Successful paediatric tympanoplasy – An overview

Introduction: Paediatric tympanoplasty is regarded by many as being less successful than in adults due to higher incidence of otitis media. In our study, we are trying to determine the pre-operative conditions that influence the success of paediatric tympanoplasty and construct a prognostic index for the same. Aims and Objectives: To determine which pre-operative conditions or surgical technique may influence the success of pediatric tympanoplasty and to construct a prognostic index for the same. Materials and Methods: 40 children between 8-15 years were included in this prospective study between June 2018August 2019 in Department of ENT, in our institution. Pure Tone Audiograms were recorded pre and post operatively. Results: The positive outcomes measured were integrity of tympanic membrane, minimum of 10decibel gain in auditory threshold and air filled space in middle ear. Higher success rate was observed in cases with elder age group (12-15 years), shorter duration of ear discharge, longer period of dry ear and small size of perforation. Conclusion: Tympanoplasty in children is a current and controversial theme. We have made a novice attempt to define factors that predict success or failure in paediatric tympanoplasty. © 2020 Published by Innovative Publication. This is an open access article under the CC BY-NC license (https://creativecommons.org/licenses/by-nc/4.0/)


Introduction
Paediatric tympanoplasty is regarded by many as being less successful than in adults due to higher incidence of otitis media. It is a current and controversial theme. Previously reported success rates for paediatric tympanoplasty in children have ranged between 56% to 94%, with this wide range being attributed to different selection criteria and definitions of success. 1 The latter parameter traditionally have been measured only by the post-operative integrity of the grafts. There exist other valuable characteristics to consider, as it is known that children in general, and those who have undergone repair of the tympanic membrane, in particular , present a greater risk for retractions, serous otitis media, and reperforation with episodes of acute otitis media. In addition, with a paediatric population, the surgery itself may be considered as being more difficult technically, due to narrowness of the external ear canal and the generally smaller size of the ear, thus contributing to a poor result, but of a functional type. 2 Therefore, over time, otorhinolaryngologists dedicated to paediatric pathology have considered it necessary to have a more complete definition of " success "-one that should include 1) Integrity of the graft or membrane; 2) post-operative gain (minimum of 10 Decibel)in the auditory threshold, or conservation of hearing; and 3) complete healing with the space of the aerated middle ear manifested by the graft located in the correct anatomical position, with neither atelectasis nor otitis media with effusion. 3 There are authors who are of the opinion that early surgery to be done to correct anatomic defects and improve hearing. Arguments in favor of surgery at an earlier age (under 5 years) are the following: 1) reduction in the number of visits to the doctor, which are required for the followhttps://doi.org/10.18231/j.ijoas.2020.025 2582-4147/© 2020 Innovative Publication, All rights reserved. 117 up of a minor with perforated ear drum; 2) hypoacusis and privation of aquatic activities will affect the quality of life; 3) higher incidence of severe secondary complications due to chronic otitis media in younger children; 4) better cochlear reserve at younger ages, with greater potential to restore and preserve hearing; 5) limitation of the damage that chronic infection can cause to other structures in the middle ear; and 6) auditory loss that alters the development and the quality of academic activities. 4 While others are of the opinion that elective surgery should be delayed , generally until 6 years of age. The support of the said arguments are the following aspects 1) alterations in the healing process or re-perforation of the graft by repeted infections of the upper respiratory tract; 2) unpredictable function of the Eustachian tubes; 3) immunological immaturity; 4) possibility of spontaneous resolution; 5) difficulty of post-operative care; 6) lack of confidence of the part of the parents in the procedure; and 7) equivalence of the function of the ventilation tube.
A number of attempts have been made to define those factors that predicts the success or failure in elective cases. 5 Some of the factors which received attention are age, surgical technique, status of the contralateral ear, duration of ear discharge, period of dry ear, size of perforation, presence of adenoids, presence of active infection, and function of the Eustachian tube.
In this case series, we are trying to define some factors which positively or negatively influence outcome.

1.
To determine which pre-operative conditions or surgical techniques may influence the success of paediatric tympanoplasty. 2. To construct and validate a prognostic index that could be used as a tool to predict the success. Clinical examination, otomicroscopy done before the surgery and Pure tone audiometry recorded pre-operatively. Paediatric tympanoplasty done under general anesthesia using Post auricular approach by harvesting temporalis fascia and placement by Under lay technique. Postoperatively antibiotic given for 1 week months. The results were statistically analysed with Paired t test.

Results
23 male and 17 female children involved in the study. There are around 11 children between the age of 8-11 years and 29 between the age of 12-15 years.15 children of the study have ear discharge for 1-2 years and 25 have ear discharge for more than 2 years.15 children of the study have duration of dry ear for 6months to 1 year and 25 children have duration of dry ear for more than 1 year.31 children have size of ear perforation more than 50% and 9 children have size of ear perforation less than 50%.  Table 1, summarizes sex distribution of the study group, the total number of males in the study was 23 (57.5%) and total number of females was 17(42.5%)  Table 2 summarizes, among the age group 8-11 years, 9 tympanoplasty out of 11 successful (81.8%) and in the age group 12-15 years, 28 out of 29 successful (96.5%).  Table 3 summarizes, among 15 cases with history of ear discharge since 1-2 years, tympanoplasty was successful in 14(93.3%) and 25 cases with history of ear discharge for more than 2 years, 23(92%) had successful outcome  Table 4 summarizes, the duration of having dry ear was between 6 months-1 year in 15, and more than 1 year in 25. The surgical outcome was favourable in 10(66.6%) and 23(92%) respectively.  Table 5 summarizes, 31(77.5%) had central perforation occupying less than 50% of the surface area and 9(22.5%) had more than 50% of the surface area.

Discussion
Tympanoplasty in adult population has established itself as an effective and rewarding operation. Considerable controversy surrounds the subject of tympanoplasty in children. The reluctance is due to the opinion that a child has a higher susceptibility to Upper Respiratory Tract Infections. The rationale for operating early in children is 3 fold 1) to prevent the possibility of ear infections and complications 2) to improve the hearing with a positive impact on language, learning and socialization 3) to enjoy the water activities. 6 Three positive outcomes measured: 1) Anatomical success-Presence of an intact tympanic membrane evaluated by microscopy and/or tympanometry at 6 months. 2) Physiological success-Minimum of 10 decibel gain in auditory threshold 3) Air filled space in middle ear based on Pure Tone Audiometry and Tympanometry.

Conclusion
Tympanic membrane perforation is a known sequela to Otitis media in children. Deciding which patient benefit from surgical repair and when is the optimal age to perform it continues to be widely debated. 8 This study shows that tympanoplasty is a valid treatment modality for tympanic membrane perforation in paediatric population. 9 Our study emphasizes on greater success rates in older children, with shorter duration of ear discharge, longer period of dry ear and small size of perforation. 10

Source of Funding
None.

Conflict of Interest
None.