Study of the relationship between the size, location, and duration of tympanic membrane perforation with the value of Air-Bone Gap on pure-tone audiogram

doi:10.21203/rs.3.rs-3499186/v1

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Study of the relationship between the size, location, and duration of tympanic membrane perforation with the value of Air-Bone Gap on pure-tone audiogram

https://doi.org/10.21203/rs.3.rs-3499186/v1

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Background

Tympanic membrane perforation can lead to hearing loss, infection, and negatively affect daily activities. Therefore, it is important to study this condition, and to further understand its causes and symptoms. We conducted this study in which we aim to evaluate the effect of the size, location, and duration of tympanic membrane perforation on the value of the air-bone gap.

Methods

a cross-sectional study in Damascus hospital, on cases from 2014 to 2023, including 83 cases of either sex, 22 cases were bilateral, so the total number of perforation cases was 105, aged 13 years and above, unilateral and bilateral, randomly selected.

Results

Our study included 83 cases, their ages ranged from [13–70] years, with an average of 31.84 ± 12.97. Of the 83 patients, 36 (43.4%) were male and 47 (56.6%) were female. Most cases of perforation were unilateral 61 (73.5%), with a preponderance of left-sided perforation 54 (51.4%). Inflammatory perforation was the most common 62 (59%). Duration of perforation was the most common (less than a year), with a rate of 22 (16.4%). For the size and location of the perforation, the largest percentage (for a central medium) was 26 (24.8%). Hearing loss was 86 (81.9%) as the most common symptom related to the perforation side, and vertigo 9 (10.8%) as the most common symptom not related to the perforation side. By studying the size and location of the perforation, we found that an increase in the size of the tympanic membrane perforation is associated with an increase in the value of the air-bone gap, and by comparing the posterior-inferior-central perforation with the anterior-inferior-central perforations, we found that the posterior-inferior-central perforations are associated with a greater value of the air-bone gap. We also found that as the duration of perforation increases, the value of the air-bone gap increases.

Otorhinolaryngology

Tympanic membrane

Air-Bone Gap

Damascus Hospital

Tympanic membrane perforation may occur following an acute or chronic infection of the middle ear or after a trauma. Whereas the effects of perforation on the mechanism of the middle ear is complex and not fully defined, we do know that conductive hearing loss (CHL) up to 50 dB may occur in isolated membrane perforations with the ossicles remaining intact [1, 2].

The site and the size of the perforation, whether or not it contacts the manubrium mallei, as well as the volume of the middle ear and of the mastoid are some of the factors that affect the level of the hearing loss [2]. Results obtained in the few previous studies show that large perforations that are posteriorly located and contact the manubrium mallei increase the CHL level, especially at lower frequencies [1, 3]. Likewise, severity of the hearing loss increases as the volumes of the air cells in the middle ear and the mastoid bone decrease [2].

Aim of the study:

Perforation of the tympanic membrane can lead to hearing loss and infection and negatively affect daily activities, so it is important to study this condition, to further understand its causes and symptoms. This knowledge helps healthcare providers diagnose and manage the condition effectively, improve patient outcomes, and prevent further complications. Additionally, research into tympanic membrane perforation could lead to the development of new treatments and interventions to improve the quality of life for those affected by this condition.

The aim of our study was: Evaluate the effect of the size and location of tympanic membrane perforation on the value of the air-bone gap, and to evaluating the effect of the duration of tympanic membrane perforation on the value of the air-bone gap.

A cross-sectional study was conducted in Damascus Hospital, on cases from 2014 to 2023, and included 83 cases of both sexes, aged 13 years and above, unilateral or bilateral, who were randomly selected. The size of the perforation was classified as follows: small perforation: It is a perforation located in one of the quarters of the tympanic membrane and its area is smaller or equal to this quarter. Medium perforation: It is a perforation that includes most of the area of the lower half of the tympanic membrane and takes the form of a kidney. Large perforation: It is a perforation that includes all or Most of the area of the taut section of the tympanic membrane. As for the location of the perforation, it was classified into anterior and posterior based on an imaginary line passing through the tympanic membrane at the level of the hammer fist, and perforations below the level of the hammer fist were considered inferior perforations.

Statistical analysis

The Statistical Analysis System (SPSS) for Windows (version 26) was used to perform the statistical analysis. Data were collected using (Microsoft Excel 2021), including demographic variables (gender, age, and residence), qualitative variables (type, destination and cause of perforation, size, location, and time of perforation), and quantitative variable (value of the air-bone gap). Descriptive analysis was performed to calculate frequencies, percentages, means, and standard deviations. Furthermore, the means of the independent comparative groups were compared using (One way ANOVA) with the homogeneity test to compare the variance of the groups, and post-hoc comparison using (Tukey), and the Chi-square test was also used. ) to study the association between qualitative variables, and when any of the expected cells were less than five, Fisher's exact test was used.

