Efficacy of Platelet Enriched Plasma in Preventing Surgery for Patients With Chronic Tympanic Membrane Perforation
Phase: PHASE1
Conditions: Tympanic Membrane Perforation
Sponsor: University of Kansas Medical Center

Efficacy of Platelet Enriched Plasma in preventing surgery for patients with chronic tympanic membrane 
perforation 
Protocol Version 3; February 7th2; January 22, 2018 
 
Background & Rationale 
Tympanic membrane (TM) perforation is the leading cause of conductive hearing loss.  TM perforations 
in adults typically arise from middle ear infections, trauma, or from iatrogenic cause.  While 
approximately 80% TM perforations close with time and conservative managements, approximately 20% 
require surgical intervention[1-3].  Often before exploring surgical options some patients opt for trial for 
paper patch myringoplasty that can be performed in the clinic.  Success rates with paper patch 
myringoplasty are variable and can range from 12 to 63% depending are whether the size of the 
perforation is large or small[4].  When patients fail conservative treatment with paper patch, patients 
will explore surgical options.  Surgical success rates for myringoplasty vary and quoted ranging from 60 -
90% in adults to 34-85% in children, and often lower in anterior TM perforations secondary to more 
difficult exposure[1].  Of those patients that do require surgical intervention, costs of tympanoplasty can 
cost upwards of twenty-four thousand dollars[5]. 
 
Multiple different biologic materials have been heavily investigated in the literature including hyalornan, 
heparin, epidermal growth factor, fibroblast growth factor, platelet derived growth factor, and 
transforming growth factor with variable success[6].  Recently platelet enriched plasma (PRP) has been 
favored in multiple surgical procedures from orthopedics, ENT, to plastic surgery[7, 8].  The rationale 
behind its use are two fold; first platelets play a fundamental role in hemostasis and wound healing, and 
secondly the alpha granules contained within platelets contain various growth factors that play a 
fundamental role in wound healing[9].  Currently there are three different PRP that are FDA approved, 
SMARTPEP (SmartPEP, Harvest Technologies Corp, Norwell, MA) and Platelet Concentrating Collection 
Systems (3i/Implant innovations, Palm Beach Gardens, FL), and Arthrex (Arthrex Naples, FL) [2].  PRP 
is an autologous blood donation, where whole is blood is collected from the patient and subsequently 
isolated through differential gradient centrifugation in an anticoagulant citrate dextrose-A[2]. 
 
PRP is widely used throughout multiple surgical subspecialties daily including Otolaryngology, 
Orhtopedic surgery, Plastic surgery, Dermatology, OMFS, and Dentistry for over two decades.  Despite 
its clinical advantages, to date there are no studies that have reliably investigated adverse events 
associated with PRP because of poor and inconsistent methodology[10].  However, there are 
intermittent case reports that report adverse events.  A case report by Kaux et al (2014) found one 
adverse event out of 1000 injections performed.  They reported one PRP injection into a 35-year-old 
male with diabetes caused an exuberant inflammatory reaction, characterized by swelling, pain, and 
erythema[11].  However, a large Cochrane data base review looking at PRP in musculoskeletal injuries 
examined over 19 trials covering over 1000 patients and found no difference in adverse events 
(including pain, infection, tendon rupture, and anaphylactic reaction) [12].  A separate systematic review 
examining six studies found no difference in complication rates between PRP and controls for acute 
muscle injuries (including hematoma, discomfort, hyperesthesia at injection site)[13].  Another 
Cochrane database review looking at PRP effectiveness for sinus lift procedures for dental implant 
rehabilitation examined over 29 trials and found no difference in complication rates or adverse events 
with PRP compared to controls (including sinusitis, infection, nerve injury, hematoma, perforation into 
sinus) [14]. 
 
Recently a study by Erkilet (2008) investigated the use of platelet enriched plasma (PRP) on 88 TM on 44 
rats, treating one ear with PRP while the contralateral ear was left to heal spontaneously[9].  They 

demonstrated that those tympanic membranes treated with PEP had faster healing times both clinically 
and on histopathology.  In a separate study, acute TM perforations were created in rabbits and PRP was 
shown to significantly quicken time to heal without any difference on a microscopic level[15].  While PRP 
has been shown to be effective as sole treatment for animal models, it has yet to be investigated 
independently humans.  A study by El-Anwar (2015) looked at concurrent use of PRP with 
myringoplasty, which involves a post-auricular incision to inlay a medial TM graft, and found statistically 
improved graft take and healing[16].  However, the use in this case is in an intraoperative setting with an 
already established surgical procedure. 
 
