Arch Otorhinolaryngol (1982) 234:253-262

Archives of Oto-Rhino-Laryngology 9 Springer-Verlag 1982

The Preoperative State of Infection in Chronic Otitis Media Correlated with Postoperative Hearing Results Kauko Ojala and Martti Sorri Department of Otolaryngology,Universityof Oulu (Head: Professor Antti Palva, MD), Oulu, Finland

Der pr~ioperative Infektionszustand bei chronischer Otitis media im Vergleich zum postoperativen H6rresultat Zusammenfassung. Unter besonderer Berticksichtigung des Schleimhautzustandes bei der Operation wurden die postoperativen H6rergebnisse bei 627 Ohren in einem Zeitraum von 5 his 14 Jahren j/ihrlich kontrolliert. Durchgeftihrt war eine Radikaloperation mit Obliteration der H6hle nach der Technik von Palva, ein Trommelfellersatz mit Temporalfaszie sowie ein Aufbau der Ossicula in bekannter Weise. Der postoperative H6rgewinn war besser, wenn die Schleimhaut im Mittelohr erhalten werden konnte. Dies war auch der Fall, wenn die Ohren bei der Operation trocken waren. Schliisseiw6rter: Chronische Otitis media - H6rresultat - Ergebnis der Ohrchirurgie

Summary. The postoperative long-term hearing results, with special reference to the state and management of the tympanic mucosa at operation, in 627 ears (574 patients) after an annual clinical follow-up period of 5-14 years are presented. The ears were operated on radically due to chronic otitis media, using the obliterative radical operation technique developed by T. Palva. The air-bone gap improved from the preoperative level significantly more in ears where the tympanic mucosa had been preserved than in ears where it had been removed at operation (p < 0.001). The improvement was also significantly better in dry ears than in ears which were moist or discharging at operation (p < 0.05). The mean late deterioration in the air-bone gap after the first follow-up year was significant in all the groups of ears (p < 0.05), and the mean long-term change in air-bone gap from pre- to late postoperative examination was the improvement of 3.0 dB in ears with, and a deterioration of 2.0 dB in ears without ossicular reconstruction. Key words: Chronic otitis media surgery

Hearing results -

Results of ear

Offprint requests to: Kauko Ojala, MD, Yliopistonkatu1-3 E 63, SF-20110 Turku 11, Finland

0302-9530/82/0234/0253/$ 02.00

254

K. Ojala and M. Sorri

H e a r i n g after radical surgical t r e a t m e n t of chronic otitis m e d i a shows p o s t o p e r a t i v e deterioration mostly due to adhesion in the t y m p a n u m , r e p e r f o r a t i o n s , recurrences of infection or c h o l e s t e a t o m a , or shortcomings in ossicular r e c o n s t r u c t i o n (Palva et al. 1968a, b; S h e e h y and C r a b t r e e 1973; O j a l a 1979). T h e state and m a n a g e m e n t of the t y m p a n i c m u c o s a at o p e r a t i o n is o n e o f the m o s t decisive factors concerning p o s t o p e r a t i v e hearing (Palva et al. 1968b, 1975). H e a r i n g results are distinctly better if the t y m p a n i c m u c o s a has b e e n salvaged during surgery than after removal, mostly due to the difference in the d e v e l o p m e n t of adhesions in the t y m p a n u m during the follow-up p e r i o d (Ojala 1979). H e a r i n g can change considerably over a period of several years after surgery (Tos 1974; Ojala 1979) because these factors, which influence the hearing results, occur during this p e r i o d (Ojala 1979). If infected t y m p a n i c m u c o s a is p r e s e r v e d at o p e r a t i o n it can be the cause of p o s t o p e r a t i v e infection (Palva et al. 1969), and the r e m o v a l o f t y m p a n i c m u c o s a increases p o s t o p e r a t i v e adhesive changes (Palva et al. 1968b, 1975; O j a l a 1979). T h e aim of this investigation was to clarify the role of the often very t r o u b l e s o m e , conservative p r e o p e r a t i v e t r e a t m e n t of chronic cases that can considerably increase the p e r c e n t a g e of dry ears and m a k e the p r e s e r v a t i o n of t y m p a n a l m u c o s a possible at o p e r a t i o n (Palva et al. 1971), and p o s t o p e r a t i v e results.

