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Published: 2023-04-21
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Recurrent tympanic perforation after myringoplasty: a narrative literature review and personal experience

Otorinolaringoiatria Universitaria, Dipartimento di Biomedicina Traslazionale e Neuroscienze, Università di Bari, Bari, Italy
Otorinolaringoiatria Universitaria, Dipartimento di Biomedicina Traslazionale e Neuroscienze, Università di Bari, Bari, Italy
Otorinolaringoiatria Universitaria, Dipartimento di Biomedicina Traslazionale e Neuroscienze, Università di Bari, Bari, Italy
Otorinolaringoiatria Universitaria, Dipartimento di Biomedicina Traslazionale e Neuroscienze, Università di Bari, Bari, Italy
Otorinolaringoiatria Universitaria, Dipartimento di Biomedicina Traslazionale e Neuroscienze, Università di Bari, Bari, Italy
Otorinolaringoiatria Universitaria, Dipartimento di Biomedicina Traslazionale e Neuroscienze, Università di Bari, Bari, Italy
myringoplasty tympanic membrane perforation recidivism recurrent residual graft failure unsuccess

Abstract

The aim of the work is to review the current literature concerning recidivism of tympanic perforation after myringoplasty and to give some tips to improve the chance of success and manage the possible scenario of failure. An analysis of the existing literature is presented and, based on it and on our experience, an algorithm of management of tympanic perforation recidivism is proposed.

Definitions and historical background

Tympanic membrane (TM) perforation is one of the most common conditions that otologists have to deal with in daily clinical practice 1. TM may result from recurrent middle ear infections, trauma, or iatrogenic causes 2. The majority (up to 80%) of these perforations have tendency to heal spontaneously. The remaining cases may be addressed to surgery, especially when patients experience major discomfort due to recurrent otorrhea, conductive hearing loss, or interdiction to water activities.

TM repair was first introduced by Berthold in 1878 3 with the term of ‘myringoplasty’, and further developed by Zollner 4 and Wullstein 5 in the 50s, when it acquired the name of ‘type I tympanoplasty’. The two terms are often used interchangeably, even if a theorical difference exists, in that tympanoplasty requires the elevation of a tympanomeatal flap while myringoplasty does not 6. To avoid any misunderstanding, both these concepts will be referred as myringoplasty throughout the rest of this manuscript.

The main aim of myringoplasty is to eradicate the disease and create an intact TM, thus preventing recurrent or chronic middle ear infection. Secondly, continuity of the air-conduction mechanism from TM to inner ear should be ensured when possible 7.

Surgical techniques

Myringoplasty can be performed microscopically or endoscopically with an endomeatal, retroauricolar, or transmeatal approach. The surgeon’s preferences and site of perforation determines the approach.

The use of autologous grafting material such as temporal fascia, perichondrium, cartilage, fat, periosteum, or vein is preferrable when available 8. Two main techniques are currently in use based on the positioning of the graft with regards to the remnants of the tympanic membrane, the underlay and the overlay.

In our institution, the underlay technique, with the graft placed entirely medial to the TM remnants, is preferably performed as long as the fibrous annulus is preserved between 2 and 4 o’clock. It is quite easy and quick to perform, and the healing process is usually fast. However, in case of anterior perforations a good visualisation and steady anterior support on the bony annulus cannot be ensured.

In these cases, an underlay variant with anterior anchorage is performed: an accessory horizontal 3-4 mm incision is made approximately 4 mm lateral to the anterior annulus at about 10 o’clock and a subcutaneous tunnel is made to create an anterior window to the middle-ear; the antero-superior edge of the graft is then pulled through this window and allocated beneath the anterior flap; after graft placement, the anterior angle of the middle ear cavity should be packed with absorbable gelatine sponge to ensure further stability.

In anterior or subtotal perforations where the fibrous annulus is absent between 2 and 4 o’clock, the overlay technique is mandatory, thus allowing excellent visualisation of the anterior meatal recess. In our institution, the TM remnants and the skin of the EAC are always completely removed to reduce the risk of iatrogenic cholesteatoma, and the graft is then placed onto the bony annulus with a minimal overriding onto the canal wall. The anterior wall is then covered with the residual skin flap or, in rare cases, with a Tiersch graft 9, and then the anterior angle is carefully packed with small pieces of gelatine sponge. The main disadvantages of this technique are the risk of blunting of the anterior recess and the lateralisation of the graft; moreover, the healing process can be laborious and often longer.

