10.14639/0392-100X-suppl.1-43-2023-05
The aim of the work is to review the current literature concerning recidivism of tympanic perforation after myringoplasty and to give some tips to improve the chance of success and manage the possible scenario of failure. An analysis of the existing literature is presented and, based on it and on our experience, an algorithm of management of tympanic perforation recidivism is proposed.
text/xml
1827-675X
2607
en
Nicola Quaranta
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
unsuccess
Recurrent tympanic perforation after myringoplasty: a narrative literature review and personal experience
Text.Serial.Journal
https://www.actaitalica.it/
43
Annual congress report
2023-04-21
2023-04-20
2023-04-28
2023-04-28
S41-S47
1
Nicola Quaranta
2023/04/21
10.14639/0392-100X-suppl.1-43-2023-05
S41
Otorinolaringoiatria Universitaria, Dipartimento di Biomedicina Traslazionale e Neuroscienze, Università di Bari, Bari, Italy
1827-675X
unsuccess
S47
Recurrent tympanic perforation after myringoplasty: a narrative literature review and personal experience
https://www.actaitalica.it/article/download/2607/942
43
ACTA OTORHINOLARYNGOLOGICA ITALICA 2023;43(SUPPL.1):S41-S47; doi: 10.14639/0392-100X-suppl.1-43-2023-05




Otology section


Recurrent tympanic perforation after myringoplasty: a
narrative literature review and personal experience
La perforazione timpanica recidivante dopo miringoplastica:
revisione narrativa della letteratura ed esperienza personale
Vito Pontillo, Giada Cavallaro, Francesco Barbara, Mauro Mastrodonato, Alessandra Murri, Nicola Quaranta
Otorinolaringoiatria Universitaria, Dipartimento di Biomedicina Traslazionale e Neuroscienze, Università di Bari, Bari, Italy



SUMMARY
The aim of the work is to review the current literature concerning recidivism of tympanic perfora-
tion after myringoplasty and to give some tips to improve the chance of success and manage the
possible scenario of failure. An analysis of the existing literature is presented and, based on it and
on our experience, an algorithm of management of tympanic perforation recidivism is proposed.
KEY WORDS: myringoplasty, tympanic membrane perforation, recidivism, recurrent,
residual, graft failure, unsuccess

RIASSUNTO
Questo studio si propone di analizzare i dati presenti in letteratura riguardanti la recidi-
va di perforazione timpanica dopo miringoplastica e di fornire degli utili suggerimenti per
aumentare le possibilità di successo e gestire il possibile scenario dell’insuccesso. Infatti,
verrà presentata la nostra proposta di un algoritmo di gestione delle riperforazioni dopo
miringoplastica.
PAROLE CHIAVE: miringoplastica, perforazione timpanica, recidiva, riperforazione,
fallimento
                                                                                                         Received: January 15, 2023
                                                                                                         Accepted: January 22, 2023

