Tuesday, 4 October 2016

Tonsillitis diagnosis and treatment


Long term effects of low dose gentamicin in unilateral Meniere/s disease - our choice.

           LONG-TERM  RESULTS  OF  LOW DOSE GENTAMICIN IN UNILATERAL                                                               MENIERE’S  DISEASE.                                                       

                                 (KEM HOSPITAL PUNE STUDY  2010 to 2016)


Abstract

Recently, the "low dose" protocol with just one or two injections in total spaced 1 month apart, has become the standard treatment for Menieres Disease with gratifying results.
Chemical perfusion of the inner ear is an increasingly popular treatment for Ménière's disease.
 The author reports on the long-term results of 50 patients treated with gentamicin delivered via a round window . Patients with Ménière's disease underwent intra-cochlear infusion of low  gentamicin  (10 mg/ml)  through round window niche  approache. Vertigo was controlled in 95 per cent, whilst preserving hearing in 90 per cent. Of patients. . Tinnitus and aural fullness remained improved in 85 percent.
 Long-term vertigo control can be achieved using low dose gentamicin, whilst preserving hearing and vestibular function in the majority of patients.. The procedure is not (very) painful a  local  anesthetic is used to numb the ear drum. A drop of phenol on the ear drum is one method. Another is a topical anesthetic such as "Emla" cream. Or 10% xylocaine spray. The drug is injected, through RW niche and  left in the middle ear for 30 minutes while the person is lying quietly, and then an attempt is made to clear it from the middle ear via the ET tube (with swallowing and "popping" the ear)..
Keywords: Ménière's Disease, Gentamicin, glycerol CDP
INTRODUCTION
Ménière's disease is a clinical disorder defined as the idiopathic syndrome of endolymphatic hydrops.1 It is an obvious finding that the Ménière's patients rated their quality of life (QoL) significantly worse in both the physical and psychosocial dimensions than the normal healthy subjects. Previous studies have shown that vertigo has more impact on the physical aspects, whereas tinnitus and hearing loss seemed to influence the psychosocial and emotional aspects more than the physical aspects.2 There is no cure for Ménière's disease and interventions do not eliminate the underlying cause of it.
In recent decades, intratympanic gentamicin administration for treatment of Ménière's disease has gained widespread popularity and has demonstrated its clinical effectiveness in the control of intractable vertigo associated with Ménière's disease in a variety of clinical studies.3, 4 Different methods of administration with gentamicin include multiple daily dosing, weekly administration for four total treatments, low-dose therapy consisting one to two injections month apart with repeating treatment only for recurrent vertigo symptoms,  Although numerous articles have been published using each of these techniques, to date there is no agreement between the otolaryngologists regarding which technique offers the greatest amount of vertigo control with the lowest rate of complications.5 According to the concept of partial vestibular ablation, only reduction in vestibular function may be enough in most patients to control the vestibular symptoms of the disease.5 However, a recent meta-analysis have shown that the low-dosage method, in contrast, trends toward worse effective vertigo control than the other methods.3
Newer techniques such as the computerized dynamic posturography (CDP) have facilitate objective evaluation of patients with balance disorders. This technique allows analysis of the information supplied by the three sensory systems (i.e. visual, vestibular and proprioceptive) which contribute to the maintenance of balance. CDP has been shown to be a cost-effective and useful technique for the characterization and monitoring of patients with balance disorders.6

