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