Chronic otitis media (COM) is defined as a middle ear inflammation that lasts more than 3 months.[1] It can be classified according to the presence of cholesteatoma.[1] The noncholesteatomatous COM is divided into closed tympanic membrane (TM) (otitis media with effusion, atelectatic otitis media, and fibrous otitis media) and open TM (chronic suppurative otitis media) subgroups.[2] Chronic suppurative otitis media courses with recurrent or episodic otorrhea, TM perforation, and, usually, conductive hearing loss.[3] Classically, chronic suppurative otitis media (CSupOM) was treated surgically by tympanoplasty with mastoidectomy,[4] based on the radiological findings of chronic mastoiditis, diseased mucosa, mastoid cell opacification, and a defective communication of the middle ear cleft and the mastoid cells.[5] Although there is growing evidence that adding mastoidectomy to tympanoplasty is not associated with additional benefit in adult patients with CSupOM,[6] many otologists continue to routinely perform mastoidectomy with tympanoplasty in pediatric patients, based in the assumption that in children, the mastoid has a more relevant role in middle ear ventilation, due to the immature Eustachian tube system.[7]

Our objective of the study is to compare the outcomes of an isolated Type 1 tympanoplasty (according to Tos classification 1993) with the outcomes of a Type 1 tympanoplasty combined with mastoidectomy in CSupOM pediatric patients.

The electronic medical records of CSupOM pediatric patients from our hospital center were retrospectively reviewed, with patients being identified according to the International Classification of Diseases 9th Revision, Clinical Modification (ICD-9 CM, code 382.1; 382.2; 382.3; 382.4). We reviewed patients, under 18 years of age, admitted for elective surgery from January 1, 2010, to December 30, 2013, and reviewed the surgical protocols of every patient to select those that underwent a Type 1 tympanoplasty with or without mastoidectomy. Only patients with at least 2 years of follow-up and with preoperative and postoperative audiologic evaluation (pure-tone hearing level performed 6 months after the surgery) were included. Patient-specific data were collected, such as age, gender, surgical technique, date of surgery, otologic examination records, and preoperative and postoperative hearing levels. Hearing status was measured at four frequencies (500, 1000, 2000, and 4000 Hz) using the 1979 modified pure-tone average air-bone gap (PTA) technique, and postoperative air-bone gap (ABG) closure was calculated by subtraction of the mean postoperative PTA gap value in dB to the mean preoperative PTA gap value in dB, for each ear individually. The patients were divided into two groups, one in which mastoidectomy (Group 1) was performed and other without mastoidectomy (Group 2).

In general, the patients were indicated for surgery when there were no signs of acute infection, and the decision to perform mastoidectomy was based on the radiologic evaluation of the middle ear together with the clinical evolution of the otitis.

All the surgeries were performed under general anesthesia, through a retroauricular approach. The tympanic graft material was temporalis fascia, placed in an underlay fashion. Surgical success was defined as the presence of an intact TM with no recurrence after 2 years of follow-up.

Statistical analysis was performed with the Mann–Whitney test for independent samples (to relate audiometric variables and Group 1 and 2) and the Chi-square association test (to relate success rate and Group 1 and 2). P < 0.05 was considered statistically significant.

From a total of 125 ears (88 pediatric patients), 59 were selected according to the inclusion criteria. Eighty-eight were excluded. The mean age of the patients was 12.5 years, with 5.1% being 7 years old or younger, 67.8% between the ages of 8 and 14 years old, and 27.1% from 15 to 18 years old, age distribution is shown in [Table 1]. Gender distribution was 67.8% boys and 32.2% girls.

Type 1 tympanoplasty alone was performed in 18 ears (30.5%-Group 2) and Tos Type 1 tympanoplasty combined with canal wall up mastoidectomy in the other 41 ears (69.5%, Group 1). In the Group 1, the mean preoperative ABG value was 20 dB ± 10.5 dB, and the postoperative ABG 9.6 dB ± 7.5 dB, with a mean ABG closure of 12.5 dB ± 9.5 dB. In the group without mastoidectomy, the mean preoperative ABG value was 16 dB ± 10.7 dB, and the postoperative ABG 5 dB ± 6.5 dB, with a mean ABG closure of 14 dB ± 8.4 dB. No statistically relevant difference in the postoperative PTA ABG (P = 0.089) or PTA ABG closure (P = 0.365) was found between Groups 1 and 2. The data are shown in [Table 2].

Surgical failure was defined as the recurrence of TM perforation or its retraction. Of the 59 ears, 6 were considered surgical failure (overall surgical success rate of 89.8%). In Group 2, one ear presented retraction of the TM after 7 months and one other showed recurrence of perforation after 3 months. In Group 1, there were 3 perforations (2-, 3-, and 5-month postoperative) and 1 retraction as surgical failures.

The appropriate age for a surgical intervention in CSupOM is controversial, with the authors stating that children under the age of 8 have poor surgical outcomes due to middle ear immaturity,[8] and others showing that age does not influence surgical success rates.[9]

In our study, Type 1 tympanoplasty with or without canal wall up mastoidectomy showed an overall success rate of 89.8%. When comparing the two groups, we observed that there was no statistically significative difference in performing the tympanoplasty with (90.2% success rate) or without (88.9% success rate) a canal wall up mastoidectomy (P = 0.755). A recent metanalysis on the role of mastoidectomy following tympanoplasty based on adult patients showed a general success rate for tympanoplasty of >80% in all studies included,[6] with most studies showing a higher success rate in tympanoplasty alone, although not statistically significative.[6]

We have observed a significant improvement in the ABG. In both groups, a significative improvement was observed, with a mean gap closure of 14 dB ± 8.4 dB in the no mastoidectomy group and 12.5 dB ± 9.5 dB in the mastoidectomy with tympanoplasty group; again, no statistically significative difference was found (P = 0.365).

This study helps demonstrate that the mastoid cells may have a diminished part in perpetuating the chronic inflammatory process of CSupOM in children, and that a mastoidectomy is unnecessary for the treatment of CSupOM in children.

In all patients, temporalis fascia autologous graft was used in an underlay fashion. At our department, fascia is the graft of choice in primary surgery, with cartilage being reserved for severe retraction cases, selected cases of cholesteatoma cases, and revision tympanoplasty where eustachian tube dysfunction is anticipated.

Our study has some limitations. It is a retrospective study, based on charts review which may be inaccurate. Moreover, it is a small study, and thus, more studies with more patients are needed to support our observations.

Type 1 tympanoplasty is effective in eradicating middle ear disease and in improving the hearing status pediatric patients with CSupOM. Our study suggests that performing a mastoidectomy in children with CSupOM is not associated with additional clinical benefit over performing a Type 1 tympanoplasty alone. This is now our established approach in the surgical treatment of CSupOM in children: mastoidectomy only in very selected cases and after a failure of primary surgery.

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Nil.

Conflicts of interest

There are no conflicts of interest.