Materials and Methods

In a prospective clinical study, 50 patients with unilateral definite Ménière's disease according to the definition of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS)8 were included in the study from January 2010 to February 2016. Criteria for offering intratympanic gentamicin as a treatment option included intractable vertigo despite lifestyle modification and drug-therapy (2 g per day sodium diet, diuretics and betahistine) for at least 6 months no symptoms suggestive of auditory or vestibular disease in the contralateral ear, and serviceable hearing in the contralateral ear. No patient had history of previous ear surgery, neurologic disorder or aminoglycoside sensitivity.
 At the beginning of study, after explanation of treatment efficacy and probability of complications including dead ear and balance problems such as “curative vertigo”,9 each patient gave written informed consent for treatment with intratympanic gentamicin. Pretreatment evaluation included a complete neuro-otologic evaluation, magnetic resonance imaging (MRI), pure tone average (PTA) measurement and impedance audiometry  SISI score  Tone decay  and Glycerol test were recorded. An arbitrary scoring system (0 = none, 1 = mild, 2 = moderate, 3 = severe) used for aural fullness and tinnitus grading.
Ten minutes before the injection, the tympanic membrane was anesthetized with topical 10% xylocaine spray. During the procedure, each patient lay supine and the tympanic membrane of the involved ear was visualized under the operating microscope with the head turned 45 degree to the opposite side to prevent leakage of the solution through the Eustachian tube and to allow for adequate contact of the drug with round window membrane. The 0.5 ml of the stock buffered  gentamicin solution (10 mg/ml) was drawn into a tuberculin syringe and with a  27-gauge, 1.5" slightly bent  needle was injected posterioinferiorly. After the injection, the patient maintained this head position for at least 45 minutes and was told to avoid swallowing to prevent any opening of the Eustachian tube. Few patients experienced some burning pain lasted seconds and resolved immediately
Patients were asked to consider water precautions for two weeks and return for initial follow-up after four weeks. In this follow-up session, the frequency of vertigo, functional level, aural fullness and tinnitus changes and severity of these symptoms were recorded and audiometry, was repeated. Patients were also asked to return after two months for follow up.
However in our study, using one-shot low-dosage gentamicin led to complete vertigo cessation  in 95% of the patients In the second follow-up, 75% of our patients reported decrease in both aural fullness and tinnitus. Similar findings regarding fullness have been reported previously,20 but our results about tinnitus decrease were striking. Some investigators have proposed that gentamicin exerts its effects primarily not only on the sensory hair cells but also on the destruction of the dark cells within the labyrinth that are responsible for endolymph production. Thus, the effect of gentamicin should be due to not only destruction of vestibular function but also relieving endolymphatic hydrops.16
Glycerol Positive test clinically confirms endolymphatic hydrops.Patient will have 30 to 40% good hearing and 80 to 90% vertigo control.A positive test would be contra indicated for Labyrinthectomy. Negative test result is indicative of no post op hearing gain and vertigo control and will be contra indicated  for endolymphatic sac surgery
The advantages of dehydration testing cannot be ignored. Such testing can easily be incorporated into a clinical test battery for the diagnosis of Meniere's disease .


Gentamicin vs. steroids vs. vestibular nerve section

There are some complex judgements that come up when one needs to have "something done" about Meniere's disease. Essentially, it comes down to cost vs. benefit
Method
Hearing Risk
Effectiveness
Durability
Other considerations
Minimal
Moderate
3 months
Not a logical treatment as doesn't last.
Low dose Gentamicin
Minimal
High
Moderate (1-2 yr)
Best choice
High dose gentamicin
Moderate
High
Usually permanent
Permanent imbalance not unusual
Labyrinthectomy
sure loss
High
Permanent
Permanent imbalance AND hearing loss AND highly invasive
Moderate
High
Permanent
Permanent imbalance
Highly invasive

 

Results:
Our results with this group of patients after interval-treatment or single-shot application of intratympanic gentamicin demonstrate the effectiveness of this treatment modality without morbidity although our experience is still limited, it allows for expanding the indication on early cases of Menière's disease before permanent hearing loss occurs.. Cochleotoxic side effects can be prevented by treatment intervals of one month. A substantial advantage of TTG treatment is low cost, compared to alternative destructive treatments (i.e. vestibular nerve section or labyrinthectomy). Most authors find that the control of vertigo is comparable to vestibular nerve section (about 90%). TTG treatment is also intrinsically of very low risk, especially compared to nerve section. Compared to labyrinthectomy, TTG treatment is also lower in risk because there is no need for general anesthesia.Even cases of bilateral Menière's disease can be treated successfully using this method.


Conclusion
One-shot low-dosage gentamicin is completely effective on controlling vertigo attacks in Ménière's disease and has useful effects on the aural fullness and tinnitus of patients as well. However, even doses as low as 10 mg gentamicin can cause hearing loss. VEMPs and CDP may have only adjunctive role in monitoring therapeutic responses in intratympanic gentamicin therapy.

