www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
ORIGINAL
ARTICLE
Treatment
of
tympanic
membrane
perforation
using
bacterial
cellulose:
a
randomized
controlled
trial
夽
,
夽夽
Fábio
Coelho
Alves
Silveira
a,∗,
Flávia
Cristina
Morone
Pinto
b,
Sílvio
da
Silva
Caldas
Neto
c,
Mariana
de
Carvalho
Leal
d,
Jéssica
Cesário
e,
José
Lamartine
de
Andrade
Aguiar
aaGraduatePrograminSurgery,DepartmentofSurgery,UniversidadeFederaldePernambuco(UFPE),Recife,PE,Brazil bNucleusofExperimentalSurgery,UniversidadeFederaldePernambuco(UFPE),Recife,PE,Brazil
cServiceofOtolaryngology,UniversidadeFederaldePernambuco(UFPE),Recife,PE,Brazil dUniversidadeFederaldePernambuco(UFPE),Recife,PE,Brazil
eMedicalCourse,UniversidadeFederaldePernambuco(UFPE),Recife,PE,Brazil
Received22March2015;accepted29March2015 Availableonline8September2015
KEYWORDS
Tympanicmembrane
perforation; Biopolymer; Bacterialcellulose
Abstract
Introduction:Promising treatments for tympanic membrane perforation closure have been studied. Therapiesderivedfromtissueengineeringprobablyeliminatetheneedfor conven-tionalsurgery.Bacterialcelluloseispresentedasanalternativethatissafe,biocompatible, andhaslowtoxicity.
Objectives: Toinvestigatetheeffectonhealingofdirectapplicationofabacterialcellulose graft on the tympanic membrane compared to the conventional approach with autologous fascia.
Methods:Randomizedcontrolled trial.Fortypatients withtympanicmembraneperforations secondarytochronicotitis mediawereincluded,andwererandomlyassignedtoan experi-mentalgroup(20),treatedwithabacterialcellulosegraft(BC)andcontrolgroup(20),treated withautologoustemporalfascia(fascia).Weevaluatedthesurgicaltime,hospitalstay,timeof epithelializationandtherateoftympanicperforationclosure.Hospitalcostswerecompared. Thestatisticalsignificancelevelacceptedwasestablishedatp<0.05.
Results:Theclosureofperforationswassimilarinbothgroups.Theaverageoperationtimein thefasciagroupwas76.50minversus14.06minbacterialcelluloseinthegroup(p=0.0001). ThehospitalcostbytheBrazilianpublichealthsystemwasR$600.00forthebacterialcellulose group,andR$7778.00forthefasciagroup(p=0.0001).
夽 Pleasecitethisarticleas:SilveiraFCA,PintoFCM,CaldasNetoSS,LealMC,CesárioJ,AguiarJLA.Treatmentoftympanicmembrane
perforationusingbacterialcellulose:arandomizedcontrolledtrial.BrazJOtorhinolaryngol.2016;82:203---8.
夽夽
Institution:ServiceofOtolaryngology,HospitaldasClínicas,UniversidadeFederaldePernambuco(UFPE),Recife,PE,Brazil.
∗Correspondingauthor.
E-mail:fcasil@ig.com.br(F.C.A.Silveira).
http://dx.doi.org/10.1016/j.bjorl.2015.03.015
Conclusion:Bacterialcellulosegraftspromotedtheclosureofthetympanicmembrane perfora-tions,andweredemonstratedtobeinnovative,effective,safe,minimallyinvasive,efficacious andtohaveaverylowcost.
© 2015 Associac¸ão Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (https://creativecommons.org/licenses/by/4.0/).
PALAVRAS-CHAVE
Perfurac¸ãoda
membranatimpânica;
Biopolímero; Celulosebacteriana
Tratamentodotímpanoperfuradocomenxertodecelulosebacteriana:ensaioclínico
controladoerandomizado
Resumo
Introduc¸ão:Tratamentos promissores para o fechamento da perfurac¸ão da membrana tim-pânicavêmsendoestudados.Terapiasprovenientesdeengenhariadetecidosprovavelmente eliminarão anecessidadedeuma intervenc¸ãocirúrgicaconvencional. Acelulosebacteriana apresenta-secomoumaalternativaporsersegura,debaixatoxicidade,biocompatível.
Objetivos: Investigar o efeito da aplicac¸ão direta do enxerto da celulose bacteriana na cicatrizac¸ãodeperfurac¸õesdamembranatimpânica,comparadoaoprocedimentoconvencional comfásciaautóloga.