Material and Methods The material of this investigation consisted of 627 ears (574 patients, 259 women and 315 men) that underwent radical surgery at the Department of Otolaryngology, University of Oulu, in 1964-1971 because of chronic otitis media. They were subsequently checked annually for 5-14 years and also thoroughly examined in the late postoperative stage during 1976-1978. The age of the patients at the time of the operation was 5-75 years of age (mean 34.9 years). All of the 702 ears operated on radically during 1964-1971 and followed annually for a minimum of 5 years are included, except the 30 ears reoperated during the follow-up period and the ears where either preoperative or postoperative gap could not be measured (two ears with missing information about bone conduction hearing thresholds, 38 ears that were deaf, and five ears that could only hear one or two of the frequencies 0.5, 1, and 2 kHz). Exact data about the state of infection at the time of surgery were available for 611 of the 627 ears and, thus, the influence of the clinical state of ears (if the ear was dry or moist/discharging at operation) on postoperative hearing results was examined in these ears. The amount of secretion determined classifications of dry, moist, or discharging. Audiometric tests were done with Madseu OB-70 and OB-60 audiometers to determine the air and bone conduction thresholds. The results are presented as air-bone gaps just before the operation, in the early (1 year), and in the late (5-14 years) postoperative stage, with special attention to the later changes in hearing after the first postoperative year. The results are reported after the method of Austin (1971) and Palva et al. (1973), comparing pre- and postoperative mean air conduction thresholds (500, 1,000, and 2,000 Hz; pure tone average, PTA) with the preoperative mean bone conduction threshold of the same frequencies; thus, examining conductive loss at different times. The operative technique developed by Tauno Palva was used exclusively. This method, as described by Palva (1963, 1973) and by Palva et al. (1968b), included thorough cortical mastoidectomy and musculoperiosteal obliteration of the surgical cavity in patients with chronic otitis media.

The Preoperative State of Infection in Chronic Otitis Media

255

If the musculoperiosteal flap did not fill the cavity completely, part of the temporal muscle was turned behind it or the cavity was filled with gelatin sponge, soaked in antibiotics, autogenous bone chips, or anorganic bone (Palva 1973; Palva et al. 1970). Temporal muscle fascia was used for reconstruction of the ear drum (underlay) and in reconstructing the ear canal by lifting it behind the meatal canal skin between the skin and the museuloperiosteal flap (Palva 1963; Palva et al. 1968b). For presentation of the hearing results, the ears were divided into six groups, according to the method of ossicular reconstruction, als follows: ossicular chain intact and remained intact (group 1); stapes present, auto- or homograft ossicle or cortical bone transposition on the stapes head (group 2); stapes present, stainless steel wire or polythene tube columnellization on the stapes head (group 3); stapes absent, auto- or homograft ossicles or cortical bone transposition on stapes footplate (group 4); stapes absent, stainless stell wire or polythene tube on stapes footplate (group 5); no ossicular reconstruction (group 6). The statistical analyses of the results were performed at the Computer Centre of the University of Oulu. The Student's t-test after application of the F-test was employed.

Results After different methods of ossicular reconstruction and after removing or preserving the tympanic mucosa (Table 1), excluding groups 3 and 4, preoperative air conduction hearing was better in ears where the mucosa had been left intact. In group 2 (stapes present, auto- or homograft ossicle or cortical bone reconstruction), the preoperative air-bone gap was significantly better in the group where the mucosa had been preserved c o m p a r e d with the cases where it had been r e m o v e d (p < 0.05). The early postoperative gap after preserving the mucosa was significantly better both in group 1 with an intact chain and in group 5 where the reconstruction had been done with allomaterial on the stapes plate when the superstructure was absent (p < 0.01). No other statistical differences were found in early postoperative air-bone gaps (p > 0.05). Late postoperative air-bone gaps were statistically better also after preserving the mucosa in group 1 (p < 0.01) and in group 2 (p < 0.05) than in the corresponding groups of reconstructed ears with r e m o v e d mucosa. T h e r e were only a few statistical differences in the gap changes between the groups formed according to the method of reconstruction ( 1 - 6 ) . The i m p r o v e m e n t in the air-bone gap from the preoperative level to the early postoperative level was greatest in group 5, where the mucosa had b e e n preserved (p < 0.05). However, when comparing the early with the late postoperative level, deterioration in group 5 was even m o r e significant (p < 0.001) than after removing the mucosa; thus, eliminating the statistically significant difference between the different reconstruction groups by the late postoperative examination. When comparing all groups of ears, the air-bone gap improved significantly m o r e in ears with preserved, than in ears with r e m o v e d tympanic mucosa (p < 0.001). P T A and air-bone gap in the group of dry ears and the group of ears that had b e e n moist or discharging at the time of operation did not differ significantly

