JIIMS final.cdr


3

ORIGINAL ARTICLE

Results of Myringoplasty in Chindren: A Comparison with
an Adult Population
Muhammad Azeem Aslam, Danyal Rashid, Ashfaq Ahmed

Introduction
Myringoplasty in adults is now considered 

to be well established and rewarding 
1procedure with high success rate  but 

controversy still surrounds the advisability 
2of tympanic membrane repair in children.  

The main concern regarding paediatric 

myringoplasty is that the child has an 

increased susceptibility to upper respiratory 

tract infections and eustachian tube 

dysfunction as compared to an adult leading 
3to recurrent middle ear infection.  This may 

j e o p a rd i z e  t h e  re s u l t s  o f  t y m p a n i c  

membrane grafting.Moreover, tympanic 

membrane perforation may favor the child 

with poor eustachian tube function as it 

provides ventilation to middle ear resulting 

in decreased likelihood of development of 
4,5effusion in it.  If tympanic membrane 

grafting is done in these children with poor 

tubal function, negative pressure will 

develop in middle ear resulting in graft 

medialization or retraction minimizing the 

benefits of surgery.  All these reservations 

about paediatric myringoplasty appear to 

be valid but we must take into account the 

effects of recurrent middle ear infections and 

decreased hearing associated with tympanic 

membrane perforation. Childhood is a 
6period of active learning and socialization.  

Impaired hearing at this stage of active 

intellectual growth can be detrimental to 
6child education and socialization.  At the 

same time, repeated infections in the middle 

ear will further damage the hearing 

ABSTRACT

Objective: To find out validity of myringoplasty in children by comparing its anatomical and functional results with 
adult myringoplasty.
Study Design: A descriptive cross sectional study
Place and Duration of Study: Department of Otolaryngology and Head and Neck Surgery at a tertiary care 
teaching hospital in Rawalpindi from January 2007 to December 2010.
Materials and Methods: A total of 89 patients having dry central tympanic membrane perforation of various 
sizes secondary to chronic tubotympanic suppurative otitis media were included in the study. The patients were 
divided in two groups. First group comprised of children upto the age of 14 years whereas those above the age of 
14 years were included in second group. Myringoplasty was performed in all patients with temporalis fascia 
utilizing underlay technique. The two groups were compared regarding graft success rate and hearing 
improvement at the end of 6 months of follow up. 
Results: Out of 89 patients included in the study, 37 (41.6%) belonged to child group whereas 52 (58.4%) were 
included in adult group.  Among 37 patients in child group, 34(91.8 %) had successful graft take at the end of 6 
months of follow up whereas 47 (90.3 %) patients out of 52 in adult group had successful graft. Average air bone 
gap closure of 13.5 dB was noted in child group whereas in adult group it was 12.5 dB.  The difference between 
graft success rate and average air bone gap closure was found to be statistically insignificant (P>0.05). 
Conclusion: Results of myringoplasty in paediatric and adult age group are comparable in terms of graft 
success rate and hearing improvement.

Key words:  Myringoplasty, tympanic membrane, paediatric, middle ear

----------------------------------------------------
Correspondence:

Dr. Muhammad Azeem Aslam

House No. 57, Main Road, Sector G-8/2, Islamabad.

E-mail   drazeemaslam@gmail.com

Phone: 0333 5131237



4

mechanism.

In this study, we tried to solve the 

controversy regarding advisability of 

paediatric myringoplasty by comparing the 

results of tympanic membrane grafting in 

children to that of adults. 

T h i s  s t u d y  w a s  c o n d u c t e d  a t  t h e  

Department of Otolaryngology and Head & 

Neck surgery at a tertiary care teaching 

hospital in Rawalpindi during the period of 

January 2007 to December 2010.  A non 

probability purposive sampling technique 

was adopted by including all patients 

coming to outpatient clinic of our 

department with dry central tympanic 

membrane perforation secondary to chronic 

tubotympanic suppurative otitis media, 

irrespective of age and gender. A detailed 

history was taken and thorough ear nose 

throat examination was done.  All patients 

were examined under otomicroscope and 

findings were recorded in a pre-designed 

performa.  The information obtained was 

age and sex of patient, duration of disease, 

size of tympanic membrane perforation, 

status of middle ear mucosa and ossicles, 

previous ear surgery and nasal complaints. 

