A Comparative Study of Closure of Tympanic Membrane Perforation between Chemical Cauterization and Fat Plug Myringoplasty

doi:10.4236/ijohns.2013.26052

Paper Menu >>

Journal Menu >>

International Journal of Otolaryngology and Head & Neck Surgery, 2013, 2, 248-252

Published Online November 2013 (http://www.scirp.org/journal/ijohns)

http://dx.doi.org/10.4236/ijohns.2013.26052

Open Access IJOHNS

A Comparative Study of Closure of Tympanic Membrane

Perforation between Chemical Cauterization and Fat Plug

Myringoplasty

Manabendra Debnath, Swagata Khanna

Department of ENT, Gauhati Medical College & Hospital, Guwahati, India

Email: [email protected]

Received July 13, 2013; revised August 15, 2013; accepted September 2, 2013

Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is

properly cited.

ABSTRACT

The purpose of closure of small dry tympanic membrane perforation s is to restore the continuity of the tympanic mem-

brane in order to improve hearing and decrease the incidence of middle ear infections. Small and cost effective proce-

dures like Chemical Cauter ization and Fat Plug Myringoplasty have been found to be effective in healing small central

perforations with significant hearing improvement. A study was carried out in 69 patients with central perforations in

the Department of ENT, Gauhati Medical College & Hospital for the duration of 1 year from Aug ust 11 to July 12 . Out

of 69 patients, 36 underwent Chemical Cauterization and 33 Fat Plug Myringoplasty. Pre- and post-operative hearing

assessments of each patient were done and statistically analyzed. The success rate was found to be 83.33% and 90.9%

respectively. In both groups, there was statistically significant hearing improvement with a P value 0.01. From our study,

it was found that the two procedures are simple, reliable and also lessened the morbidity of the patient. Thus we rec-

ommend the use of these two official procedures for the treatment of central perforations of tympanic membrane less

than 5 mm.

Keywords: Fat Plug Myringoplasty; Chemical Cauterization; Paper Patching; Central Perforations

1. Introduction

Tympanic membrane perforations result mainly from

infectious and traumatic etiologies. Perforations result

from acute otitis media and trauma heal spontaneously in

the majority of cases. But if there is repeated infections

or if the infection is persisten t, there is less possibility of

spontaneous healing of these perforations. Long-standing

tympanic membrane perforations may cause conductive

hearing loss and middle ear infection even if they are

small. The purpose of closure of chronic dry tympanic

membrane perforations is to restore the continuity of the

tympanic membrane in order to improve hearing and

decrease the incidence of middle ear infections.

Myringoplasty is the procedure of closure of the per-

forations of the pars tensa of the tympanic membrane.

The first attempt at myringoplasty was recorded by Mar-

cus Banzer in 1640 [1]. The first surgical closure of

tympanic membrane perforations using an autograft (a

full thickness free skin g raft) was performed by Berthold

in 1878 and he introduced the term “Myringoplasty” [1].

Although Tympanoplasty (myringoplasty + ossicular

chain reconstruction) is the ideal treatment, simple and

cost effective procedures like chemical cauterization and

fat plug myringoplasty h ave been found to be effectiv e in

healing small central perforations with significant hear-

ing improvement.

Fat Plug Myringoplasty has many advantages com-

pared with conventional myringoplasty using temporalis

fascia, as it is short, simple, cost-effective and minimally

invasive. Fat from ear lobule has been in use for last 15 -

20 years. Microscopic study of fat from ear lobule

showed that the fat cells are more compact and contain

more fibrous tissue. It provides scaffolding for the

growth of tympanic membrane epithelium and mucus

membrane by bridging the gap. In 1962, Ringenberg

successfully used adipose tissue (Fat) to repair a small

tympanic membrane pe rforation [2].

M. DEBNATH, S. KHANNA 249

2. Aims and Objectives

1) To study the efficacy of chemical cauterization in

small central perforations of tympanic membrane.

2) To study the efficacy of Fat Plug Myringoplasty in

small central perforations of tympanic membrane.

3) To evaluate the outcome of these two procedures

and compare them.

