What is in this issue

In most clinical practices, traumatic perforations of the pars tensa are uncommon. To date, the general advice is to let them heal by themselves as spontaneous healing is likely and the only thing that onemight consider doing is repositioning any inverted/everted edges. In recent years, large studies, mainly from one centre in China, have been published in this journal. The Chinese authors over the same time period have also widely published randomised controlled or case-controlled studies of the management of traumatic perforations in other journals. Perusal of all these papers has not identify any potential overlap in what they were reporting, which has been a combination of different patients (adults, females, children), size of perforation (small, large, all sizes), aetiology (direct trauma, all trauma) and intervention (none, topical gelfoam, growth factor, repositioning edges). In this issue (page 289), a case-controlled trial of the management of 58 patients with traumatic perforations, affecting more than 50% of the pars tensa with inverted edges, is reported. These patients were recruited between February and May 2012. Such patients were sequentially allocated to; no intervention, approximation of the edges or growth factor applied topically at presentation and continued by the patient until healing had occurred. None of the previous studies had investigated this particular comparison, which is a particularly clinically relevant one. The main outcome at 6 months was the percentage healed and rate of healing. At 6 months, no difference was found in the percentage healed in the ears that had approximation of the edges compared with those that had no intervention (60% versus 56%). It also did not shorten the healing time (mean of 48 versus 46 days).This finding corroborates one of these groups’ earlier papers that showed that if followed up for 12 months, there was no difference in spontaneous healing rates between those with inverted/everted edges than those without curled edges. This should settle the question of benefit of repositioning of the edges; there is none. The main positive finding in the current paper was the significantly greater percentage healed at 6 months when topical growth factor was used with no intervention (100% versus 56%). In those that healed, the healing rate was also significantly shorter (12 versus 48 days). All these findings were confirmed by photographic otoscopy. Audiometry was not performed as the authors were of the opinion that ‘healing of the perforation was always associated with successful closure of the air-bone gap’. This would indeed appear to be the case from their earlier paper. So where does this take us, along with the paper from the same author that was published in Clinical Otolaryngology that looked at the factors that might affect the spontaneous healing rate and time to closure. At 12 months, small, medium and large perforations had similar healing rates (91%, 84% and 80%, respectively), but the larger perforations took longer to heal. So it is likely that the paper in this issue, if patient follow-up had been 12 months, there would be no difference in closure rates between groups but with faster healing with growth factor. This Chinese group previously have no difficulty with lost to follow-up so supplementing the current paperwith a 12-month follow-up should be easily achievable.