Patients with chronic rhinosinusitis, prior 

ear surgery, atticoantral type of disease were 

excluded from the study.  Pure tone 

audiometery with air and bone conduction 

threshold was done in all patients.  Patients 

selected according to the above mentioned 

criteria were divided in two groups 

according to age. First group comprised of 

children up to the age of 14 years and the 

second group consists of patients above 14 

years of age. All the patients underwent 

myringoplasty under general anesthesia 

Materials and Methods

using post aural approach and underlay 

technique of tympanic membrane grafting.  

Post operative antibiotic cover was given for 

5 days. Patients were discharged on second 

postoperative day and were followed up 

after three weeks when bismuth iodoform 

paraffin paste pack was removed from the 

external auditory canal.  Status of graft (full 

take or failure) was noticed on that visit.  

They were then followed up at monthly 

interval for up to at least 6 months.  During 

that period, they were observed for graft 

success. At the end of 6 months of follow up, 

pure tone audiogram with air and bone 

conduction thresholds was repeated. Both 

groups of patients were compared in terms 

of graft success rate (anatomical gain) and 

hearing improvement (functional gain). 

Graft take was defined as full, intact healing 

of tympanic membrane graft at 6 months 

postoperatively. Hearing improvement was 

reviewed as the change in air-bone gap at the 

end of six months follow up period. Gap 

change was defined as the difference 

between the pre and postoperative air-bone 

gap. Air-bone gap was calculated as the 

average difference between air conduction 

and bone conduction at 0.5, 1 and 2 kHz. 

Results were statistically analyzed using 

SPSS version 10.0. Chi square test was 

performed to find out the difference 

between graft success rates of both the 

groups.  Pre and postoperative air-bone gap 

change in dB between the two groups was 

analyzed by using t test. Statistical 

significance was accepted as p<0.05. 

A total of 89 patients fulfilled the inclusion 

criteria between January 2007 to December 

2010. Thirty seven of them, up to the age of 

Results



5

14 years, were included in child group 

whereas 52 having more than 14 years of age 

w e r e  i n c l u d e d  i n  a d u l t  g r o u p .  

Demographics of both the groups are shown 

in Table I.

Average follow up duration was 8.8 months 

(range 6 to 29 months). Graft success rates 

and hearing improvement (air-bone gap 

closure in successful graft) in both the 

groups are shown in Table II. The difference 

between graft success rate and air-bone gap 

closure in two groups were found to be 

statistically insignificant     (P >0.05).

Overall hearing improvement was noted in 

all patients of both groups except those who 

met with graft failure.

Table-I: Demographics of Child and Adult Group

Child Group Adult Group

Total No. of
Patients in each group

37
(41.6%)

52
(58.4%)

Male

Female

Mean Age (Years)

Age Range (Years)

Average Duration of
Disease (Years)

Size of Tympanic
membrane perforation

19
(51.4%)

18
(48.6%)

13

6 to 14

7.6 (1 to 13

Small = 3
Medium = 25

Large = 9

16
(30.8%)

36
(69.2%)

28.5

15 to 57

12.5 (0.5 to 35)

Small = 1
Medium = 32

Large = 19

Table-II: Graft Success Rates and Air Bone Gap Closure in Both Groups

Graft Success rate

Child Group
n = 37

34
(91.8%)

47
(90.3%)

13.5
(Range 5 to 33.3

12.5
(Range 3 to 24)

Adults Group
n = 52

Average Air-Bone gap
closure (dB)



6

Discussion
Myringoplasty in children is still a 

controversial issue. Although a number of 

studies appeared in literature on this subject 

in the recent past but opinions still differ on 

this subject.  In the present study, we tried to 

solve this controversy by comparing the 

results of paediatric myringoplasty with 

that of same procedure in the adults.  We 

obtained graft success rate of 91.8% in 

children between the ages of 6 to 14 years. 

Comparable graft success rate (90.3%) were 

achieved in adult patients (> 14 yrs) utilizing 

the same underlay technique and graft i.e., 

temporalis fascia. The difference between 

graft success rates was statistically not 

significant. These results are similar to 

certain other studies in which adult and 

pediatric myringoplasty results were 
7compared .

In literature, we find wide variations 

between the graft success rates of paediatric 

m y r i n g o p l a s t y  r a n g i n g  f ro m  3 5  t o  
8,9,10,11100%.  One local study reported graft 

success rate of 72.96% at six months of 

follow up in a study of thirty cases of 

paediatric myringoplasty in children less 
12than 18 years of age.  Another study 

reported graft success rate of 88% at one year 

of follow up, in 100 cases of myringoplasty 

performed in children less than 14 years of 
13age.  In another study of 231 cases of 

paediatric myringoplasty, 93.5% graft 

success rate was achieved at one year of 
14follow up.  

