This study evaluated the use of platelet rich fibrin (PRF) matrix to repair traumatic tympanic membrane perforations. 25 patients with small central perforations underwent cauterization with trichloroacetic acid and placement of an autologous PRF plug under local anesthesia. The closure rate was 92% with a mean closure time of 8 days. Pre-operative air-bone gap averaged 20.2 dB, improving to 8.1 dB post-operatively, with 88% of patients achieving significant hearing improvement. The PRF plug technique proved effective for traumatic perforation repair in an outpatient setting without general anesthesia.

1. Journal presentation
On
Application of Platelet Rich Fibrin Matrix to Repair Traumatic
Tympanic Membrane Perforations: A Pilot Study
DEPARTMENT OF E.N.T.

2. Introduction
• Trauma in the form of instrumentation, slap, blast, accident, and sporting injury can result in tympanic
membrane (TM) perforations which spontaneously recover in 53–94%.
• The closure rates of TM perforation due to above causes do not vary greatly, however some
otolaryngologists prefer to perform immediate microsurgical procedures to accelerate the recovery
process.
• Platelet-rich fibrin (PRF) was first described by Choukroun in 2001.
• Dohan et al. conducted a detailed biochemical analysis in 2006. He reported that PRF consists of an
intimate assembly of cytokines, glycemic chains and structural glycoproteins enmeshed within a slowly
polymerized fibrin network. These natural bio mediators are cheaper, less invasive and readily obtained
which may correct cellular events in wound healing, such as cell proliferation, differentiation and
chemotaxis.
• PRF membrane has a strong, elastic fibrin structure containing growth factors; it may be an ideal
patching material in the treatment of traumatic TM injuries.

3. Aims & Objectives
• The objective of this study was to evaluate efficacy of Trichloroacetic acid (50%) and PRF Plug
Myringoplasty technique for management of traumatic tympanic membrane perforation with regards to
recovery rates, healing time and correction of the mean air–bone gap.

4. Materials & Methods
• A pilot study was carried amongst 25 selected patients with traumatic tympanic membrane (central)
perforations for a duration of 2 years.
• All patients underwent Pure tone Audiometry (PTA) assessment & TCA (50%) and Autologous PRF Plug
Myringoplasty technique was done under Local Anaesthesia and followed up to 6 months
postoperatively.
• Informed consent was obtained from all patients.
Inclusion Criteria
1. Traumatic Tympanic membrane perforation <4
mm which failed to heal spontaneously.
2. Inactive Middle ear cleft.
3. Functional Eustachian tube.
4. Well Pneumatized Mastoid air cell system.
5. Pure Tone Audiogram with Conductive hearing
loss and intact ossicular chain.
6. No disease that could progress to a clotting
disorder and no use of anticoagulants within the
previous 10 days.
Exclusion Criteria
1. Tympanic membrane perforation[4 mm.
2. History of Previous otological surgery.
3. Active Middle ear cleft Disease.
4. Dysfunctional Eustachian tube & poorly
pneumatized Mastoid air cell system.
5. Pure Tone Audiogram with Sensorineural
hearing loss and ossicular chain disruption.
6. Symptomatic Deviated Nasal Septum and
Sinusitis (acute or chronic)
7. HBV and HIV Positive status.

5. Procedures
• Patients with traumatic tympanic membrane
perforations were included in the study according to
the inclusion criteria (Fig. 1).
• A thorough clinical, medical history with routine
otorhinolaryngological examination was done which
includes an in office based diagnostic nasal
endoscopy to rule out symptomatic deviated nasal
septum and sinusitis (acute or chronic), eustachian
tube orifice for any mechanical and functional
obstruction, nasopharynx, eustachian tube patency
was assessed by valsalva’s maneuver, oto-
endoscopy were done for all the cases.
• Size of the perforation is measured by oto-endoscopy by positioning the patient in supine posture with
the involved ear facing upwards. If there is any associated wax or secondary fungal infection of the
external auditory canal, it is cleared.
• Measurement was performed using a custom-designed measuring pick formed by attaching a 4 mm part
onto the extremity of a straight pick with a 90 angle.
• Taking into account that the diameter of tympanic membrane is 8–9 mm, the patients with perforations 4
mm (small perforations) were selected and then PRF 1.5-times larger than the perforation site was
applied.