Total ears

Removed

52.2 48.5

395

627

Total

41.1 47.8 47.1 52.1 53.4 61.9

34 74 85 24 72 106

42.1

232

36.0 40.4 49.1 52.3 48.3 50.2

1 2 3 4 5 6

82 65 41 3 21 20

1 2 3 4 5 6

Not r e m o v e d

Preoperative pure-tone average

Total

No. of ears

Groups

Management of tympanic mucosa at operation

34.0

36.4

29.2 34.6 33.3 40.1 38.4 40.6

30.0

25.6 29.9 32.7 32.7 36.7 34.6

26.0

29.1

25.5 25.2 24.4 27.2 31.5 36.2

20.8

16.0 21.0 24.1 35.8 19.1 31.7

Early

32.0

35.0

30.1 30.8 31.7 30.5 36.3 42.7

27.8

21.1 25.4 33.4 27.6 34.3 35.4

Late

9.3

-

-

8.0

7.3

- 3.7 - 9.3 - 8.9 -12.9 - 6.9 - 4.4

-

- 9.7 - 9.0 - 8.6 + 3.0 -17.6 - 2.9

-2.0

-1.4

+0.9 -3.7 -1.6 -9.6 -2.1 2.1

-3.1

-4.6 -4.6 +0.6 -5.1 -2.4 +0.8

F r o m preto late postoperative

F r o m preto early postoperative

Preoperative

Postoperative

C h a n g e s in air b o n e gaps

Air-bone gaps

4.6 5.6 7.3 3.3 4.8 6.6

+ 6.0

+ 5.9

+ + + + + +

+ 6.2

-

+ 5.1 + 4.4 + 9.3 8.2 +15.2 + 3.7

Late changes after 1 year

Table 1. M e a n air-bone gaps (dB) of ears reconstructed in different ways correlated with the m a n a g e m e n t of t y m p a n i c m u c o s a at operation

e~

t~t~

Total ears

T ota l

1 2 3 4 5 6

T ota l

1 2 3 4 5 6

Dry

Moist or discharging

State and m an age m e n t of ossieular chain at operation (group)

Clinical state of ears at operation

49.4 48.5

611

38.3 43.9 48.5 53.4 52.2 62.0

46.9

35.6 43.4 47.4 49.2 53.1 59.4

Preoperative pu re -t on e average

387

65 84 80 16 59 83

224

50 49 43 11 32 39

No. of ears

34.0

34.6

28.4 32.1 33.5 38.4 36.9 40.9

33.1

24.2 32.8 33.2 40.7 39.9 37.1

Preoperative

A i r - b o n e gaps

18.6 26.1 31.4 35,4 34.8 41.8 29.7 27.8 29.9 32.2 28.1 36.9 42.4 33.6 32.1

23.2 23.3 25.0 24.9 29.2 28.4 37.1 27.8 26.1

La t e

12.8 20.7 23.5 28.3 29.9 32.9

Ea rl y

Postoperative

-

-

-

-

7.9

6.7

5.1 7.1 8.6 9.2 8.5 3.8

9.9

-11.4 -12.1 - 9.7 -12.4 -10.0 - 4.2

F r o m preto early postoperative

3.4

5,6 6.7 1.8 5.3 5.1 4.1

-

-

1.9

1.0

- 0.6 - 2.2 - 1.3 -10.4 + 0.0 + 1.5

-

+

F r o m preto late postoperative

Cha nge s in air b o n e gaps

Table 2. M ean air-bone gaps (dB) of ears reconstructed in different ways correlated with state of infection in ears at o p e r a t i o n

+6 ,0

+5.6

+4 .0 +5 .0 +7 .6 -1.3 +7.1 +5 .2

+6.5

+5.8 +5 .4 +7 .9 +7.1 +4 .9 +8.3

Late changes after 1 y ear

~.

