Combined mastoidectomy is generally preferred to tympanoplasty alone when treating patients with chronic otitis media (COM), particularly when temporal bone computed tomography (TBCT) shows that the mastoid cavity contains opacification of soft tissue density. However, in cases with Eustachian tube dysfunction, a mastoid cavity volume may be a burden to its function. We hypothesized that tympanoplasty alone might be better than tympanoplasty combined with mastoidectomy because soft tissue in the mastoid cavity is a sequel to a protective physiological response. Thus, we explored the efficacy of tympanoplasty without mastoidectomy in COM patients exhibiting mastoid air cell opacification on TBCT.
Between 2010 and 2014, a total of 33 patients, diagnosed with COM and with evidence of mastoid cavity opacification on TBCT, underwent tympanoplasty without mastoidectomy. All ears had been dry for ≥3 months before surgery. All procedures were performed by the same surgeon. We retrospectively analyzed the preoperative otoscopic findings, pre- and postoperative pure tone averages (PTAs; the mean of the values at 0.5, 1, 2, and 4 kHz), surgical procedures, and complications or recurrence.
Of the 33 patients, 28 (84.8%) exhibited hearing improvement after surgery. The mean pre- and postoperative PTAs were 46.9±21.2 dB and 29.4±17.0 dB, respectively (
Tympanoplasty alone, i.e., without mastoidectomy, may adequately control COM, if it shows dry-up status for at least 3 months even though mastoid cavity opacification is detected in TBCT.
The efficacy of mastoidectomy combined with tympanoplasty for treating chronic otitis media (COM) in patients without cholesteatoma remains controversial among otologists. One issue is whether mastoidectomy should be routine when tympanoplasty is performed [
Today, temporal bone computed tomography (TBCT) plays a key role in COM diagnosis and the choice of surgical intervention [
In terms of physiological recovery, a chronically infected mastoid mucosa will scar during tissue repair [
A total of 33 ears, of COM patients who had undergone tympanoplasty alone (i.e., without mastoidectomy) and in whom TBCT revealed mastoid cavity opacification, were retrospectively reviewed. All operations were performed by a single surgeon (YHC) at a tertiary referral center (Ajou University Hospital, Suwon, Korea) between 2010 and 2014. Our inclusion criteria were COM without cholesteatoma, no otorrhea for ≥3 months prior to enrolment, and clear middle ear mucosa upon microscopic examination in the operating room. We analyzed preoperative otoscopic findings, pre- and postoperative pure tone averages (PTAs), TBCT images, surgical procedures, and complications or recurrence. Postoperative hearing outcomes were assessed using the relevant Korean guidelines [
Soft tissue opacification of mastoid cavity was evaluated by radiologists. Postoperative TBCT was performed if a complication or recurrence was suspected, and to evaluate the opposite side in patients with bilateral COM.
The paired
Twenty-eight patients (84.8%) fulfilled at least one of the success criteria described above [
Of the 28 patients exhibiting postoperative hearing gains, one complained of a small tympanic perforation after surgery and underwent fat tissue myringoplasty. Overall, >80% of patients enjoyed hearing gains without any complication or recurrence. Attic destruction was developed in one patient during follow-up; we performed revision tympanoplasty with mastoidectomy. Otoscopic examination revealed otorrhea around tympanic membrane in two patients. These two cases exhibited granular myringitis without a tympanic perforation, which resolved rapidly on application of otic drops. Two patients whose hearing did not improve after tympanoplasty underwent additional ossiculoplasty and further observation (
We performed TBCT after surgeries in seven patients who had ear diseases on the opposite side, complained otorrhea or hearing impairment after surgeries, or were suspicious the possibility of cholesteatoma during follow-up period. In four patients, the preoperative status of the middle ear and mastoid cavity did not change (
The middle ear cavity plays an important role in sound conduction, especially by reserving air. There are two principal ear pressure regulation systems, namely Eustachian tube functionality and gas exchange, principally in the mastoid mucosa [
The significance of mastoid cavity opacification on TBCT requires consideration. In cholesteatoma, for example, opacification reflects a progressive pathological condition that must be eradicated via mastoidectomy. On the other hand, in patients with COM without cholesteatoma, it is doubtful that opacification indicates a pathological lesion that will later trigger disease recurrence. Recently, Wilkinson et al. [
It has been speculated that mucosal thickening evident on TBCT is a self-limiting process [
We found that tympanoplasty alone afforded hearing gains in 84.8% of patients. Attic destruction developed in one patient 11 months after surgery. This indicates that accurate differential diagnosis of COM and cholesteatoma is essential; cholesteatoma patients require mastoidectomy. This was the only case of disease recurrence after operation.
