To gather and analyse information from the literature concerning the management of otitis media with effusion in adults.

A review of the English-language literature from 1970 to the present.

Ventilation tubes have been the standard treatment for otitis media with effusion in adults, but examination of the results of published studies shows that they are associated with disappointing outcomes and significant complications, notably intermittent or chronic discharge, particularly in cases associated with nasopharyngeal carcinoma. Balloon dilatation of the Eustachian tube, intratympanic steroid therapy and cortical mastoidectomy appear to be possible alternatives.

A rethink of the management of otitis media with effusion in adults is needed, together with further research. For cases not associated with nasopharyngeal carcinoma, intratympanic steroid therapy appears to be a promising option.

The success of tympanoplasty is mainly defined by the post-operative integrity of the tympanic membrane, as well as the absence of any need for further operating. Among the factors affecting the outcome, the surgical grafting technique is still a matter of debate. Our aim is to report the results of the split two-layer cartilage–perichondrium technique.

We carried out a retrospective study of 108 consecutive adult patients undergoing myringoplasty, assessing both surgical and audiological outcomes of the split two-layer cartilage–perichondrium technique, including primary and revision cases.

Complete perforation closure was observed in 97/108 (89.7 per cent) of the cases; 101/108 (93.5 per cent) had no need for further intervention. Failures were observed only in cases with total perforations without any differences between primary and revision cases. The average air–bone gap improved from 29.75 dB pre-operatively to 5.8 dB post-operatively.

The results indicate high success rates of the technique with failures occurring only in total perforations.

This study aimed to analyse social, health and environmental factors associated with the development of chronic otitis media by age nine.

This was a prospective, longitudinal, birth cohort study of 6560 children, reviewed at age nine. Chronic otitis media defined as previous surgical history or video-otoscopic changes of tympanic membrane retraction, perforation or cholesteatoma. Non-affected children were used as the control group.

Univariate analysis demonstrated an association between chronic otitis media and otorrhoea, snoring, grommet insertion, adenoidectomy, tonsillectomy, hearing loss, abnormal tympanograms and preterm birth. Multivariate analysis suggests many of these factors may be interrelated.

The association between chronic otitis media and otorrhoea, abnormal tympanograms and grommets supports the role of the Eustachian tube and otitis media (with effusion or acute) in the pathogenesis of chronic otitis media. The role of snoring, adenoidectomy and tonsillectomy is unclear. Associations suggested by previous studies (sex, socioeconomic group, parental smoking, maternal education, childcare, crowding and siblings) were not found to be significant predictors in this analysis.

This study aimed to describe the microscopic over-under cartilage tympanoplasty technique, provide hearing results and detail clinically significant complications.

This was a retrospective case series chart review study of over-under cartilage tympanoplasty procedures performed by the senior author between January 2015 and January 2019 at three tertiary care centres. Cases were excluded for previous or intra-operative cholesteatoma, if a mastoidectomy was performed during the procedure or if ossiculoplasty was performed. Hearing results and complications were obtained.

Sixty-eight tympanoplasty procedures met the inclusion criteria. The median age was 13 years (range, 3–71 years). The mean improvement in pure tone average was 6 dB (95 per cent confidence interval 4–9 dB; p < 0.0001). The overall perforation closure rate was 97 per cent (n = 66). Revision surgery was recommended for a total of 6 cases (9 per cent) including 2 post-operative perforations, 1 case of middle-ear cholesteatoma and 3 cases of external auditory canal scarring.

Over-under cartilage tympanoplasty is effective at improving clinically meaningful hearing with a low rate of post-operative complications.

Multiple tympanoplasty techniques have been developed with numerous differences in grafting and approach. This study aimed to improve type 1 tympanoplasty outcomes by using the ‘en hamac’ technique as well as performing a complete canalplasty for anterior perforations.

A retrospective review was performed using the prospective Otology-Neurotology Database tool for otological surgery. All primary type 1 tympanoplasty cases performed for tympanic membrane perforations from 2010 to 2016 were selected for analysis, all performed by one author. Minimal clinical and audiometric follow up was 18 months.

Tympanic membrane perforation closure was achieved in 62 of the patients (96.88 per cent). None of the en hamac cases had residual or recurrent perforation (p = 0.02). The mean remaining air–bone gap was 8.50 dB. The remaining air–bone gap was less than 10 dB in 72.55 per cent, 10–20 dB in 25.49 per cent and more than 20 dB in 1.96 per cent.

Using the en hamac technique for anterior perforations as well as systematically performing a complete canalplasty provides multiple surgical advantages with excellent post-operative results.

