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Trans canal Tympanoplasty with Fibrin Glue:
An Effective and Simple Strategy to Manage
Tympanic Perforations in Modern Otological Surgery
Waleed M Alshehri* , Fahad N AL Tamimi, Mohammed T Hazazi, Jose K Cletus and Bandar M AL Qahtani
Otolaryngology Department, King Saud Medical City, Saudi Arabia
Submission: January 03, 2020; Published: January 13, 2020
*Corresponding author: Waleed M Alshehri, Otolaryngology Department, King Saud Medical City, Riyadh 12746, Saudi Arabia
How to cite this article: Waleed M A, Fahad N AL T, Mohammed T H, Jose K C, Bandar M AL Q. Trans canal Tympanoplasty with Fibrin Glue: An
Effective and Simple Strategy to Manage Tympanic Perforations in Modern Otological Surgery. Glob J Oto, 2020; 21(3): 556065. DOI: 10.19080/GJO.2019.20.556065
Tympanic membrane perforation is one of the commonly encountered clinical complications by an otolaryngologist or an otologist. Although various management strategies and surgical techniques have been described in literature to restore the normal anatomical function of the tympanic membrane, limited studies have reported the use of fibrin glue in routine clinical practice. This case series shows that the trans canal with fibrin glue use is less painful and effective for the post-operative recovery of patients with tympanic membrane perforation.
Fibrin has an essential role in wound healing. It has hemostatic effects, induces cellular response to wound damage by forming fibrin strands, which eventually builds a matrix, and assists in neovascularization and fibroblast proliferation . Staindl  introduced the potential use of fibrin tissue adhesive in otorhinolaryngological surgeries; Tidrick & Warner  first used fibrinogen and thrombin as tissue adhesives in otorhinolaryngological procedures. Since then, use of fibrin sealant has been popular in both otological and neuro-otological procedures [4-6]. Other materials used in end aural techniques to simplify tympanoplasty include fat , micropore tape [8,9], atelocollagen , cellophane sheet , etc. In the past 2 years, a total of 50 tympanoplasty surgeries have been performed using fibrin glue at our center. Using an end aural approach provides the added advantage of scarless results for patients.
Fifty patients presented to the outpatient clinic in the past 2 years with complaints of decreased hearing or tympanic perforation and sought surgical treatment. After obtaining complete patient history, patients underwent full head and neck examination, otological assessment with pure tone audiometry (PTA) was performed to determine the type of hearing loss. Our sample selection was based on the perforation size (preferably small), and on the type and degree of air bone gap in PTA.
Cases with simple dry perforations and those without cholesteatoma were indicated for simple underlay myringoplasty. The exclusion criteria were the presence of wet ear, cholesteatoma, or large tympanic perforation. An end aural approach was used to gently clean any debris, with subsequent refreshing of the perforation margin using a needle. A vasoconstrictive pack was used to achieve a bloodless field while harvesting the tragal cartilage; at this point, the fibrin glue is prepared for application. A sizer is placed to measure the size of cartilage needed; thereafter, a gel foam is placed as an underlay and the cartilage graft is placed just above it. The fibrin sealant is then injected all around the perforated area to stabilize the graft and to provide a tight seal layer; subsequently, the gel foam application is repeated. The final step involves applying a cotton ball soaked with fusidic acid ointment 20mg/g to plug the ear canal. The patient is discharged on the same day with instructions and follow up in outpatient department.
Of the 50 cases that underwent surgery for tympanic perforation repair, the surgery was successful in 47 cases. At postoperative day 14 follow-up, remnants of the gel foam pack were noted inside the ear canal along with intact graft. At postoperative one-month follow-up, the air bone gap showed improvement (Figures 1 & 2); the surface of the graft showed angiogenesis and epithelization (Figure 3). Six months postoperatively, the eardrum
was epithelialized completely (Figure 4). The rate of closure of the
tympanic perforation was 94% after the initial attempt.
With recent advances in the field of otological surgery both
surgeons and patients expect reasonable improvement of hearing
postoperatively . Therefore, recently, many otologists have
perfected various surgical techniques that uses auto-, homo-, and
allo-implants ; in all these approaches, an adhesive agent with
stable characteristics and biocompatibility is frequently used to
stabilize and rejoin various anatomical structures. For trans canal
closure of a tympanic perforation in chronic otitis media, Yuasa
, in 1989, developed a simple underlay myringoplasty with
The simple underlay myringoplasty has been widely
performed in Japan over the last 15 years because of its high
success rate for tympanic membrane closure and extremely low
risk of sensorineural hearing loss [15-17]. In our study, we aimed
for minimal invasiveness and optimal outcome. The postoperative
surgical outcome and satisfaction in all patients were assessed at
2 weeks, 1 month, and 6 months of follow-up.
All patient had painless recovery and could regain their
daily activities within a few days. High success rate, ability for
scarless surgery, and decrease risk of hematoma and infection
were other reasons for considering this surgical approach over
other established techniques for tympanic membrane perforation
repair such as post auricular approach. Additionally, this surgical
method had no complications.
In conclusion, trans canal tympanoplasty is a simple, effective,
and minimally invasive procedure which uses fibrin glue to repair
tympanic perforations and has a high rate of success, with no
complications. This method may provide shorter operative time.
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