Background: Chronic Otitis Media (COM) is a relatively common condition and the occurrence of hearing loss is probable. COM may lead to ossicular discontinuity, and unless the operation is performed, it won't be determined. Identifying possible cases of erosion and discontinuity of ossicles is helpful in surgical planning and in anticipation of the probable need for procuring ossicular prosthesis.Purpose: The aim of this study was to evaluate the relationship between preoperative clinical findings and intraoperative findings.Methods: This is a cross sectional study carried out in 2012 in two tertiary referral hospitals of Tehran, (the Loghman and the Taleghani hospitals). The sample under study consisted of COM patients who referred to the otolaryngology clinics and were tymponoplasty candidates. Two hundred and seven  patients with the mean age of 36.2±13.9 (ranging from 9-67 years) were enrolled in the study. Pre-surgical findings were investigated and the relationship between ossicular discontinuity and pre-surgical findings were evaluated.Results: Incus-Stapes discontinuity (IS Discontinuity) and Incus-Malleus discontinuity (IM Discontinuity) were seen in 60 (29%) and 25 (12.1%) patients, respectively. We found IS Discontinuity in 38 (24.1%) patients with central perforation and 22 (48.9%) cases of marginal perforations (P=0.005). IM Discontinuity was observed in 14 (8.9%) cases with central perforation, while this was seen in 11 (22.4%) cases with marginal perforations (P=0.011). On the other hand, 34 (42%) patients with otorrhea had IS Discontinuity whereas 26 (20.6%) cases of dry ears showed this type of ossicular problem (P&lt;0.001). IM Discontinuity was detected in 13 (16%) and 12 (9.5%) cases with and without otorrhea, respectively (P=0.011). IS Discontinuity and IM Discontinuity were significantly more common in the patients with Air Bone Gap of more than 40 db.Conclusion: Our finding showed that surgical results may be unpleasant in the patients with marginal perforation, otorrhea and ABG&gt;40 db