Dr.K.K.Desarda.
Prof.Emeritus BJMC & Head otolaryhgology
KEM Hospital,
Pune.

REFERENCES:
  • Abou-Halawa AS, Poe DS. Efficacy of increased gentamicin concentraion for intratympanic injection therapy in Meniere's disease. Otol Neurotol 23:494-503, 2002
  • Adamonis J and others. Electrocochleography and gentamicin therapy for meniere's disease: a preliminary report. Am. J. Otol 21:534-542, 2000
  • Bauer PW, MacDonald CB, Cox LC. Intratympanic gentamicin therapy for vertigo in nonserviceable ears. Am J Otolaryngol 2001 Mar-Apr;22(2):111-5
  • Beck C, Schmidt CL (1978) Ten years experience with intratympanically applied Streptomycin (gentamicin) in the therapy of morbus Meniere. Arch Otolaryngol 221, 149-152
  • Blakely BW. Clinical Forum: A review of intratympanic therapy. Am J. Otol, 18:520-526, 1997
  • BOTTRILL I, Wills AD, Mitchell AL. Intratympanic gentamicin for unilateral Meniere's disease: results of therapy. Clin Otolaryngol 2003; 28: 133-41
  • Brandtberg K, bergenius J, Tribukait A. Gentamicin treatment in peripheral vestibular disorders other than meniere's disease. ORL 1996;58:277-279
  • Casani, A., D. Nuti, S. S. Franceschini, et al. (2005). "Transtympanic Gentamicin and Fibrin Tissue Adhesive for Treatment of Unilateral Meniere's Disease: Effects on Vestibular Function." Otolaryngol Head Neck Surg133(6): 929-35.
  • Chia, S. H., A. C. Gamst, J. P. Anderson, et al. (2004). "Intratympanic gentamicin therapy for Meniere's disease: a meta-analysis." Otol Neurotol25(4): 544-52.
  • Cureoglu S and others. Effect of parenteral aminoglycoside administration on dark cells in the crista ampularis. Arch Otol HNS 2003:129: 626-628
  • Driscoll CL, Kasperbauer JL, Facer GW, Harner SG, Beatty CW. Low-dose intratympanic gentamicin and the treatment of Meniere's disease: preliminary results. Laryngoscope 107(1):83-9, 1997
  • Eklund and others. Effect of intratympanic gentamicin on hearing and tinnitus in Meniere's disease. Am J. Otol 20:350-356, 1999
  • Flanagan, S., P. Mukherjee and J. Tonkin (2005). "Outcomes in the use of intra-tympanic gentamicin in the treatment of Meniere's disease." J Laryngol Otol: 1-5.
  • Gabra N, Saliba I. The Effect of Intratympanic Methylprednisolone and Gentamicin Injection on Meniere's Disease. Otolaryngol Head Neck Surg. 2013 Jan 11. [Epub ahead of print].
  • Gode S, Celebisoy N, Akyuz A, Gulec F, Karapolat H, Bilgen C, Kirazli T. Single-shot, low-dose intratympanic gentamicin in Ménière disease: role of vestibular-evoked myogenic potentials and caloric test in the prediction of outcome. Am J Otolaryngol. 2011 Sep-Oct;32(5):412-6. Epub 2010 Sep 18.
  • Hanson HV (1951). The treatment of endolymphatic hydrops (Meniere's disease) with Streptomycin . Ann ORL 60, 676-691
  • Harner, S. G., C. L. Driscoll, et al. (2001). Long-term follow-up of transtympanic gentamicin for Meniere's syndrome. Otol Neurotol 22(2): 210-4.
  • Helling K, Schönfeld U, Clarke AH. Treatment of Ménière's Disease by Low-Dosage Intratympanic Gentamicin Application: Effect on Otolith Function.Laryngoscope. 2007 Sep 28;
  • HOFFER ME, Allen K, Kopke RD, Weisskopf P, Gottshall K, Wester D. Transtympanic versus sustained-release administration of gentamicin: kinetics, morphology, and function. Laryngoscope 2001; 111: 1343-57.
Dr. K.K.Desarda.
Prof.Emeritus B.J.Medical college  & Head otolaryngology
KEM Hospital
Pune