9 ,.~.'-' ~'

o =

9. O = 5

~0

o

m:

258

K. Ojala and M. Sorri

No of ears 180 160

,Q \

140

/ / /

120

~

~ \ \

Dry:Deterioration of gap 65 dB (pO,05)

IO0 7O 6O

2O i

-30

I

-20

-10

I

I

0 10 20 30 40 50 Change in air-bone gap (dB)

Fig. 1. Late changes in air-bone gap in ears operated on when dry (224 ears, early postoperative air-bone gap 23.2 dB = 0) or when moist or discharging (387 ears, early postoperative air-bone gap 27.8 dB = 0)

(p > 0.05, Table 2). The difference became significant by the early postoperative examination (23.2 dB and 27.8 dB, respectively; p < 0.05), for in ears that had been dry at surgery the air-bone gap improved more than in ears that had been moist or discharging at the time of operation. This difference remained significant at the late postoperative examination (p < 0.05). A late air-bone gap deteriorated by 6.5 dB in the former group and by 5.7 dB in the latter group was found, which means that the air-bone gap increased significantly in both groups (p < 0.01). There was no statistical difference between these two groups in this respect (Table 2, Fig. 1). There was no statistical difference in any of the reconstruction groups when comparing conductive loss in the groups made up of the ears that had been dry at operation and ears that had been moist or discharging at the time of operation (p > 0.05). In group 1 (intact ossicular chain) the air-bone gap was found to be significantly better early postoperatively in the group of dry ears (12.8 dB) than in ears that had been infected at the time of operation (23.3 dB; p < 0.01; Table 2). The difference was still significant at the late postoperative checkup. This difference was due to the fact that the air-bone gap that had already been considerably better preoperatively in dry ears improved significantly more than in ears that had been operated upon when infected (11.4 dB and 5,1 dB respectively; p < 0.01). Otherwise, there were no statistical differences in the gap changes between any of the groups 1-6. In ears in which the tympanic mucosa had been preserved at operation, no significant difference could be found in preoperative hearing or preoperative

Dry Discharging

Dry Discharging

Tympanic mucosa left intact

Tympanic mucosa removed

Total ears

State of ears preoperatively

Management of tympanic mucosa at operation

611

111 279

113 108

No. of ears

48.5

52.2 52.0

41.6 42.7

PTA

34,0

35.3 36.3

30.4 30.4

26.1

28.0 29.8

18.0 23.0

Early

32.1

34.6 35,4

24.5 28.9

Late

- 7.9

- 7.3 - 6.4

-12.4 - 7.4

From preto early postoperative

Preoperative Postoperative

-1.9

-0.7 -0.9

-5.9 -1.5

From preto late postoperative

Changes in air-bone gaps

Air bone gaps

+6.0

+6.6 +6.3

+6.5 +6.9

Late changes after 1 year

Table 3. Preoperative pure-tone averages (PTA) and air-bone gaps (dB) at different times correlated with the management of tympanic mucosa at operation in ears operated on when dry and when discharging O

O

P~

260

K. Ojala and M. Sorri

air-bone gaps between the groups of 113 ears operated upon when dry and the groups of 108 ears that were moist or discharging (Table 3). The early postoperative air-bone gap, on the contrary, was significantly better in the dry ears than in the ears that were discharging (p < 0.05, Table 3). The difference was also significant late postoperatively (p < 0.05) and the improvement of air-bone gap from preoperative to late postoperative level was also significantly better in the former group Co < 0.05). The late change in the gap did not differ statistically (6.5 dB in the former group, 6.9 dB in the latter group; p > 0.05). When the tympanic mucosa was removed no statistical differences could be found in the air-bone gap or in the changes in gaps at different times between the groups of ears operated upon when dry or discharging (p > 0.05, Table 3).

Discussion

Hearing often improves very little after surgical treatment of chronic otitis media and postoperative hearing may also be worse than that preoperatively (Palmgren 1977; Fikentscher et al. 1978). Taking this into consideration, the hearing results of the present material are satisfactory and even if late changes in the air-bone gap were considerable, as they were also in the material of Tos (1974), improvement as a whole was significant - expecially in the ears in which the tympanic mucosa could be saved at surgery. This emphasizes the importance of the state and management of the tympanic mucosa in connection with the surgical treatment of chronic cases, as also stated by Palva et al. (1968b, 1973). The results of this investigation also show that it is possible to improve hearing results by using ossicular reconstruction, since air-bone gap improved 3 dB in ears with ossicular reconstructions and deteriorated by 2 dB in ears without ossicular reconstructions when the preoperative air-bone gap was compared with that late postoperatively. The overall results in the present study are especially deteriorated by some of the cases where stainless steel wire columnellas were used, because some of them extruded through the repaired tympanic membrane during development of adhesions in the tympanum and had to be removed because of debris retention and infection. The air-bone gap became very large and often worse than the preoperative one in these cases. The improvement in air-bone gap was better in ears where the tympanic mucosa was present at operation than in ears where it had to be removed (Table 1). This is emphasized by the fact that the starting level (preoperative gap) was worse in the latter group of ears. This means, according to Ojala (1979), that in these ears the chances for improving conductivity by operation would have been greater. The contradiction in the results is mainly due to the fact that preserving the mucosa reduces the amount of adhesive changes, mainly during the early follow-up period (Palva et al. 1968b; Ojala 1979). The same phenomenon could be noticed in the hearing results obtained in the reconstruction groups. The largest improvements in air-bone gap were usually achieved in ears where the tympanic mucosa could be saved at operation and the bony reconstruction of ossicular chain was made on the head of stapes with remaining superstructure.

