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• W1584696636 abstract "Surgical tympanoplasty under general anesthesia is currently the standard of care for chronic (more than 3 months) tympanic membrane perforations. Office-based myringoplasty, as an alternative, would reduce the burden on the patient and the health care system. Are there situations in which the two techniques are equally effective in terms of closure rates and hearing outcomes? A literature review was performed in PubMed from January 1, 1900 to January 1, 2013. There were 4,969 studies identified using the search terms “tympanoplasty” or “myringoplasty.” Only papers in English were reviewed. To avoid confusion in the nomenclature, we define office-based myringoplasty as a transcanal procedure performed without sedation or general anesthesia and without creating a tympanomeatal flap. The best available techniques, in terms of closure rates, were chosen for comparison. If hearing results are available, they are discussed. Unfortunately, the lack of reporting in the literature makes comparisons on hearing results difficult. In contrast, a surgical tympanoplasty is the standard procedure used by most otolaryngologists, using a postauricular incision, and a tympanomeatal flap is elevated. Standard tympanoplasty techniques adapted for use in the office, or techniques currently under clinical investigation or not yet approved by the US Food and Drug Administration (FDA) were not included in this review. The following techniques involve substances all approved by the FDA, although they are off-label uses. A prospective, randomized trial of 45 patients compared paper patch to underlay fat (ear lobule) and perichondrium (tragal) in dry chronic perforations of 3 mm or less.1 Following excision of the perforation rim, the paper patch was applied by onlay after moistening with iodine. The reported success was 67% compared to 87% in both the fat and perichondrium groups; however, this was not statistically significant. The hearing results were also worse in the paper patch group, with an average of 5-dB improvement compared to 8 dB in the fat group and 10 dB in the perichondrium group. Paper patch used for >3 to 5 mm perforations show less rates of success and often does not restore conductive hearing above 4 kHz. Although the differences were not significant, this article suggests that paper patch is an inferior alternative to both fat plug and perichondrium tympanoplasty. A prospective clinical trial of 21 patients combined hyaluronic acid (Epidisc Otologic Lamina; Xomed-Medtronic, Jacksonville, FL) with a fat plug myringoplasty.2 The theory in this study was to provide a more natural scaffold using hyaluronic acid for keratinocyte migration. An important step in both arms of the study is de-epithelialization of the perforation rim prior to repair. This study also included small, large, and subtotal perforations, although the number of patients within each group is not reported. The reported success rate of closure was 81%, with a mean of 17 dB air-bone gap closure and no statistical difference in success of closure if perforations were divided into groups according to size. It would have been useful to include a control group, where either a fat plug without hyaluronic acid or a control group with the perforation rimmed without any other intervention was studied. This would have helped identify the effect of the fat plug alone and the effect of the application of the hyaluronic acid. Application of trichloroacetic acid, often referred to as the Derlacki method, was first described in 1944 by Linn. One recent study reported results in 81 patients.3 The technique involves applying trichloroacetic acid to the perforation and is often combined with excision of the perforation rim. Antiseptic powder is insufflated over the area before covering the perforation with a pledget of cotton instilled with a euthymol solution, a commercial preparation containing antiseptic and anti-inflammatory substances. The patient applies euthymol via the ear canal daily on leaving the office. Closure rates were reported at 84%; however, some patients required multiple applications. Half of the patients required one to three treatments but some as many as 12. Smaller perforations required fewer treatments. It most likely works by removing the squamous mucosal junction at the perforation edge and activates the acute inflammatory process. It would have been useful to compare a control group without the euthymol and rimming the perforation only. The ease of application makes this attractive; however, having over half the patients requiring four or more applications makes it less attractive as a definitive procedure. The article reported that most of the conductive hearing losses were reversed, but did not provide statistics, making it impossible to comment on the hearing results of this method. The success rate of closure with surgical tympanoplasty, in large series, using either cartilage or temporalis fascia is over 84%.4, 5 The highest rates of closure in office-based procedures are, at most, as successful as the lower rates of success in surgical tympanoplasty. Additionally, surgical tympanoplasty has hearing results that are as good as, or better than, office-based procedures.4, 5 Using the best available evidence, the gold standard remains an inpatient tympanoplasty under general anesthesia (Fig. 1). Research surrounding office-based myringoplasty lacks a blinded control group, or in some cases no control group at all. It could be argued that healing may have occurred simply by excising the perforation rim without any other intervention. This would be a useful procedure to test on its own. Office-based techniques have not shown the ability to restore conductive hearing at high frequencies, and the number of patients treated in the literature is small compared to the thousands of patients treated with standard tympanoplasty techniques.5 Studies have only included dry perforations and typically exclude discharging perforations. Office-based myringoplasty appears safe and suitable for stable, dry, small perforations in which the patient or surgeon wants to avoid general anesthesia. The best available office-based myringoplasty technique, in terms of closure rates, is the topical application of trichloroacetic acid, although the other methods presented had similar results, and there has been no direct comparison. For those based in the United States, the coding for this procedure has a 10-day global period, allowing for repeated procedures within a short time frame. Growth factors and other techniques under research may provide a better alternative in the future, but are not yet available. If undertaking the procedure, the patient must be prepared for the possibility of multiple procedures and unknown long-term complication rates. When an office-based procedure fails, underlying factors should be examined, and a surgical tympanoplasty can be offered. The best level of evidence in the literature is level 2b." @default.
• W1584696636 created "2016-06-24" @default.
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• W1584696636 date "2013-10-02" @default.
• W1584696636 modified "2023-10-06" @default.
• W1584696636 title "Is office‐based myringoplasty a suitable alternative to surgical tympanoplasty?" @default.
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• W1584696636 doi "https://doi.org/10.1002/lary.24221" @default.
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