10th August 2016

Wednesday, 27 January 2016

Endoscopic Fat graft myringoplasty


ENDOSCOPIC FAT GRAFT MYRINGOPLASTY WITH EVICEL(SEALANT) APPLICATIONS
DR.K.K.DESARDA
A prospective study at KEM Hospital Pune
Abstract:
The aim of endoscopic fat graft myringoplasty (FGM) under local anaesthesia  clinical trial was to evaluate the success rate of our newly developed surgical technique We also aimed to assess the correlations between the size of perforations and closure rates, as well as the results of re-gained hearing in successful cases with respect to sizes of perforations. Fifty consecutive patients with persistent tympanic membrane perforation were included in this study. All patients underwent  endoscopic fat graft myringoplasty with evicel (Human selant fibrin glue)  .application.  Treatment success was defined as an intact and mobile tympanic membrane (TM) at the 3-month follow-up visit. Bone conduction (BC) and air conduction (AC) thresholds at the frequencies of 0.5, 1, 2, 3, and 4 kHz were recorded preoperatively and at the 3rd month postoperatively.
The fat graft tympanoplasty can be performed under local anesthesia . The harvesting of the graft is very quick and there is no visible scar and minimum donor site morbidity.  It avoids extensive middle ear manipulation.  It is a safe and simple procedure for the closure of a dry, small central perforation.  Its success rate is as good as tympanoplasty using temporalis fascia or perichondrium.The success rate is 98 to 100% for small central perforations.A fat graft myringoplasty achieves its highest success rate in perforations smaller than 30% of the pars tensa.We strongly recommend the endoscopic fat graft myringoplasty procedures  for small central perforations which achieves 98% graft take up with 15 db air bone gap closure.