Recidivism of tympanic membrane perforation

Myringoplasty can be a challenging procedure, and great variation in outcomes has been reported among different institutions and surgeons. In particular, the reported closure rates widely vary between 46% and 100% 9, depending on different factors which are often multiple and interconnected (Tab. I).

Recidivism of the perforation is one of the major complications after myringoplasty. Specifically, a distinction must be made between late re-perforation of a completely healed neotympanum, caused by a new trauma or infection or resulting from a progressive graft atrophy, and immediate post-operative graft failure, due to septic or aseptic graft necrosis, or inadequate anterior graft adaptation 10,11. To avoid any confusion, late re-perforation will be referred as ‘recurrent perforation’ and immediate graft failure as ‘residual perforation’ throughout the rest of the manuscript.

Risk factors for recidivism

Several prognostic factors, often interconnected, can affect the results of myringoplasty.

DEMOGRAPHIC AND SOCIAL FACTORS

Age

Myringoplasty has historically been thought to be less successful in children than in adults, due to the immaturity of immune system and Eustachian tube (ET), prominent adenoid tissue and frequency of upper respiratory tract infections 12,13. In fact, mean paediatric closure rates have been found to be slightly lower than in adults in both single studies 13-16 and in a recent meta-analysis by Tan et al. 17 (Tab. I).

Socioeconomic level

Lower success rates have been reported in patients with low socioeconomic levels, probably due to poor post-operative care, low attendance of control dates, frequent airway infections and worse middle ear conditions 18.

Smoking

A recent systematic review 19 has demonstrated the negative impact of smoking on graft uptake rates after myringoplasty (77% of smokers vs 89% of non-smokers).

The effects of smoking on the middle ear physiology can be divided into 3 categories:

- local effects include those on middle ear and ET mucociliary clearance, by changing the amount and viscosity of the mucus, disrupting the ciliated cells and unsyncing ciliary activity 20. Moreover, the vasoconstriction and thrombosis promoted by nicotine and the reduced tissue oxygenation induced by carbon monoxide increase the risk of graft necrosis 21;

- regional effects consist in causing eustachian tube obstruction by nasal chemical irritation 22;

- systemic effects are immunosuppressive and chemoallergic properties that may increase the susceptibility to infections 21.

PATHOLOGICAL FACTORS

Size and location of the perforation

The highest failure rates have been recorded in total or near-total perforations 17,23-25 (Tab. I) and in case of involvement of the anterior half of the TM 18,26-27. This is likely due to the reduced visibility, small area of overlap between the graft and residual TM, poor anterior support for the graft, and lower vascular perfusion of anterior quadrants 28,29.

Middle ear mucosa conditions

Higher failure rates have been reported in pre-operative discharging ears 15,25,30-32, and in the presence of intratympanic granulation tissue or tympanosclerotic plaques 33. All these factors are thought to interfere with the normal healing process by affecting the vascularisation of the TM remnants, impairing the scaffold for epithelisation and displacing the graft.

Other pathological conditions

Poorer outcomes have been found in patients with contralateral chronic otitis media 11,23,34 and in children with no history of adenoidectomy or with craniofacial disorders 24,35, confirming the role of ET function in middle ear physiology.

ANATOMICAL FACTORS

Relevant technical issues can be caused by anterior wall prominence, exostosis or EAC stenosis, thus determining poor visualisation of the anterior angle 36.

TECHNICAL FACTORS

No consensus exists about the best technique, which is often chosen based on the surgeon’s skills and preference. The vast ambiguity of the results of various studies that compared the different procedures is probably due to the different technical variations and skills, selection methods, definitions of favourable outcome and follow-up.

Posterior vs endaural approach

Higher closure rates have been found using a retroauricolar approach compared to an endaural one in two studies 37,38. This is probably due to improved visualisation of the anterior angle, limiting the indication of the endaural approach to small posterior perforations. However, this was not confirmed in the meta-analysis by Tan et al. 17.

Microscopic vs endoscopic myringoplasty

Transcanal endoscopic ear surgery has been proposed as an alternative to the microscopic retroauricolar approach. Several endoscopic series have shown success rates greater than 80% that is fully comparable to the microscopic rates 7, although other authors have shown better results for their microscopic cases (1-year failure rate 5.7% vs 12.5% with endoscopy) 36.

Primary vs revision myringoplasty

There is consensus that revision surgery is associated with slight lower success rates compared to primary surgeries 39-41. This is probably due to altered anatomic landmarks and the necessity to use unusual graft materials.

