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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 32  |  Issue : 2  |  Page : 141-145

The effect of topical estrogen on healing of chronic tympanic membrane perforations and hearing threshold


Department of Otorhinolaryngology, Faculty of Medicine, Benha University, Benha, Egypt

Date of Submission02-Jan-2016
Date of Acceptance27-Jan-2016
Date of Web Publication14-Apr-2016

Correspondence Address:
Omneya E Bioumy
MBBCh, Department of Otorhinolaryngology, Faculty of Medicine, Benha University, Benha, Qalubia, 13717
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-208X.180329

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  Abstract 

Background
Tympanic membrane (TM) perforations can arise from a variety of causes. Major causes include trauma and middle ear disease. Surgical treatment involves higher costs, more effort, and surgical risks. Therefore, many investigators have studied topical use of substances to facilitate TM repair. Estrogen can influence the various phases of wound healing in cutaneous repair. Topical estrogen application may influence the repair of TM perforations.
Aim of the work
The aim of the work was to evaluate a new procedure for repairing TM perforation and improving hearing threshold after 30 days using estrogen paper patch.
Patients and methods
After obtaining informed consent, patients were randomly allocated into two groups. One group was treated with estrogen paper patch (paper patch impinged with1% estrogen ointment to act as the study group), and the second group was treated with paper patch impinged with local antibiotic ointment to act as the control group (we used 1% tetracycline ointment in our study).
Conclusion
Perhaps, there is a significant and promising result for estrogen paper patching as a method of repairing TM perforation.

Keywords: Estrogen, myringoplasty, paper patch, tympanic membrane perforation


How to cite this article:
Seliet AM, Abdel Razik MM, Kazeem NG, Ibrahim AA, Bioumy OE. The effect of topical estrogen on healing of chronic tympanic membrane perforations and hearing threshold. Benha Med J 2015;32:141-5

How to cite this URL:
Seliet AM, Abdel Razik MM, Kazeem NG, Ibrahim AA, Bioumy OE. The effect of topical estrogen on healing of chronic tympanic membrane perforations and hearing threshold. Benha Med J [serial online] 2015 [cited 2022 Jul 1];32:141-5. Available from: http://www.bmfj.eg.net/text.asp?2015/32/2/141/180329


  Introduction Top


History always provides an insight into the future. The history of tympanoplasty nearly sums up the history of evolution of otology as a whole. The goal for each surgeon is to eradicate underlying disease and provide a functional hearing to the patient as far as practicable. The question is still on how to devise a method so as to give maximum postoperative hearing using minimal instrumentation [1],[2]. In 1878, Emil Berthold was the first to describe the surgical procedure of myringoplasty, using a free skin graft from the forearm [3]. For surgical treatment of tympanic membrane (TM) perforations, the use of autologous autografts, including muscle fascia or perichondrium, is reported in most studies, with a success rate between 88 and 97%. However, surgical treatment involves higher costs, more effort, and surgical risks. Therefore, many investigators have studied the topical use of substances to facilitate TM repair and alternative methods for the surgical repair of TM perforations [4]. Estrogen can influence the various phases of wound healing in cutaneous repair. In the inflammatory phase, neutrophils are the first cells to arrive at the wound site in significant numbers [1]. Estrogen regulates the synthesis of interleukin-1 and platelet-derived growth factor by macrophages and may have an indirect effect on the proliferative phase. Interleukin-1 stimulates hyaluronic acid synthesis and collagen deposition, whereas platelet-derived growth factor stimulates angiogenesis. It also influences matrix formation and remodeling phase and increases the tensile strength of the wound [1]. Topical estrogen application may influence the repair of TM perforations. This study was performed to investigate the effects of estrogen-impinged paper patch on the healing of chronic TM perforations and to compare it with simple paper patch in a double-blinded clinical trial.


  Aims and objectives Top


The aim of the work was to study the effect of topical estrogen on healing of chronic TM perforations as an office procedure for myringoplasty.


  Participants and methods Top


It was an office procedure carried out during the period from November 2013 to November 2014.

Inclusion criteria

Inclusion criteria were as follows: presence of central perforation for more than 3 months, unilateral perforation, perforation size less than 40% of the total area of the TM, dry ear for at least 2-3 months preoperatively, air-bone gap less than 30 dB in the affected ear, and absence of ossicular or mastoid pathology as evidenced in computed tomography scan.