3. Materials and Methods

The study was carried out in the Department of ENT,

Gauhati Medical College and Hospital, Guwahati for

duration of 1 year from August 2011 to July 2012. The

study group included patients above 15 years of age with

central perforations of tympanic membrane up to 5 mm

in size. The locations of the perforations in th e pars tensa

were variable from patient to patient as demonstrated in

Figure 1. This study consisted of a total of 69 patients

out of which 36 underwent Chemical Cauterization and

33 underwent Fat Plug Myringoplasty.

Criteria for patient selection:

1) Inclusion criteria:

a) Patients with central perforation of tympanic mem-

brane following Chronic Suppurative Otitis Media or

traumatic perforations of tympanic membrane.

b) At least 2 months old dry perforations were in-

cluded.

c) Central perforations not more than 5 mm (35%) by

visual assessment were included in the study.

2) Exclusion criteria:

a) History of previous ear surgery;

b) Attico-antral disease;

c) Active discharge;

d) Nasopharyngeal pathology;

P ostero-inferior

Postero-

superior

Anter-inferior

Antero-superior

Post-

inferio r+Po st. s

up.

P ost-inf+Ant.-

inf

Ant.

Inf+ant.sup

Ant. Sup.+Post.

Sup

Figure 1. Pie diagram showing location of perforations in

different quadrants of pars tensa.

e) Eustachian tube dysfunction and;

f) Active rhinosinusitis.

Hearing assessment both before and after the proce-

dures was done by Tuning fork tests and Pure Tone

Audiometry.

Nasal Endoscopy was done to rule out any naso-

pharyngeal pathology, Eustachian tube dysfunction and

rhinosinusitis etc.

3.1. Chemical Cauterization (Paper Patching)

1) Patients with central perforations less than 5 mm

selected according to the section criteria mentioned

above.

2) Patients were properly explained about the proce-

dure and possible outcome and written and informed

consent taken.

3) Cotton ball soaked in 4% xylocaine was applied in

the external auditory cana l.

4) Under microscope, the edges of the tympanic mem-

brane perforations were cauterized by using cotton tipped

applicator dipped in trichloroacetic acid.

5) After the procedure, a thin paper preferably tissue

paper was placed over the perforation followed by appli-

cation of 1 - 2 drops of steroid containing antibiotic ear

drop.

6) The perforation is inspected after 2 weeks and if

required patient is called for subsequent sitting. A maxi-

mum of four applications were made.

7) After complete healing of the perforation the patient

is followed up at 6 weeks and Pure Tone Audiometry

was done to assess the hearing improvement.

3.2. Fat Plug Myringoplasty

1) After proper written and informed consent the con-

cerned ear was prepared by betadine solution and then

properly draped.

2) 2% xylocaine + adrenaline was infiltrated in the

posterior aspect of the pinna and also in the external

auditory canal.

3) Now by giving an incision in the posterior aspect of

the ear lobule fat graft was harvested and the incision site

was closed by 4 - 0 Et hilon.

4) Now under an operating microscope the edges of

the tympanic membrane perforation were de-epithelial-

ised (Figure 2).

5) The harvested fat plug is then wedged like a dumb-

bell one part of which is in the middle ear and other lat-

eral to tympanic membrane then it is supported by a few

pieces of g el foam from outside.

6) A course of antibiotic and anihistaminic drugs was

given in the post-operativ e period

7) The patient was then followed up after 2 weeks, 6

weeks and then at 3 months and Pure Tone Audiometry

was done to assess the hearing improvement (Figure 3).

Open Access IJOHNS

M. DEBNATH, S. KHANNA

250

Figure 2. Central perforation (right tympanic membrane)

of pars tensa.

Figure 3. Healed right tympanic membrane perforation.

3.3. Statistical Analysis

The hearing gain after the two procedures was analyzed

with Student’s t-test, and the Pearson correlation coeffi-

cient (r) was determined by using Statistical Package

for Social Science (SPSS) version 10.0. The other cal-

culations performed for the present study was done by

spreadsheets developed by Microsoft Excel (2007). A p

value of 0.05 or less was considered significant for the

study.

4. Results and Observations

The present study consisted of 69 patients out of which

40 were male and 29 female. The average age of the

study group was 35 years. Out of 69 patients 30 patients

had bilateral central perforations and 39 had unilateral

perforations. 55 patients had perforations due to infective

etiology and 14 had due to trauma. Out of 69 patients 36

underwent chemical cauterization and 33 underwent Fat

Plug Myringoplasty.