Barati, Behrouz

Ebrahimi, Khadijeh

Goljanian tabrizi, Ali

Mehrparvar, Golfam

English

Journals Portal, Shahid Beheshti University of Medical Sciences

Journal of Otorhinolaryngology & Facial Plastic Surgery  Vol: 2017; e2. This open-access article distributed under the terms of the Creative Commons Attribution Non Commercial 3.0 License (CC BY-NC 3.0). Copyright © 2017 Shahid Beheshti University of Medical Sciences. All rights reserved. www.journals.sbmu.ac.ir/otolaryngology  Original Article  Evaluation of the relashionship between clinical findings before tympanoplasty and ossicular discontinuity and erosion in patients with chronic otitis media  Behrooz Barati1, Ali GoljanianTabrizi2, Golfam Mehrparvar3, Khadijeh Ebrahimi4 1. Department of Otorhinolaryngology,Head and Neck Surgery, Taleghani hospital, Shaheed Beheshti University of Medical Sciences, Tehran, Iran.2. Department of Otolaryngology, Head and Neck Surgery, School of Medicine, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.3. Department of Otolaryngology, Head and Neck Surgery, School of Medicine, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.4. Otolaryngologist, Private physician, Tehran, Iran.   Article Info  Abstract Received:April 2017 Accepted: May 2017 Publish:20 Aug 2017  Corresponding Author:  Ali Goljanian Tabrizi Email:  Ali.goljanian@gmail.com  Keywords: Tympanoplasty, Ossicular discontinuity, Tympanic membrane   Background: Chronic Otitis Media (COM) is a relatively common condition and the occurrence of hearing loss is probable. COM may lead to ossicular discontinuity, and unless the operation is performed, it won't be determined. Identifying possible cases of erosion and discontinuity of ossicles is helpful in surgical planning and in anticipation of the probable need for procuring ossicular prosthesis. Purpose: The aim of this study was to evaluate the relationship between preoperative clinical findings and intraoperative findings. Methods: This is a cross sectional study carried out in 2012 in two tertiary referral hospitals of Tehran, (the Loghman and the Taleghani hospitals). The sample under study consisted of COM patients who referred to the otolaryngology clinics and were tymponoplasty candidates. Two hundred and seven  patients with the mean age of 36.2±13.9 (ranging from 9-67 years) were enrolled in the study. Pre-surgical findings were investigated and the relationship between ossicular discontinuity and pre-surgical findings were evaluated. Results: Incus-Stapes discontinuity (IS Discontinuity) and Incus-Malleus discontinuity (IM Discontinuity) were seen in 60 (29%) and 25 (12.1%) patients, respectively. We found IS Discontinuity in 38 (24.1%) patients with central perforation and 22 (48.9%) cases of marginal perforations (P=0.005). IM Discontinuity was observed in 14 (8.9%) cases with central perforation, while this was seen in 11 (22.4%) cases with marginal perforations (P=0.011). On the other hand, 34 (42%) patients with otorrhea had IS Discontinuity whereas 26 (20.6%) cases of dry ears showed this type of ossicular problem (P<0.001). IM Discontinuity was detected in 13 (16%) and 12 (9.5%) cases with and without otorrhea, respectively (P=0.011). IS Discontinuity and IM Discontinuity were significantly more common in the patients with Air Bone Gap of more than 40 db. Conclusion: Our finding showed that surgical results may be unpleasant in the patients with marginal perforation, otorrhea and ABG>40 db. Cite this article that: Barati B, GoljanianTabrizi A, Mehrparvar G, Ebrahimi Kh. Evaluation of the relashionship Clinical Findings before Tympanoplasty and Ossicular Discontinuity and Erosion in Patients with Chronic Otitis Media Journal of Otorhinolaryngology & Facial Plastic Surgery. 2017; 2017; e2.  Introduction Chronic otitis media (COM) is a relatively common condition in different societies and accounts for one of the most common otolaryngology visits. This is not usually accompanied by considerable mortality rate except for cases of intracranial complications, nevertheless, the main reason why considerable attention should be paid to this disorder is that the occurrence of hearing loss complication is probable. The severity of hearing loss can increase with age and health condition (1, 2) The hearing loss is conductive in most cases, but it can also be sensorineural, and if left untreated, permanent loss may develop (3). Hearing loss can be detected in almost all patients and it can reach 50-60 dB in cases of ossicular disruption or fixation (4). Inner ear involvement is probably due to the effect of infectious agents on permeable round window 2  Barati B. et al.  