Exclusion criteria

Exclusion criteria were as follows: perforation size greater than 40% of the total area of the TM, presence of cholesteatoma or granulation tissue or polyp in the middle ear, presence of otorrhea in the past 3 months, presence of marginal perforation or recent perforation of the TM, infected external auditory canal, previously operated ear, or nonfunctioning Eustachian tube.

Informed consent was obtained from all patients. All patients were subjected to complete history taking, general examination, full ENT examination, and pure-tone audiometry. Patients were followed up weekly for reduction in size of perforation until complete closure at the end of fourth week.

The office procedure was performed by the same ENT surgeon as follows.

Patients were randomly allocated into two groups of 15 each. Under vision of an operating microscope, local anesthesia was induced using 10% lidocaine spray applied inside the external auditory canal. The margin of the perforation was refreshed with a sharp curved needle to create a fresh edge. Using a crocodile forceps, patches were placed and spread over the perforation using a straight blunt-ended needle [Figure 1]. Paper patch should be more than one and half the size of the perforation. The external ear canal was filled with gel foam to stabilize the patch. Thereafter, the external ear was slightly packed with small sterile gauze soaked in tetracycline ointment, and the sterile gauze and adhesive plaster were placed over the auricle. Medications included antibiotic ear drops three times per day (we used cipro ear drops), prophylactic antibiotic, and antihistaminic. Patients were instructed to prevent water from entering the ear and notify if any discharge occurs. The procedure was nearly painless and took 15 min or less. The patients returned to the office a week later for removal of aural pack. Medical treatment was stopped and weekly examination of the ear was carried out under microscope. After 2 weeks, suction of the gel foam was carried out. Thereafter, at the end of 1 month after the procedure, a photograph of the TM was taken for assessing the size of the perforation [Figure 2], and complete closure was detected [Figure 3]. Pure-tone audiogram was performed after 1 month of the procedure [Figure 4],[Figure 5],[Figure 6] and [Figure 7].
Figure 1: Paper patch in place over perforation.

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Figure 2: Image obtained through circumscription of the tympanic membrane and of its perforation [the selected image was evaluated by circumscribing (by tracking with a mouse) the total area of the tympanic membrane, which was then measured by means of pixel counting, the same procedure was applied to the area of the perforation. Both measures were transported to an Excel (Microsoft) spreadsheet] (USA, Microsoft, offi ce, Excel, 2007, (12.0.4518.1014) mso (12.0.4518.1014)).

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Figure 3: Perforation at fourth week (healed tympanic membrane).

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Figure 4: Case A: Preprocedure pure-tone audiogram (PTA) showing ABG 15 dB.

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Figure 5: Case A: At the end of 1 month after procedure PTA showing normal ABG.

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Figure 6: Case B: PTA showing ABG 10 dB.

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Figure 7: Case B: 1 month after procedure showing normal PTA.

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  Results Top


As regards age, sex, and duration of symptoms, the difference was not significant (P > 0.05). At the end of the study, pure-tone audiogram was performed for both groups. The results revealed that in the study group the mean air bone gap (ABG) was markedly reduced to 1.33 dB with SD 3.52 dB, whereas the mean ABG in the control group was 7.33 dB with SD 4.17 dB. The difference (P < 0.001) between postoperative and preoperative ABG was statistically significant [Table 1] and [Figure 8].
Figure 8: Comparison of the study group and the control group with regard to ABG before and after the procedure.

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Overall, as shown in [Table 2] and [Figure 9], 13 of 15 cases (86.7%) in the study group showed complete healing and only two cases showed failure (13.3%). In the control group, only one case (6.7%) showed complete healing, whereas 14 cases (93.3%) showed failure. The difference was significant, with a P value less than 0.001.
Figure 9: Comparison of the study group and the control group with regard to results.