                                                                                                         Correspondence
Definitions and historical background                                                                    Vito Pontillo
                                                                                                         Otorinolaringoiatria Universitaria
Tympanic membrane (TM) perforation is one of the most common conditions                                  Policlinico di Bari, Università di Bari, piazza Giulio
that otologists have to deal with in daily clinical practice 1. TM may result                            Cesare 11, 70124 Bari, Italy
from recurrent middle ear infections, trauma, or iatrogenic causes 2. The ma-                            Tel. +39 080 5592299
                                                                                                         E-mail: pontillovito@gmail.com
jority (up to 80%) of these perforations have tendency to heal spontaneously.
The remaining cases may be addressed to surgery, especially when patients ex-
                                                                                                           How to cite this article: Pontillo V, Cavallaro G,
perience major discomfort due to recurrent otorrhea, conductive hearing loss,                              Barbara F, et al. Recurrent tympanic perforation
or interdiction to water activities.                                                                       after myringoplasty: a narrative literature review
                                                                                                           and personal experience. Acta Otorhinolaryngol
TM repair was first introduced by Berthold in 1878 3 with the term of ‘myrin-                              Ital 2023;43(SUPPL.1):S41-S47. https://doi.
goplasty’, and further developed by Zollner 4 and Wullstein 5 in the 50s, when                             org/10.14639/0392-100X-suppl.1-43-2023-05
it acquired the name of ‘type I tympanoplasty’. The two terms are often used
                                                                                                         © Società Italiana di Otorinolaringoiatria
interchangeably, even if a theorical difference exists, in that tympanoplasty                            e Chirurgia Cervico-Facciale
requires the elevation of a tympanomeatal flap while myringoplasty does not 6.
To avoid any misunderstanding, both these concepts will be referred as myrin-                                           OPEN ACCESS
goplasty throughout the rest of this manuscript.                                                         This is an open access article distributed in accordance with
The main aim of myringoplasty is to eradicate the disease and create an in-                              the CC-BY-NC-ND (Creative Commons Attribution-Non-
                                                                                                         Commercial-NoDerivatives 4.0 International) license. The
tact TM, thus preventing recurrent or chronic middle ear infection. Secondly,                            article can be used by giving appropriate credit and mentio-
                                                                                                         ning the license, but only for non-commercial purposes and
continuity of the air-conduction mechanism from TM to inner ear should be                                only in the original version. For further information: https://
ensured when possible 7.                                                                                 creativecommons.org/licenses/by-nc-nd/4.0/deed.en




                                                                                                                                                                 S41
V. Pontillo et al.




Surgical techniques                                              different factors which are often multiple and intercon-
                                                                 nected (Tab. I).
Myringoplasty can be performed microscopically or
                                                                 Recidivism of the perforation is one of the major complica-
endoscopically with an endomeatal, retroauricolar, or
                                                                 tions after myringoplasty. Specifically, a distinction must
transmeatal approach. The surgeon’s preferences and site
                                                                 be made between late re-perforation of a completely healed
of perforation determines the approach.
                                                                 neotympanum, caused by a new trauma or infection or re-
The use of autologous grafting material such as temporal
                                                                 sulting from a progressive graft atrophy, and immediate
fascia, perichondrium, cartilage, fat, periosteum, or vein
                                                                 post-operative graft failure, due to septic or aseptic graft
is preferrable when available 8. Two main techniques are
                                                                 necrosis, or inadequate anterior graft adaptation 10,11. To