Método: Incluíram-se40pacientescomperfurac¸ãodamembranatimpânica porotitemédia crônicasimples.Randomizadosde1a40,ondeosímpares(20)foramtratadoscomenxertode celulosebacteriana(CB),eospares(20),comenxertodefásciatemporalautóloga(fáscia). Estudoclínicocontroladoerandomizado.Otempocirúrgicoedehospitalizac¸ãoforamotempo deepitelizac¸ãoecustoshospitalares.
Resultados: Ofechamentodasperfurac¸ões foisemelhante nosdoisgrupos.Otempo médio dacirurgia nogrupo fásciafoide 76,50minutosede 14,06minutosnogrupo comcelulose bacteriana(p=0,0001).OcustohospitalarpelatabeladoSUSfoideR$600,00paraogrupoCB eR$7.778,00paraogrupofáscia(p=0,0001).
Conclusão:A celulose bacteriana promoveu o fechamento da perfurac¸ão do tímpano,
mostrando-seinovador,seguro,eficaz,efetivo,minimamenteinvasivoedebaixocusto. © 2015 Associac¸ão Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Publi-cado por Elsevier Editora Ltda. Este é um artigo Open Access sob a licença CC BY (https://creativecommons.org/licenses/by/4.0/deed.pt).
Introduction
Promising treatments for closure of tympanic mem-brane perforation (TMP) have been studied, in search of outpatient,minimally invasive procedures that are effec-tive, safe, affordable and technically feasible.1---5 Among some innovative alternatives, the use of gelfoamTM and atelocollagenTM stand out, in association with fibroblast growth factor (-FGF),1---4 autologous serum, and chitin membranes.5
The establishment of a therapy developed from tissue engineering for treatment of TMP will probablyeliminate the need for conventional surgery. However, it is critical tounderstandthefactorsthatcontributetothesuccessor failureofTMPtreatment.4
An alternative material is cellulosic polysaccharide, obtained by bacterial synthesis. In previous studies, cel-lulosic polysaccharide proved to be a safe, low-toxicity,6 biocompatible7product,withtheabilitytoencourage cellu-largrowthanddifferentiation---afeaturethatispromising fortissueengineering.8Preclinicalandclinicalstudieshave demonstrated that this biomaterial was effective func-tioningas a mechanical barrier and as an adjunct in the treatmentofulcerativelesions9andsurgicalwounds.10
Theobjectiveofthisstudywastoinvestigatetheeffect ofdirectapplication ofa bacterialcellulose(BC)graft on
thehealingoftympanicmembraneperforations,compared withaconventionalprocedurewithautologousfascia.
Method
Fortypatientswithtympanicmembraneperforationscaused by otitis media wereenrolled in a randomizedcontrolled clinical study of spontaneous demand at Otolaryngology ServiceinateachinghospitalinPernambucostate,Brazil, from 2013 to 2014. Patients with marginal, damp or cholesteatomatous perforations were excluded. Patients were randomly allocated to two groups: 20 in an experi-mental group, who were treated with bacterial cellulose membrane graft, and 20 controls treated conventionally withautologousfasciagraft.
This study was approved by the Ethics Committee on Research,HealthSciencesCenter,UniversidadeFederalde Pernambuco, under CAAE 21109913.7.0000.5208, Opinion CEP/CONEPNo.527.461ofDecember18,2013.
Bacterialcellulosegraft
Technicalprocedures
Patientsincludedincontrolgroupunderwentmiringoplasty withtemporalfasciagraft,performedundergeneral anes-thesia,accordingtostandardoperatingproceduresforthis surgery. The graft of fascia was applied medial to the tympanic remants under the handle of malleus and mid-dle ear, and held in position with GelfoamTM fragments. At the end of the procedure, the incisionwas suturedin anatomicalplanes,andapressuredressingwasapplied.The patientremainedinthehospitaluntilthenextday. Atthe timeofhospitaldischarge,cephalexin500mg,orally, four timesdailyfor7dayswasprescribed, andthepatientwas instructedtoreturntohis/heractivitiesafter8---15days.
For patientsin the experimental group, theprocedure was performed under local anesthesiawith infiltration of xylocaine(2%solution)5.0mlwithvasoconstrictor,divided into twoparts: 2.5ml for external application and 2.5ml into the external auditory canal. The perforation edges were scarified, and then a bacterial cellulose membrane wasplacedovertheperforation,laterallytothetympanic remains.Themembranewasheldinplacebyself-adhesion. The patient wasdischarged immediately after the proce-dure,beinginstructedtoreturntohis/heractivitieswithout restrictions.Antibioticswerenotprescribed.
