REDUCTION IN THE RATE OF RE-PERFORATION RATE AFTER SIMPLE UNDERLAY MYRINGOPLASTY BY USING FIBRIN GLUE

Yasuhiro Manabe,1 Kazuhiro Ogi,1 Yukihiro Kimura,2 Takehisa Saito,2 Shigeharu Fujieda2

1Dept. of Otorhinolaryngology, Shinseikai Toyama Hospital, Toyama, Japan; 2Dept. of Otorhinolaryngology, Head and Neck Surgery, University of Fukui, Fukui, Japan

Introduction

Myringoplasty with a post-auricular incision is routinely performed to repair tympanic membrane perforation. The transcanal approach has also been used in an attempt to simplify myringoplasty by using substances such as fat or micropore tape. However, these techniques did not produce satisfactory results comparable to those of conventional myringoplasty. Yuasa1 developed a simple underlay myringoplasty (SUM) method using fibrin glue in 1989. Although SUM is a satisfactory technique for repairing tympanic membrane perforation, its success rate is lower than that of simple myringoplasty. Therefore, a re-closure operation is required in unsuccessful cases. A method that decreases the rate of re-perforation may improve the effectiveness of SUM. The objective of the present study was to evaluate the efficacy of the gelatin sponge in preventing postoperative re-perforation.

Materials and methods

SUM was performed in 25 ears for repairing tympanic perforation due to chronic otitis media. The subjects comprised 11 men and 14 women with a mean age of 60.9 years. Indications for SUM included a simple dry perforation, the absence of cholesteatoma, hearing gain in a paper patch, and the lack of a shadow in the attic on computed tomography. Typically, SUM was performed under local anesthesia, except in patients who preferred general anesthesia. The margin of the perforation was excised and removed by using a fine pick through an ear speculum. Subcutaneous tissue from the retro-auricular region was used for the graft. The graft was inserted under the eardrum, and the perforation was closed by using the graft. After ensuring contact between the graft and the margin of the perforation, several drops of fibrin glue were applied. Following this step, a gelatin sponge (Gelfoam®, Pfizer, USA), which was slightly larger than the perforation, was immediately placed on the eardrum. Closure of the eardrum perforation was examined during the postoperative course and finally at 6 months after surgery.

Results

We were able to perform this operation in 25 ears and observe the results for a follow-up period of at least 6 months. The gelatin sponges placed on the eardrum disappeared after a mean duration of 12.8 days. The postoperative re-perforation rate was 1/25 (4.0%). No serious complications were observed in this study.

Discussion

The success rate of closure by using conventional myringoplasty for chronic otitis media is often more than 90%. The advantages of SUM are that it is minimally invasive, easy to perform, and has no serious complications; however, postoperative re-perforation has been found in 20 to 30% of the patients undergoing this procedure.2,3 Therefore, patients in whom closure is unsuccessful require a re-closure operation performed using an autologous frozen material. The high rate of postoperative re-perforation may be because the tampon was not placed in the ear. A tampon is required to attach the harvested graft to the eardrum in conventional myringoplasty. In SUM, fibrin glue plays the role of a tampon; however, the adhesive action of fibrin glue may be weak and may disappear in approximately 1 week. A gelatin sponge has a good affinity with human tissues and is routinely used as a stabilizing material in surgical procedures of the middle ear in many countries. In 1983, Hellstrom et al. reported increased fibrosis in rats after insertion of a gelatin sponge in the middle ear.4 In the present study, the gelatin sponge may have increased fibrosis between the edge of the eardrum perforation and the graft. Thus, placing a gelatin sponge on the eardrum is recommended as the last step in SUM because this procedure is very easy and is useful for the prevention of re-perforation.

Conclusion

SUM is recommended for repairing tympanic membrane perforation. Although the postoperative re-perforation is generally 20 to 30%, the re-perforation rate decreased to 4% when a gelatin sponge was placed on the eardrum immediately after the operation.

References

1.Yuasa R, Saijo S, Tomitaka Y, Kusakari C, Kakehata S, Katori Y, et al. Office closure of ear drum perforation with fibrin glue. Otolaryngol Head Neck Surg (Tokyo) 61:1117–1122, 1989 (in Japanese)

2.Sakagami M, Yuasa R, Yuasa Y. Simple underlay myringoplasty. J Laryngol Otol. 121(9):840–844, 2007

3.Hellström S, Salén B, Stenfors LE. Absorbable sponge (Gelfoam®) in otosurgery: one cause of undesirable postoperative results? An experimental study. Acta Otolaryngol. 96(3–4):269–275, 1983

Address for correspondence: Yasuhiro Manabe, MD, Shinseikai Toyama Hospital, 89–10 Shimowaka, Imizu-city, Toyama 939–0243, Japan. Fax: +81 766 52 2197. manabe@shinseikai.or.jp

Cholesteatoma and Ear Surgery – An Update, pp. 433–434

Edited by Haruo Takahashi

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