Seven patients underwent follow-up TBCT (
All 33 cases had undergone medical and clinical management for ≥1 year prior to surgery.
We suggest that tympanoplasty alone (i.e., without mastoidectomy) when mastoid cavity opacification is evident on TBCT is appropriate when (1) COM is not accompanied by cholesteatoma; (2) the middle ear has been dry for ≥1 year; and (3) sclerotic change is evident in the mastoid cavity. The dry period was ≥3 months in the present study; a longer period would be preferable. Although radiologists seek to differentially diagnose mastoid haziness [
Our study had certain limitations. If our 33 patients had been compared with a group who underwent simple mastoidectomy, the efficacy of tympanoplasty alone would have been clearer. A case-control study is required to confirm our findings. Furthermore, our mean follow-up time was only 19.6 months; long-term follow-up is required.
Tympanoplasty alone may be effective for COM patients even if the mastoid cavity is opaque on TBCT. Before tympanoplasty is performed, the middle ear must be dry. The hearing levels and pre- and perioperative findings must be considered. We suggest that tympanoplasty alone (i.e., without mastoidectomy) is appropriate for patients with COM without cholesteatoma, whose ears have been dry for ≥3 months and who exhibit sclerotic changes in the mastoid cavity.
▪ Tympanoplasty alone may adequately control chronic otitis media in dry patients.
▪ Mastoid opacification on computed tomography does not always indicate pathological lesions.
▪ Tympanoplasty alone successfully improved hearing with a low complication rate.
▪ A period of medical and clinical management should precede surgery.
No potential conflict of interest relevant to this article was reported.
This research was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education, Science and Technology (NRF-2015R1A2A15055956), Republic of Korea.
Audiometric evaluation of the successful 28 patients. Both air conduction and the air-bone gap improved significantly.
Complications and their management after tympanoplasty. Mastoidectomy was performed on one patient because of progressive attic destruction after surgery. Overall, >80% of patients experienced better hearing outcomes without any complications.
No change in opacification was evident on follow-up temporal bone computed tomography of four patients. (A) A 22-year-old female: type I tympanoplasty, left. (B) A 47-year-old male: type III tympanoplasty, left. (C) A 42-year-old female: type III tympanoplasty, left. (D) A 52-year-old female: type I tympanoplasty, right.
Resolution of mastoid cavity haziness during post-tympanoplasty follow-up temporal bone computed tomography. (A) A 68- year-old male: type I tympanoplasty, right. (B) A 42-year-old female: type I tympanoplasty, right. (C) A 55-year-old female: type I tympanoplasty, right.
Patient characteristics
Characteristic | Value (n=33) |
---|---|
Mean age (yr) | 44±12 |
Sex | |
Male | 12 (36.4) |
Female | 21 (63.6) |
Side | |
Right | 19 (57.6) |
Left | 14 (42.4) |
Anesthesia | |
General | 12 (36.4) |
Local | 21 (63.6) |
Tympanoplasty | |
Type I tympanoplasty | 26 (78.8) |
Type III tympanoplasty | 7 (21.2) |
Surgical approach | |
Transcanal | 22 (66.7) |
Retroauricular | 11 (33.3) |
Perforation size | |
Small (<25%) | 11 (33.3) |
Medium (25%–50%) | 11 (33.3) |
Large (>50%) | 10 (30.3) |
Retraction of the tympanic membrane | 1 (3.0) |
Mean follow-up period (mo) | 20±13 |
Values are presented as mean±standard deviation or number (%).