currently in use based on the positioning of the graft with
                                                                 avoid any confusion, late re-perforation will be referred as
regards to the remnants of the tympanic membrane, the un-
derlay and the overlay.                                          ‘recurrent perforation’ and immediate graft failure as ‘re-
In our institution, the underlay technique, with the graft       sidual perforation’ throughout the rest of the manuscript.
placed entirely medial to the TM remnants, is preferably
performed as long as the fibrous annulus is preserved be-        Risk factors for recidivism
tween 2 and 4 o’clock. It is quite easy and quick to perform,    Several prognostic factors, often interconnected, can affect
and the healing process is usually fast. However, in case of     the results of myringoplasty.
anterior perforations a good visualisation and steady ante-      Demographic and social factors
rior support on the bony annulus cannot be ensured.
                                                                 Age
In these cases, an underlay variant with anterior anchor-
age is performed: an accessory horizontal 3-4 mm inci-           Myringoplasty has historically been thought to be less
sion is made approximately 4 mm lateral to the anterior          successful in children than in adults, due to the immatu-
annulus at about 10 o’clock and a subcutaneous tunnel is         rity of immune system and Eustachian tube (ET), promi-
made to create an anterior window to the middle-ear; the         nent adenoid tissue and frequency of upper respiratory
antero-superior edge of the graft is then pulled through         tract infections 12,13. In fact, mean paediatric closure rates
this window and allocated beneath the anterior flap; after       have been found to be slightly lower than in adults in both
graft placement, the anterior angle of the middle ear cav-
ity should be packed with absorbable gelatine sponge to
ensure further stability.                                        Table I. Metanalysis of success rates after myringoplasty in different condi-
                                                                 tions (from Tan et al., 2016, mod.) 17.
In anterior or subtotal perforations where the fibrous annu-
                                                                   Variables                             No.      Success rate          P
lus is absent between 2 and 4 o’clock, the overlay technique                                           patients        (%)
is mandatory, thus allowing excellent visualisation of the        Age               Children (≤ 17)            4136    83.42         0.017
anterior meatal recess. In our institution, the TM remnants                         Adults (> 17)              2049    89.25
and the skin of the EAC are always completely removed to
                                                                  Perforation       Otitis media               8597    83.86         0.86
reduce the risk of iatrogenic cholesteatoma, and the graft is     cause             Traumatic                   472    87.25
then placed onto the bony annulus with a minimal overrid-
                                                                  Perforation       ≤ 50%                      5859    85.56         0.019
ing onto the canal wall. The anterior wall is then covered        size              > 50%                      3374    79.44
with the residual skin flap or, in rare cases, with a Tiersch
                                                                  Perforation       Central                    4948    86.03         0.822
graft 9, and then the anterior angle is carefully packed with     location          Anterior                   1268    85.42
small pieces of gelatine sponge. The main disadvantages of
this technique are the risk of blunting of the anterior recess                      Posterior                   479    88.72
and the lateralisation of the graft; moreover, the healing        Ear status        Dry                        13048   87.02         0.155
process can be laborious and often longer.                                          Wet                         741    83.44
                                                                  Approach          Endaural                    5341   86.02         0.112
                                                                                    Postaural                   8188   88.06
Recidivism of tympanic membrane
                                                                  Technique         Underlay                   13359   86.71         0.712
perforation                                                                         Overlay                     2745   86.83
Myringoplasty can be a challenging procedure, and great                             Inlay                       1593   85.39
variation in outcomes has been reported among different           Graft             Fascia                     14806   88.00         0.048
institutions and surgeons. In particular, the reported closure    material          Cartilage                   1746   90.80
rates widely vary between 46% and 100% 9, depending on           Legend. In bold: statistically significant results.