In the group that underwent Chemical Cauterization

the mean preoperative hearing threshold (dB) was 24.66

± 3.69 and after the procedure the mean hearing thresh-

old (dB) was 16 ± 2.03 and there was a mean gain of

about 8.66 ± 3.69 dB (Figure 4) which was found to be

statistically significant(r = 0.849, p = 0.01). Out of 36

patients who underwent Chemical Cauterization 6 pa-

tients had residual perforations. The success rate was

found to be 83.33%.

In the group that underwent Fat Plug Myringoplasty

the mean preoperative hearing threshold (dB) was 33.83

± 4.41 and after the procedure the mean hearing thresh-

old (dB) was 17.83 ± 2.84 and there was a mean gain of

about 16 ± 4.02 dB (Figure 5) which was found to be

statistically significant (r = 0.782, p = 0.01). Out of 33

patients who underwent Fat Plug Myringoplasty 3 pa-

tients had residual perforations. The success rate was

found to be 90.9%.

Therefore, in our study we have found that Fat Plug

Myringoplasty is a better option (success rate being

90.9%) for the closure of Tympanic Membrane perfora-

tion less than 5 mm with only one surgical sitting.

Whereas in Chemical Cauterization single application

may not be sufficient in all cases.

In both the groups mentioned in the study, the number

of patients having residual perforations (i.e. 6 out of 36

in Chemical Cauterization and 3 out of 33 in Fat Plug

Myringoplasty) was not found to be statistically signifi-

cant.

147 10131619222528

Pre ‐oper ative

he aring

threshold(dB)

Post‐ope rative

he aring

threshold(dB)

‐‐‐‐No.ofPatients‐‐‐‐>

‐HearingTHreshold(dB)>

Figure 4. Line diagram showing comparison between pre

and post operative hearing threshold (dB) of patients un-

dergoing chemical cauterization.

147 10131619222528

‐‐‐‐Hearingthr eshold(dB)‐‐‐>

‐‐‐‐‐‐‐‐‐No.ofpatients‐‐‐‐‐‐‐‐‐>

Pre ‐

operative

he aring

th resho ld( d

Post‐

operative

he aring

th resho ld( d

Figure 5. Line diagram showing comparison between pre

and post-operative hearing threshold (dB) of patients un-

dergoing fat plug myringoplasty.

Open Access IJOHNS

M. DEBNATH, S. KHANNA 251

5. Discussion

The first recorded use of silver nitrate to stimulate clo-

sure of tympanic membrane perforations is by William

Wilde in 1848 [3]. The office chemical myringoplasty

was introduced by Roosa in 1876 and was popularized by

Derlacki in the 1950s who reported good results and the

procedure came to be known as the Derlacki method [4].

In his method he used trichloroacetic acid to cauterize

perforation followed by antibiotic sufflation and covering

with sterile cotton pledgets and prescribing Euthymol ear

drops. Two decades later, Derlacki reported that he and

his colleagues (Shambaugh, Harrison and Clemis) at

Otologic Professional Associates at Chicago and cumula-

tively treated 1277 pars tensa perforations between 1953

and 1972 and had successfully healed at least 1027 of

them (80.4%) [5].

From our study it was found that the two procedures

showed significant improvement in post operative hear-

ing threshold. The overall success rate of 90.9% in pa-

tients undergoing Fat Plug Myringoplasty and 83.33 % in

patients undergoing Chemical Cauterization observed in

the present study is in agreement with the rates of 80% -

92% reported in other studies. No significant difference

in the tympanic membrane perforation closure rate was

observed according to the perforation sites in different

quadrants of the tympanic membrane.

Dursun E. et al. found out in 2008 that there were no

statistically significant differences in tympanic mem-

brane closure rates between paper patch, fat and peri-

chondrium myringoplasty which is also found in our

study [6].

Landsberg R. performed fat plug myringoplasty on a

population comprising 27 adults and 11 children. The

speech reception threshold improved significantly in his

study. This is also seen in this study [7].

Nelson C. Goldman performed chemical cauterization

in 11 patients and found 82.7% success rate [8]. Similar

outcome is also seen in a study by Louis F. Scaramella et

al. where success rate with chemical cauterization was

84.2% which holds true in our study also [9].

