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What is the Role of Hyaluronic Acid Ester in Myringoplasty? Systematic Review and Meta-Analysis

Wong, Wai Keat; Luu, Eric H.

doi: 10.1097/MAO.0000000000002274

Objective: To reveal odds of tympanic membrane closure and postoperative hearing outcomes for myringoplasty utilizing hyaluronic acid ester via systematic review and meta-analysis.

Data Sources: 1) Search of English articles in PubMed/Medline, Embase, and Cochrane databases published between January 1, 1998 and March 31, 2018.

Study Selection: Inclusion criteria: 1) English language; 2) clinical studies; 3) reported posttreatment perforation status, hearing outcomes, or complications. Exclusion criteria: hyaluronic acid used for middle ear packing or topical application of hyaluronic acid solution.

Data Extraction: Number of patients, surgical technique, mean age, overall rate of tympanic membrane closure, success rate based on size of perforation, mean air-bone gap improvement, and postoperative speech scores and complications.

Data Synthesis: Ten studies encompassing 531 patients met criteria. Reported success rates for closure of chronic perforation ranged from 70.0 to 92.7% (mean, 85.21%). Smaller perforation predicted success in complete closure. Mean air-bone gap closure was 10.6 dB (4–24 dB). There were five complications reported. Meta-analysis was performed on five studies. No difference was noted in the success rates between hyaluronic acid ester myringoplasty and conventional tympanoplasty using fascia or perichondrium, with an overall closure rates of 89.8 and 89.4%, respectively (odds ratio [OR] 1.04, 95% confidence interval [CI] 0.59–1.82, p = 0.896). A higher closure rate was seen in hyaluronic acid ester myringoplasty (87.9%) when compared with fat graft myringoplasty (70.8%), (OR 3.01, 95% CI 1.42–6.35, p = 0.004).

Conclusions: Hyaluronic acid (HA) ester myringoplasty appears to be safe and effective at attaining complete closure of tympanic membrane perforation, although there exists significant selection bias and inconsistent reporting among existing papers.

Department of Otolaryngology, Head and Neck Surgery, Waikato Hospital, Hamilton, Waikato, New Zealand

Address correspondence and reprint requests to Wai Keat Wong, M.B.Ch.B., Department of Otolaryngology, Head and Neck Surgery, Waikato Hospital, Pembroke Street, West Hamilton, 3204 Waikato, New Zealand; E-mail:

This study was conducted in accordance with the ethical standards of the responsible committee on human experimentation (institutional) and with the Helsinki Declaration.

The authors have no funding, financial relationships, or conflicts of interest to disclose.

Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company