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                                                                             Analysis of risk factors and proposal of a management algorithm




single studies 13-16 and in a recent meta-analysis by Tan et        Anatomical factors
al. 17 (Tab. I).                                                    Relevant technical issues can be caused by anterior wall
                                                                    prominence, exostosis or EAC stenosis, thus determining
Socioeconomic level
                                                                    poor visualisation of the anterior angle 36.
Lower success rates have been reported in patients with low
socioeconomic levels, probably due to poor post-operative           Technical factors
care, low attendance of control dates, frequent airway in-          No consensus exists about the best technique, which is of-
fections and worse middle ear conditions 18.                        ten chosen based on the surgeon’s skills and preference.
                                                                    The vast ambiguity of the results of various studies that
Smoking
                                                                    compared the different procedures is probably due to the
A recent systematic review 19 has demonstrated the nega-            different technical variations and skills, selection methods,
tive impact of smoking on graft uptake rates after myringo-         definitions of favourable outcome and follow-up.
plasty (77% of smokers vs 89% of non-smokers).
The effects of smoking on the middle ear physiology can be          Posterior vs endaural approach
divided into 3 categories:                                          Higher closure rates have been found using a retroauricolar
• local effects include those on middle ear and ET muco-            approach compared to an endaural one in two studies 37,38.
   ciliary clearance, by changing the amount and viscosity          This is probably due to improved visualisation of the ante-
   of the mucus, disrupting the ciliated cells and unsync-          rior angle, limiting the indication of the endaural approach
   ing ciliary activity 20. Moreover, the vasoconstriction and      to small posterior perforations. However, this was not con-
   thrombosis promoted by nicotine and the reduced tissue           firmed in the meta-analysis by Tan et al. 17.
   oxygenation induced by carbon monoxide increase the
                                                                    Microscopic vs endoscopic myringoplasty
   risk of graft necrosis 21;
• regional effects consist in causing eustachian tube ob-           Transcanal endoscopic ear surgery has been proposed as
   struction by nasal chemical irritation 22;                       an alternative to the microscopic retroauricolar approach.
• systemic effects are immunosuppressive and chemoal-               Several endoscopic series have shown success rates great-
   lergic properties that may increase the susceptibility to        er than 80% that is fully comparable to the microscopic
   infections 21.                                                   rates 7, although other authors have shown better results for
                                                                    their microscopic cases (1-year failure rate 5.7% vs 12.5%
Pathological factors                                                with endoscopy) 36.
Size and location of the perforation                                Primary vs revision myringoplasty
The highest failure rates have been recorded in total or            There is consensus that revision surgery is associated with
near-total perforations 17,23-25 (Tab. I) and in case of involve-   slight lower success rates compared to primary surgeries 39-41.
ment of the anterior half of the TM 18,26-27. This is likely due
                                                                    This is probably due to altered anatomic landmarks and the
to the reduced visibility, small area of overlap between the
                                                                    necessity to use unusual graft materials.
graft and residual TM, poor anterior support for the graft,
and lower vascular perfusion of anterior quadrants 28,29.           Temporalis fascia vs cartilage
Middle ear mucosa conditions                                        Within the full gamut of graft materials, from autologous
                                                                    to xenograft, no evidence exists with respect to the most
Higher failure rates have been reported in pre-operative
                                                                    effective grafting material for a given location, size, or
discharging ears 15,25,30-32, and in the presence of intratym-
                                                                    type. Although temporalis fascia has been the material of
panic granulation tissue or tympanosclerotic plaques 33.
                                                                    choice for a long time, the use of tragal or conchal chondro-
All these factors are thought to interfere with the normal
                                                                    perichondral grafts has recently been proposed, with the
healing process by affecting the vascularisation of the TM
                                                                    theoretical advantages of providing a rigid support against
remnants, impairing the scaffold for epithelisation and dis-
                                                                    negative middle ear pressures and having minimal aesthetic
placing the graft.
                                                                    consequences 11. Although fascia provides adequate clo-
Other pathological conditions                                       sure rates (nearly 90%) 42,43, cartilage has shown slightly
Poorer outcomes have been found in patients with con-               better results in the meta-analysis by Tan et al. (Tab. I) 17,
tralateral chronic otitis media 11,23,34 and in children with       especially in high-risk perforations such as in case of ET
no history of adenoidectomy or with craniofacial disor-             dysfunction, diffuse tympanosclerosis, atelectasis, revision
ders 24,35, confirming the role of ET function in middle ear        surgery, anterior perforations, purulent discharge at the
physiology.                                                         time of surgery, and larger perforations 18,25,44-47.



                                                                                                                                      S43
V. Pontillo et al.




