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Evaluation of Prognostic Factors and Middle Ear Risk
Evaluation of Prognostic Factors and Middle Ear Risk
Received March 16, 2008; revised May 19, 2008; accepted May 28,
2008.
0194-5998/$34.00 © 2008 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.
doi:10.1016/j.otohns.2008.05.623
Pinar et al Evaluation of prognostic factors and middle ear risk . . . 387
Table 1
obtain independent prognostic factors and to assess the
Middle Ear Risk Index 2001 relative importance.
Risk Assigned
Risk factor value risk
RESULTS
Otorrhea (Bellucci)
I - Dry 0 There were 89 male and 142 female patients in this study.
II - Occasionally wet 1 The age range of the patients was 11 to 58 years (mean,
III - Persistently wet 2
IV - Wet, cleft palate 3 30.65 ⫾ 10.97). The pediatric age group included 42 pa-
__ tients (range, 11 to 16 years of age). The adult group had
Perforation 189 patients. Intact canal wall group (ICW) (176 patients,
None 0 76.1%) included myringoplasty, tympanoplasty with atticot-
Present 1 omy, and intact canal wall technique mastoidectomy. My-
__
Cholesteatoma ringoplasty was performed in 41 patients, tympanoplasty
None 0 with atticotomy in 14 patients, and intact canal wall tech-
Present 1 nique mastoidectomy in 121 patients. Canal wall down
__ (CWD) mastoidectomy was performed in 55 (23.8%) pa-
Ossicular status (Austin/Kartush) tients. Graft success rates for tympanoplasty without mas-
0) M⫹I⫹S⫹ 0
A) M⫹S⫹ 1 toidectomy (myringoplasty, tympanoplasty with atticot-
B) M⫹S⫺ 2 omy) was higher compared with intact canal wall technique
C) M⫺S⫹ 3 mastoidectomy (P ⫽ 0.011).
D) M⫺S⫺ 4 The overall graft success rate was 74.4% (172 of 231
E) Ossicular head fixation 2 patients), and the mean air-bone gap improvement was 8.2 ⫾
F) Stapes fixation 3
Table 3
Multivariate analysis of the significant prognostic parameters
13.2. Based on the univariate analysis, central perforation and tympanoplasty success. Furthermore, the mean MERI
(P ⫽ 0.022), size of the perforation (⬍50%) (P ⫽ 0.001), score was found as 7.8 ⫾ 11.8 in the canal wall down
healthy opposite ear (P ⫽ 0.000), more than 3 months dry mastoidectomy group and 4.6 ⫾ 9.2 in the canal wall-up
period of the ear (P ⫽ 0.003), absence of myringosclerosis group. The mean MERI score was significantly higher in
(P ⫽ 0.027), operation type (intact canal wall group) (P ⫽ CWD mastoidectomy group compared with ICW group
0.01) and the low MERI score (ⱕ3) (P ⫽ 0.000) were found (Table 4).
to be statistically significant prognostic factors that affect The correlation between the significant variables and the
success rate (Table 2). MERI was analyzed with Spearman’s correlation coeffi-
The other variables did not show any statistically signif- cient. The operation type and the healthy opposite ear were
icant relationship with surgical success. Multivariate anal- correlated with the MERI, but the other significant variables
ysis was carried out on these significant prognostic factors were not (Table 5). The location of the perforation was also
to assess the relative importance of the independent vari- correlated with the size of the perforation (r ⫽ 0.579; P ⫽
ables and yielded the following results: the size of the 0.00). There was no significant correlation between the
perforation (⬍50%) (OR:8.11), healthy opposite ear (OR: other significant prognostic factors.
5.64), more than 3 months dry period (OR:2.21), absence
of myringosclerosis (OR:4.01) and the low MERI score
(OR:87.1) were found as independent prognostic factors
(Table 3). The location of the perforation (P ⫽ 0.949) and DISCUSSION
the operation type (P ⫽ 0.694) were not found as indepen-
dent prognostic factors. There have been many reports that discuss the prognostic
We used the MERI 2001 to stratify patients according to factors and hearing results in tympanomastoid surgery. Age
known preoperative and intraoperative risk factors for tym- is one of the prognostic factors. In general, the success of
panoplasty. The MERI generates a numeric value that cor- pediatric tympanoplasty is slightly lower than in adults.9,10
relates to severity of disease and prognosis. A MERI of 0 to This has been traditionally attributed to the fact that children
3 represents mild disease, 4 to 6 moderate disease, and 7 to have a higher incidence of eustachian tube dysfunction.11
12 severe disease. Patients were stratified into above risk On the other hand, some authors12-14 concluded that patient
categories. 102 (44.1%) patients had low risk, 80 (34.6%) age did not influence the surgical success of tympanoplasty.
nedium risk, and 49 (21.2%) high risk. There was a statis-
tically significant association between the low MERI score
Table 5
Correlation analysis of significant prognostic factors
with the MERI
Table 4
Association of the MERI and type of the operation Correlation
Variables coefficient P value
Mean MERI
Variables score P value Location of perforation 0.070 0.356
Size of perforation 0.115 0.129
Operation type 0.03* Healthy opposite ear 0.197 0.009*
ICW mastoidectomy group 4.6 ⫾ 9.2 More than 3 months dry period ⫺0.100 0.187
CWD mastoidectomy group 7.8 ⫾ 11.8 Absence of myringosclerosis 0.052 0.494
Operation type 0.209 0.005*
*Significant value, 2 statistical method; ICW, Intact canal
wall group; CWD, canal wall down group. *Significant correlation.