6. Aims & Objectives
• All patients were explained about the procedure in detail, written and informed consent obtained for documentation,
visual recording of the office procedure.
• The procedure doesn’t involve hospitalization and General Anaesthesia. Laboratory & radiological investigations was
carried out on outpatient basis (complete hemogram test, retroviral and HbsAg status, X ray of Bilateral Mastoid, pure
tone audiometry, patch test) (Fig. 2, 3, 4).

7. Patch Test
• A small piece of paper patch was trimmed to approximately 1.5-times larger than the perforation site and
laid over the perforation using ear forceps under oto-endoscopic guidance (Fig. 5).
• Pure tone Audiometry is done post patch test to compare with the first Audiogram report, which could
help in clinical assessment of hearing improvement by measurement of the mean air–bone gap before
and after the procedure (Fig. 6).
• Assessment of ossicular chain continuity could be indirectly assessed from the pure tone audiogram
average and closure of air–bone gap post patch test. Paper patch is then removed after the patch test.

8. PRF Preparation
• A 10-cc venous blood sample was taken by catheter from the patients into dry, glass vacuum tubes. The
tubes were immediately centrifuged (2400 rpm, 12 min).
• After completing the process, three layers were observed to have formed. The base layer was red blood
cells, the top layer was non-cellular plasma and the middle layer was PRF coagulate.
• With sterile forceps, the PRF was removed from the tube and stripped from the adjacent red blood cell
layer. With absorption of the PRF serum into a gauze pad, a membrane, rich in fibrin from the matrix and
with high resistance, was obtained.
• The membrane was cut to size approximately 1.5-times larger than the perforation (Fig. 7).
Patient Position
• Patient positioned supine with the affected ear turned upwards.
Anaesthesia
• Under Local Anaesthesia, 4% Xylocaine was used to
anaesthetize the tympanic membrane by instilling few drops
into a small cotton ball and placing it into the external canal
wall over the surface of the tympanic membrane for about 10
min and later removed.

9. Preparation Technique
• Under Oto-endoscopic guidance, the rim of the perforation was cauterized using a cotton tipped
applicator dipped in freshly prepared 50% trichloroacetic acid until a white cauterized margin 0.5 mm in
width, care was taken not to scar the promontory.
• Autologous PRF membrane was cut to size approximately 1.5-times larger than the perforation was
plugged through the perforation site, no middle ear packing material used.
• External auditory canal was packed with gelfoam soaked with platelet poor plasma. Sealing the external
auditory canal with cotton ball impregnated with antibiotic soaked ointment.
Fig. 8 Autologous platelet rich fibrin matrix plug
Myringoplasty technique.
A) Left ear traumatic tympanic membrane perforation,
B) 4% xylocaine soaked cotton for local anaesthesia,
C) 50% Trichloroacetic acid application to freshen the
margins of the perforation,
D) And E) drawing 10 cc blood to obtain Platelet rich
fibrin tube placed in centrifuge,
F) centrifuge apparatus, set at 2400 rpm for 12 min,
G) And H) Platelet rich fibrin obtained and separated
from Red blood cell layer,
I) Platelet rich fibrin plugging myringoplasty done,
J) Postprocedure oto-endoscopy day 15,
K) post-procedure oto-endoscopy day 60

10. Post Procedure Management
All 25 patients received the following advice post procedure.
1. Broad spectrum antibiotics, antihistamines, analgesics, antioxidant therapy are advised for 1 week.
Combination of Antibiotic with steroid ear drops (Neosporin H, Otek AC, Ciplox D) 3 drops was instilled
twice daily for 3 weeks.
2. Avoid Ear canal instrumentation, forceful coughing, sneezing or blowing of nose, smoking & alcohol
consumption.
3. Being an office procedure, patient can be followed up after 1st week, 4th week, 2nd month, 3rd to 6th
month. Otoscopic examination, an oto-endoscopy was performed to evaluate the speed of healing &
closure rates of tympanic membrane perforation and PTA (2nd month) to determine mean air–bone gap.
Follow-Up
• All 25 patients were followed up ranged from 3 months to 2 years. The mean duration of follow up was 1
year.
Statistical Methods
• Data collected will be entered on excel spread sheet after coding and further processed using SPSS
Version 17.0 (Statistical package for social sciences). The data analysis will be done by computing
proportions, mean of standard deviation.
• Appropriate test of significance will be used based on type of data. A p value0.05 will be considered
significant.