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Table 2: Comparison of the study group and the control group with regard to results

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  Discussion Top


The repair of the TM has been attempted with a large variety of synthetic, homologous and autogenous tissue. However, the temporalis fascia, areolar tissue, and the perichondrium are used most commonly today. Nevertheless, it is limited by the need for expensive equipment in the operating room, microsurgical skills of the surgeon, and donor site morbidity [5]. The trend toward increasingly less-invasive medical procedures, with shorter hospitalization stay, has led to a demand for materials to replace autologous grafts. Theoretical advantages include the elimination of morbidity related to graft harvesting, faster healing, no visible scarring, less pain, and less risk for infection, in addition to a faster procedure and early discharge. These grafts, however, make the procedure more expensive and have shown no real advantages thus far [3]. Paper patching is technically simple, time saving, safe to perform, cost-effective, and suitable as an outpatient procedure and has a good success rate [6]. Numerous growth factors have been investigated to stimulate healing of TM perforations, including epidermal growth factor, fibroblast growth factor, and platelet-derived growth factor, with mixed results. Topical insulin application in acute TM perforations in guinea pigs showed no beneficial effect on closure rate, epithelial thickness, and TM thickness [7]. Previous studies showed that the benefits of paper patching were low and limited to small perforations. Closure rates using rice paper patching after excision of the perforation margin under local anesthesia for persistent TM perforation were lower than 30% [8]. Our study was conducted to find a simple, noninvasive, effective procedure for repairing TM perforations with the criteria mentioned earlier, avoiding the disadvantages of the ordinary techniques. The present study showed that myringoplasty with estrogen paper patch was performed for 15 patients: closure of the TM perforation failed in two patients, one case developed severe upper respiratory tract infection shortly after the operation, followed by middle ear infection, and the other case did not follow the instructions after procedure and removed the aural pack shortly.

This good result in audiology was attributed mainly to estrogen effect, selection of the patients depending on the preoperative audiometry, which can exclude any ossicular pathology and good preoperative examination for the state of air conduction and computed tomography scan to exclude any hidden mastoid pathology. As regards the hearing improvement with estrogen paper patch, the mean A-B gap was 8.67 dB preoperatively. After the procedure, the mean A-B was 1.33 dB (P < 0.001). In the control group the mean preoperative ABG was 7.67 dB and the postoperative ABG was 7.33 (P > 0.05).


  Conclusion Top


Day-stay surgery has become an integral part of modern otolaryngology. Myringoplasty under local anesthesia is a short, simple, cost-effective, and minimally invasive technique compared with traditional myringoplasty [9]. Considering the presence of squamous epithelial cells and fibroblasts in the TM, topical estrogen application may influence the repair of TM perforations [1]. Perhaps, there is a significant and promising result for estrogen paper patching as a method of repairing TM perforation and improving hearing threshold as shown in our study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Barati B, Abtahi SH, Hashemi SM, Okhovat SA, Poorqasemian M, Tabrizi AG The effect of topical estrogen on healing of chronic tympanic membrane perforations and hearing threshold. J Res Med Sci 2013; 18 :99-102.  Back to cited text no. 1
    
2.
Sarkar S. A review on the history of tympanoplasty. Indian J Otolaryngol Head Neck Surg 2013; 65 (Suppl 3): 455-460.  Back to cited text no. 2
    
3.
Freitas MR, Oliveira TC. The role of different types of grafts in tympanoplasty. Braz J Otorhinolaryngol 2014; 80 :275-276.  Back to cited text no. 3
    
4.
Kartush JM. Tympanic membrane Patcher: a new device to close tympanic membrane perforations in an office setting. Am J Otol 2000; 21 :615-620.  Back to cited text no. 4
    
5.
Laidlaw DW, Costantino PD, Govindaraj S, Hiltzik DH, Catalano PJ. Tympanic membrane repair with a dermal allograft. Laryngoscope 2001; 111 (Pt 1): 702-707.  Back to cited text no. 5
    
6.
Golz A, Goldenberg D, Netzer A, Fradis M, Westerman ST, Westerman LM, Joachims HZ Paper patching for chronic tympanic membrane perforations. Otolaryngol Head Neck Surg 2003; 128 :565-570.  Back to cited text no. 6
    
7.
Eken M, Ates G, Sanli A, Evren C, Bozkurt S. The effect of topical insulin application on the healing of acute tympanic membrane perforations: a histopathologic study. Eur Arch Otorhinolaryngol 2007; 264 :999-1002.  Back to cited text no. 7
    
8.
Spandow O, Hellström S, Dahlström M, Bohlin L. Comparison of the repair of permanent tympanic membrane perforations by hydrocolloidal dressing and paper patch, J Laryngol Otol 1995; 109 :1041-1047.  Back to cited text no. 8
    
9.
Saliba I. Hyaluronic acid fat graft myringoplasty: how we do it. Clin Otolaryngol 2008; 3:610-614.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
 
 
    Tables

  [Table 1], [Table 2]



 

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Abstract
Introduction
Aims and objectives
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