The aim of the present study was to evaluate the surgical and functional results of endoscopic butterfly-inlay cartilage myringoplasty and endoscopic push-through myringoplasty in the treatment of anterior perforation of the tympanic membrane.

This open-label randomised clinical study was conducted on 71 patients with small- and medium-sized anterior perforations of the tympanic membrane. Graft success rate, hearing results, operative time and complications were analysed.

Graft success rates for endoscopic butterfly-inlay cartilage myringoplasty and endoscopic push-through myringoplasty were 94.1 and 91.8 per cent, respectively (p > 0.05). Post-operative air–bone gap values significantly improved in both the endoscopic butterfly-inlay cartilage myringoplasty and endoscopic push-through myringoplasty groups. The average operative time was significantly shorter in the endoscopic butterfly-inlay cartilage myringoplasty group (31.5 minutes) compared to the endoscopic push-through myringoplasty group (41.7 minutes; p < 0.05).

When compared with the endoscopic push-through myringoplasty, the endoscopic butterfly-inlay cartilage myringoplasty technique, which is technically easier to perform, does not require packing and has a shorter operating time. It is a reasonable approach for repair of anterior perforations of the tympanic membrane.

To evaluate the healing and hearing outcomes related to the everted or inverted edge area on slap- and fist-induced large tympanic membrane perforations.

A total of 120 patients with slap- or fist-induced tympanic membrane perforations, with inverted or everted edges, affecting 50–75 per cent of the entire tympanic membrane, were randomly divided into 2 groups: an edge approximation group and a spontaneous healing group. The edge approximation group was divided into subgroups A and B based on the reversed edge area (reversed edge was more or less than 50 per cent of the total perforation, respectively). Healing outcomes and hearing improvements at six months were compared.

The data of 118 patients were analysed. The closure rate of perforations in subgroup A, subgroup B, and the spontaneous healing group was 90.9 per cent, 92.1 per cent and 84.5 per cent, respectively; the difference between the three groups was not significant (p = 0.393).

The area of reversed edges for slap- or fist-induced tympanic membrane perforations did not seem to affect healing and hearing outcomes, regardless of edge approximation and everted or inverted edges.

To evaluate the impact of platelet-rich fibrin therapy in tympanoplasty type 1 surgery on graft survival and frequency-specific hearing outcomes.

Patients who underwent tympanoplasty type 1 surgery were randomised into temporal fascia graft alone (n = 55) and temporal fascia graft plus platelet-rich fibrin therapy (n = 36) groups. Graft survival and hearing outcomes were recorded.

Graft survival rates were significantly higher in the temporal fascia graft plus platelet-rich fibrin therapy group than in the temporal fascia graft alone group at one (100.0 vs 85.5 per cent, p = 0.020), three (97.2 vs 80.0 per cent, p = 0.024) and six months post-operatively (94.4 vs 74.5 per cent, p = 0.031). The difference in hearing gain between groups was not significant.

Our findings revealed that the use of a platelet-rich fibrin plus temporal fascia graft for type 1 tympanoplasty was associated with more favourable post-operative outcomes than the use of temporal fascia alone, both in terms of tympanic membrane healing and graft survival; hearing restoration outcomes were similar.

Surgery for chronic suppurative otitis media performed in low- and middle-income countries creates specific challenges. This paper describes the equipment and a variety of techniques that we find best suited to these conditions. These have been used over many years in remote areas of Nepal.

Extensive chronic suppurative otitis media is frequently encountered, with limited pre-operative investigation or treatment possible. Techniques learnt in better-resourced settings with good follow up need to be modified. The paper describes surgical methods suitable for resource-poor conditions, with rationales. These include methods of tympanoplasty for subtotal wet perforations, hearing reconstruction in wet ears and open cavities, large aural polyps, and canal wall down mastoidectomy with cavity obliteration. Various types of autologous ossiculoplasty are described in detail for use in the absence of prostheses. The following topics are discussed: decision-making for surgery on wet or best hearing ears, children, bilateral surgery, working with local anaesthesia, and obtaining adequate consent in this environment.

Factors specific to sub-Saharan Africa could have an impact on tympanic membrane perforation characteristics. Obtaining precise information on these characteristics and determinants of hearing loss severity would enable better management.

To determine the relationship between characteristics of tympanic membrane perforation and subsequent hearing impairment.

A cross-sectional study of consenting patients presenting with tympanic membrane perforation was conducted. They were examined using otoendoscopy with a digital camera to obtain precise measurements, followed by pure tone audiometry.

