145 / 232
surgeons
to
trainees
[15,28]
but
no
study
has
previously
investigated
specifically
success
rate
of
tympanoplasty
in
estab-
lished
surgeons. While
the
surgeons’
choices of
surgical
approach,
technique and graft material may have
influenced
their
individual
success
rate,
this
study
was
not
powered
to
detect
factors
to
explain
individual
surgeon’s
success
rate.
While
there appeared
to be a
strong association between use of
acellular
dermis
and
success
rate,
the
association
between
graft
material,
specifically
acellular
dermis,
and
success
rate was
not
maintained
on multivariate
analysis.
This may
have
been
due
to
the
fact
that
the
association
may
have
been
explained
by
the
surgeon’s
identity, as
surgeons 2 and 3 were
the main users of
this
material.
It may also be due
to a
lack of power due
to
the small size
of
the study. Given some of
the advantages of acellular dermis such
as
avoidance
of
a
post-auricular
incision
in
trans-canal
tympano-
plasty,
further
research
is
needed
to
determine whether
acellular
dermis
is
a
acceptable
graft
material
alternative
for
pediatric
tympanoplasty.
Other
factors
that
have
been
previously
evaluated
for
their
possible
association
with
pediatric
tympanoplasty
success
rate
were
evaluated
as
part
of
our
study. On multivariate
analysis,
in
addition
to
surgeon,
surgical
approach
and
etiology of perforation
were
found
to
be
associated with
success
rate
of
tympanoplasty.
The
only
study having directly
evaluated
the
success
rate
of post-
auricular
compared
to
trans-canal
tympanoplasty
in
children had
not
found
any
difference
in
the
success
rate
between
the
two
approaches
[2]
. However,
given
the
narrower
ear
canal
in
young
children,
the
post-auricular
approach
could
be
advantageous
in
providing
better
exposure
to
the
tympanic membrane
and
thus
lead
to
better
success
rate. With
the
increased use
of
the
otologic
endoscope and
increased exposure associated with
this
technique,
it
would
be
interesting
to
evaluate
whether
this
will
lead
to
a
decrease
rate
of
perforation
post-tympanoplasty
in
transcanal
tympanoplasties.
In
summary,
the otolaryngologist
should notify
the
caregivers
of
the
pros
and
cons
of
early
repair
and
inform
the
parents
of
the
potential
for
an
unsuccessful
outcome
in
younger
children
undergoing
tympanoplasty.
Advantages
of
early
repair
include
prevention
of
complications
such
as
potential
reduction
of
chronic
otitis
media,
improved
hearing
and
the
ability
to
participate
in water activities. Disadvantages
include a potential-
ly
more
technically
difficult
surgical
procedure
due
to
the
smaller
size
of
the
external
auditory
canal
and
higher
failure
rate and possible need
for a
revision procedure or
tympanostomy
tubes.
5.1.
Strengths
and weaknesses
The major
strength
of
this
study
is
the
large
number
of
pre-
school age children
included
in
the analysis as well as
the
large size
of
our
cohort.
In
addition,
these
results
represent
a
‘‘real
life’’
situation
with
children
with
and
without
comorbidities
having
undergone
surgery
by multiple
surgeons
using
different
surgical
techniques.
Finally,
this
is
one
of
few
studies
having
performed
multivariate
analysis
in
order
to
determine
the
factors
associated
with
failure
of
pediatric
tympanoplasty.
The most
important weakness of
this study
is
the short duration
of
follow-up.
One
hundred
twenty-nine
children
had
less
than
6 months
of
follow-up
and
the median duration
of
follow-up was
only
7
months.
This
is
partially
attributed
to
the
fact
that
the
tympanoplasties were performed
in a
tertiary care
institution with
a
large
referral
base
and
that
some
children may
have
had
post-
operative
care performed by an otolaryngologist
closer
to home.
It
is possible
that
the
results obtained would have differed
if
follow-
up had been
longer. The differences
in
results between all children
and
children with 6
or more months
of
follow-up
could be due
to
the
fact
that
children with
an
intact
tympanic membrane
at
the
first
follow-up
visit
may
be
less
likely
to
return
for
follow-up.
Conversely,
it
is
possible
that
children
who
did
not
have
a
minimum
of
6
months
of
follow-up
may
have
developed
a
recurrent
or
residual
perforation
that went
undiagnosed
due
to
their
failure
to
return
for
a
follow-up
visit
thus
lowering
the
recurrent
or
persistent
perforation
rate when
including
children
with
less
than
6 months
of
follow-up
in
the
current
analysis.
6. Conclusion
This
is
the
first
study
evaluating
the
success
rate
of
tympanoplasty
in
pre-school
children
and
the
study
with
the
largest
number
of
children
under
6
years
old.
After
adjusting
for
confounders,
pre-school
children
appear
to
have
a
significantly
higher
odd
of
perforation
post-tympanoplasty. While
it
remains
uncertain whether
the possible
improvement
in quality of
life and
small
improvement
in hearing
thresholds
associated with
tympa-
noplasty
outweighs
the
risk
of
tympanoplasty
failure
in
young
children,
the 26%
rate of
revision
tympanoplasty
in children age 2–
4
years
old
suggest
that
surgery may
be
best
delayed
in
that
age
group.
Prospective
studies
with
a
longer
follow-up
period,
large
sample
size
and
quality
of
life measures
are
needed
to
elucidate
some
of
the
key
questions
generated
from
this
and
prior
studies.
Table
6
Adjusted odds
ratio of association between perforation and age group by
logistic
regression after controlling
for confounding effect of surgeon, surgical approach and etiology
of
perforation.
Variable
Level
Adjusted OR
of
perforation
OR
(95%CI)
n
=267
Adjusted OR
of
perforation
if
follow-up
>
6mos
OR
(95%CI)
n
= 146
Age
group
2–4
years
old
2.46
(1.04–5.85)
5.48
(1.68–17.93)
5–7
years
old
2.06
(1.06–4.00)
2.27
(0.94–5.46)
8–13
years
old
1.0
1.0
Surgeon
1
1.0
1.0
2
1.62
(0.71–3.73)
1.16
(0.40–3.33)
3
3.48
(1.49–8.11)
5.07
(1.64–15.62)
4
3.66
(0.95–14.15)
3.12
(0.61–15.80)
Approach
Post-auricular
1.0
1.0
Trans-canal
2.37
(1.15–4.90)
2.76
(1.07–7.09)
Etiology
Tympanostomy
tubes
1.0
1.0
Chronic
otitis media
0.32
(0.06––1.56)
0.13
(0.01–1.47)
Trauma
0.25
(0.03–2.16)
0.57
(0.05–6.30)
M. Duval
et al.
/
International
Journal
of
Pediatric Otorhinolaryngology
79
(2015)
336–341
123