To determine which preoperative conditions or surgical techniques may influence the success of tympanoplasty in the paediatric population

A MEDLINE search of the English language literature from 1966 to May 1997 was conducted using the search terms 'pediatric' or 'child' and 'tympanoplasty' or 'myringoplasty'.

Study designs of evaluations included in the review

Articles that provided age-specific data on tympanoplasty or myringoplasty were included. Studies where the focus of the report was presented to non-otolaryngologist audience were excluded. When the same series of patients was reviewed, only the most recent article was included in the analysis.

Specific interventions included in the review

The effect of surgical technique, prior adenoidectomy, presence of active infection, size of perforation, status of the contralateral ear, age and the eustachian tube function on healing of the tympanic membrane (TR) after surgery for sequelae of otitis media was assessed. Studies that investigated other otologic procedures (e.g. trauma, aural atresia), pathophysiology of otitis media and the surgical management of chronic otitis media (e.g. cholesteatoma, ossiculoplasty) were excluded.

Participants included in the review

Paediatric patients (aged 6 to 18 years). Studies that presented the results of tympanoplasty where the data relating to the adults was not separated from that of the children were excluded.

Outcomes assessed in the review

Success was defined as an intact TM following surgery. Other defining characteristics such as hearing results and incidence of postoperative complications were also included.

How were decisions on the relevance of primary studies made?

The authors do not state how the papers were selected for the review, or how many of the reviewers performed the selection.

The authors do not state that they assessed quality.

Data were tabulated by consensus of 2 reviewers.

How were the studies combined?

The mean weighted differences were compared and subjected to sensitivity analysis (by deleting the most positive and most negative study, adjusting for length of follow-up, and adjusting for tympanoplasty type). For age data, the mean weighted difference was calculated for each age, and a linear regression analysis was performed. The analysis of the effect of infection and surgical technique necessitated a comparison between studies, therefore an unpaired t-test was used.

How were differences between studies investigated?

The authors do not state how differences between the studies were investigated.

A total of 30 articles were included in the data analysis. Seventeen of the articles were case series limited to type 1 tympanoplasty. In the remaining articles, most cases were type 1 tympanoplasties. Total number of included participants is not clear.

Seven articles provided data on the size of the perforation. For patients with perforations up to 50% of the TM, 388 of 484 achieved an intact TM on follow-up. For those with perforations more than 50% of the TM, 102, of 147 were successful (weighted mean difference (WMD) 1.46, 95% confidence interval (CI): -25.20 to 28.11, p=0.91).

Four articles provided data on eustachian tube function. Success rate with good function was 83 of 95 vs 41 of 53 when poor function was present (WMD 14.69, 95% CI: -20.76 to 50.14, p=0.42).

Six articles provided data on adenoidectomy. Patients having prior or concurrent adenoidectomy healed in 115 of 146 cases. When no adenoidectomy had been performed 187 of 235 cases achieved an intact TM (WMD 3.10, 95% CI: -23.55 to 29.75, p=0.82).

Data on the status of the contralateral ear were available in seven articles. The success rates of those with normal and abnormal contralateral ears were 401 of 495 and 182 of 254, respectively (WMD 6.48, 95% CI: -14.99 to 27.94, p=0.55).

Success rates in the presence or absence of infection were reported in three articles, while an additional 4 articles reported results on dry ears only. For infected ears, 44 of 60 healed (WMD 73 .31, 95% CI: 38.50 to 108.11), while 408 of 514 dry ears healed (WMD 81.18, 95% CI: 65.42 to 96.95). An unpaired t-test found no significant difference (p=0.26).

Technique was addressed in eighteen articles, although none compared results of medial grafting and lateral grafting. Success for lateral grafts was achieved in 692 of 830 cases (WMD 90.40, 95% CI: 79.29 to 101.52) and for medial grafts 872 of 1069 (WMD 88.16, 95% CI: 78.53 to 97.82). The unpaired t-test found no significant difference (p=.86).

Nineteen articles provided data for calculation of success rate according to age. The WMD of success at younger vs older than a given age were calculated, and a linear regression analysis yielded a slope of -2.92 (p=0.005), indicating an association of greater success with advancing age.

The incidence of post operative complications, excluding recurrent perforation, included otitis media with effusion (10.6%), atelectasis (6.7%), myringotomy and tube (5%) and cholesteatoma (2.3%).

Sensitivity analysis did not change the interpretation of any of the results.

Greater success in healing of the tympanic membrane following tympanoplasty in children is seen with advancing age. None of the other parameters studied was shown to be a significant predictor of success. Guidelines for reporting results of tympanoplasty are presented.

The review states a clear objective and pre-specified inclusion/ exclusion criteria. MEDLINE was the only electronic database that was searched and only studies published in the English language were included. In addition, no attempt was made to search for unpublished data. This means that important information may have been missed and publication bias cannot be ruled out. The quality of included studies were not assessed and very little data from the primary studies was presented. The possible heterogeneity of included studies was not investigated and therefore the appropriateness of pooling could not be assured.

The author's conclusions seem to follow from the results presented.

The authors did not state any implications for further research and practice.

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.