Temporalis fascia vs cartilage

Within the full gamut of graft materials, from autologous to xenograft, no evidence exists with respect to the most effective grafting material for a given location, size, or type. Although temporalis fascia has been the material of choice for a long time, the use of tragal or conchal chondro-perichondral grafts has recently been proposed, with the theoretical advantages of providing a rigid support against negative middle ear pressures and having minimal aesthetic consequences 11. Although fascia provides adequate closure rates (nearly 90%) 42,43, cartilage has shown slightly better results in the meta-analysis by Tan et al. (Tab. I) 17, especially in high-risk perforations such as in case of ET dysfunction, diffuse tympanosclerosis, atelectasis, revision surgery, anterior perforations, purulent discharge at the time of surgery, and larger perforations 18,25,44-47.

Underlay vs overlay

No univocal evidence about the superiority of one technique over the other has been demonstrated in literature so far 2,48-51. However, higher rates of residual perforation have been found in cases where an underlay technique was performed to treat anterior perforations 2. In addition, overlay myringoplasty is inevitably associated with longer healing times 2.

Surgeon’s experience

While several authors have reported statistically better graft success rates when myringoplasty was performed by experienced surgeons 16,31,52, others asserted that technical skills and attention to some details could be more relevant than the experience of the surgeon 53.

How to prevent recidivism

From the aforementioned analysis of risk factors for residual or recurrent perforation according to our experience and the literature, we next present some tips and tricks in order to increase the chances of success.

INDICATION AND TIMING

Paediatric closure rates are not so low as to contraindicate myringoplasty in children 23, although some authors have suggested to delay surgery until the age of 8 54-56. One of the drawbacks of delayed surgery is the potential evolution to cholesteatoma or permanent inner ear damage in case of recurrent infections 57. In our experience, myringoplasty can be performed in children, regardless of the age in case of cholesteatoma, preferably after age 6 in chronic otitis media (COM) with no evidence of cholesteatoma, and in the presence of dry ear and stable rhino-pharyngeal conditions.

A decisive factor in the success of myringoplasty is the incidence of post-operative infections. The management and timing of chronically discharging perforations is never simple, but every effort should be made to perform ear surgery only after appropriate drying by the aid of antibiotic-steroid ear drops and acetic acid solutions. When this is not possible, this should not be a restrictive factor in performing myringoplasty, because middle ear normalisation may be promoted by closure of the middle ear cavity, as suggested by the literature 11. However, in these cases the use of peri- and post-operative systemic antibiotics may help in reducing the risk of infection and thus graft displacement. In fact, even though a Cochrane review found no difference in graft failure rates when comparing intra-operative antibiotics with placebo 58, a prospective double-blind placebo-controlled randomised study did demonstrate decreased infectious risk when intra-operative antibiotics were used in perforations with pre-operative discharge 59.

TECHNICAL PRECAUTIONS

As mentioned, two of the main risk factors for residual perforation after myringoplasty are the presence of tympanosclerotic plaques and involvement of the anterior half of the TM, conditions that may require several adjustments to the technique.

Removal of tympanosclerotic plaques should be always performed before each TM reconstruction, especially in the anterior remnant of the drum, to facilitate the epithelisation process. This can be done by gently dissection using a sharp needle.

Three main methods have been proposed to prevent weak anterior adaptation in case of anterior perforations: the overlay technique 2, the underlay with anterior anchoring 60, and the circumferential flap method. The latter requires that the fibrous annulus be elevated 360°, thus completely exposing the bony anulus all around, on which the graft is placed 61. No significant difference between the three techniques have been found in terms of graft uptake rates, hearing results and post-operative complications 60,61. In our institution, the anterior anchoring technique is usually performed in anterior perforations with satisfying results (success rate 95%), while the overlay myringoplasty is reserved for cases when the fibrous annulus is not maintained between 2 and 4 o’clock.

Additionally, some authors have proposed cartilage reinforcement myringoplasty as a reliable technique in anterior perforations, especially in revision cases, demonstrating good closure rates with no effect on hearing results 47.

Regardless of the chosen technique, adequate drilling of the anterior bulge of the external auditory canal is the first precaution to take in case of anterior perforation, thus improving the exposure of the anterior angle 2,62. Some authors claim that endoscopic techniques can help manage the issue of anterior wall overhang by providing a more detailed and broader surgical view compared to the microscope 63.

In order to maximise the results, some surgeons opt to perform simultaneous canal-wall up cortical mastoidectomy in chronically discharging ears, especially in case of hyperplastic and polypoid chronic otitis media and in ET dysfunctions 64. The opening of abnormal mastoid cells and the resection of granulations will both remove a future source of infection that may result in graft failure and improve middle ear aeration 65,66. However, conflicting evidence exists regarding the benefit of this additional procedure 64,67.

