Braz. j. . vol.80 número5

BrazJOtorhinolaryngol.2014;80(5):386---389

Brazilian

Journal

of

OTORHINOLARYNGOLOGY

www.bjorl.org

ORIGINAL

ARTICLE

Objective

comparison

between

perforation

and

hearing

loss

夽

,

夽夽

Fernando

de

Andrade

Quintanilha

Ribeiro

,

Verônica

Reche

Rodrigues

Gaudino

,

Caio

Dinelli

Pinheiro

_,

_Gil

_Junqueira

_Marc

_¸al

_,

_Edson

_Ibrahim

_Mitre

a_{DepartmentofOtorhinolaryngology,FacultyofMedicalSciences,SantaCasadeSãoPaulo(FCMSCSP),SãoPaulo,SP,Brazil} b_{FacultyofMedicalSciences,SantaCasadeSãoPaulo(FCMSCSP),SãoPaulo,SP,Brazil}

Received19October2013;accepted22March2014 Availableonline23July2014

KEYWORDS

Evaluation;

Tympanicmembrane

perforation; Hearingloss

Abstract

Introduction:Thereappearstobenorelationshipbetweenthesizeoftympanicperforations andhearingloss.Somestudiesintheliteraturehaveassessedthisconnection,withconflicting dataandwithoutpropermethodology,especiallyconcerningthemeasurementofthesizeof theperforation,whichwasperformedinasubjectivemanner.

Objective:Toevaluatethesizeoftympanicperforationsandtorelatethemtohearinglossin fourdifferentsoundfrequenciesthroughtheuseofanobjectivemethod.

Methods:Transversalretrospectivestudy.Thepresentstudyevaluated187perforationsthrough digitalimaging,calculated thepercentagesofthetympanicmembranethatwasperforated usingImageScopesoftwareversion11.1.2.760andcorrelatedperforations’sizewithhearing lossatfourfrequencies.

Results:DatawerestatisticallyanalyzedusingPearson’scorrelationtest.

Conclusion:Therewas nosignificantrelationship betweenthesizeoftympanicperforations andhearinglossinthefouranalyzedfrequencies.

© 2014Associac¸ãoBrasileira de Otorrinolaringologiae CirurgiaCérvico-Facial. Publishedby ElsevierEditoraLtda.Allrightsreserved.

夽 _{Pleasecitethisarticleas:RibeiroFA,GaudinoVR,PinheiroCD,Marc¸alGJ,MitreEI.Objectivecomparisonbetweenperforationand}

hearingloss.BrazJOtorhinolaryngol.2014;80:386---9.

夽夽

Institution:FacultyofMedicalSciences,SantaCasadeSãoPaulo,SãoPaulo,SP,Brazil. ∗_{Correspondingauthor.}

E-mail:quintanilha.f@uol.com.br(F.A.Q.Ribeiro).

http://dx.doi.org/10.1016/j.bjorl.2014.07.007

Objectivecomparisonbetweenperforationandhearingloss 387

PALAVRAS-CHAVE

Avaliac¸ão; Perfurac¸ãoda

membranatimpânica;

Perdaauditiva

Comparac¸ãoobjetivaentreperfurac¸ãotimpânicaeperdaauditiva

Resumo

Introduc¸ão: Parecenãohaverrelac¸ãoentreotamanhodasperfurac¸õestimpânicaseaperda auditiva.Algunstrabalhosnaliteraturaestudaramestarelac¸ão,comdadosconflitantesesem usoadequadodametodologiaempregada,principalmentequanto àmedic¸ãodotamanhoda perfurac¸ãoquesefazdemodosubjetivo.

Objetivo: Analisaratravésdeummétodoobjetivootamanhodessasperfurac¸õeserelacioná-las comperdasauditivasemquatrofrequênciassonoras.

Método: Estudoretrospectivodecortetransversal.Foramavaliadas187perfurac¸ões timpâni-cas através de digitalizac¸ão de imagem, medidas porcentualmente como uso do software ImageScopeVersion11.1.2.760ecorrelacionadascomoslimiaresauditivosemquatro frequên-cias.