Eighty-six cases of tympanic membrane perforation were included. Mean tympanic membrane perforation proportion was 34.1 ± 18.4 per cent. Medium-sized tympanic membrane perforations were predominant (47.7 per cent). Median tympanic membrane perforation duration was 20 years. Tympanic membrane perforation size was found to be a predictor of hearing loss severity (odds ratio = 2.5, 95 per cent confidence interval = 1.02–6.13, p = 0.04).

Tympanic membrane perforation size was a predictor of hearing loss severity in our setting. Site, duration and aetiology seem to have no impact on hearing loss severity.

Anteriorly located tympanic membrane perforations can negatively affect surgical success rates. This study aimed to present, using our case series results, endoscopic triple-C (composite chondroperichondrial clip) tympanoplasty as an alternative method in the repair of tympanic membrane anterior quadrant perforations.

This study included patients with a perforation sized greater than 3 mm, who had an anterior quadrant dominant perforation where the anterior portion could not be seen during microscopic examination; all underwent endoscopic triple-C tympanoplasty.

Operating time was 30–79 minutes (mean, 46.6 minutes). The post-operative graft success rate at six months was 92 per cent (23 out of 25). Mean post-operative follow-up duration was 21.5 ± 7.3 months (range, 11–40 months), and no intratympanic cholesteatoma was observed.

Endoscopic triple-C tympanoplasty is a comfortable, minimally invasive alternative method to repair anterior tympanic membrane perforations. The graft success rate and the degree of recovery from hearing loss were in accordance with the literature. However, more reliable results may be obtained in a larger series with longer follow-up times.

Endoscopic ear surgery is becoming an accepted technique in otological surgery, in the management of chronic otitis media.

The technique was introduced to the humanitarian care setting of an ear camp in Nepal to consider the appropriateness of the technique in this type of clinical setting.

Fifteen cases of myringoplasty were successfully completed.

The apparent advantages of the endoscopic approach over the traditional microscopic one were the ease of transporting the equipment and the optimal view obtained of the tympanic membrane. The ability for pathology and operative technique to be observed equally well by the surgeon and local staff was helpful for teaching, and enables a move towards self-sufficiency of care. Easy image capture also has potential for remote telemedicine applications.

To study the clinical effect of lens cleaning paper patching on traumatic eardrum perforations.

A total of 122 patients were divided into 2 groups, of which 56 patients were treated with lens cleaning paper patching and 66 acted as controls. The closure rate and healing time were compared between the two groups.

The healing rate of small perforations was 96.4 per cent (27 out of 28) in the patching group and 90 per cent (27 out of 30) in the control group. The difference was not statistically significant (p > 0.05). The healing rate of large perforations was 89.3 per cent (25 out of 28) and 80.6 per cent (29 out of 36) in the two groups, respectively. The difference was statistically significant (p < 0.05). The healing time of large perforations was shorter in the patching group than in the control group (p < 0.01).

Patching with lens cleaning paper under an endoscope can accelerate the closure of large traumatic eardrum perforations.

Does revision myringoplasty have worse outcomes than primary surgery?

The International Otology Database has been used to record data on surgery for middle-ear disease in Norfolk, UK, over nine years. The data show the results of all myringoplasty cases and the results of revision cases. Outcome measures are perforation and hearing change. Comparison is made with benchmark centres of excellence.

A total of 611 operations included myringoplasty; 356 (58 per cent) of cases had a recorded follow up at 3 months. Twenty-nine patients (8.1 per cent) had a post-operative perforation. Benchmark centres performed 2319 operations; 1284 (55 per cent) of these had a follow up at 3 months, and 82 patients (6.4 per cent) had a perforation at follow up. Sixty-nine of the Norfolk patients were revision cases. Six of the 69 patients (8.7 per cent) had a perforation at follow up. The average hearing gain in the revision myringoplasty patients in Norfolk was 7 dB.

The results of the revision myringoplasty cases are the same as those for the primary myringoplasty cases in this series.

This study aimed to evaluate the surgical success of a modified inlay tympanoplasty technique, known as circumferential subannular tympanoplasty, for anterior and subtotal perforations.

This prospective study was performed in a tertiary care teaching hospital between October 2013 and April 2016. A total of 58 adult patients of both sexes with anterior or subtotal perforations underwent circumferential subannular tympanoplasty under local anaesthesia. In this technique, after tympanomeatal flap elevation, the temporalis fascia graft is placed directly onto the annulus instead of being tucked underneath the tympanic membrane remnant. Outcome data were graft uptake and hearing improvement.