.
Key Features:   Endoscope,fat graft, evicel sealant glue,.myringoplasty
INTRODUCTION:
  A prospective clinical study of  endoscopic fat graft myringoplasty  for small  central tympanic membrane perforations due to: trauma, infection, post-tympanostomy tube extraction and post myringoplasty residual perforations was carried out at KEM  and Sahyadri speciality Hospital Pune during 2014 to 2015. Fifty cases of fat graft myringoplasties were done using evicel selant ( J & J co. ltd ) application .The post op results were excellent about (98%) were analysed.Temporalis fascia  and  perichondrium  use to be the most common grafts being used in closure of the tympanic perforations.   However for a dry, small central perforation the adipose tissue fat is a good alternative. 
 A myringoplasty is one of the most common operations performed in Otosurgery, due to the high incidence of tympanic membrane perforation.  The first attempt to close the tympanic perforation was done by Banzer in 1640 who inserted a small tube of elkhorn covered with pig’s bladder.1  Berthold in 1878 used a full-thickness free skin graft for tympanic membrane closure.2  Ringenberg used a fat tympanoplasty for the first time for the closure of a small tympanic perforation.
 The fat graft tissue tympanoplasty has certain advantages as this procedure can be done in an office basis or on an outpatient basis. The patient goes home on the same day. There is very limited postoperative care.  Fat can be harvested in a very short time and it avoids invasive extensive surgical manipulation of the middle ear.  It avoids general anesthesia and is very safe for a dry, small, central perforation.  It is a simple and cost effective technique in managing small tympanic membrane perforation and the success rate of a fat-plug myringoplasty is comparable with the results of temporalis fascia tympanoplasty.
Fifty patients aged between 20 to 55 years; with fat graft myringoplasty were operated endoscopically for closure of tympanic membrane perforation at KEM  and Sahyadri speciality Hospital Pune during 2014 to 2015 under local anaesthesia Follow up visits for tympanic membrane evaluation, were in the 1, 3, 6 and 12th post-operative months. Failure cases were counted at the end of the 1st month post-operatively. Hearing evaluation was done pre-operatively and in the 4th postoperative month. Closure of the air bone gap was the parameter of hearing improvement. The outcome measures were the post-operative state of tympanic membrane, hearing improvement in closure of the air-bone gap and incidence of failures and complications.Three groups of the patients were selected for fat graft myringoplasty procedure The groups included. Were residual perforation,traumatic perforations and post grommet extrusion perforations.All perforations were small central type with minimum conductive hearing loss.  
 The Mean operative time was 30 minutes. No side effects or operative complication occurred during the procedure.The successful procedures were (98%) from the entire patient group. Post-operatively, the mean improvement in the air/bone gap was about 15 dB for the successful cases.
Materials  and  Methods:
A retrospective study was done in the Department of Otorhinolaryngology, KEM and Sahyadry Hospital Pune during 2014 to 2015, to evaluate myringoplasty using only fat (adipose tissue) to close the eardrum perforation.    All the surgeries were done by the first author.  A total of 50 cases that underwent consequent fat-plug myringoplasty were included in the study.  30 adult male and 20 female patients were selected for this procedure under local anaesthesia.The children age group was excluded from this study because of their recurrent URTI and Eustachian tube dysfunction.
  The perforation was situated in the anterior inferior quadrant in twenty cases,and posterior inferior quadrant in thirty cases . The criteria for the small perforation was that the size of the perforation be approximately 5 by 5 mm or 25  to 30%  of the drum's surface .Free fat grafts have been known to reduce in size during long-term follow up. This is the reason why the grafts used were approximately two times larger than the size of the perforation. In this study subtotal and total perforations were excluded. The subsequent otoendoscopic evaluation revealed closure of the perforation which was considered as successful criteria for a fat-graft myringoplasty.  The subsequent post.op. audiometric evaluations were done and compared with pre.op.audiometrtic profie which revealed closure of AB gap bt 15db.
  Surgical Technique:
  Endoscopic Transcanal transtympanic approach without raising
  tympanomeatal flap:
  Graft Harvesting:
The ear lobe was infiltrated using 2% lidocaine with 1:200,000 adrenaline and a 5 mm incision was made at the medial surface of the tip of the ear lobe with no. 15 blade. The skin was undermined and an amount of fat as twice as the size of the perforation was harvested in one piece and was put in a sterile saline solution. The incision was closed by one or two 5–0 absorbable sutures(Fig.1)
With 4 mm zero degree endoscopic  vision, the edges of perforation were freshened. The middle ear was filled with antibiotic soaked gelfoam.The fat was trimmed at an approximately twice the size of the perforation or lesser. It was placed over the perforation and plugged in it as an hourglass through the perforation using a pick or blunt needle. The lateral fat bulge should not be too high to help epithelial closure of the perforation. Oversized fat plug may cause a tear in the tympanic membrane or overstretching of the perforation margins leading to atrophy or necrosis later on. Undersized fat plug should be avoided to prevent dehiscence in grafting .The graft was kept humidified by pieces of gelfoam upon and around the outer portion of the fat and stabilized by using a thin film of evicel selant (human fibrin glue) covering the tympanic membrane. The external ear was filled with pieces of gelfoam soaked with local antibiotic drops  The external ear opening is sealed with a merocel ear pack. No ear dressing was used. The merocel pack was removed after 48 hrs.

                       The sequential pictures of fat graft myringoplasty:


Fig.1       Fat graft harvesting from post.surface of ear lobule.





Fig,2  Endoscopically  freshening of edges of perforation of Small CP


                         
         Small cenral perforation                                Freshening the edges

                                            
                 Removal of perforation ring              post excision of perforation                                                              



Fig.3                 Endoscopically  Fat plugging of the perforation

         



Fig .4                        Gelfoam packing & Evicel glue application
                         
           Geifoam packing                                              Evicel sealant application


  
Fig.5.        Endoscopic  fat graft  pictures pre & post  operation after 8 wks
                
A)      Pre op central perforation.          B) post op fat graft  as neotympanum
                                                                    
           The clinical criteria established by Fiorino and Barbieri for admission to fat
            graft myringoplasty

1. Period of time elapsed from previous surgery equal to or longer than 6 months.
2. Perforation of the pars tensa no larger than 5 mm.
3. Non-marginal localization, i.e. not involving the annulus or exposing the
    malleus handle.
4. Absence of calcific plaques or atrophic areas adjacent to the perforation.
5. Normal appearance of mucosa in the tympanic cavity.
6. Absence of any acute inflammation.
7. Absence of middle ear discharge in last 3 months.
8. No evidence of cholesteatoma.
9. No planned ossicular reconstruction.
10. Absence of major Eustachian tube dysfunction.