Outcomesevaluated
Clinicaloutcomes
Inbothgroups,thefollowingvariableswereevaluated: sur-gical time, hospital stay, time for epithelialization, TMP closingrateint0=15days,t1=30daysandt2=60days;the impedanceaudiometrycurve60 dayspost-treatment,and adverseevents.
Hospital costs were analyzed separately for use of BC (experimental group) versus temporal fascia (control group).Thesecostswereestimatedaccordingtothetable of the Brazilian Unified Health System (SUS) from Min-istry of Health, 2007, taking intoaccount:for autologous fascia,tympanoplasty (uni/bilateral)(code: 04.04.01.035-0),surgical specialty ofmedium complexity; the assigned value includes one (1) day of hospitalization (R$ 388.94 per patient); for BC grafting, a grade II dressing (code: 04.01.01.001-5), surgical specialtyof medium complexity, withnoinclusionofhospitalstay(R$30.00perpatient).
Tympanometry: The evaluation of tympanicmembrane mobility was obtained based on the impedance chart, consideringairpressure(markedontheXaxisindecaPascal, daPaX)andadmittance(ontheYaxis,daPaYinml).12
Effectiveness: Effectiveness represents the rela-tive reduction of risk or of negative outcome (TMP closure) obtained with the intervention (in this case, the use of BC). Relative risk [RR=R(BC)/R (fascia)] was calculated, followed by absolute reduction in risk (ARR=[R(fascia)−R(BC)]×100) and effectiveness [EF=(1−RR)×100] calculations. When the risk is equal inboth groups,RR=1.Iftheriskfor interventiongroupis lower than the risk for control group, RR<1; otherwise, RR>1.
Parametric continuous variables were compared using Student’s t test, while scores were compared using the
chi-squaredtest. Mann---Whitneytestwasusedtoevaluate the sum of hospital costs. A 95% confidence interval was used,and the statistical significance wasset at p≤0.05. StatisticalanalysiswasperformedusingGraphPadPrism5.0 software(GraphPadSoftwareInc.,USA).
Results
Atotal of 40 patients underwent treatment for tympanic membrane perforation; 20 received a BC graft (30% men and70% women); and 20 --- the control group --- received anautologousfasciagraft(40%menand60%women).The meanageofthegroupswas38.15±12.63,and34.5±10.16 years,respectively(Table1).
Inthe groupofpatients whoreceivedBCgraft,65% of TMPswereintheleftear,whileinthegroupthatreceived anautologousfasciagraft,most(55%)TMPswereintheright ear.Perforationsweremoreoftenofsmallsize,accounting for70%ofcasesineachgroup.Closureoccurredinallsmall perforationstreatedbyBCgraft,whencomparedwith fas-ciagraft (92.9%). Morethan half(66.6%) ofmedium-sized perforationsclosedwithBCgraft(Table1).
Surgicaltimefortheprocedurewasstatistically signifi-cant (p<0.001),when comparingthe group thatreceived BCgraft (14.06±5.23min) versus autologous fascia graft (76.50±17.92min);andepithelializationtimewassimilarin bothgroups,correspondingto30days(Table1)(Figs.1---3). Toevaluatetympanicmembranecompliance,14patients treated with BC graft underwent tympanometry, and of these,13 (92.9%) had Gt within the normal range (mean Gt=0.86±0.28)andanexpectedAt(−0.58±0.28)(Fig.4). Therelativerisk(RR)ofnon-closureoftympanic mem-branein thegroup treatedwithBCgraft waslower(50%) thanthat for the group withautologous fascia graft. The effectivenesswas50%, a resultsimilar for both materials
Table1 Outcomesevaluatedbetweengroupstreatedwithbacterialcelluloseandautologousfasciagrafts,fortreatmentof perforatedtympanicmembrane.