Our management algorithm proposal

Despite all the forementioned technical precautions, graft failure with consequent recidivism of the perforation is still a possibility to take into account after myringoplasty. Based on our experience and the literature review we have proposed an algorithm for management of graft failure (Fig. 1).

While in case of late re-perforation of a healed neotympanum revision myringoplasty is often necessary, in the case of a residual perforation in the first three months after surgery a careful analysis of the issue should be made. When an ear infection is thought to be the reason for graft displacement, prompt medical treatment with systemic and local antibiotics can reduce ear discharge and promote healing. When this precaution is still not effective, or when the graft necrosis does not result from an infection, a surgical option must be taken into consideration. In case of small perforations, an outpatient Gelfoam® plug procedure 68 can be attempted after proper freshening of the margins. In case of failure or large perforations, revision myringoplasty should be performed. When residual perforation is assumed to be the consequence of a technical fault resulting in a poor anterior adaptation of the graft, revision myringoplasty with correction of the defects is often proposed to the patient.

Revision myringoplasty

Revision myringoplasty for residual or recurrent TM perforation is often more challenging than the primary procedure which is due to the altered anatomy and distorted surgical landmarks 10,69 and to the restricted availability of autologous grafting materials, making the use of bovine xenografts or human allografts compulsory 70. The main aim of revision myringoplasty is to avoid and correct the technical faults made in primary surgery.

Conclusions

Myringoplasty is one of the most common surgeries performed by an otologist, but can be a challenging procedure. Recidivism of tympanic membrane perforation after myringoplasty can result from different causes. Understanding the factors that can have an effect on outcomes can help the surgeon to prevent failure, while a prompt analysis of the causes or faults of unsuccessful myringoplasty can minimise the sequelae of the complication. In this paper, contemporary literature results and our experience were analysed in order to help the otologist facing this scenario.

Acknowledgements

We would like to show our gratitude to the University of Bari for the support and for providing all the scientific material for the research.

All data and material are available and can be provided if requested.

Conflict of interest statement

The authors declare no conflict of interest.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author contributions

VP and NQ have conceived, designed, written and revised the work. GC, FB, MM and AM have taken part to the writing of the present paper.

VP, NQ, GC, FB, MM and AM have contributed to the diagnostic and therapeutic processes and to the writing of the present paper.

Ethical consideration

Not applicable.

Figures and tables

Figure 1.Proposed algorithm for the management of recidivism of MT perforation after myringoplasty.

Variables No. patients Success rate (%) P
Age Children (≤ 17) 4136 83.42 0.017
Adults (> 17) 2049 89.25
Perforation cause Otitis media 8597 83.86 0.86
Traumatic 472 87.25
Perforation size ≤ 50% 5859 85.56 0.019
> 50% 3374 79.44
Perforation location Central 4948 86.03 0.822
Anterior 1268 85.42
Posterior 479 88.72
Ear status Dry 13048 87.02 0.155
Wet 741 83.44
Approach Endaural 5341 86.02 0.112
Postaural 8188 88.06
Technique Underlay 13359 86.71 0.712
Overlay 2745 86.83
Inlay 1593 85.39
Graft material Fascia 14806 88.00 0.048
Cartilage 1746 90.80
Legend. In bold: statistically significant results.
Table I.Metanalysis of success rates after myringoplasty in different conditions (from Tan et al., 2016, mod.) 17.

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Affiliations

Vito Pontillo

Otorinolaringoiatria Universitaria, Dipartimento di Biomedicina Traslazionale e Neuroscienze, Università di Bari, Bari, Italy

Giada Cavallaro

Otorinolaringoiatria Universitaria, Dipartimento di Biomedicina Traslazionale e Neuroscienze, Università di Bari, Bari, Italy

Francesco Barbara

Otorinolaringoiatria Universitaria, Dipartimento di Biomedicina Traslazionale e Neuroscienze, Università di Bari, Bari, Italy

Mauro Mastrodonato

Otorinolaringoiatria Universitaria, Dipartimento di Biomedicina Traslazionale e Neuroscienze, Università di Bari, Bari, Italy

Alessandra Murri

Otorinolaringoiatria Universitaria, Dipartimento di Biomedicina Traslazionale e Neuroscienze, Università di Bari, Bari, Italy

Nicola Quaranta

Otorinolaringoiatria Universitaria, Dipartimento di Biomedicina Traslazionale e Neuroscienze, Università di Bari, Bari, Italy

Copyright

© Società Italiana di Otorinolaringoiatria e chirurgia cervico facciale , 2023

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