Underlay vs overlay                                                Technical precautions
No univocal evidence about the superiority of one tech-            As mentioned, two of the main risk factors for residual per-
nique over the other has been demonstrated in literature so        foration after myringoplasty are the presence of tympano-
far 2,48-51. However, higher rates of residual perforation have    sclerotic plaques and involvement of the anterior half of the
been found in cases where an underlay technique was per-           TM, conditions that may require several adjustments to the
formed to treat anterior perforations 2. In addition, overlay      technique.
myringoplasty is inevitably associated with longer healing         Removal of tympanosclerotic plaques should be always
times 2.                                                           performed before each TM reconstruction, especially in the
                                                                   anterior remnant of the drum, to facilitate the epithelisa-
Surgeon’s experience                                               tion process. This can be done by gently dissection using a
While several authors have reported statistically better graft     sharp needle.
success rates when myringoplasty was performed by expe-            Three main methods have been proposed to prevent weak
rienced surgeons 16,31,52, others asserted that technical skills   anterior adaptation in case of anterior perforations: the
and attention to some details could be more relevant than          overlay technique 2, the underlay with anterior anchoring 60,
the experience of the surgeon 53.                                  and the circumferential flap method. The latter requires
                                                                   that the fibrous annulus be elevated 360°, thus completely
How to prevent recidivism                                          exposing the bony anulus all around, on which the graft
From the aforementioned analysis of risk factors for residu-       is placed 61. No significant difference between the three
al or recurrent perforation according to our experience and        techniques have been found in terms of graft uptake rates,
the literature, we next present some tips and tricks in order      hearing results and post-operative complications 60,61. In
to increase the chances of success.                                our institution, the anterior anchoring technique is usually
                                                                   performed in anterior perforations with satisfying results
Indication and timing                                              (success rate 95%), while the overlay myringoplasty is re-
Paediatric closure rates are not so low as to contraindicate       served for cases when the fibrous annulus is not maintained
myringoplasty in children 23, although some authors have           between 2 and 4 o’clock.
suggested to delay surgery until the age of 8 54-56. One of the    Additionally, some authors have proposed cartilage rein-
drawbacks of delayed surgery is the potential evolution to         forcement myringoplasty as a reliable technique in anterior
cholesteatoma or permanent inner ear damage in case of re-         perforations, especially in revision cases, demonstrating
current infections 57. In our experience, myringoplasty can        good closure rates with no effect on hearing results 47.
be performed in children, regardless of the age in case of         Regardless of the chosen technique, adequate drilling of the
cholesteatoma, preferably after age 6 in chronic otitis me-        anterior bulge of the external auditory canal is the first pre-
dia (COM) with no evidence of cholesteatoma, and in the            caution to take in case of anterior perforation, thus improv-
presence of dry ear and stable rhino-pharyngeal conditions.        ing the exposure of the anterior angle 2,62. Some authors
A decisive factor in the success of myringoplasty is the in-       claim that endoscopic techniques can help manage the is-
cidence of post-operative infections. The management and           sue of anterior wall overhang by providing a more detailed
timing of chronically discharging perforations is never sim-       and broader surgical view compared to the microscope 63.
ple, but every effort should be made to perform ear surgery        In order to maximise the results, some surgeons opt to per-
only after appropriate drying by the aid of antibiotic-steroid     form simultaneous canal-wall up cortical mastoidectomy in
ear drops and acetic acid solutions. When this is not pos-         chronically discharging ears, especially in case of hyper-
sible, this should not be a restrictive factor in performing       plastic and polypoid chronic otitis media and in ET dys-
myringoplasty, because middle ear normalisation may be             functions 64. The opening of abnormal mastoid cells and the
promoted by closure of the middle ear cavity, as suggest-          resection of granulations will both remove a future source
ed by the literature 11. However, in these cases the use of        of infection that may result in graft failure and improve
peri- and post-operative systemic antibiotics may help in          middle ear aeration 65,66. However, conflicting evidence ex-
reducing the risk of infection and thus graft displacement.        ists regarding the benefit of this additional procedure 64,67.
In fact, even though a Cochrane review found no difference
in graft failure rates when comparing intra-operative anti-        Our management algorithm proposal
biotics with placebo 58, a prospective double-blind placebo-       Despite all the forementioned technical precautions, graft
controlled randomised study did demonstrate decreased              failure with consequent recidivism of the perforation is
infectious risk when intra-operative antibiotics were used         still a possibility to take into account after myringoplasty.
in perforations with pre-operative discharge 59.                   Based on our experience and the literature review we have



S44
                                                                                           Analysis of risk factors and proposal of a management algorithm




Figure 1. Proposed algorithm for the management of recidivism of MT perforation after myringoplasty.