Resultados: Osdadosforamavaliadosestatisticamentepelotestedecorrelac¸ãodePearson, quenãodemonstroucorrelac¸ãoentreotamanhodaperfurac¸ãotimpânica eograudeperda auditiva.

Conclusão:Nãohárelac¸ãosignificativaentreotamanhodasperfurac¸õestimpânicaseasquatro frequênciasestudadas.

©2014Associac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial.Publicado por ElsevierEditoraLtda.Todososdireitosreservados.

Introduction

Thiswasalongitudinalretrospectivecohortstudy.Itisclear

that there appears to be no direct relationship between

thesizeofthetympanicmembraneinsimplechronicotitis

media and hearing loss assessed by pure tone

audiome-try. This suspicion has been studied and evaluated, but

by using subjective methods to measure the size of the

perforations.1---5_{Withtheadventofmoderncomputer}

pro-grams,thepercentageoftheseperforationsin relationto

thetotalareaofthemembrane canbeobjectively

evalu-ated. These more accuratedata can be usedtocompare

morereliablythisfindingwitheachaudiometryfrequency. Fewsimilarstudieswereretrievedintheliterature.6,7_This

study aimed toanalyze the correlation between the

per-centual size of the perforation and hearing loss in four

frequencies.

Methods

This was a retrospective cohort trial conducted at the

Department of Otorhinolaryngology of a medicalteaching

institution, approved by the Research Ethics Committee

under N◦ _{9228. Images of the tympanic membrane were}

acquiredusinga3mmdiameterrigidfiberoptictelescope coupledtoadigitalcameraandwithcomputerdigital cap-ture.

Only pictures of simple chronic otitis media (dry

per-forationsassequelae ofnecrotizing otitis)were selected,

with more than six months without otorrhea reportedby

thepatients.Hearinglossinfourfrequencies(500Hz,1kHz,

2kHz, and 4kHz), withany degree of conductive hearing

loss,wasconsidered.Theaudiometrieswereperformedby

phonoaudiologists,usingtheKatztechnique.8

ImageScope,version11.1.2.760byAperioTechnologies®_,

wasused.The selectedimageswereevaluatedby

circum-scribing(by tracking witha mouse) the totalarea of the

tympanic membrane, which was then measured by pixel

counting(Fig.1).The sameprocedurewasappliedtothe

areaoftheperforation.Bothmeasuresweretransportedto anExcel®_{(Microsoft)spreadsheet.Sincethedetermination}

oftheareaofperforationwasthencalculatedasa

percent-ageofthe areaof thetympanicmembrane,therewasno

distortionbecauseoftheangleofviewortheproximityof

388 RibeiroFAetal.

Gap

500 Hz

60

50

40

30

20

10

0

0.00 10.00 20.00 30.00 40.00 50.00 60.00 70.00

Percentage of tympanic membrane perforation

Figure2 Correlationbetweenpercentageoftympanic mem-brane perforation and air-bone gap observed at a 500Hz frequency.

theimage capture. These measurementswere performed

bytwoexaminers,at differenttimes,andonlythosethat

coincidedwithanerrorfactorof<5%wereconsidered. Theinclusionandexclusioncriteriaofthestudywereas follows:

- Inclusion --- images of tympanic membrane with

perfo-rationwithout evidenceofinflammation or otorrheafor

more than six months duration, simple chronic otitis

media.

- Exclusion --- evaluation of the perforation size by two

examinerspresentingadifference>5%.

The audiograms were evaluated only with respect to

their conductive hearing loss, i.e. the air-bone gap that

characterized the tympanic involvement (membrane or

ossicular chain). The following frequencies were used:

500Hz,1000Hz,2000Hzand4000Hz.

Data obtained from the perforations of the tympanic

membraneswerecorrelatedwiththeair-bone gapineach

ofthefrequenciesanalyzedbyPearson’scorrelationtest.

Results

Thestudyincluded187earsthatpresentedsimplechronic

otitismedia.Theageofpatientsanalyzedrangedfrom4to 75years.Therightearwasinvolvedin79patients,while108 exhibitedtheprobleminleftear.Thecorrelationbetween thesizeof theperforation andthefrequencies islistedin Table1.

