20 years | 3 (9.7%) | 28 (90.3%) | 31 |
| > 20 years | 11 (22.9%) | 37 (77.1%) | 48 |
| Total | 36 (19.5%) | 149 (80.5%) | 185 |
Table 6.
Duration of inactivity versus graft uptake
| Duration of inactivity | Graft failure | Graft successful | Total |
|---|---|---|---|
| Active ear | 4 (22.2%) | 14 (77.8%) | 18 |
| < 3 months | 19 (21.3%) | 70 (78.7%) | 89 |
| 4–6 months | 4 (9.5%) | 38 (90.5%) | 42 |
| 7–12 months | 6 (37.5%) | 10 (62.5%) | 16 |
| > 1 year | 1 (5.9%) | 16 (94.1%) | 17 |
| No history of ear discharge | 2 (66.7%) | 1 (33.3%) | 3 |
| Total | 36 (19.5%) | 149 (80.5%) | 185 |
Table 7.
Size of perforation versus graft uptake
| Size of perforation | Graft failure | Graft accepted | Total |
|---|---|---|---|
| No perforation | 0 (0.0%) | 3 (100.0%) | 3 |
| Small perforation | 6 (16.2%) | 31 (83.8%) | 37 |
| Medium perforation | 12 (15.9%) | 58 (84.1%) | 70 |
| Large perforation | 18 (24.0%) | 57 (76.0%) | 75 |
| Total | 36 (19.5%) | 149 (80.5%) | 185 |
The total number of patients with MERI score 1–3 (mild disease) were 67%, with score 4–6 (moderate disease) were 24.3% and with score 7–12 (severe diseases) were 8.7%. Patients with score 1–3 had graft acceptance of 83.9%, with score 4–6 had graft acceptance 82.2% and with score 7–12 had 50% success (χ2 = 12.60; p = 0.005). Before surgery, hearing loss > 40 dB was found in 8.1% cases with MERI 1–3, in 24.4% cases with MERI 4–6 and in 68.8% cases with MERI 7–12 (c2 = 12.868; p = 0.045). After surgery, hearing loss > 40 dB was found in 2.4%, 11.1% and 25% cases with MERI 1–3, 4–6 and 7–12, respectively (χ2 = 29.893; p < 0.001). Hence from the present study it can be concluded that MERI scoring can be useful in predicting the outcome of tympanoplasty and for prognosticating the patients for graft acceptance rate and hearing improvement after surgery (Tables 8, 9).
Table 8.
MERI score versus graft uptake
| Risk category | No. of ears | Graft acceptance rate | ||||
|---|---|---|---|---|---|---|
| No. | % | Graft accepted | % | Graft rejected | % | |
| MERI 1–3 | 124 | 67 | 104 | 83.9 | 20 | 16.1 |
| MERI 4–6 | 45 | 24.3 | 37 | 82.2 | 8 | 17.8 |
| MERI 7–12 | 16 | 8.7 | 8 | 50 | 8 | 50 |
Table 9.
Pre-op PTA and post-op PTA versus MERI score
| MERI | Pre-op PTA | Post-op PTA | ||||
|---|---|---|---|---|---|---|
| < 25 dB | 26–40 dB | > 40 dB | < 25 dB | 25–40 dB | > 40 dB | |
| 1–3 | 31 (25%) | 83 (66.9%) | 10 (8.1%) | 91 (73.4%) | 30 (24.2%) | 3 (2.4%) |
| 4–6 | 11 (24.4%) | 23 (51.2%) | 11 (24.4%) | 26 (57.8%) | 14 (31.1%) | 5 (11.1%) |
| 7–12 | 0 (0%) | 5 (31.2%) | 11(68.8%) | 1 (6.2%) | 11 (68.8%) | 4 (25%) |
| Total | 42 | 111 | 32 | 118 | 55 | 12 |
Discussion
The study “Prognostic parameters and their relevance in outcome of middle ear surgeries” was conducted from October 2015 to May 2017 in our institute. 185 cases of mucoid type of chronic suppurative otitis media were admitted and investigated. The preoperative, operative and postoperative follow-up data was compiled, analysed and compared with previous studies.
Otitis media has been categorised as a neglected tropical disease with highest prevalence in India, approx. 6% (according to WHO report 2015). Young rural population with low socio-economic class are the most common suffers of chronic suppurative otitis media. Tympanic membrane perforations are long standing and they are poorly treated by general practitioners. Treatment can be conservative including aural toileting, topical or oral antibiotics or it can be surgical, including tympanoplasty with or without mastoid exploration, depending on persistent otorrhoea, ossicular status and extent of disease [5].