Our study included 83 cases, 22 of which were bilateral, so the total number of perforation cases was 105. (Table 1) shows the demographic information for the cases, where females constituted more than half of the sample and reached 47 (56.6%), compared to males 36 (43.4%). The ages of the cases ranged from 13 to 70 years, with a mean of 31.84 ± 12.97. Regarding place of residence, approximately half of the cases were from Rif-Dimashq Governorate, 42 (50.6%), and Damascus Governorate came next, with 24 (28.9%).

Table 1
		N	%
Sex	Male	36	43.4
Sex	Female	47	56.6
Total		83	100
Governorate	Damascus	24	28.9
	Rif-Dimashq	42	50.6
	Daraa	5	6
	Deer Al Zour	6	7.2
	Hama	2	2.4
	Homs	1	1.2
	Al Raqqah	2	2.4
	Aleppo	1	1.2
Total		83	100
Age	Mean		31.84
	Std. Deviation		12.97
	Minimum		13
	Maximum		70

Perforation characterization:

(Table 2) shows that the largest percentage was for unilateral perforations, 61 (73.5%), compared to 22 (26.5%) for bilateral perforations. It also shows that the cases of perforation included the left ear, 54 (51.4%), with a slight predominance over the right ear, 51 (48.6%).

Table 2
		N	%
Type of perforation	Unilateral	61	73.5
Type of perforation	Bilateral	22	26.5
Total		83	100
		N	%
Perforation side	Right ear	51	48.6
Perforation side	Left ear	54	51.4
Total		105	100

(Table 3) shows that: The most common cause of perforation was (inflammation), with a rate of 62 (59%), and trauma, direct injury, came in second place, with a rate of 23 (22%). Regarding the size and location of the perforation, (central average) had the largest percentage, 26 (24.8%), followed by (small, anteroinferior central), with 22 (21%). As for the time of perforation, the category (less than one year) had the largest percentage, 22 (16.4%), followed by (more than 20 years), with 21 (15.7%).

Table 3
		N	%
Cause of perforation	Direct trauma	23	22
	Trauma due to explosive pressure	20	19
	inflammatory	62	59
Total		105	100
		N	%
Size and location of perforation	Small anterior inferior central	22	21
	Small posterior inferior central	21	20
	Central average	26	24.8
	Large central	18	17.1
	Small posterior inferior marginal	18	17.1
Total		105	100
		N	%
Perforation period	less than one year	22	16.4
	From 1–5 years	19	14.2
	From 5–10 years	9	6.7
	From 10–15 years	16	11.9
	From 15–20 years	18	13.4
	More than 20 years	21	15.7
Total		105	100

(Table 4) shows the symptoms accompanying the perforation and not related to the location of the perforation, where hearing loss was the most common symptom accompanying the perforation, 86 (81.9%), followed by recurrent gonorrhea, 66 (62.8%), and dizziness was the most common symptom, not related to the location of the perforation, at 9 (10.8%).

Table 4
		N	%
Symptoms unrelated to the location of the perforation	Nothing	70	84.3
	Headache	4	4.8
	Vertigo	9	10.8
Total		83	100
		N	%
Symptoms accompanying perforation	Hearing loss	86	81.9
	Recurrent gonorrhea	66	62.8
	Tinnitus	37	35.2
	Otalgia	27	25.7

The gap value ranged between 10 and 53 dB, with an average of 29.22 and a standard deviation of 8.571 (Table 5).

Table 5
Air-Bone Gap
Mean	29.22
Std. Deviation	8.571
Minimum	10
Maximum	53

The number of experimental and clinical studies is still insufficient due to the complex and difficult mechanisms of modeling the tympanic membrane and middle ear functions.

We excluded patients with middle or inner ear disease from our study in order to investigate only perforation-related hearing loss. While this approach may, in theory, create an isolated population, in practice, it cannot eliminate the possibility of various diseases that may have an impact on hearing loss.

Our study included 83 cases, 22 of which were bilateral, so the total number of perforation cases was 105. The ages of the patients ranged from 13–70 years, with an average of 31.84 ± 12.97.

Out of 83 patients, 36 were male and 47 were female, and this increase in females may be due to their greater awareness and seeing a health care provider when perforation occurs, or due to females’ interest in cleaning the ear with cotton swabs, and this is consistent with a 2017 study conducted by Khan et al. [6], as they had a higher incidence of infection among females compared to males.

Most perforation cases were unilateral (61 (73.5%)), compared to 22 (26.5%) bilateral cases, perforations included 51 (48.6%) right ear and 54 (51.4%) left ear.