proposed an algorithm for management of graft failure                          grafts or human allografts compulsory 70. The main aim of
(Fig. 1).                                                                      revision myringoplasty is to avoid and correct the technical
While in case of late re-perforation of a healed neotym-                       faults made in primary surgery.
panum revision myringoplasty is often necessary, in the
case of a residual perforation in the first three months af-
                                                                               Conclusions
ter surgery a careful analysis of the issue should be made.
When an ear infection is thought to be the reason for graft                    Myringoplasty is one of the most common surgeries per-
displacement, prompt medical treatment with systemic                           formed by an otologist, but can be a challenging proce-
and local antibiotics can reduce ear discharge and pro-                        dure. Recidivism of tympanic membrane perforation after
mote healing. When this precaution is still not effective,                     myringoplasty can result from different causes. Under-
or when the graft necrosis does not result from an infec-                      standing the factors that can have an effect on outcomes
tion, a surgical option must be taken into consideration.                      can help the surgeon to prevent failure, while a prompt
In case of small perforations, an outpatient Gelfoam® plug                     analysis of the causes or faults of unsuccessful myringo-
procedure 68 can be attempted after proper freshening of                       plasty can minimise the sequelae of the complication. In
the margins. In case of failure or large perforations, revi-                   this paper, contemporary literature results and our experi-
sion myringoplasty should be performed. When residual                          ence were analysed in order to help the otologist facing
perforation is assumed to be the consequence of a tech-
                                                                               this scenario.
nical fault resulting in a poor anterior adaptation of the
graft, revision myringoplasty with correction of the de-
                                                                               Acknowledgements
fects is often proposed to the patient.
                                                                               We would like to show our gratitude to the University of
                                                                               Bari for the support and for providing all the scientific ma-
Revision myringoplasty                                                         terial for the research.
Revision myringoplasty for residual or recurrent TM perfo-                     All data and material are available and can be provided if
ration is often more challenging than the primary procedure                    requested.
which is due to the altered anatomy and distorted surgical
landmarks 10,69 and to the restricted availability of autolo-                  Conflict of interest statement
gous grafting materials, making the use of bovine xeno-                        The authors declare no conflict of interest.



                                                                                                                                                    S45
V. Pontillo et al.




Funding                                                                         15
                                                                                     Pignataro L, Grillo Della Berta L, Capaccio P, et al. Myringoplas-
                                                                                     ty in children: anatomical and functional results. J Laryngol Otol
This research did not receive any specific grant from fund-                          2001;115:369-373. https://doi.org/10.1258/0022215011907893
ing agencies in the public, commercial, or not-for-profit                       16
                                                                                     Emir H, Ceylan K, Kizilkaya Z, et al. Success is a matter of expe-
sectors.                                                                             rience: type 1 tympanoplasty: influencing factors on type 1 tympa-
                                                                                     noplasty. Eur Arch Otorhinolaryngol 2007;264:595-599. https://doi.
Author contributions                                                                 org/10.1007/s00405-006-0240-6
VP and NQ have conceived, designed, written and revised
                                                                                17
                                                                                     Tan HE, Santa Maria PL, Eikelboom RH, et al. Type I tympanoplasty
                                                                                     meta-analysis: a single variable analysis. Otol Neurotol 2016;37:838-
the work. GC, FB, MM and AM have taken part to the writ-                             846. https://doi.org/10.1097/MAO.0000000000001099
ing of the present paper.                                                       18
                                                                                     Tek A, Karaman M, Uslu C, et al. Audiological and graft take results
VP, NQ, GC, FB, MM and AM have contributed to the di-                                of cartilage reinforcement tympanoplasty (a new technique) versus
agnostic and therapeutic processes and to the writing of the                         fascia. Eur Arch Otorhinolaryngol 2012;269:1117-1126. https://doi.
                                                                                     org/10.1007/s00405-011-1779-4
present paper.                                                                  19
                                                                                     Visvanathan V, Vallamkondu V, Bhimrao SK. What effect does smok-
                                                                                     ing have on the surgical closure of tympanic membrane perforations?
Ethical consideration                                                                A review. Otol Neurotol 2018;39:1217-1221. https://doi.org/10.1097/
Not applicable.                                                                      MAO.0000000000002011
                                                                                20
                                                                                     Gulya AJ. Environmental tobacco smoke and otitis me-
                                                                                     dia. Otolaryngol Head Neck Surg 1994;111:6-8. https://doi.
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