Due to the scarcity of data on this complication, we designed a cross-sectional study to evaluate the associations and incidence rate of GT formation following tympanomastoidectomy and stapedotomy surgeries. Of 180 (17.22%) participants with GT diagnosis, none was from the stapedotomy group; thus, GT formation incidence in tympanomastoidectomy cases was 23.44%. The incidence rate of GT development for CWD and ICW approaches were 43% and 16.5%, respectively. Females were significantly less likely to develop GT (p < 0.001). Those with CWD mastoidectomy were more likely to develop GT than ICW and stapedotomy surgeries (p = 0.001). We found 164 (91.1%) participants with complete resolution after 2 months of treatment at the second visit. The remaining 16 patients, were all CWD cases and 10 and 6 were cured at the third (2 months later) and fourth visits, respectively.
GT manifests as a granulomatous mass, and the pathologic studies usually report granular tissue with epithelioid histiocytes, fibroblast proliferation, dense vasculature with ingrowing capillaries, and inflammatory cells like lymphocytes, plasma cells, and neutrophils [10].
Granulation tissue grows in the areas which lack suitable epidermal coverage. This is part of the reparative process in the secondary wound repair. So, it is not strange to have higher incidence of GT in CWD cases where the secondary repair is expected, in contrast to ICW cases where canal skin defects happen rarely [2].
While we found a significantly higher incidence of GT formation in males following tympanomastoidectomy, we found no similar article to compare our results. Despite the rarity of research on GT formation, granular myringitis, a similar but localized condition, gained more attention in the literature. It is a chronic inflammation manifesting on the external surface of the tympanic membrane but restricted to the squamous epithelium of the ear [11]. We found no significant sexual predominance regarding the incidence of granular myringitis in our database search [10, 11]. Future prospective studies are needed to elucidate the possible role of sex (and subsequently sexual hormones) in developing GT and granular myringitis.
CWD approach accompanied a higher rate of GT formation. As the procedures explained in the method section, the surgical intervention's complexity and extent might play a pivotal part in GT growth; This is consistent with proposed inciting events of granular myringitis, which signify traumatic injury and surgical ear interventions as possible factors [12, 13]. Faramarzi et al. used amniotic membrane and temporalis fascia to cover the musculoperiosteal flap in the CWD approach [5]. They concluded that the epithelialization time is significantly shorter in the amniotic membrane group and GT development was three times less than in the temporalis fascia group. The graft success rates were over 92% in both groups. Additionally, these patients did not experience recurrence of the cholesteatoma.
There is no consensus on the standard management of the GT. Our study showed about 91% (164 of 180 cases) complete resolution of GT with well-timed diagnosis and triple treatment with otic ciprofloxacin and betamethasone ear drops, plus chemical cauterization with Trichloroacetic acid 25% solution. Of note, the rest of the patients were cured completely by continuing this regimen and timely visits. This signifies the importance of surveillance over surgical treatment. Our study was empowered by its relatively high sample size. However, we did not use culture and staining studies on otorrhea secretions for the GT Group to determine a potential microbial etiology. Future studies should be designed prospectively to gain more confident results and assess whether routine follow-up of patients after otologic surgeries to diagnose GT in time is beneficial. Another limitation of our study was that tympanoplasty and myringoplasty cases were not included in the study because all the surgeries in this study was done by the first author and tympanoplasty and myringoplasty as minor surgeries was mostly done by junior surgeons. Hence, we do not include them in the study.