Outcomes Typeofgraft p-Value
BC Fascia
N 20 20
---Gender
Male 06(30%) 08(40%) 0.5073a
Female 14(70%) 12(60%)
Age 38.15±12.63 34.5±10.16 0.3204b
TMPlocation
Rightear 7(35.0%) 11(55.0%) 0.2036a
Leftear 13(65.0%) 9(45.0%)
TMPsize
Small 14(70.0%) 14(70.0%) 1.000a
Medium 6(30.0%) 6(30.0%)
Surgicaltime(min) 14.06±5.23 76.50±17.92 <0.0001b*
TMPclosure
General 18(90.0%) 16(80.0%) 0.3758a
Bysize
Small 14(100%) 13(92.9%) 0.6264a
Medium 04(66.7%) 03(50%) 0.5582a
Hospitalcostestimatec
Perpatient 30.00 388.94
Total 600.00 7778.80 <0.0001c
Riskandefficacyanalysis
RR% 0.5 0.3758a
ARR 10%
---Efficacy 50%
BC,Bacterialcellulose;TMP,Tympanicmembraneperforation;RR,Relativerisk;ARR,Absoluteriskreduction. Valuesinmean±SDandn(%).
aQui-squaredtest.
b Student’sttest,significantif(*)p≤0.05.
c Hospitalcostestimate,accordingtothetableofcostsforsurgicalproceduresoftheBrazilianUnifiedHealthSystem(SUS);valuesin
Reais(R$).Mann---Whitneytest.
Figure2 OtoendoscopyofbacterialcellulosegraftoverTMP.
(BCorfascia),despiteanabsoluteriskreductionof10%for TMPclosureinBCgroup(Table1).
Discussion
Figure3 Tympanicmembraneafterapplicationofbacterial cellulosegraft,onmicroscopicexamination.
Some factors can influence the success of the surgery orof thegraft, asfollows:age, perforationlocation,size ofperforation,auditorytubefunction,statusofmiddleear mucosa,typeofgraftused,andsurgeon’sexperience.15 As tothe study population, it can be added that the use of BCmembranewaseffective,regardlessofpatient’sageand locationandsizeoftympanicperforation.Noadverseevents related to this membrane occurred. It is noteworthy the reductionof alittlemorethan1h (62.44min)inthe time requiredfortheprocedure,whencomparingBCgroupversus temporalfascia(control)group,indicatingthatBC,in addi-tiontobeingeffective,showsahighlevelofeffectiveness andpracticality.
ThereductionintheoperatingtimeusingBCmembrane isself-explanatory,becausetherewasnoneedforincisions, removaloffascia,orliftingflaps.Fromthecostestimatefor eachprocedure(fasciaorBCmembranegraft),wefounda reductionof13times inhospitalcosts withthe useof BC membrane; this figure represents a saving of R$ 7,178.8, consideringthat,withthechoiceofBC,thereisnoneedfor additionaltests (hematology and cardiology), hospitaliza-tionorgeneralanesthesia.TheuseofBCalsoobviatesthe useofspecialmaterials, suchasGelfoamTM,suture mate-rialandantibiotics;ontheotherhand,theuseofBCavoids complicationssuchasearpain,bleeding,andhematomas. Thepatientcanresumeimmediatelytheirdailyactivities.
Totheseaspectswecanaddefficiency,effectivenessand practicality,in additiontosecurity,becausethis is a low-cytotoxicityandhigh-biocompatibilitymaterial.6,7
Asdescribed intheliterature,thetympanicmembrane shouldberebuiltwithaconnectivetissuethatallowsfor,in replacingthe eardrum, ensuring its properties:elasticity, strengthandability tovibrate.Manymaterials have been used in the history of tympanoplasty, including free skin graft, sclera, perichondrium, temporal fascia, cartilage, andfat,amongothers.16,17Itwasobservedthatthese prop-erties were recovered, withproven datacorroborated by tympanometry findings; this technique assessed tympanic
0 10 20 30 40 50 60 70 80 90 100
Fascia Polysaccharide
Groups
Success (%)
0 10 20 30 40 50 60 70 80 90
Risk of failure (%)
Sucesso (%) Risk of failure (%) Mean procedure time (min.)
membrane compliance and showed that most patients (92.9%) had Gt in the normal range and At as expected. Tympanometry, used in this study to evaluate tympanic membranefunction,is aclassicmethodappliedinclinical practice,bybeingfastandatraumatic.18
Another important feature, demonstrated in previ-ous studies, refers to BC’s ability to function as an inducer of tissue remodelingand, thus, as a promoter of the healing process,8---10 by enabling an intensive process of revascularization19 and epithelialization,11 which may explaintheregenerationof theeardrumremainsand also theclosureofTMP.
Conclusion
TheuseofabacterialcellulosegraftpromotedTMP regen-eration, showing it to be an innovative, safe, efficient, effective,minimallyinvasive,low-costoption.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
References
1.KanemaruS,UmedaH,KitaniY,NakamuraT,HiranoS,ItoJ. Regenerativetreatmentfor tympanicmembraneperforation. OtolNeurotol.2011;32:1218---23.
