What is the optimal age to repair tympanic membrane perforations in pediatric patients?

BACKGROUND Tympanic membrane perforation is a common pediatric otolaryngology diagnosis that most frequently occurs after myringotomy tube extrusion, complicated otitis media, or traumatic perforation. Repair is often necessary if it does not heal spontaneously. Untreated perforations can lead to conductive hearing loss, speech delays, chronic otorrhea, the need for precautions during water sports, and migration of squamous epithelium into the middle ear space where it can form cholesteatoma. Repair is typically performed with autologous fascia and/or cartilage grafts and can be described as a tympanoplasty or myringoplasty. The reported success of repair ranges from 35% to 94%, which is lower than in the adult population. This difference may be due to relatively more frequent upperrespiratory tract infections or persistent Eustachian tube dysfunction in children. The variability in criteria for surgical and audiologic success contributes to the wide range reported in the literature. Most studies on this topic do not exactly follow the American Academy of Otolaryngology– Head and Neck Surgery 1995 guidelines for the evaluation of treatment results of conductive hearing loss. Duration, size, and location of the perforation; status of the contralateral middle ear; Eustachian tube function; adenoid hypertrophy; and surgeon experience can all influence the outcome. Disagreement exists regarding the optimal age to repair tympanic membrane perforations and whether there is benefit to waiting until the child is past a certain age. Many different algorithms for timing repair have been proposed. The purpose of this study is to evaluate the literature to determine the optimal time to repair tympanic membrane perforations in the pediatric population. LITERATURE REVIEW Preceding studies that recommended delaying tympanic membrane repair to 7 to 11 years of age lacked longterm follow-up. In 2007, Yung et al. published results from a full year after primary repair of central perforations due to chronic otitis media. Previous studies may have missed late failures. Fifteen children aged 4 to 8 years were compared to 36 children aged 9 to 13 years, and success was defined as an “intact tympanic membrane, free from OME, atelectasis, ear discharge, and myringitis, and with no worsening of hearing.” Success was achieved 63% of the time. They found no difference in outcome between the older and younger age groups for either the full definition of success or for any of the components of the definition. The majority of publications evaluating pediatric age assessed repair with fascia grafts. After positive reports of perforation closure with cartilage grafts in adults, Friedman et al. compared type I cartilage tympanoplasty outcomes in a total of 119 patients in three age groups: age 4 to 7, 7 to 10, and 10 to 13 years. They found no difference in graft take or audiological outcomes between the three groups. Their overall success ranked high at 95% at an average of 1.5 years after surgery. Their clinical algorithm is to perform tympanoplasty after 4 years of age. If the contralateral middle ear is abnormal, they will treat the nose, consider adenoidectomy, and delay tympanoplasty until age 7. A prolonged delay of tympanic membrane repair may have negative long-term effects. An analysis by Knapik et al. of a cohort of 201 patients without dysmorphic syndromes who underwent tympanoplasty alone found no difference in anatomic outcomes between 0 to 11 years olds compared to 12 to 18 year olds. Anatomic failures were defined as ears with “perforations, middle ear cholesteatoma or tympanic membrane retractions higher than grade 1.” Although there was no difference in air–bone gaps between the two age strata, preoperative and postoperative bone conduction thresholds were significantly worse in the older cohort. Knapik et al postulated that this may be due to recurring infections in the setting of a chronic perforation that result in long-term irreversible inner ear damage. Complications can also occur as a result of the procedure itself. Ribeiro et al. divided 79 tympanoplasties From the Division of Head and Neck Surgery and Communication Sciences, Department of Surgery, Duke University Medical Center (M.A.R., D.K.), Durham, North Carolina, U.S.A.