Outcomes of primary myringoplasty in indigenous children from the Northern Territory of Australia

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Abstract

Aim

To report the surgical and audiological outcomes of myringoplasty (Type I tympanoplasty) in Indigenous Australian children living in remote and regional communities in northern Australia.

Method

An observational cohort study, with prospective recording of the details of surgery. Audiological outcomes were collected independently, and these data were integrated in the present study. Children aged 5–18 year underwent myringoplasty in the Northern Territory during a program initiated by the Australian Government. Surgery was performed by surgeons drawn from across Australia.

Results

412 primary myringoplasties were performed. The mean age at surgery was 11 years. The tympanic membrane was closed in 64.2% of cases. Fascial grafting was associated with greater surgical success than cartilage. Dryness of the ear at surgery did not affect drum closure. Post-operative aural discharge was half that reported in historical literature. Surgical success was independent of the patient's age at surgery. Post-operative audiograms were available on 216 cases. At last review, hearing had improved even when the operation was not a surgical success, with hearing aid candidacy falling from 84 to 34%. Hearing was similar irrespective of the size of the perforation at surgery or the graft used and did not change with the time between surgery and review. The best hearing was associated with drum closure and Types A or C tympanograms. A conductive hearing loss persisted after surgery that was greater when there was an immobile drum.

Conclusions

Indigenous children benefited from myringoplasty, even when the operation was not a “surgical success” as deemed by drum closure. There lower incidence of post-operative discharge from persistent perforations suggests an improvement in the ear health of the population. A persistent conductive loss persists, likely a consequence of the underlying disease but possibly from the surgery.

Introduction

Myringoplasty (Type I tympanoplasty) is the treatment of choice for tympanic membrane perforation, as it prevents further aural discharge and improves the hearing. It is widely practiced to treat tympanic membrane perforation in Aboriginal and Torres Strait Islander peoples, but with mixed success. Surgeons typically judge the success of the operation on the basis of tympanic membrane closure, but the drum-closure-rates reported are typically low (around 30–70%) [[1], [2], [3], [4], [5]] compared with those reported in urban hospital-based practices where the median closure rate upon review is ~90 (ranging from 25 to 93%) [6,7]. A persistent perforation means that the ear could still experience aural discharge, the hearing may not improve and whether the under these circumstances patient has benefited is not well documented. It may be that drum-closure is too narrow a definition of the success of the operation, and that a broader view based upon aural discharge and hearing improvement should be considered.

Here we report on the surgical and hearing outcomes of a large cohort of Indigenous Australian children, who underwent myringoplasty during a governmental program from 2008 to 2010. All recipients lived in regional or remote communities in the Northern Territory of Australia. Otitis media is exceptionally prevalent in this population. The post-nasal space is colonised with pathological bacteria within the first 3 months of life [8], most children have experienced otitis media by the age of one year, and a quarter have tympanic membrane perforations in early childhood [9]. Many of these perforations persist, causing a conductive hearing loss and frequent aural discharge [10].

Hearing outcomes following myringoplasty are often reported as pure-tone averages. While this may be convenient, it obscures detail available that could provide insights into the success of the surgery and speech perception [11,12]. Specifically, an examination of the air-bone gap across frequency may provide insights into the likely presence of ossicular and/or tympanic membrane scarring [13], outcomes that may indicate whether the surgery could be improved. For this reason, we report frequency-specific audiometric results.

There is diverse literature on the importance of graft types [14], perforation size [[15], [16], [17], [18], [19]], chronic active otitis media at the time of surgery [[20], [21], [22], [23]], age at surgery [7,17,22,[24], [25], [26], [27]] upon the success of myringoplasty. Much of this literature is derived from urban tertiary hospitals, so it cannot be assumed that conclusions drawn from this literature will apply in the remote and regional context, where the severity of otitis media is much greater. These surgical factors were explored in this study, to help provide guidance for their application to the treatment of Indigenous ear disease.

Section snippets

Patient cohort

The patients underwent myringoplasty as part of Australian Government's Northern Territory Emergency Response (NTER), a program that intended to reduce the burden of disease amongst Indigenous Australians living in the Territory. Patients requiring an ENT opinion were identified during the NTER's Child Health Check Initiative (CHCI). The clinical assessments, surgical recommendations, operations and follow-up were undertaken by teams of ENT surgeons and audiologists who visited hospitals in

Demographics and outcomes of surgical procedures

Surgical results were available from 412 primary myringoplasties. The majority of these cases were undertaken at three rural and remote hospitals; Alice Springs Hospital, Katherine District Hospital and Gove District Hospital, with a smaller proportion performed at Tennant Creek Hospital. These hospitals differ in their local geography. Alice Springs is in the deserts of central Australia. Katherine is approximately 300 km inland from the northern coast of the Territory, and Gove is situated

Discussion

Myringoplasty was found to be effective in improving hearing even when it was not a “surgical” success, namely that a tympanic membrane perforation persisted. In intact drums, the best hearing was observed when the tympanic membrane was mobile. Myringoplasty meant that the number of ears eligible for a hearing aid according to Australian Hearing criteria dropped from 84 to 34% with this intervention.

A significant outcome of this study is that the performance of myringoplasty had a greater

Conflicts of interest

The authors declare no conflicts of interest.

Acknowledgements

SOL was funded by a Practitioner Fellowship from the National Health and Medical Research Council of Australia.

References (35)

  • D. Merenda et al.

    Otolaryngol. Head Neck Surg.

    (2007)
  • G.B. Singh et al.

    Int. J. Pediatr. Otorhinolaryngol.

    (2005)
  • Y. Uyar et al.

    Int. J. Pediatr. Otorhinolaryngol.

    (2006)
  • R. Caylan et al.

    Otolaryngol. Head Neck Surg.

    (1998)
  • H. Kurokawa et al.

    Otolaryngol. Head Neck Surg.

    (1995)
  • A. Foreman

    Aust. J. Oto Laryngol.

    (1999)
  • D. Mak et al.

    Clin. Otolaryngol. Allied Sci.

    (2004)
  • D. Mak et al.

    J. Laryngol. Otol.

    (2000)
  • D.B. Mak et al.

    Med. J. Aust.

    (2003)
  • S. Soumya et al.

    Aust. J. Otolaryngol.

    (2018)
  • S.S. Chandrasekhar et al.

    Arch. Otolaryngol. Head Neck Surg.

    (1995)
  • J.T. Vrabec et al.

    Arch. Otolaryngol. Head Neck Surg.

    (1999)
  • A.J. Leach et al.

    Pediatr. Infect. Dis. J.

    (1994)
  • P.S. Morris et al.

    BMC Pediatr.

    (2005)
  • Northern Territory Outreach Hearing Health Program: July 2012 to December 2016. Cat No

    (2017)
  • H.G. Choi et al.

    Clin. Exp. Otorhinolaryngol.

    (2011)
  • D.T. Kent et al.

    JAMA Otolaryngol. - Head Neck Surg.

    (2014)
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