The Preoperative State of Infection in Chronic Otitis Media

261

More improvement in the air-bone gap was achieved in the ears which were dry at the time of operation than in the ears which were moist or discharging. Late deterioration was considerable in both groups and total long-term improvement was greater in the former group than in the latter. Since there was no essential difference in the initial air-bone gap levels between the various groups, the difference in the hearing results is caused to a great extent by the fact that the changes in the tympanum mucosa in the ears with an acitive infection (operated on when moist or discharging) were often very severe. Thus, it was necessary to surgically remove all or most of the mucosa and the adhesive changes, because of new raw surfaces, were postoperatively more severe, as also noticed by Palva et al. (1971). The dryness of the ears at the time of the surgery seemed to be the greatest advantage in ears with an intact ossicular chain, although the initial levels were not greatly different. On the whole, preoperative conservative treatment of chronic ears with discharge seems to be worthwhile on the basis of this work and the report of Palva et al. (1971), who reported a great increase in the number of preoperatively dry or culture-negative ears by conservative treatment. The preoperative dryness of the ear is especially important if the tympanic mucosa is to be saved. If the ear is meticulously treated preoperatively by conservative treatment, i.e., cleansings and the use of local eardrops, the possibility of saving the promontorial mucosa at operation when the infection subsides and the mucosa comes less edemic may be increased. The preserved mucosa can, however, be the reason for postoperative infection (Palva et al. 1969) and it should be removed if it is granulated or very polypous at operation.

References Austin DF (1969) Types and indications of staging. Arch Otolaryngol 89:253-242 Austin DF (1971) Ossicular reconstruction. Arch Otolaryngol 65:525-531 Fikentscher R, Rosenburg B, Spinar H (1978) H6rverm6gen nach sanierenden Mittelohroperationen mit Tympanoplastik. Arch Otorhinolaryngol (NY) 218:269-276 Ojala K (1979) Late results of obliteration in operation chronic otitis media. Acta Univ Ouluensis, D 47, Ophthalmologica et Oto-Rhino-Laryngologica 5:1-106 Palmgren O (1977) Operationsresultat vid aktiv kronisk mellan6roninflammation. En klinisk studie rid lgtng observationstid. Meder-Offset, Espoo, Finland Palva T (1963) Surgery of chronic ear without cavity. Arch Otolaryngol 77:570-580 Palva T (1973) Operative technique in mastoid obliteration. Acta Otolaryngol (Stoekh) 75 : 289-290 Palva T, Palva A, Dammert K (1968a) Middle ear mucosa and chronic ear disease. Arch Otolaryngol 87:3-11 Palva T, Palva A, Salmivalli A (1968b) Radical mastoidectomy with cavity obliteration. Arch Otolaryngol 88 : 119-123 Palva T, K~rj~i J, Palva A, Raunio V (1969) Bacteria in the chronic ear. Pre- and post-operative evaluation. Pract Oto-Rhino-Laryngol 31 : 30-45 Palva T, Palva A, K/irj~i J (1970) Cavity obliteration and ear canal size. Arch Otolaryngol 92:366-371 Palva T, K~irj~ J, Palva A (1971) Bacterial analyses in chronic otitis media. ORL Digest 33 : 19-26

262

K. Ojala and M. Sorri

Palva T, Palva A, K~irj~iJ (1973) Ossicular reconstruction in chronic ear surgery. Arch Otolaryngol 98 : 340- 348 Palva T, K/irj~i J, Palva A (1975) Staged surgery in ears with excessive disease of tympanum. Arch Otolaryngol 101 : 211-216 Sheehy JL, Crabtree JA (1973) Tympanoplasty: staging the operation. Laryngoscope 83: 1594-1621 Tos M (1974) Late results in tympanoplasty. Arch Otolaryngol 100:302-305 Received November 2, 1981/Accepted January 12, 1982