Bilateral Chronic Otitis Media with Persistent
Tympanic Membrane Perforation: A Case Report
Abstract
Background: Chronic otitis media (COM) is a common middle-ear disorder
that may result in persistent tympanic membrane perforation and conductive
hearing impairment. Tympanoplasty is performed to restore the integrity of the
tympanic membrane and, when possible, improve hearing.
Case Presentation: A 24-year-old male presented with bilateral decreased
hearing of approximately 10 years' duration. He had a history of bilateral
foul-smelling, yellowish ear discharge that had remained absent for
approximately 10 years. He had previously undergone right tympanoplasty
approximately 10 years earlier, but hearing impairment persisted. Examination
demonstrated large central tympanic membrane perforations involving multiple
quadrants bilaterally. Audiometry showed hearing thresholds of 7/33 dB in the
right ear and 15/37 dB in the left ear. The patient was diagnosed with
bilateral chronic otitis media of inactive mucosal type. Revision Type I
tympanoplasty was subsequently performed on the right ear.
Outcome: Intraoperatively, a 7 × 7 mm central perforation was
identified with healthy middle-ear mucosa and intact ossicular mobility. A
temporalis fascia graft was placed using the underlay technique. The procedure
and immediate postoperative period were uneventful, with preserved facial nerve
function and a healthy surgical wound at discharge.
Conclusion: Revision Type I tympanoplasty using a temporalis fascia
graft can be an appropriate surgical approach for persistent tympanic membrane
perforation in selected patients with inactive mucosal chronic otitis media.
Keywords: Chronic otitis media; tympanic membrane perforation;
tympanoplasty; revision tympanoplasty; temporalis fascia; conductive hearing
loss.
1. Introduction
Chronic otitis media is characterized
by persistent or recurrent inflammation of the middle ear and may be associated
with a permanent tympanic membrane perforation and hearing impairment.
Tympanoplasty aims to eradicate disease when necessary and reconstruct the
tympanic membrane, with the additional goal of improving hearing.
Revision tympanoplasty may be
required when a previous repair has failed or when a residual or recurrent
perforation persists. This case describes a patient with bilateral inactive
mucosal chronic otitis media and persistent right-sided tympanic membrane
perforation following previous tympanoplasty, subsequently managed with
revision Type I tympanoplasty.
2. Case Presentation
A 24-year-old male presented to the
ENT outpatient department with bilateral decreased hearing for approximately 10
years.
The patient reported a history of
bilateral ear discharge beginning approximately 15 years earlier. The discharge
was described as yellowish and foul-smelling and had an insidious onset. The
ears had remained dry for approximately 10 years before the current evaluation.
The patient had previously undergone
right-sided tympanoplasty approximately 10 years earlier under local
anesthesia. Despite the previous surgical procedure, hearing impairment
persisted.
On otological examination, large
central tympanic membrane perforations involving multiple quadrants were noted
bilaterally. Facial nerve function was normal on both sides.
Based on the clinical findings, the
patient was diagnosed with bilateral chronic otitis media of inactive mucosal
type. In view of the persistent right-sided perforation and previous
unsuccessful tympanoplasty, revision surgery was planned.
3. Investigations
3.1
Pure Tone Audiometry
Pure Tone Audiometry demonstrated
the following findings:
|
Ear |
Audiometric
Finding |
|
Right |
7/33
dB |
|
Left |
15/37
dB |
Routine preoperative investigations
and a Pre-Anaesthetic Check-up were advised before surgery.
4. Management
The patient was admitted for planned
surgical management of the right ear.
On 2 August 2023, revision Type I
tympanoplasty was performed under local anesthesia using 2% xylocaine with
adrenaline.
4.1
Intraoperative Findings
Intraoperative examination revealed:
- A single central tympanic membrane perforation
measuring approximately 7 × 7 mm.
- Healthy middle-ear mucosa.
- Intact and mobile ossicular chain.
4.2
Surgical Technique
A postauricular Wilde's incision was
made. A temporalis fascia graft was harvested and prepared.
The margins of the tympanic membrane
perforation were freshened. The temporalis fascia graft was subsequently
positioned using the underlay technique.
The external auditory canal was
packed with medicated Gelfoam.
The surgical procedure was completed
without intraoperative complications.
5. Outcome and Follow-up
The immediate postoperative period
was uneventful.
On postoperative assessment, facial
nerve function remained intact and the patient's general condition was stable.
At discharge, the surgical wound was
healthy, with no evidence of collection, wound gaping, or discoloration. Vital
signs were stable.
The available clinical records
document an uncomplicated immediate postoperative course.
6. Discussion
Chronic otitis media can lead to
persistent tympanic membrane perforation and hearing impairment. When the
disease is inactive and the middle-ear mucosa is healthy, tympanoplasty can be
considered for reconstruction of the tympanic membrane.
Type I tympanoplasty is generally
used when the ossicular chain is intact and mobile, with the principal
objective of closing the tympanic membrane perforation. In this case,
intraoperative examination demonstrated healthy middle-ear mucosa and an
intact, mobile ossicular chain, supporting the choice of Type I tympanoplasty.
Revision tympanoplasty can be
technically more challenging than primary surgery because previous surgery may
alter the normal anatomy and available graft tissue. In the present case, a
temporalis fascia graft was used and positioned by the underlay technique.
The case also highlights the
importance of evaluating the condition of the middle-ear mucosa and ossicular
chain during surgery when determining the appropriate reconstructive procedure.
7. Conclusion
This case demonstrates the
management of persistent tympanic membrane perforation in a patient with
bilateral inactive mucosal chronic otitis media and a history of previous right
tympanoplasty.
Revision Type I tympanoplasty using
a temporalis fascia graft was performed successfully. The intraoperative
finding of healthy middle-ear mucosa and an intact, mobile ossicular chain
supported the reconstructive approach. The immediate postoperative course was
uncomplicated, with preserved facial nerve function and a healthy surgical
wound at discharge.
8. References
- Flint PW, Haughey BH, Lund VJ, et al. Cummings
Otolaryngology: Head and Neck Surgery. Elsevier.
- Glasscock ME, Shambaugh GE. Surgery of the Ear.
PMPH-USA.
- Browning GG, Weir J, Kelly G. Chronic otitis media. In:
Watkinson JC, Clarke RW, editors. Scott-Brown's Otorhinolaryngology and
Head and Neck Surgery. CRC Press.
- Merchant SN, Rosowski JJ. Surgical management of the
ear. In: Flint PW, et al., editors. Cummings Otolaryngology: Head and
Neck Surgery. Elsevier.
Medical Disclaimer: The information provided in this article is strictly for educational, study, and exam-preparation purposes. It does not constitute professional medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider for clinical decisions.
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