International Journal of Pediatric Otorhinolaryngology
Pediatric myringoplasty: Postaural versus transmeatal approach
Introduction
Many surgical problems have more than one solution, and where the results are similar, it is often difficult to decide which technique to use. In this situation Occam's razor (after William of Occam 13th century English philosopher – “entias non sunt multiplicare sin necesitatum”) employs the simplest and/or fastest/and or least invasive method.
When performing myringoplasty, otologists are faced with at least two choices concerning which approach is to be used during the intervention: postaural, or transmeatal. There is also a third approach feasible, the endaural approach, which is little used in our clinic due to its visible scar. The choice for an approach is, for many surgeons, often determined by their surgical teachers or personal preference [1], [2]. This is mainly due to the lack of scientific evidence of the outcome parameters of the various tympanoplasty techniques [2].
Most otologists have long favoured postaural approach as a standard (one size fits all) approach to the middle ear and mastoid. It is commonly used to expose the mastoid area during the same procedure, enabling a mastoidectomy to be performed if necessary [3]. This approach generally also provides an adequate view of the entire tympanic membrane [4]. Autologous temporalis fascia graft may be harvested without an additional scar. In 1967, Jako [5] described the advantages of postaural exposure over endaural. He stated that postaural exposure preserves more usable tissues and gives a better functional auditory canal as well as providing a better viewing angle of the middle ear.
However, in the same article he also mentioned that endaural incision is less extensive and does not require removal of normal mastoid bone. The approach to the middle ear is shorter than postaural path and the exposure of the middle ear is better. When the aesthetic results of both approaches are compared, the endaural approach achieves a more satisfying result, regardless the graft take and hearing results [3]. Transmeatal approach without external incisions has not been compared to other methods, perhaps due to the continuing bias amongst many otologists that it is suitable only for small and posterior or postero-inferior perforations. In 2008, Seidman [6] did investigate the success rate of anterior transcanal (transmeatal) tympanoplasty. He suggested that it is a minimally invasive procedure that is suitable for anterior perforations, though he did not compare it with perforations located elsewhere. In our hospital we have gradually come to use the transmeatal approach for all perforations, including anterior and subtotal perforations.
In this study, we compared the differences between only the postaural and transmeatal approaches, for the endaural incision leaves a visible scar and is rarely used by us now.
Age remains a controversial factor in assessing a child's suitability for undergoing a myringoplasty procedure. Many otologists have advocated waiting until a given age, due to the belief that an older age is associated with a greater success rate [4], [7], [8], [9]. However, there are also some reports of a comparable success rate in younger children, suggesting that surgery could be done at any age [10], [11], [12], [13]. Especially where larger perforations produce frequent otitis media and significant hearing loss and consequently schooling problems, it may be better to operate earlier. In these patients a hearing aid is often not a good alternative because of the high incidence of otitis media associated with the perforation. Voss et al. [16] has demonstrated that it is the size of the perforation rather than its location that determines the degree of conductive hearing loss.
The size of the perforation is also thought to play a role in determining the success of myringoplasty. Larger perforations are often associated with lower success rate, perhaps due to the extent of the problem and the surgical difficulty it entails [6], [14]. Gaslin et al. [15] however, found that the preoperative perforation size does not significantly correlate with the success rate of the operation, although only a small number (n = 4) of patients with a perforation of ≥3 quadrants was included in that study. This concept of there being no significant difference in success rates in relation to perforation size is shared by Koch et al. [9].
Patients in this pediatric age group frequently remain at risk for developing secretory otitis media and in a small percentage we found that the eardrum developed a pin-hole perforation during healing. Since this does not affect the hearing levels, is not associated with increased incidence of otitis media, and heal spontaneously without requiring further surgery we considered these amongst the successes. This small group was analysed separately to determine if this phenomenon is age related.
Section snippets
Methods
All case files of pediatric patients who had undergone myringoplasty due to tympanic membrane (TM) perforation at Sophia Children's Hospital over a 14-year period (1993–2006) were examined. Closure rate was analysed and the possible determining role of age and size of the perforation was evaluated.
The perforations were classified into three groups: 1 (one quadrant), 2 (two quadrants) and 3 (more than two quadrants – subtotal), based on the area in relation to the malleus handle. All operations
Results
At the time of surgery, age ranged from 4 to 18 years, with a median of 10.0 years. The male:female ratio was 0.9:1.0 (105 boys and 113 girls).
Patients who had undergone myringoplasty using the postaural approach (84 ears) were in 79.8% of the cases successful. Six ears (7.1%) retained pin-hole perforation within 1-year post-operative and subsequently healed without further surgery. In the transmeatal group (134 ears), 10 ears (7.5%) had a micro-perforation within 1-year post-operative, with an
Discussion
We found no significant difference between the success rate of postaural and transmeatal repair of the tympanic membrane. The site of the perforation is often used as an indicator for deciding which approach is to be used during the procedure, with larger and anterior perforations being operated via the postaural approach. However, this study indicates that virtually all perforations even in pediatric patients may be reached via the transmeatal approach if adequate ear specula are selected, and
Conclusion
When faced with several surgical options having similar results, it is useful to apply Occam's razor and select the approach that is simpler/faster/less invasive/less painful for the patient, and ultimately less costly due to shorter operating time. The transmeatal approach seems to include most of these factors and may be used effectively for all types of perforations.
Although larger perforations are associated with lower success rate, it is advisable to nevertheless perform myringoplasty for
Acknowledgment
We would like to thank Dr Marjan Wieringa for her invaluable assistance in the statistics part of this research.
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