European Journal of Cardiovascular Medicine

Chronic infection of the middle ear is a widely prevalent condition in India, as it is in other developing countries. Chronic otitis media erodes the bone, destroys the ossicles, and has the potential to cause life-threatening complications. Surgical treatment of CSOM remains one of the most challenging surgeries in otology.

The primary goal of chronic otitis media surgery is to clear the disease and produce a safe and dry ear. Maintenance or improvement of hearing is important but should not come at the cost of the primary goal. There is a longstanding and largely unresolved debate as to whether these goals are best achieved by canal wall down or canal wall up procedures. ¹

Over the years, a great variety of materials have been used for middle ear reconstruction. The materials that provided the most successful results are refashioned ossicles, cartilage in its different forms, and various types of prostheses, i.e., synthetic (biocompatible, bioinert, bioactive) TORP and PORP. Each of them has advantages and disadvantages. ²

Minimally destroyed autograft or homograft ossicles can be refashioned and used for reconstruction. This is a safe and inexpensive method. If extensive destruction of ossicles has occurred, they will have to be replaced with other materials from tragal, conchal, or nasal septal spur cartilage. ³⁻⁴

This is a prospective study involving patients with chronic otitis media. The study was conducted between September 2019 and February 2020. Ninety patients were included, and all of them underwent ossicular reconstruction, either through canal wall down or intact canal wall surgery. Autograft ossicles, autograft tragal cartilage, and synthetic prostheses (TORP/PORP) were used to restore ossicular integrity.

INCLUSION CRITERIA:

1. Patients with Chronic Otitis Media active and inactive squamous disease
2. Patient with Chronic Ot it is    Media –   active and inactive mucosal disease

EXCLUSION CRITERIA:

1. Patients with previous history of surgery for Chronic Otitis Media —active squamous.
2. Patients with severe sensory neural hearing loss.
3. Patients not willing to participate in the study.
4. Patients medically unfit for surgery.

In our study, 90 patients were included and divided into two groups. Group 1 comprised 60 patients in whom the Canal Wall Up (CWU) technique was used; all patients in this group had CSOM of the Tubotympanic (TT) type. Group 2 comprised 30 patients in whom the Canal Wall Down (CWD) technique was used; these patients had CSOM of the Atticoantral (AA) type.

Both groups were further divided into three subgroups based on the material used for ossiculoplasty:

• Group 1A and 2A: Autologous refashioned incus was used for ossicular reconstruction.
• Group 1B and 2B: Autologous tragal cartilage was used for ossicular reconstruction.
• Group 1C and 2C: Titanium PORP/TORP ossicular implants were used for ossicular reconstruction.

According to the sex distribution:

• Group 1A: 65% male, 35% female
• Group 1B: 50% male, 50% female
• Group 1C: 40% male, 60% female
• Group 2A: 60% male, 40% female
• Group 2B: 50% male, 50% female
• Group 2C: 50% male, 50% female

In terms of age distribution, the most common age group was 21–30 years.

Table 1:  Post Operative A-B Gap in group 1

Table 2: Post operative AB gap status in group 2

As per Wehr’s classification, 80% of patients in Group 1A showed improvement in the air-bone (A-B) gap, while 20% failed to show improvement. In Group 1B, 75% of patients showed improvement, and 25% failed to improve in the A-B gap. In Group 1C, 65% of patients showed improvement, and 35% failed to show improvement in the A-B gap.

Similarly, as per Wehr’s classification, 70% of patients in Group 2A showed improvement in the A-B gap, while 30% did not improve. In Group 2B, 80% of patients showed improvement, and 20% failed to show improvement. In Group 2C, 70% of patients showed improvement, while 30% failed to show improvement in the A-B gap.

Table 3: Comparison of mean A-B gap within the group 1

Table 4: Comparison of mean A-B gap within the Group 2

The mean (±SD) in Group 1A pre-operative A-B gap was 35.45 ± 12.7 dB, and post-operative A-B gap was 23.4 ± 7.18 dB, showing a highly significant result (p < 0.001).

In Group 1B, the pre-operative A-B gap was 36.15 ± 14.8 dB, and post-operative was 23.6 ± 8.8 dB, again showing a highly significant result (p < 0.001).

In Group 1C, the pre-operative A-B gap was 34.55 ± 12.7 dB, and post-operative was 25.15 ± 8.59 dB, with a highly significant result (p < 0.001).

In Group 2A, the mean pre-operative A-B gap was 34.15 ± 10.61 dB, and post-operative was 25.4 ± 9.19 dB, showing a highly significant result (p < 0.001).

In Group 2B, the pre-operative A-B gap was 36.5 ± 11.05 dB, and post-operative was 23.8 ± 7.74 dB, again highly significant (p < 0.001).

In Group 2C, the pre-operative A-B gap was 35.5 ± 12.4 dB, and post-operative was 24.6 ± 8.24 dB, showing high significance (p < 0.001).

The primary surgical goal in treating chronic otitis media is the complete exenteration of disease. The secondary aim is to improve hearing to the extent possible through proper ossiculoplasty.

All surgeries for CSOM have inherent disadvantages. Ideally, the treatment choice should both completely eradicate the disease and reconstruct the hearing apparatus in a single stage.

In our study, Group 1A showed a pre-operative mean A-B gap of 35.45 ± 12.7 dB and post-operative 23.4 ± 7.18 dB (p < 0.001).

Group 1B had a pre-operative gap of 36.15 ± 14.8 dB, and post-operative 23.6 ± 8.8 dB (p < 0.001).
Group 1C showed a pre-operative gap of 34.55 dB, and post-operative 25.15 ± 8.59 dB (p < 0.001).
On further analysis between subgroups, the differences in A-B gap improvement were found to be statistically insignificant (p > 0.05).

Similarly, in Group 2A, the pre-operative gap was 34.15 ± 10.61 dB, and post-operative was 25.4 ± 9.19 dB (p < 0.001).

Group 2B had pre-operative values of 36.5 ± 11.05 dB and post-operative 23.8 ± 7.74 dB (p < 0.001).

Group 2C showed a pre-operative gap of 35.5 ± 12.4 dB and post-operative 24.6 ± 8.24 dB (p < 0.001).

Again, comparison between these subgroups showed no statistically significant difference (p > 0.05).

**Goldenberg RA et al.**⁵ showed that using autograft incus resulted in a mean A-B gap of 18.6 dB, and Siddiq et al. achieved a mean post-operative gap of 21 dB using the same material.

In our study, the mean post-operative A-B gap was 23.4 dB in Group 1A and 25.4 dB in Group 2A.

All three ossiculoplasty modalities (autologous incus, tragal cartilage, and titanium prostheses) provided statistically significant improvement (p < 0.001) in A-B gap and hence hearing outcomes.
However, among the three groups, no statistically significant difference was found in the improvement of A-B gap (p > 0.05).

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