 Results

Fifty patients were included in this endoscopic study,  fourty two  patients had unilateral, while eight patients had bilateral perforations.who had fat graft myringoplasty. The eight bilateral perforation cases were all due to post-long term tympanostomy tube extraction and the selection of which ear to be operated upon was the ear with a larger air bone gap. If both air bone gaps are equal, the larger perforation was operated first. The second ear was operated upon after 3 months of complete healing of the 1st ear.
There was no side effect or complication at the time of the procedures. The mean operative time for the procedure counted from the beginning of the marginal refreshing of the perforation to closure of external ear canal by merocel pack was 30 min.
Fat graft myringoplasty procedure has a minimal technique failure especially if the selection criteria were applied to the patients for this surgery. All cases had evicel selant(Fibrin glue ) application for graft take up.The graft take up was 98% in all cases and failure cases  were 4%.The advantages of fat graft include: It does not need support from the middle ear side to prevent collapse like underlay grafts especially at the area near the anterior annulus.



Discussion
Ringenberg first described FM, with a success rate of 87% for small perforations. [Since then, studies have shown success rates ranging from 85% to 92% in cases of small perforations.  Deddens et al. had reported that size of TM perforation was a crucial factor. Perforations, in their series, were 5-30% of the drum surface, which was a good prognostic factor for an FM as compared to larger perforations for fat graft alone as was also observed by us. 

The fat graft can be harvested from the abdomen, buttock and ear lobule. The ear lobule fat harvesting is much simpler as it is done from the same sterile area of the surgical field prepared for the fat tympanoplasy and its scar is almost invisible. The fat of ear lobule is denser with big revascularization activity and acts as a good template for mucosal and epithelial growth.  There is significant bulging postoperatively on the TM till the end of the 3 rd month and after that it progressively disappears and gets converted into a smooth sclerotic area on the TM at the 5 thmonth .  This phenomenon was also observed by us in patients where graft uptake was there. There are two histological theories of fat grafts."The host cell replacement theory" of Neuhof and "The cell survival theory" of Peer. The host cell replacement theory states that all the original cells die and are totally replaced by new wondering adipocytes or by fibroblasts. The cell survival theory states that not all the original adipose cells die. Those fat cells which receive adequate blood supply survive whereas remaining degenerate, thus explaining loss of volume. The transplanted fat cells are not replaced by scar tissue, instead a connective tissue capsule outside the fat graft begins 3 weeks after transplantation, which becomes progressively thinner over the course of a year. Fat tissue provides the basic requirement for the grafting of the TM with its own favorable characteristics. 