Pinar et al Evaluation of prognostic factors and middle ear risk . . . 389
We also did not find a relationship between success rate of Furthermore, mean MERI score was significantly higher in
surgery and patient age. CWD tympanoplasties compared with ICW tympanoplas-
The location and size of the perforation have been fre- ties. Possible explanations of this significant association
quently examined in the literature. Technically anterior per- could be: 1) moderate and severe MERI indicates presence
forations are more difficult to access and place grafts. Sur- of cholesteatoma, ossicular discontinuity, and middle ear
prisingly, previous studies15,16 reported that the location of pathology; 2) smoking is one of the parameters of the
the perforation had no effect on the surgical or hearing MERI; high MERI scores may indicate smoking, which has
result. Conversely, we found that graft success rate for negative local, regional, and systemic effects on the middle
central perforations was higher compared with posterior and ear mucosa; 3) these patients also need more extensive
anterior perforations. With respect to size, Lee et al17 and surgery; CWD tympanoplasty is often required to eradicate
Onal et al18 demonstrated a significantly higher success rate the disease in patients with severe MERI.
with perforations smaller than 50%. We also found a sig-
nificant relationship between graft success and smaller per-
foration. However, no statistically significant association CONCLUSION
was found between perforation size and successful tympa-
noplasty in recent studies.15,19 The size of the perforation (⬍50%), healthy opposite ear,
Many otolaryngologists believe that dry ear is critical for more than 3 months of dry period, absence of myringoscle-
graft uptake, whereas some believe it plays little role in rosis, and low MERI scores were found as independent
success. Uyar et al20 found that there was a significantly prognostic factors and carried respectively a eight-, five-,
higher rate of graft uptake in patients who had dry ear for 3 two-, four-, and eighty-seven–fold increase on the surgical
months preoperatively. We also found a significant associ- success rate, respectively. Although the location of the per-
ation between dry ear and success of tympanoplasty similar foration and the operation type were significant variables in
to this study. We recommend performing tympanoplasty the univariate analysis, they were not found as independent
when the ears have been dry for 3 months. On the other prognostic factors in logistic regression analysis. This study
hand, there are also studies that found no statistically sig- showed that high MERI had a much higher possibility of
nificant correlation with respect to dry ear.14,18 CWD surgery and lower chance of successful tympano-
The status of the opposite ear is an important prognostic plasty. The consideration of the high MERI allows the
factor. Our study also revealed that the status of the opposite surgeon to counsel the patient more accurately before sur-
ear was a prognostic factor. Success of graft uptake was gery and provide realistic expectations. This will enable the
poorer in patients whose opposite ears were athelectatic or surgeon to design a case-specific operation strategy for each
perforated. Collins et al21 had similar findings. Merenda et patient.
al15 also reported that contralateral disease was associated
with lower success rates. Conversely, Singh et al16 found no
association between contralateral ear status and surgical AUTHOR INFORMATION
success.
From the Ataturk Training and Research Hospital, ENT Clinic, Izmir,
Effect of the presence of myringosclerosis on surgical Turkey.
success was not investigated thoroughly during assessment
Corresponding author: Ercan Pinar, MD, Sair Esref Bul. No: 80/13, 35220
of the prognostic factors. This factor was investigated pre- Alsancak-Izmir, Turkey.
viously only in Onal’s study.18 The author reviewed 74 E-mail address: [email protected].
tympanoplasties and did not find a correlation between
success and myringosclerosis. In our large series, we found
that absence of myringosclerosis increased success of tym-
panoplasty. AUTHOR CONTRIBUTION
We found that ICW tympanoplasties actually had higher Ercan Pinar, study design; Kerim Sadullahoglu, data collection; Caglar
surgical success rates of graft compared with CWD tympa- Calli, data collection; Semih Oncel, design and approval of manuscript.
noplasties. Onal et al18 did not agree with this finding in
their series. Success rates were higher in canal wall down
tympanoplasties compared with canal wall up tympanoplas- FINANCIAL DISCLOSURE
ties and their result was close to the level of significance.
We used the MERI 2001 to stratify patients according to None.
known preoperative and intraoperative risk factors for tym-
panoplasty. The relationship between MERI and surgical
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