The correlationbetweenthe percentageofperforation

ofthetympanicmembraneandtheair-bonegapthatexists

ineachoftheevaluatedfrequenciesisshowninFigs.2---5. Fig.2illustratesthecorrelationbetweenthepercentage

ofperforationofthetympanicmembraneandtheair-bone

gapobservedatafrequencyof500Hz.

Fig.3showsthecorrelationbetweenthepercentageof

perforationofthetympanicmembraneandtheair-bonegap

observedatafrequencyof1000Hz.

Gap

1

KHz

60

50

40

30

20

10

0

0.00 10.00 20.00 30.00 40.00 50.00 60.00 70.00

Percentage of tympanic membrane perforation

Figure 3 Correlation between the percentage oftympanic membraneperforationandair-bonegapobservedata1000Hz frequency.

Gap

2

KHz

60

50

40

30

20

10

0

0.00 10.00 20.00 30.00 40.00 50.00 60.00 70.00

Percentage of tympanic membrane perforation

Figure 4 Correlation between the percentage oftympanic membraneperforationandair-bonegapobservedata2000Hz frequency.

InFig.4,acorrelationbetweenthepercentageof

per-foration of thetympanic membraneand theair-bone gap

observedinthefrequencyof2000Hzisshown.

Finally,inFig.5,thecorrelationbetweenthepercentage

ofperforationofthetympanicmembraneandtheair-bone

gapobservedatafrequencyof4000Hzisshown.

Discussion

The linear correlation between the size of the tympanic

perforation in patients with simple chronic otitis media

Objectivecomparisonbetweenperforationandhearingloss 389

Table1 Pearson’scorrelationcoefficientfoundforeachfrequencyanalyzed.

500Hz 1000Hz 2000Hz 4000Hz

Pearson’scorrelationcoefficient 0.415 0.372 0.282 0.325

Gap

4

KHz

60

50

40

30

20

10

0

0.00 10.00 20.00 30.00 40.00 50.00 60.00 70.00

Percentage of tympanic membrane perforation

Figure5 Correlationbetweenpercentageoftympanic mem-brane perforation and air-bone gap observed at a 4000Hz frequency.

Thecorrelationforthefrequencyof500Hzwasfoundto bemoderatelysignificantfortheissueexamined,whilethe

correlationsobserved for theother frequencies proved to

beoflittlesignificance.

Intheliterature,Pannuetal.9_{reporteddifferentresults,}

demonstrating an increase in hearing loss with

increas-ingsizes of the tympanicperforation in 100patients who

alsohadperforationswithoutsignsofactiveinflammation

or secretion. Importantly, in that study, the perforation

size was estimated by measuring their greater vertical

(R1) and greater horizontal (R2) diameters with a 1-mm

wire, inserting the values into the formula: perforation

area=␲_×R1_×R2.

Ibekwe et al.,10 _{analyzed 67 patients with a total of}

77 perforations. Using the Pearson correlation: p=0.01,

r=0.05,theyconcludedthatthelargerthetympanic mem-braneperforation,thegreaterthelossinsoundperception.

The article by Ahmad and Ramani1 _{is in agreement}

with the studies previously mentioned. In that study, 70

patients with dry central perforation were analyzed. The

patientsweredividedintofourgroupsaccordingtothesize,

expressed as a percentage, of the observed perforation.

Theseauthorsanalyzedthehearinglossineachfrequency

ineachoftheirgroups,andconcludedthatthehearingloss increasedwiththesizeofperforation.

Therefore, thepresent study,with a largernumber of

patientsandusingamoremodernmethodology,contradicts

theliteratureandleadstotheconclusionthatfactors,other thanthesizeofperforation(e.g.,disjunctionsorfixations oftheossicularchain), compromisetheauditoryacuityin patientswithsimplechronicotitismedia.

Conclusion

There was no correlation between the size of tympanic

membraneperforationsinsimple chronicotitismediaand

hearinglossat500Hz;1000Hz;2000Hzand4000Hz.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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