The  transcanal approach seems to be safer for the patient in comparison to the classic myringoplasty techniques since no manipulations of the middle ear are performed and the related complications are avoided. Fat is not the only material used when the tympanic membrane is approached via the external auditory meatus but it is somewhat easy to harvest and handle. Dursun et  compared the effectiveness of perichondrium and fat in repairs of perforations smaller than 3mm in 30 patients and found no statistically significant differences in the use of the two techniques. In fat subgroups, 2mm and 3mm perforations had an 90% success rate and 1mm perforations a 100% success rate again equal to the perichondrium results
 Free fat grafts have been known to reduce in size during long-term follow up. This is the reason why the grafts used were approximately two times larger than the size of the perforation. Nishimura et observed in an experimental study that apoptotic cells were present 30 days after transplantation.
Although fat graft myringoplasty is a simple, safe and cost-effective procedure, it has been underused despite its numerous advantages.7 However, it cannot be always an alternative procedure to the classic surgical myringoplasty in every tympanic membrane perforation. Certain clinical criteria should be fulfilled and applied for the perforation to have the highest possibility of this procedure’s success
 The clinical criteria established by Fiorino and Barbieri for admission to fat graft myringoplasty were sufficient for the selection of patients eligible for this procedure ..
The first utilization of fat plug myringoplasty was reported by Ringenberg8 with the success rate of 90%. In the following studies the success rate was ranging from 80% to 92% in cases of small perforations including primary procedures. In this study, the success rate of the entire group of patients was 98%.
.
The failure rate for this study was 4 out of 50 ears (8%) with a mean air bone gap of 10 dB and the causes were due to infection, detached fat graft and dehiscence due to undersized grafts. Fiorino and Barbieri  attributed the failure causes to: immediate failures due to technical difficulties such as anterior perforations, inadequate graft support, poor vascular supply or infection; and delayed failures due to tympanic membrane atrophy, infections or Eustachian tube dysfunction. Fat graft myringoplasty procedure has a minimal technique failure especially if the selection criteria were applied to the patients for this surgery. All cases had evicel selant(Fibrin glue ) application for graft take up.
Local anaesthesia was used in most of the literature as the procedure is easy, simple, fast and minimally invasive. 
In this study, the traumatic, the tubotympanic chronic otitis media, the post tympanostomy tube extraction perforation groups were operated upon after 3 months of dryness and failure of closure, while the post myringoplasty residual perforation cases were operated upon after 6 months of failure of closure.
Technical operative points during fat grafting (such as graft size in the perforation, degree of lateral bulge of the fat plug and moistening of the lateral side of the graft are also considered to be important factors of success in the fat grafting procedure.
Fat is also an active material containing angiogenic and survival factors e.g. Monobutyrin, prostaglandins, interleukins 1 and 6, cytokines and tumour necrosis factor which, stimulate restoration and repair of the fibrous layer and promote revascularization which are both essential for survival of the free flap. Fat graft promotes growth factors including vascular endothelial growth factor, transforming growth factor beta, platelet derived growth factor and fibroblast growth factor which promote the process of the tissue repair. Fat contains high population of multipotent cells referred as adipose-derived stem cells which are similar in activity to those of the bone marrow derived mesenchymal stem cells in the ability to differentiate into mesenchymal tissues such as endothelial and fibrous types promoting the healing process of the tympanic membrane.



 Conclusion


Fat graft myringoplasty is an easy, simple, fast and minimally invasive procedure for the repair of small tympanic membrane perforations with favourable hearing results. It can be performed under local . It can be done for small tympanic membrane perforations due to: trauma, infection, post  tympanostomy tube extraction and post myringoplasty persistent residual perforations with good success rate without complication
The evicel sealant (Ethicon J&J co.Ltd) applied as thin film gets absorbed in two weeks leaving the neo-tympanum intact because of its adhesive properties.We strongly recommend this  endoscopic fat graft myringoplasty procedures  for small central perforations which achieves 98% graft take up.A fat graft myringoplasty achieves its highest success rate in perforations smaller than 30% of the pars tensa. Tympanosclerosis should not be a contraindication for fat grafting.







References

1.Ringenberg JC. Fat graft tympanoplasty.  Laryngoscope. 1962;72:188-192
PubMed   |  Link to Article
2.Sterkers JM. Ultra-thin adipogenic graft for tympanoplasty (obtained by crushing subcutaneous adipose tissue under pressure) [in French].  Ann Otolaryngol Chir Cervicofac. 1964;81:265-270
PubMed
3,Terry RM, Bellini MJ, Clayton MI, Gandhi AG. Fat graft myringoplasty—a prospective trial.  Clin Otolaryngol Allied Sci. 1988;13(3):227-229
PubMed   |  Link to Article
4.Gross CW, Bassila M, Lazar RH, Long TE, Stagner S. Adipose plug myringoplasty: an alternative to formal myringoplasty techniques in children.  Otolaryngol Head Neck Surg. 1989;101(6):617-620
PubMed
5.Landsberg R, Fishman G, DeRowe A, Berco E, Berger G. Fat graft myringoplasty: results of a long-term follow-up.  J Otolaryngol. 2006;35(1):44-47
PubMed   |  Link to Article
6. Landsberg R, Fishman G, DeRowe A, et al. Fat graft myringoplasty: results of a long-term follow-up. J. Otola
7.Terry RM, Bellini MJ, Clayton MI, et al. Fat graft myringoplasty – a prospective trial. Clin. Otolaryngol. Allied Sci. 1988;13:227–229. [PubMedryngol. 2006;35:44–47. [PubMed]
8.Bertoli GA, Barbaro M, Giangande V, Bava G, Seta ED, Filipo R. Fat graft myringoplasty: An office procedure for the repair of small perfoations of the tympanic membrane. Mediterr J Otol 2007;3:120-5.