MUCOSAL GRADING AND ITS USE IN THE MANAGEMENT OF CHRONIC OTITIS MEDIA - MUCOSAL DISEASE

Aims and Objectives: This observational study is intended to identify the effectiveness of individual approach for each patient instead of a universal law of either Tympanoplasty alone or Cortical mastoidectomy with Tympanoplasty as a treatment for COM – mucosal type. Materials and Methods: This study comprises 100 consecutive patients who underwent surgery for the treatment of COM Mucosal type. We graded the Middle ear mucosa into six grades. All patients were followed up for a minimum of six months post operatively. Results: The graft uptake in our study was found to be 96% at the end of 6 months. Conclusion: A concomitant Mastoidectomy adds cost, surgical time and hospital stay to the patient among other things. However, Mastoidectomy should be done when there is evidence to suggest involvement of the mastoid compartment by the disease. The middle ear mucosa gives an indication of the disease status.


INTRODUCTION
Chronic otitis media (COM) is a chronic inflammatory disease of the middle ear cleft. The diagnosis of COM Mucosal type implies a permanent abnormality of the pars tensa of the tympanic membrane, most likely a result of earlier acute otitis media, negative middle ear pressure or otitis media with effusion [1].
The treatment for the disease varies from person to person, according to the degree of involvement. There are many studies in the literature comparing outcomes of Tympanoplasty alone and tympanoplasty with cortical mastoidectomy in the treatment of COM Mucosal type. However, there is no general consensus regarding the selection of patients -as to who require only tympanoplasty and which of the patients will be benefitted by undergoing a concomitant mastoidectomy along with tympanoplasty.

MATERIALS AND METHODS SOURCE OF DATA:
A total of 100 patients with COM Mucosal type who underwent tympanoplasty with or without mastoidectomy by a single surgeon in the Department of Otorhinolaryngology and head & neck surgery at Jubilee Mission Medical College and Research Institute, Thrissur were studied during the period of February 2017 to August 2018. Assessment of hearing, Eustachian tube function, radiological evaluation of Mastoids done preoperatively. Graft uptake was assessed postoperatively and hearing assessment was done postoperatively.

INCLUSION CRITERIA:
Ÿ All cases of COM -mucosal type undergoing tympanoplasty with or without mastoidectomy by a single surgeon.

EXCLUSION CRITERIA:
Ÿ Patients with Diabetes Mellitus of more than 5 years duration. Ÿ Cases of COM -Squamous type. Ÿ Surgery done for coalescent mastoiditis cases; in actively discharging ears, where a staged procedure may be ideal.

METHODOLOGY:
After taking an informed written consent from those willing to enroll in the study, data were systematically recorded. A detailed proforma was filled for each patient with regard to history and ENT examination.
Ears examined using an otoscope & subsequently under a microscope. All the patients were treated initially by a medical line of management, which consisted of antibiotics -systemic and local, antihistamine and decongestants. Those patients with active ear discharge even after a course of oral antibiotics were admitted and a course of IV antibiotics were given.
All the 100 cases were operated by the same senior surgeon. Prior to surgery, using operating microscope, the perforation and middle ear mucosa was assessed once more and graded accordingly [2] and the decision to whether to do a mastoidectomy or not was taken. Postoperatively all patients received prophylactic antibiotic therapy, antihistamines, analgesics and other supportive treatments. Patients were followed up regularly 1 week, 2 weeks, 1 month and 6 months after surgery. Symptom profile of patients evaluated during post-op visits. Ear pack removed during the first postoperative visit. Condition of graft & its uptake examined under microscope on the 2nd postoperative visit. Any reperforation occurring in the six month follow up period was considered as graft failure. PTA was done at the end of 6 months, in patients with intact graft, to assess hearing improvement. The data was statistically analyzed with the help of IBM SPSS (version 20) software.

RESULTS AND DISCUSSION
Tympanoplasty is a surgical procedure performed to eradicate infection and restore the function of the middle ear. The two opposing demands of tympanoplasty namely, removal of all disease process and at the same time trying to maintain as much of normal tissue as possible to facilitate reconstruction of the hearing mechanism is a demanding task. As long as there is infection lurking in and around the middle ear cleft and mastoid antrum, any attempt at reconstruction may seem futile [3].
Tympanoplasty with mastoidectomy has been identified as an effective method of treatment of chronic ear infection resistant to antibiotic therapy, but the effect of mastoidectomy on patients without evidence of active infectious disease remains highly debated and unproven [4].
There are three opinions in this issue. Ÿ The first is that mastoidectomy is useful for both infected and dry ears [5]. Ÿ The second is that mastoidectomy is useful for infected ears, but not for dry ears [6]. Ÿ The third is that mastoidectomy is not useful for either infected or dry ears [7].
S.Z. Toros et al. [8], advocated mastoidectomy along with tympanoplasty in cases where there was radiological evidence of a small sclerotic contracted mastoid on the diseased side. In our study, the Middle ear mucosa was thoroughly examined using the operating microscope and was graded into 6 grades [2] pre-operatively.
A concomitant mastoidectomy along with tympanoplasty was done only in cases with Grade V and Grade VI mucosa, in spite of a course of oral and intravenous antibiotic therapy and topical antibiotic therapy pre-operatively. Other factors taken into consideration during decision making were: Appearance of mastoid air cell system on radiological evaluation. It was taken into consideration only in unilateral cases with sclerosed mastoid on the diseased side and cellular mastoid on the contra lateral normal side. Eustachian tube function does have an important role in middle ear function and, hence, in the long term success of middle ear surgery. But it did not seem to have much role in the immediate success of the surgery.
In this prospective study conducted from February 2017 to August 2018; a total number of 100 cases of COM Mucosal type, who underwent Tympanoplasty with or without mastoidectomy for the treatment of the same has been included.

AGE INCIDENCE:
In our study the youngest patient was 8 years old and the oldest patient was of 72 years. Mean age was 33.82 years.

ASSOCIATED FACTORS:
20% patients had Bilateral COM -all were mucosal type of which, two patients had both their ears operated at subsequent sittings during the period of study. 36% patients had deviated nasal septum. 30% patients had Nasal allergy. 10% patients were diabetic (all were of less than five years duration).

X RAY MASTOIDS:
In our study, 37% patients had a cellular mastoid on x-ray on the diseased side, while 51% had sclerotic and 12% patients had hypocellular mastoid on x-ray. In a study published by Akriti Sharma et al. [9], cellular mastoid was observed in 25% patients and sclerotic mastoid in 75% of the patients. In a study published by Huang et al. [10]; 48.67% mastoid air cells were cellular, 11.5% mastoid air cells were sclerotic, and 39.82% mastoid air cells were diploetic. Both were in contrast with our study.

HEARING ASSESMENT:
The average AB gain was 24 dB. The average AB gain among the Tympanoplasty group was 22.48 dB and among the Tympanoplasty with Mastoidectomy group was 22.61 dB.