2.Zhang Q,Lou Z.Impact ofbasic fibroblastgrowthfactor on healingoftympanicmembraneperforationsduetodirect pen-etratingtrauma:a prospectivenon-blinded/controlled study. ClinOtolaryngol.2012;37:446---51.
3.Lou Z,Xu L, YangJ, Wu X.Outcome ofchildrenwith edge-evertedtraumatictympanicmembraneperforationsfollowing spontaneoushealingversusfibroblastgrowthfactor-containing gelfoam patching withor without edge repair. IntJ Pediatr Otorhinolaryngol.2011;75:1285---8.
4.HakubaN,HatoN,OkadaM,MiseK, GyoK.Tympanic mem-braneregenerationtherapy.JAMAOtolaryngolHeadNeckSurg. 2014;23:E1---7.
5.KakehataS,HiroseY,KitaniR,FutaiK,MaruyaS,IshiiK,etal. Autologous serum eardropstherapy with a chitinmembrane for closingtympanic membrane perforations. OtolNeurotol. 2008;29:791---5.
6.CastroCMMB,AguiarJLA,MeloFAD,SilvaWTF,MarquesE,Silva DB.Sugarcanebiopolymercytotoxicity.AnFacMedUnivFed Pernamb. 2004;49:119---23 http://www.anaisdemedicina. revistaonline.org/Secao/3289/Pagina/Revista/Artigo Visualizar.aspx?artigoId=172&ass=67765258
7.LucenaMT,MeloJúniorMR,Lira MMM,CastroCM,Cavalcanti LA,MenezesMA,etal. Biocompatibilityand cutaneous reac-tivityofcellulosicpolysaccharidefilmininducedskinwounds in rats.J MaterSci Mater Med. 2015;26, http://dx.doi.org/ 10.1007/s10856-015-5410-x.
8.Fragoso AS, Silva MB, de Melo CP, Aguiar JLA, Rodrigues CG, de Medeiros PL, et al. Dielectric study of the adhe-sion of mesenchymal stem cells from human umbilical cord onasugarcanebiopolymer.JMaterSciMaterMed.2014;25: 229---37.
9.Teixeira FMF, Pereira MF, Ferreira NLG, Miranda GM, Aguiar JLA. Spongy film of cellulosic polysaccharide as a dressing for aphthous stomatitis treatmentin rabbits. Acta Cir Bras. 2014;29:231---6.
10.Martins AGS, Lima SVC, Araujo LAP, Vilar FO, Cavalcante NTPA. Wetdressing for hypospadias surgery.IntBraz JUrol. 2013;39:408---13.
11.SilvaDB,AguiarJLA,MarquesA, CoelhoARB,RolimFilhoEL. Miringoplastia com enxerto livre de membrana de polímero da cana-de-ac¸úcar e fáscia autóloga em Chinchillalaniger. AnFacMedUnivFed Pernamb.2006;51:45---55. Availableat:
http://www.anaisdemedicina.revistaonline.org/Arquivo.aspx/ artigo/186/Caminho/186.pdf[accessedon14.08.2014]. 12.ASHA,AmericanSpeech-Language-HearingAssociation.
Guide-lines for screening for hearing impairment and middle-ear disorders. Working Group on Acoustic Immittance Measure-ments and the Committee on Audiologic Evaluation. ASHA. 1990;Suppl.:17---24.
13.BhatNA,RanitDe.Retrospectiveanalysisofsurgicaloutcome, symptomchanges,andhearingimprovementfollowing myringo-plasty.JOtol.2000;29:229---32.
14.FukuchiI,CerchiariDP,GarciaE,RezendeCEB,RapoportPB. Timpanoplastias: resultados cirúrgicos e análise dos fatores quepodeminterferirnoseusucesso.BrazJOtorhinolaryngol. 2006;72:267---71.
15.Spiegel JH, Kessler JL. Tympanic membrana perforation repair with acellular porcine submucosa. Otol Neurotol. 2005;26:563---6.
16.GlasscockME,KanockMM.Tympanoplasty---achronological his-tory.OtolaryngolClinNorthAm.1977;10:469---77.
17.Shanks J, Shelton C, Basic Principles. Clinical applica-tion of tympanometry. Otolaryngol Clin North Am. 1991;24: 299---328.
18.OliveiraJAA,HyppolitoMA,NettoJC,MruéF.Miringoplastiacom autilizac¸ãodeumnovomaterialbiossintético.BrazJ Otorhi-nolaryngol.2003;69:138---55.