Similar to previous studies, we also found that most affected population were young age-group, those belonging to rural areas and from a poor socioeconomic group. Most common presenting symptoms were recurrent otorrhoea and decreased hearing [5–7].
In our study, overall graft acceptance rate was 80.5%. Various factors which were found to be significantly associated with graft uptake rate were socioeconomic status, smoking, middle ear mucosa and duration of inactivity. Whereas, size of perforation and duration of disease were found to have no association with graft uptake rate. In the study conducted by Pinar et al. [8], bilateral disease and type of surgery were found to be statistically significant with result of tympanoplasty while size and site of perforation had no significant association. While Onal et al. [9], showed size of perforation, smoking and contralateral disease had significant association with results of surgery and type of surgery, duration of dry ear and active ear during surgery had no association with results of surgery. Similar to other studies, we also concluded that a significant association exists between the MERI score and success rate of tympanoplasty [10].
Conclusion
By this study, we conclude that a good correlation exist between MERI and result of tympanoplasty and hearing improvement and it can further be useful for preoperative risk stratification, counselling of the patient regarding graft uptake and hearing improvement after surgery. Shortcomings of this study were short period of follow-up, patients lost to follow-up, and lack of uniformity in disease severity among patients.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Orji F. A survey of the burden of management of chronic suppurative otitis media in a developing country. Ann Med Health Sci Res. 2013;3(4):598. doi: 10.4103/2141-9248.122126. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Santoshi Kumari M, Madhavi J, Bala Krishna N, Raja Meghanadh K, Jyothy A. Prevalence and associated risk factors of otitis media and its subtypes in South Indian population. Egypt J Ear Nose Throat Allied Sci. 2016;17(2):57–62. doi: 10.1016/j.ejenta.2016.04.001. [DOI] [Google Scholar]
- 3.Monasta L, Ronfani L, Marchetti F, Montico M, Brumatti LV, Bavcar A, et al. Burden of disease caused by otitis media: systematic review and global estimates. PLoS ONE. 2012;7(4):e36226. doi: 10.1371/journal.pone.0036226. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Chronicsuppurativeotitis_media.pdf [Internet]. [cited 2019 Nov 19]. https://www.who.int/pbd/publications/Chronicsuppurativeotitis_media.pdf
- 5.Ahmed A, Sharma SC. Middle Ear Risk Index [MERI] as prognostic factor in tympanomastoidectomy with tympanoplasty. Madr J Otorhinolaryngol. 2016;1(1):15–22. doi: 10.18689/mjol-1000103. [DOI] [Google Scholar]
- 6.Vignadutt P, Shaik A. A retrospective study on middle ear risk indices in analysing the postoperative outcome following tympanoplasty. Int J Otorhinolaryngol Head Neck Surg. 2019;5(5):1234. doi: 10.18203/issn.2454-5929.ijohns20193861. [DOI] [Google Scholar]
- 7.Parmar SM, Sood A, Chakkal HS. Prevalence of chronic suppurative otitis media in schoolgoing children. Indian J Otol. 2018;24(4):223. [Google Scholar]
- 8.Pinar E, Sadullahoglu K, Calli C, Oncel S. Evaluation of prognostic factors and middle ear risk index in tympanoplasty. Otolaryngol Neck Surg. 2008;139(3):386–390. doi: 10.1016/j.otohns.2008.05.623. [DOI] [PubMed] [Google Scholar]
- 9.Onal K, Uguz MZ, Kazikdas KC, Gursoy ST, Gokce H. A multivariate analysis of otological, surgical and patient-related factors in determining success in myringoplasty: a multivariate analysis in determining success in myringoplasty. Clin Otolaryngol. 2005;30(2):115–120. doi: 10.1111/j.1365-2273.2004.00947.x. [DOI] [PubMed] [Google Scholar]
- 10.Kumar N, Madkikar NN, Kishve S, Chilke D, Shinde KJ. Using Middle Ear Risk Index and ET function as parameters for predicting the outcome of tympanoplasty. Indian J Otolaryngol Head Neck Surg. 2012;64(1):13–16. doi: 10.1007/s12070-010-0115-4. [DOI] [PMC free article] [PubMed] [Google Scholar]