This technique had a surgical success rate of 97 per cent and led to significant hearing improvement.

Circumferential subannular tympanoplasty has a definitive role in managing anterior and subtotal perforations.

Bilateral tympanic membrane perforation closure is usually performed by otosurgeons in two sittings. However, in this study, transperforation myringoplasty was performed alongside contralateral tympanoplasty in a single sitting. The effectiveness of transperforation myringoplasty procedure and the benefits of single sitting bilateral surgery were evaluated.

A prospective study of 50 selected patients with mucosal-type bilateral chronic otitis media was conducted. All patients underwent transperforation myringoplasty on the side that met the inclusion criteria and tympanoplasty on the contralateral side. Graft uptake and hearing improvement were evaluated after 6 months.

At the 6-month follow up, the graft uptake rate was 82 per cent, the hearing gain was 11.5 dB and the air–bone gap gain was 11.6 dB.

This procedure offers perforation closure in a single sitting to patients with bilateral chronic otitis media who meet the inclusion criteria.

Subtotal petrosectomy combined with cochlear implantation is a procedure required in specific situations.

A retrospective review of all cases of subtotal petrosectomy in cochlear implant surgery over a five-year period was performed. The indications, complications and outcomes for this procedure are outlined.

Sixteen patients underwent cochlear implantation in combination with subtotal petrosectomy and blind sac closure of the external auditory meatus from 2008 to 2013. Seventy-five per cent of these were completed as a two-stage procedure and 25 per cent as a single-stage procedure. The most common indications for the procedure were chronic otitis media, previous radical cavity, and for surgical access in challenging anatomy or in drill-out procedures. Mastoids were obliterated with fat or musculoperiosteal flaps. The complication rate relating to blind sac closure was 6 per cent. Cochlear implants were successfully placed in all cases and there was no incidence of device failure.

For patients with chronic suppurative otitis media or existing mastoid cavities, subtotal petrosectomy with blind sac closure of the external auditory canal, closure of the eustachian tube, and cavity obliteration is an effective technique to facilitate safe cochlear implantation.

The treatment of traumatic tympanic membrane perforations varies in different investigations, ranging from observation to early surgical repair. The present study aimed to focus on the closure rate and the closure time in a group of patients treated with a watchful waiting policy.

The study comprised 133 consecutive patients with a total of 137 perforations. Data were evaluated in terms of aetiology, location and size of perforation, audiometric findings, closure rate, and closure time.

The overall closure rate was 97 per cent. For patients with a known closure time within three months, the median closure time was between three and four weeks. The probability of spontaneous closure over time was further analysed with Kaplan–Meier plots, for those perforations with known closure times and for all perforations including those with unknown closure times. Perforation size was the only significant determining factor for closure time.

Small perforations had a high probability of spontaneous closure within three to four weeks, justifying a watchful waiting policy. Larger uncomplicated perforations might warrant early surgical repair, depending on the patient's needs and the availability of surgery.

There are many reports of operations performed to successfully close ear drum perforations. Hearing deterioration after myringoplasty is not a widely published topic. This paper presents an audit of this complication.

A six-year retrospective analysis of a series of myringoplasty operations was performed using electronic patient records. Patients with post-operative hearing loss were identified and those with hearing loss greater than 10 dB were further scrutinised.

Out of 187 patients who underwent myringoplasty procedures, 44 (23.53 per cent) experienced a reduction in hearing thresholds. In seven cases (3.74 per cent), the hearing loss was greater than 10 dB. A case note review revealed no obvious predictive factors, although posterior perforations and the possibility of ossicular chain manipulation were considered.

Hearing loss following myringoplasty is not rare, and this may alter the consent process for this procedure.

We used an artificial dermis (Terdermis®), which is an atero-collagen sponge covered with a sheet of silicon.

Nineteen ears of 17 patients with perforation of the tympanic membrane under various conditions, including large and wet perforations, underwent operation using this collagen sponge.

The success rate of closure after the initial surgery was 8/19. The overall success rate of closure after initial and re-operation was 14/19. The success rate of closure was 12/14 for small-sized perforations, 1/4 for middle-sized perforations and 1/1 for a large-sized perforation. Middle- and large-sized perforations required multiple surgeries. The success rate of closure was 11/11 for dry perforations, 3/4 for perforations with light otorrhoea and 0/4 for perforations with extensive otorrhoea.

This surgery is a low-cost and minimally invasive surgery and has a high closure rate. This surgery is effective on small-sized, dry perforations although it can also close middle- and large-sized dry perforations.