This systematic review and meta-analysis examines the effectiveness of platelet-rich fibrin (PRF) in treating tympanic membrane perforations. The analysis included 7 studies with 522 patients. PRF achieved satisfactory healing rates, with a complete closure rate of 94% and a reduction in infection rates. However, PRF did not significantly improve hearing outcomes. While PRF shows promise in membrane healing, more high-quality studies are needed due to limitations such as small sample sizes and lack of long-term follow-up data to establish PRF as a standard treatment.

1. Journal Club: Critical Appraisal
Tympanic membrane regeneration using platelet-rich fibrin:
a systematic review and meta-analysis
Presenter: Sqn Ldr Revathi S
Moderator: Maj Naman Surya

2. Layout
• Background Knowledge
• Research Question
• Article in Focus
• Critical Appraisal
• Conclusion

3. Background Knowledge
• Common in both developed and developing countries
• TM perforations- fail to heal spontaneously  morbidity and Disability
• Progress of tissue engineering-growth factors
• Platelet-rich fibrin (PRF)-II generation of platelet concentrate products

4. Background Knowledge

5. Background Knowledge
• Contains platelets, WBC & growth factors- effective in wound healing.
• Since 2001,have been used to repair TMs with satisfactory healing results
• Application of PRF is not universal and remains controversial.

6. Research question
• “can the application of PRF achieve better results
than conventional treatments in terms of healing
and hearing for patients with TM perforations?”

7. Article in Focus
INTRODUCTION

8. Research article
• Title: Tympanic membrane regeneration using platelet-rich fibrin:
a systematic review and meta-analysis
• Journal: European Archives of Oto-Rhino-Laryngology
• Authors: Juntao Huang
• Year published: 2021

9. Research article
• Type of Study: systematic review and meta-analysis
• Level of Evidence:

10. Research question
• P - 522 patients with Tympanic membrane perforation.
• I – PRF was used
• C - Nil
• O – Healing & Hearing
• T - Studies published from 2014-2021
• S – Systematic review & Meta-analysis

11. Objective
 Assessing the effectiveness of PRF in the treatment of tympanic membrane
(TM) perforations.

12. Inclusion and Exclusion Criteria
• Included-
• Excluded

13. Materials and Methods
• Searched articles on PRF in TM repair by screening PubMed, Embase, the
Cochrane Library and Web of Science from inception to February 28th, 2021.
• Patients who were enrolled with TM perforations and treated with PRF were
selected

14. Materials and Methods
• Quantitative comparison Cochrane Collaboration's risk-of-bias tool.
• The risk of bias measured according to 7 criteria.
• Green-Low, Yellow- Unclear & Red –High Risk

15. Materials & Methods

16. Materials & Methods

17. Materials and Methods
Outcome Measurement
• Primary outcome- healing, complete closure rates in the PRF groups.
• Secondary measures- differences in auditory improvements between the pre-
and postoperative periods.
• Incidence of infections after treatment -effectiveness of PRF.

18. Materials and Methods
Statistical analysis
• Review Manager version 5.3.
• Data were taken for both the treatment and control groups:

19. Materials and Methods
Statistical analysis
(i) number of enrolled patients
(ii) percentage of closure
(iii) percentage of infections
(iv) mean and standard Deviation

20. Materials and Methods
Statistical analysis
• A sensitivity analysis was performed with STATA version 12.0 software
• Publication bias was tested via funnel plots.
• All outcomes were considered significantly different when the P value was less
than 0.05.

21. Discussion
Study Study Design Type of
Perforatio
n
Size of
Perforat
ion
Intervention Follow-up No of
Enrolled
Patients
Success rate
(n%)
RCT Chronic S-L PRF+TFT 3 25
25
19 (76)
13 (52)
Prospective Chronic S-L PRF + PM 6 20
20
19(95)
14(70)
RCT Chronic S-L PRF+TFT 6 36
55
34 (94)
41 (75)
RCT Chronic S-L PRF + BCT 3 43
42
42 (98)
34(81)
Prospective Chronic S PRF 11.4 25
25
24 (96)
19 (76)
RCT Acute S-L PRF 1.5 30
30
28(93)
25 (83)
RCT Acute S PRF 1 14
18
9 (64)
4 (22)
Prospective Chronic S-M PRFM 6 41 35 (85)
Prospective Chronic S PRFM 12 25 23 (92)
Retrospective Chronic NA PRF + TFT/CT 12 48 45 (94)

22. Discussion

23. Discussion

24. Discussion
• Achieved satisfactory results in wound healing; But not in hearing
• Easily prepared & do not have stringent storage requirements or high costs
• PRF is the second-generation product and is similar in composition to PRP.
• According to our results, PRF has a better success rate than no intervention or
paper patches in closing acute perforations (OR = 4.30).

25. Discussion
• For large /chronic perforations, surgical interventions- often required
• In chronic subgroups use of PRF can enhance the survival rates of autografts .
• Gokce et al reported that the addition of PRF to TFT improves the graft uptake
rate in large perforations.
• reduce the incidence of infections

26. CRITICAL APPRAISAL

27. 1. Deciding whether you should read this article:
• Feasible:
- It was feasible for us to find relevant studies related to the article
• Title:
- Interesting
• Element of novelty:
- Few studies; no consensus/ guidelines
• Ethical:
- Yes
• Relevant:
- Conclusions derived are relevant to our clinical practice

28. 2. Research question:
Clear research question
• Population
- Clearly defined
• Intervention
- Well-defined intervention
• Comparison
- Nil
• Outcome
- Hearing & Healing
• Time
- Studies published from 2014-2021
• Study
- Systematic Review & Meta-analysis

29. 3.Objective of the study
• The objective of the study was clearly mentioned

30. 4. Assess the validity of the study
• Research formed & clearly defined
• Study selection process was not systematic
• Study design was not appropriate
• Results stated matched objective of the study
• Outcome assessed is clinically relevant

31. 5. Analysis
• Data is presented in a simple & legible form
• Statistical tests were correct for the type of study
• Conclusions drawn are based on actual findings in the study.

32. STRENGTHS AND LIMITATIONS

33. Strengths
• Level of Evidence-
• Novel study
• Appropriate Statistical analysis was used.

34. Limitations
• Small no of eligible studies
• Difficult to perform quantitative comparisons of outcome measures.
• Long-term follow-up is necessary
• Lack of evidence based study for comparing PRF,PRP other growth factors.
• Surgical expertise of the surgeon was not considered

35. Other Articles

36. Other Articles

37. Standard Textbook (Scott Brown)

38. Standard Textbook (Cummings)

39. Take Home Message
• PRF is found to be effective in wound healing, the application of PRF is
not universal and remains controversial
• The use of PRF does not influence on the final degree of hearing
improvement.

40. Thank you