11. Results
• The patients included 15 males & 10 females with a mean age of 28.9 years. None of them had bilateral
perforation.
• No statistically significant differences were observed in terms of perforation size, gender, or pre-operative
audiological evaluations (p[0.05) (Table 1).
• Closure was obtained in 23 patients (92%). In the 2 cases where closure was not obtained, PRF was re-
applied: one closed & one did not. Mean closure time of TM perforation was 8 days(Fig. 9).
• Full closure of the TM was observed in 23 (92%) on post-operative day 10 (p0.05) after exclusion of two cases
where tympanic membrane closure was not obtained. Suggesting a significant improvement (p0.05) in closure
of traumatic tympanic membrane perforation.

12. Audiological Evaluations
• Initial and final air conduction (AC) and bone conduction (BC)
average values of patients in a series of frequencies.
• Bone Conduction (BC) thresholds on 2000 and 4000 Hz are more
affected than lower frequencies. On assessment, there was more
improvement at lower frequencies compared to higher
frequencies in ABG (air–bone gap) averages.
• There was more improvement at 500 Hz compared to 2000 and
4000 Hz, and at 1000 Hz compared to 4000 Hz after the
treatment (p0.05) (Table 2).
• Improvements in ABG after the treatment in PRF membrane
showed more improvement in 1000 and 2000 Hz (p0.05; Mann–
Whitney U-test) (Table 3).
• The mean preoperative air–bone gap was 20.2 db. On post-
operative 2nd month, the mean improvement in the air–bone gap
was 12.1 dB (p0.05). 22 patients of 25 showed significant
hearing improvement (success rate 88% ABG closure).

13. Discussions
• Spontaneous recovery of traumatic TM perforations of any size heal without any interventions occurs in
53–94% cases, however few may present with persistent perforation and hearing loss it is preferable to
wait for at least 3 weeks prior to any intervention.
• Non-healing perforations typically require tympanoplasty for closure.
• The purposes of closing chronic dry perforations of the tympanic membrane are to improve hearing and
prevent middle ear infections.
• While surgical closure of tympanic membrane perforation still remains the choice of management,
effective closure of tympanic membrane perforation can be achieved by using chemical cautery and
patch technique together for small and moderate sized perforations.
• Three types of traumatic perforations can occur: penetrating, blunt, and iatrogenic. It is important to
keep in mind that inner ear injury may accompany acute traumatic perforations, a possibility that should
be evaluated by careful questioning.
• PRF is totally autologous & does not require a second procedure, making it more cost-effective.
• PRF also enables more rapid healing with better audiological improvement.

14. Conclusions
• Autologous PRF, a product derived from whole blood through the process of gradient density
centrifugation which is safe and effective in promoting the natural processes of wound healing.
• Its Potential value lies in its ability to incorporate high concentrations of platelet derived growth factors,
as well as fibrin, into the graft mixture which provides rapid and effective healing of traumatic TM
perforation.
• From this study, the closure rate in small central perforations by TCA (50%) and PRF Plug Myringoplasty
technique without general anesthesia was 92% & success rate 88% air–bone gap closure.
• This procedure does not require general anesthesia or hospitalization.
• PRF provides rapid healing of TM perforation and successful audiological results with no requirement for
a second procedure.
• PRF is a promising biotechnology that is fuelling growing interest in tissue engineering and cellular
therapeutics.
• This technique would be used as a time and cost effective office based procedure for the treatment of
small central TM perforations in selected cases.

15. Summary
• To Evaluate Success rate of healing traumatic tympanic membrane perforation with autologous platelet
rich fibrin matrix under local anesthesia as an outpatient clinic procedure.
• In this study, 25 patients with persistent traumatic tympanic membrane perforation as per inclusion
criteria were included.
• The closure rate in small central perforations by TCA (50%) and PRF Plug Myringoplasty technique was
92%. The mean time to closure was 8 days. Full closure of the TM was observed in 23 (92%) on post-
operative day 10 (p0.05).
• The mean pre-operative air–bone gap was 20.2 db. On post-operative day 45, the mean improvement in
the air–bone gap was 12.1 db. 22 patients of 25 showed significant hearing improvement (success rate
88% ABG closure).
• Autologous PRF plug myringoplasty technique can be recommended as a natural bio mediator, time and
cost effective office based procedure for treatment of traumatic tympanic membrane perforation.