This open-access article distributed under the terms of the Creative Commons Attribution Non Commercial 3.0 License (CC BY-NC 3.0). Copyright © 2017 Shahid Beheshti University of Medical Sciences. All rights reserved. www.journals.sbmu.ac.ir/otolaryngology  membrane and damage to the hearing end organs (5, 6). Tympanic Membrane (TM) perforations can arise from a variety of causes. Major causes include trauma and  middle ear disease (1). Most of these perforations especially, those caused by acute trauma heal spontaneously while others remain open and need surgical closure (7). The surgical treatment of COM has two main goals: eradication of the infection and hearing restoration. Different surgical techniques can be used depending on the severity of the disease (8). These surgical operations are associated with achieving socially acceptable hearing levels (>30dB) in 80-90% of cases, although in more complex procedures the range will come down to 60-80% (9). Consequently, some patients do not experience acceptable postoperative improvement which is mainly the result of ossicular erosion or discontinuity (10). In this regard, otologists wonder what factors are prognostic in the erosion or discontinuity of ossicles. The answer to this question is important from two viewpoints: firstly, the possible cases of erosion and discontinuity of ossicles can be identified which can help surgical planning and the anticipation of the probable need for procuring ossicular prosthesis. Secondly, with regard to patients with poor outcome, it will be possible to inform the patient- or the executor- about the purposes and consequences of the operation. In this study, we decided to evaluate the relationship between preoperative factors and ossicular erosion/ discontinuity.  Patients and Methods This is a cross sectional study carried out in 2012 in two teaching hospitals of Tehran, (the Loghman and the Taleghani hospitals). This study was approved by the Ethics Committee of Shahid Beheshti University of Medical Sciences, Tehran, Iran. The sample under study consisted of COM patients who referred to the otolaryngology clinics and were tymponoplasty candidates. The patients that were excluded from the study: • Patients with acute otitis media • The ones requiring another operation on the involved ear • Cases of preoperative permanent hearing loss in the involved ear Convenience or accessible sampling method was used and all patients who met the inclusion criteria were assessed. We applied the equation that uses the proportion of an attribute in a population for calculating the sample size. According to the estimation of ossicular disruption in similar patients (16%), first type error (α) of 0.05 and level of precision (0.05), the sample size was calculated to be 207 patients. After letting the patients know about the goals and methods of the study, an informed consent was obtained.  Preoperative clinical findings included the location of tympanic membrane perforation, the condition of the middle ear mucosa, presence or absence of otorrhea, the status of incudostapedial (I-S) joint and air bone gap (ABG). These data were obtained through physical examinations and audiometry. During the operation, it was examined to find out whether or not ossicular erosion and discontinuity were presented. The relationship between preoperative and intraoperative findings was assessed. We used frequency and frequency percentage to report quantitative data and the Chi-square test to compare the proportions. The significant level was considered less than 0.05. The statistics software SPSS-15 was used.  Table 1. The preoperative clinical findings and their frequencies. Preoperative clinical findings Frequency (%) Perforation Central 158(76.3) Marginal 49(23.7) Middle ear mucosa Normal 119(57.5) Edematous 88(42.5) Otorrhea Present 81(39.1) Absent 126(60.9) I-S joint Exposed 49(23.7) Non- exposed 158(76.3) ABG <20dB 66(31.9) 20-40dB 80(38.6) >40dB 61(29.5) I-S joint: incudostapedial joint ABG: air bone gap   Results Two hundred and seven patients with the mean age of 36.2±13.9 (ranging from 9-67 years) were enrolled in the study. Table 1 and 2 show Evaluation of the relashionship  3   the pre and intraoperative clinical findings and their frequencies. Table 3 shows the frequency distribution of each intraoperative finding in terms of the location of tympanic membrane perforation. Consequently, the location of perforation is correlated with ossicular discontinuity and incus erosion. Table 4 demonstrates the frequency of different intraoperative findings in terms of presence or absence of otorrhea and indicates that there is a correlation between the otorrhea and ossicular discontinuity, incus and malleus erosion. Table 5 displays the frequency of each intraoperative finding with reference to the air bone gaps. Its contents establish that there are statistically significant relationship between ABG and factors of ossicular discontinuity, erosion and fixation.   