Few studies reported delayed perforations 

reducing the overall initial success rate. In 

one study, overall graft success rate of 87% 

was reported with 3 years of follow up 

whereas in another with longer follow up 

period, 80.5% graft success rate was 

re p o r t e d  i n  4 1  c a s e s  o f  p e a d i a r t i c  

Myringoplasty. The mean follow up period 
9in that study was 39 months.  We reported 

91.8% graft success rate in children at 6 

months of follow up. We suggest studies 

with long term follow up of at least three 

years to evaluate the issue of delayed graft 

failures in paediatric myringoplasty.

The functional results of paediartic 

myringoplasty are not only promising but 

are also comparable to same procedure in 

adults. All of our patients in both child and 

adult group had hearing improvement after 

the surgery except those with graft failures. 

We noted an average air-bone gap closure of 

13.5 dB and 12.5 dB in child and adult group 

respectively. The difference in air bone gap 

closure in both groups was statistically 

insignificant. These results showed that the 

functional results of paediatric and adult 

myringoplasty are comparable. This view is 

shared by number of other studies reported 
13,15in literature.

We believe that the results of our study may 

be of considerable importance in resolving 

the controversy of paediatric myringoplasty 

in favor of early surgical intervention. This 

will confer considerable benefits to children 

with tympanic membrane perforation in 

terms of improved hearing and decrease in 

number of recurrent ear discharge, which in 

turn leads to better overall academic and 

intellectual performance and socialization. 

In spite of our study results, we suggest that 

further studies should be carried out with 

larger number of patients and longer follow-

ups to resolve the controversy regarding 

paediatric myringoplasty.

The success rate of myringoplasty in 

Conclusion



children is comparable to that of same in 

adults both in terms of anatomical and 

functional gains.

1. Ashfaq M, Aasim MU, Khan N. Myringoplasty: 

anatomical and functional results. Pak Armed 

Forces Med J 2004; 54:155-8.

2. Sheahan P, Dwyer T, Blayney A. Results of type 1 

tympanoplasty in children and parental 

perceptions of outcome of surgery. J Laryngol 

Otol2002 ;116: 430-34.

3. Kessler A, Potsic WP, Marsh RR. Type 1 

tympanoplasty in children. Arch Otolaryngol 

Head Neck Surg. 1994;120: 487-90.

4. Isaacson G.  Tympanoplasty in children. 

Otolaryngol Clin North Am1994; 27: 593-605.

5. Koch WM, Friedman EM, McGill TJ, Healy GB. 

Tympanoplasty in children. Arch Otolaryngol 

Head Neck Surg 1989; 116:35-40.

6. Mak D, MacKendrick A, Bulsana M et al. 

Outcomes of myringoplasty in Australian 

Aboriginal children and factors associated with 

success: a prospective case series. Clin 

Otolaryngol Allied Sci. 2004; 29:606-11.

7. Gersdorff M, Garin P, Decat M, Juantequi M. 

Myringoplasty : long- term results in adults and 

References

children. Am J Otol 1995;16: 532-5.

8. Bluestone CD, Cantekin EI, Douglas GS. 

Eustachian tube function related to the results of 

tympanoplasty in children. Laryngoscope 1979; 

89: 450-8.

9. Pignataro L, Berta L, Capaccio P, Zaghis A. 

Myringoplasty in children: anatomical and 

functional results. J Laryngol Otol 2001; 115: 369-

73.

10. Chandrasekhar SS, House JW, Devgan U. 

Pediatric tympanoplasty. A 10 years experience. 

Arch Otolaryngol Head Neck Surg 1995; 121: 873-

8.

11. P o t s i c  W P,  Wi n a w e r  M R ,  M a r s h  R R .  

Tympanoplasty for the anterior- superior 

perforation in children. AmJ Otol 1996; 17:115-8.

12. Rafi T. Tympanoplasty in children-A study of 30 

cases. J Surg Pakistan2001; 6:11-12.

13. Umapathy N, Dekker PJ. Myringoplasty: is it 

worth performing in children? Arch Otolaryngol 

Head Neck Surg.2003;129:1053-5.

14. Denoyelle F, Roger G, Chauvin P, Garabedian EN. 

Myringoplasty in children: predictive factor of 

outcome. Laryngoscope. 1999;109:47-51.

15. Alberna R, Riontino E, Giordano L, Gervasio CF et 

al. Myringoplasty in children: a comparison with 

an adult population. Acta Otorhinolaryngol Ital 

1998; 18: 295-9.

7