We found that the most common cause of perforation was inflammatory 62 (59%), which may explain that recurrence of acute otitis media in childhood often leaves a permanent perforation of the tympanic membrane, unlike traumatic tympanic membrane perforations which tend to fuse, as traumatic perforation heals in 90% of cases within two weeks [7, 8].

The most common duration of perforation is (less than one year) 22 (16.4%), and this is in contrast to what Pannu found in his study [4], where the duration of more than five years was the most common. This may indicate good awareness among these patients, or that they suffered Symptoms of perforation that affected their daily lives, prompting them to see a health care provider early.

The most common symptom in our study was hearing loss 86 (81.9%), followed by gonorrhea 66 (62.8%). Pannu et al also mentioned in their study [4], that the main symptoms in them were hearing loss and gonorrhea.

The value of the air-bone gap according to the size of the perforation: We found in our study that the average value of the larger air-bone gap was associated with the larger size of the perforation, as it was (P-Value < 0.05), and it can be said that the value of the air-bone gap increases with the increase in the area of the perforation, and this is consistent with Both the study of Pannu and colleagues [4] and Gulati and colleagues [5] also found that hearing loss increases with the size of the perforation.

The value of the air-bone gap according to the location of the perforation: By comparing the posterior-inferior-central perforations with the anterior-inferior-central perforations, we found that the posterior-inferior-central perforations are associated with a larger air-bone gap value, which may explain that the inferior-central perforations are closer to the bony chain, which negatively affects the transport mechanism. In the middle ear. By comparing mesocentral perforations with central posterior inferior quadrants, we found that mesocentral perforations are associated with a larger air-bone gap value, and this is what Balcı and colleagues found in their study [9], that perforations located in the posterior inferior quadrant caused greater hearing loss. Comparing the marginal posterior inferior perforation with the central posterior inferior perforation, we did not find any statistically significant differences.

The value of the air-bone gap depending on the duration of the perforation: During our study, we found statistically significant differences between the duration of the perforation based on the value of the air-bone gap, as the value of the air-bone gap increased with the increase in the duration of the perforation, which explains the occurrence of complications at the level of the middle ear with the increase in the duration of the perforation. During our study, we found that the period during which complications appear is after 10 years. Our result agreed with the study of Pannu and colleagues [4], who reported that hearing loss increased with increasing disease duration at all frequencies. Comparison of the average hearing loss in all three groups showed that the average hearing loss increased statistically significantly with increasing disease duration.

In the context of our study, we found that perforation due to inflammatory causes was associated with young ages, and perforation due to traumatic causes was associated with advanced ages.

Ethical statement:

The ethical consent was obtained from Syrian private university ethical committee Competing Interest: the authors declare no competing of interests.

Availability of data and materials:

All data are available from the corresponding author on reasonable request.

Funding:

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Voss SE, Rosowski JJ, Merchant SN, Peake WT. How do tympanic-membrane perforations affect human middle-ear sound transmission? Acta Otolaryngol 2001; 121; 169-73.
Park H, Hong SN, Kim HS, Han JJ, Chung J, Suh MW, et al. Determinants of conductive hearing loss in tympanic membrane perforation. Clin Exp Otorhinolaryngol 2015; 8; 92-6.
Gaur S, Sinha ON, Bhushan A, Batni G. Observations on tympanic membrane perforations (safe type) and hearing loss. Indian J Otolaryngol Head Neck Surg 2017; 69; 29-34.
Pannu, K. K., Chadha, S., Kumar, D., & Preeti (2011). Evaluation of hearing loss in tympanic membrane perforation. Indian journal of otolaryngology and head and neck surgery: official publication of the Association of Otolaryngologists of India, 63(3), 208–213. https://doi.org/10.1007/s12070-011-0129-6
Gulati SP, Sachdeva OP, Kumar P. Audiological profile in CSOM. Indian J Otolaryngol. 2002; 8:24–28. [Google Scholar]
Khan, N. B., Thaver, S., & Govender, S. M. (2017). Self-ear cleaning practices and the associated risk of ear injuries and ear-related symptoms in a group of university students. Journal of public health in Africa, 8(2), 555. https://doi.org/10.4081/jphia.2017.555
https://www.ncbi.nlm.nih.gov/books/NBK557887/
Moustafa, A. (2022). Clinical evaluation in ear, nose and throat diseases. Damascus.
Balcı, M. K., İşlek, A., Bakiş, Y. B., & Önal, H. K. (2021). Effects of location, size and shape of tympanic membrane perforations on hearing: analysis of 400 cases. The Journal of laryngology and otology, 135(11), 993–999. https://doi.org/10.1017/S0022215121002486

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Study of the relationship between the size, location, and duration of tympanic membrane perforation with the value of Air-Bone Gap on pure-tone audiogram

Status:

Version 1

Abstract

Background

Methods

Results

Background

Aim of the study:

Methods

Results

Discussion

Declarations

References

Status:

Version 1