Discussion In our study, most patients were suffering from central perforations (with a central to marginal ratio of 3:1). Since central perforation is of more benign nature, most patients in this study belonged to the group with more favorable prognosis. The middle ear mucosa was normal in more than half of the patients. Otorrhea was observed in less than 50% of the cases. The I-S joint was exposed in about 25% of subjects. ABG of more than 40 dB was seen in one third of the patients. Therefore in the majority of the cases clinical conditions were favorable.  Table 2. The intraoperative clinical findings and their frequencies.    Table 3. Frequency distribution of each intra operative finding in terms of the location of tympanic membrane perforation.  Finding Perforation Frequency (%) P value** Odds ratio  (95% CI) IS discontinuity  Central 38(24.1) 0.005* 1.37 (1.06-1.8)  Marginal 22(48.9) MI discontinuity  Central 14(8.9) 0.011* 1.2 (1.01-1.4)  Marginal 11(22.4) Incus erosion  Central 49(31) 0.002* 1.53 (1.1-2.1)  Marginal 27(55.1) Malleus erosion  Central 16(10.1) 0.058 1.13 (0.97-1.31)  Marginal 10(20.4) Stapes erosion  Central 27(17.1) 0.144 1.13 (0.97-1.31)  Marginal 13(26.5) IS fixation  Central 43(27.2) 0.461 1.1 (0.87-1.3)  Marginal 16(32.7)  MI fixation  Central 25(15.8) 0.933 1 (0.87-1.16)  Marginal 8(16.3) IS: incudostapedial MI: malleoincudeal: *significant  **chi-2 test Observation Frequency (%) IS discontinuity: + 60(29) _ 147(71) MI discontinuity: + 25(12.1) _ 82(87.9) Incus erosion: + 76(36.7) _ 131(63.3) Malleus erosion: + 26(12.6) _ 181(87.4) Stapes erosion: + 40(19.3) _ 167(80.7) IS fixation:  + 59(28.5) _ 148(71.5) MIfixation: + 33(15.9) _ 174(84.1) IS:incudostapedial  MI: malleoincudeal: 4  Barati B. et al.  This open-access article distributed under the terms of the Creative Commons Attribution Non Commercial 3.0 License (CC BY-NC 3.0). Copyright © 2017 Shahid Beheshti University of Medical Sciences. All rights reserved. www.journals.sbmu.ac.ir/otolaryngology  Table 4. Frequency of different intraoperative findings in terms of presence or absence of otorrhea.  Finding Otorrhea Frequency (%) P value** Odds ratio   (95% CI) IS discontinuity      + 34(42) 0.001* 2.8 (1.5-5.2)  _ 26(20.6)  MI discontinuity      + 13(16) 0.160 1.8 (0.78-4.21)  _ 12(9.5) Incus erosion      + 39(48.1) 0.006* 2.23 (1.25-3.99)  _ 37(29.4) Malleus erosion      + 16(19.8) 0.012* 2.8 (1.22-6.66)  _ 10(7.9) Stapes erosion      + 20(24.7) 0.117 1.74 (0.87-3.5)  _ 20(26.1) IS fixation      + 19(23.5) 0.197 1.12 (0.95-1.33)  _ 40(31.7) MI fixation      + 13(16) 0.973 1.01 (0.47-2.17)  _ 20(15.9) IS: incudostapedial MI:malleoincueal: *significant **chi-2 test +: presence _: absence       Table 5. The frequency of each intraoperative finding with reference to the air bone gaps.  Finding ABG Frequency (%) P value** IS discontinuity <20dB 1(1.5) <0.001* 20-40dB 24(30) >40dB 35(57.4)  MI discontinuity  <20dB 1(1.5) <0.001* 20-40dB 7(8.8) >40dB 17(27.9) Incus erosion <20dB 4(6.1) <0.001* 20-40dB 32(40) >40dB 40(65.6) Malleus erosion <20dB 2(3) <0.001* 20-40dB 9(11.3) >40dB 15(24.6) Stapes erosion <20dB 1(1.5) <0.001* 20-40dB 13(16.3) >40dB 26(42.6) IS fixation <20dB 3(4.5) <0.001* 20-40dB 31(38.8) >40dB 25(31) MI fixation <20dB 2(3) <0.001* 20-40dB 11(13.8) >40dB 20(32.8) IS: incudostapedial MI:malleoincudeal *significant **chi-2 test      Evaluation of the relashionship  5   With a glance at the intraoperative findings, it can be seen that most patients did not show any signs of ossicular erosion or discontinuity, however there is actually a significant correlation between these complications and some of the preoperative findings. For example, in the case of marginal perforation, the risk of ossicular discontinuity increased 1.2 to 1.4 fold. Additionally, marginal perforation was associated with 1.5 times increase in the risk of incus erosion. There was a stronger relationship between otorrhea and erosion than the one between marginal perforation and ossicular erosion and discontinuity, but the strongest correlation was found to be between ABG and these complications so that there were very uncommon and almost negligible in patients who had ABG of 20 dB or less. However, in patients with more than 40 dB gap, ossicular erosion, discontinuity, and even fixation were found to be much more common. It is noteworthy that these complications were not  related to age and exposure of I-S joint. In comparison to previous similar studies, some new prognostic factors were taken into account. Most of earlier studies carried out on this issue evaluated the correlation between surgical results and cholesteatoma which now is a well understood concept. A study conducted by  Carrillo and colleges  showed that in chronic suppurative otitis media (CSOM) without cholesteatoma ABG of 20 or less at 500 Hz and 30 or less at 1 KHz decreased the probability of ossicular discontinuity from 33 to 5.6% and 15.5%, respectively. The ability of ABG to alter probability of ossicular discontinuity was not significant in the presence of cholesteatoma (11). In the study of Ebenezer and colleges, factors associated with incus necrosis were reported as: active ear discharge, anterosuperior location of