Healing of the tympanic membrane after surgical intervention for atelectasis of the middle ear in sixty‐two adults

Abstract

In treating atelectasis of the middle ear multiple techniques have been described, including grafting of the eardrum defect, for example with perichondrium or cartilage. 1 Several studies suggested that excision of the retraction pocket in paediatric ears does not require grafting. The spontaneous healing capacity of the paediatric tympanic membrane (TM) ranged from 87.2% to 96.8%. 2-5 These results are comparable to spontaneous healing after traumatic perforations of the tympanic membrane, which is generally treated conservatively, and to results of myringoplasty operations for perforated membranes. 6,7 As it appears that excision of the atrophic segment of the tympanic membrane in paediatric ears does not require grafting, and traumatic perforations in adults generally heal as well as in children, this might be an appropriate treatment for adults as well. Methods Ethical considerationsThis study was approved by the Institutional Ethics Committee. Patient selection and characteristicsCase files of all adult patients (≥18 years of age) who have undergone excision of the atrophic segment of the tympanic membrane in the Tergooi hospital in the Netherlands between 2010 and 2013 were examined to determine the spontaneous healing rate of the tympanic membrane and hearing thresholds. Exclusion criteria were tympanoplasty in the past or need for an atticoantrostomy in cholesteatoma. Every patient was classified according to the Erasmus atelectasis classification, a classification for retraction pockets of the pars tensa, previously described for paediatric patients (Table 1). 8 Sixty-two patients were included in this study. Median age at time of surgery was 43.0 years (range 18-71 years). The male-to-female ratio was 1 : 1. Thirteen patients received surgery on both ears. Two patients received a second surgery on one ear because atelectasis recurred, which were also included in our analysis. Therefore, seventy-seven ears were included. Surgical techniqueSurgery was performed by, or under supervision of, the last author.The majority of middle ear operations were performed transmeatally, and two retraction pockets required a combined mastoidectomy approach for a cholesteatoma was present that could not be resected completely via the transmeatal approach. These cases were only included if an atticotomy was not performed. If the tympanic membrane was not fixed to middle ear structures, simple excision was carried out, and the atrophic section of the tympanic membrane was removed up to the normal margins. A fixed tympanic membrane was approached via a tympanomeatal incision, the atrophic drum being very carefully separated from middle ear structures to prevent tearing, and everted completely before subsequent excision; the atrophic section of the tympanic membrane being removed entirely up to the normal margins.After resection, a margin of normal membrane remains from which the new drum regenerates. In fifty-three cases, a T-tube was inserted through the perforation that remains after excision to facilitate middle ear venti...

Management of tympanic membrane retractions: a systematic review

“… 1 year Healed created perforation in 72 (94%) Pre-op: 13.1 Post-op: 11.5 Gain: 1.6 5 persistent perforation, three required myringoplasty Rath [ 23 ] ( n = 40) 7.2 (3–14) M: 14 F: 16 PT N.A. 16.1 months (6–29) 6 recurrences (15%), 6 s interventions (15%), 4 of 6 healed Pre-op: 22.4 dB Post-op: 9.7 dB Gain: 12.7 dB 38/40 created perforation closed 0% cholesteatoma Cassano [ 25 ] ( n = 45) 5–12 M: 19 F: 18 PT WS 24 months VT: 15 (94%) WS: 14 (35%) N.A Recurrence in 5 ears (11%) Borgstein [ 39 ] ( n = 86) 9 (4–18) M: 28 F: 34 PT N.A 7–15 months 94% of created perforations healed Recurrence in 17 (20%) Significant improvement of ABG at final follow-up ( P < 0.01) Postoperative discharge in the operated ear: 8.1% Srinivasan [ 24 ] ( n = 31) 9 (3–14) M: 16 F: 10 PT N.A. 16 months (range: 8–34) Recurrence in seven ears, one ear with persistent perforation.…”

“…The rationale behind this technique is that it may recover the difference between atmospheric pressure and middle-ear pressure, and thus abolish the driving force causing the tympanic membrane to be retracted. Six studies [24][25][26][27][28][29] have been described that excised the TMR and subsequently placed ventilation tubes. Rath et al [25] was the only prospective study in 40 children, of whom 38 (95%) of the created perforation healed.…”

“…In all six studies mentioned above (n = 243), it can be summarized that the created perforations remain persistent in 3-13% and that recurrences of the TMR occur in 11-25% of operated patients. The summary can be found in Table 2 [24][25][26][27][28][29].…”