Jadia S. et al. in their study found 92% and 88.8% out-

come with fat plg myringoplasty and chemical cauteriza-

tion which is also seen in this study [4].

Iqbal Hussain Udaipurwala et al. in 2008 in their stud y

achieved 95.2% success rate with Fat Plug Myrin-

goplasty for central perforations of tympanic membrane

which is consistent with this study [10].

Kuljit S. Uppal et al. in 1997 achieved 78% success

rate with chemical cautery of tympanic membran e perfo-

rations which is consistent with this study [11].

6. Conclusion

A reliable tympanic membrane closure rate in small cen-

tral perforations was achieved with Fat Plug Myrin-

goplasty and Chemical Cauterization without general

anaesthesia in an official setting with a good amount of

success. These two procedures are easy to perform, reli-

able with a satisfactory outcome, virtually simple and

rapid risk free and also lessen the financial burden and

morbidity on the part of the patient. Although both

methods can be considered as convenient official proce-

dures, the success rate is higher in Fat Plug Myrin-

goplasty (90.9%), and this procedure can be recom-

mended as a better alternative/preferable choice for first

line treatment of central perforations of the tympanic

membrane in pars tensa less than 5 mm in size.

7. Acknowledgements

We are highly grateful to The Principal and the Superin-

tendant of Gauhati Medical College and Hospital, Gu-

wahati for allowing us to carry out the study in this In-

stitution.

REFERENCES

[1] U. Chalishazar, “Fat Plug Myringoplasty,” Indian Journal

of Otolaryngology and Head Neck Surgery, Vol. 57, No.

1, 2005, pp. 43-44.

[2] J. C. Ringerberg, “Closure of Tympanic Membrane Per-

forations by the Use of Fat,” Laryngoscope, Vol. 88, No.

6, 1978, pp. 982-993.

http://dx.doi.org/10.1288/00005537-197806000-00010

[3] W. R. Wilde and A. Hewson, “Practical Observations on

Aural Surgery and the Nature and Treatment of Diseases

of the Ear,” Blanchard & Lea, Philadelphia, 1853, pp.

292-293.

[4] S. Jadia, et al., “Office Procedure for the Management of

Central Perforation: A Comparative Study,” Indian Jour-

nal of Otology, Vol. 16, 2010, pp. 5-9.

[5] E. L. Derlacki, “Office Closure of Central Tympanic

Membrane Perforation: A Quarter Century Experience,”

Transactions of the American Academy of Ophthalmology,

Vol. 77, 1973, pp. 53-56.

[6] E. Dursun, et al., “Comparison of Paper Patch, Fat and

Perichondrium Myringoplasty in Repair of Small Tym-

panic Perforations,” Otolaryngology Head Neck Surgery,

Vol. 138, No. 3, 2008, pp. 353-356.

http://dx.doi.org/10.1016/j.otohns.2008.01.003

[7] R. Landsberg, G. Fishman, A. DeRowe, E. Berco and G.

Berger, “Fat Graft Myringoplasty: Results of a Long-

Term Follow-Up,” Journal of Otolaryngology, Vol. 35,

No. 1, 2006, pp. 44-47.

http://dx.doi.org/10.2310/7070.2005.4124

[8] N. C. Goldman, “Chemical Closure of Chronic Tympanic

Membrane Perforations,” ANZ Journal of Surgery, Vol.

77, No. 10, 2007, pp. 850-851.

http://dx.doi.org/10.1111/j.1445-2197.2007.04256.x

[9] L. F. Scaramella, et al., “Effectiveness in Non-Surgical

Office Closure of Tympanic Membrane Pars Tensa Per-

forations,” Ear, Nose and Throat Journal, Vol. 81, No. 8,

Open Access IJOHNS

M. DEBNATH, S. KHANNA

Open Access IJOHNS

252

2002, pp. 556-560.

[10] I. H. Udaipurwala, et al., “Efficacy of Fat-Plug Myrin-

goplasty in Small and Dry Perforation of Pars Tensa,”

Medical Channel, Vol. 16, No. 1, 2010, pp. 62-64.

[11] K. S. Uppal, et al., “Closure of Tympanic Membrane

Perforations by Chemical Cautery,” IJO & HNS, Vol. 49,

No. 2, 1997, pp. 151-153.