perforation, exposure of I-S joint, edematous middle ear mucous membrane, middle ear granulations, foreshortening of the handle of malleus, moderate to moderately severe hearing loss and ABG>40 dB (12). Jeng showed that in the cholesteatoma ears, both cholesteatoma extension into the tympanic sinus and persistently draining ears were predictive of ossicular discontinuity. The ABG was not significantly correlated with ossicular discontinuity (13). Another study carried out by Dadgarnia and associates revealed that the average improvement of hearing threshold was +7.9 dB in patients without cholesteatoma and -1.1 in patients with cholesteatoma. An average ABG increase of 6.4dB was reported in patients with cholesteatoma whilst, while in patients without cholesteatoma it decreased by 5.3 dB (14). Feng and others showed that in patients with COM there is a significant correlation between the ossicular discontinuity and ABG, marginal perforation of tympanic membrane, otorrhea and cholesteatoma (15).  Conclusion: Our observations disclosed that in patients with marginal perforation of tympanic membrane, otorrhea and more importantly patients with ABG of 40 dB or more, one should expect poor postoperative hearing outcome and the treatment team should keep this issue in mind while planning the operation and inform the patients and their families about the risks and outcomes of surgery.  Conflict of Interest: The authors report no conflict of interests.  Acknowledgments: The authors appreciate the support of Clinical Research Development Center of Loghman Hakim hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.  Funding: The authors received no financial support for this research.  References: 1. Vikram BK, Khaja N, Udayashankar SG, Venkatesha BK, Manjunath D. Clinico epidemiological study of complicated and uncomplicated chronic suppurative otitis media. J Laryngol Otol. 2008; 122(5):442-6. 2. Peyvandi, A. and N. A. Roozbahany (2013). "Hearing loss in chronic renal failure patient undergoing hemodialysis." Indian Journal of Otolaryngology and Head & Neck Surgery 65(3): 537-540. 3. Dohar JE. Old and new ototopical agents for the acute and chronic draining ear. Seminars in Otitis Media Management. 1998; 1-14. 4. Matsuda Y, Kurita T, Ueda Y, Ito S, Nakashima T. Effect of tympanic membrane perforation on 6  Barati B. et al.  This open-access article distributed under the terms of the Creative Commons Attribution Non Commercial 3.0 License (CC BY-NC 3.0). Copyright © 2017 Shahid Beheshti University of Medical Sciences. All rights reserved. www.journals.sbmu.ac.ir/otolaryngology  middle-ear sound transmission. J Laryngol Otol. Suppl. 2009 ;(31):81-9. 5. Smith JA, Danner CJ. Complications of chronic otitis media and cholesteatoma. Otolaryngol Clin North Am. 2006; 39(6):1237-55. 6. Hannley MT, Dennenny JC 3rd, Holzer SS. Use of ototopical antibiotics in treating 3 common ear diseases. Otol Head Neck Surg. 2000; 122(6):934-40. 7. Barati B, Abtahi SHR, Hashemi SM, Okhovat SAR, Poorqasemian M, Tabrizi AG. The effect of topical estrogen on healing of chronic tympanic membrane perforations and hearing threshold. J Res Med Sci. 2013; 18(2):99-102. 8. Wright D, Safranek S. Treatment of otitis media with perforated tympanic membrane. Am Fam Physician. 2009; 79(8):650-654. 9. Kenna MA. Etiology and pathogenesis of chronic suppurative otitis media. Ann Otol Rhinol Laryngol. 1988; 97:16-17. 10. van der Veen EL, Schilder AG, van Heerbeek N, Verhoeff M, Zielhuis GA, Rovers MM. Predictors of chronic suppurative otitis media in children. Arch Otolaryngol Head Neck Surg. 2006; 132(10):1115-8. 11. Carrillo RJ, Yang NW, Abes GT. Probabilities of ossicular discontinuity in chronic suppurative otitis media using pure-tone audiometry. Otol Neurotol. 2007; 28(8):1034-7. 12. Ebenezer J, Rupa V. Preoperative predictors of incudal necrosis in chronic suppurative otitis media. Otolaryngol Head Neck Surg. 2010; 142(3):415-20. 13. Jeng FC, Tsai MH, Brown CJ. Relationship of preoperative findings and ossicular discontinuity in chronic otitis media. Otol Neurotol. 2003; 24(1):29-32. 14. Dadgarnia MH, Karimi GH. The prevalence of cholesteatoma in patients with chronic otitis media and the comparison of postoperative results in patients with and without cholesteatoma. J Rafsanjan Univ Med Sci. 2005; 4(1):49-55. [Persian]. 15. Feng H, Chen Y, Ding Y. Analysis of preoperative findings and ossicular condition in chronic suppurative otitis media. Lin Chuang Er Bi Yan Hou Ke Za Zhi. 2005; 19(1):7-8, 11. [Chinese].  

Evaluation of the relashionship between clinical findings before tympanoplasty and ossicular discontinuity and erosion in patients with chronic otitis media

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Evaluation of the relashionship between clinical findings before tympanoplasty and ossicular discontinuity and erosion in patients with chronic otitis media

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