We wish to pursue and investigate the use of PRP in a clinical setting as the sole treatment for small 
tympanic membrane perforations.  While no studies exist on the specific use of PRP as sole treatment 
modality, multiple studies have shown success with various growth factors such as PDGF and ECF[17].  
PRP is promising because its ability to use a variety autologous growth factors stored within their alpha 
granules, negating the need for exogenous growth factors.  Ultimately if PRP can increase the rate of 
tympanic membrane perforation healing thus negating the need for surgical intervention, PRP can 
potentially save the health care industry millions of dollars every year. 
 
Specific Aim 
The goal of our proposed prospective project is to investigate the efficacy of platelet enriched plasma 
(PRP) as a treatment for patients with chronic tympanic membrane perforation. Our primary outcome 
includes the prevention of patients requiring surgery for their perforation.  
 
Inclusion Criteria 
• 
Patients aged 18 or older  
• 
Patients who have a chronic anterior tympanic membrane perforation that is <50% of the 
eardrum who meet criteria for tympanoplasty procedure 
• 
Patients willing to comply with the protocol and attend all study visits. 
• 
Patients is able to provide written informed consent 
 
Exclusion Criteria 
• 
Patients who are aged 17 or younger 
• 
Patients who have previously undergone middle ear or lateral skull base surgery 
• 
Patients who have a chronically draining ear who would not qualify for a tympanoplasty 
• 
Any type of platelet disorder, cancer, or ongoing systemic infection. 
• 
Any type of hemodynamic instability, septicemia, infection, tobacco use, any use of steroids to 
the ear drums, and patient unwilling to accept the risks of the procedure.   
• 
Type I diabetes or other autoimmune pathology (based on case report by Kaux et al (2014) [11]) 
 
Benefits and Risks 
There are some risks associated with a tympanoplasty, however, these risks are not associated with this 
study and will be covered in a separate consent for surgery. 
 
There is a minimal risk for patients associated with the possibility for an unintentional breach of 
confidentiality. All records will be adequately protected to assure that this risk is minimized to the best 
of our ability. 
 

Potential benefits of this study include the possibility of avoiding surgery for this subset of patients. This 
will decrease overall cost for the patient and avoid the inherent complications and pain associated with 
tympanoplasty surgery. 
 
Study Procedures 
During routine clinical care visits, the patients will be screened for selection according to the inclusion 
and exclusion criteria. Each patient matching these criteria and deemed eligible for the study by the 
study personnel will be approached for participation in the study. Study personnel will consent the 
patients in the clinic space behind closed doors. All patients will be given the opportunity to determine 
their interest in participation and ask any questions necessary to the study personnel.  We will stress to 
the patient’s that involvement in this study will not delay standard of care and will not delay or 
negatively impact eligibility for any type of surgical intervention.  Dr. Staecker is currently scheduling 
cases out by about 3 months, which is beyond the 6 week window we expect to complete this study.   
The only way involvement in this study will change any surgical plans is if PRP is able to successfully heal 
the tympanic membrane perforation. 
 
This study consists of an initial visit, followed by three additional follow up visits. The initial visit may last 
up to one hour and will include consenting the patient for the procedure, a blood draw for PRP 
extraction, completing a short questionnaire (attached), history and physical, taking pictures of the 
perforation and application of the PRP. Patients will be scheduled for surgery approximately 5-8 weeks 
after their initial appointment. Prior to surgical intervention, they will be seen in clinic for follow up and 
given the same questionnaire (attached). The three additional visits will consist of shorter visits to 
evaluate the perforation size and need for surgery. Patients will be given compensation of $10 for each 
visit they participate in in the study. 
 
Patients will only be treated once with the PRP isolate.  During the initial visit, the patient’s blood will be 
drawn by study personnel. While the PI is completing other parts of the initial visit, the blood will be 
drawn in the clinic and centrifuged down into PRP in the clinic. This will take approximately 15 minutes. 
Please see below for step by step. We have also provided the Arthrex handout information sheet for 
PRP. The PRP has a gel-consistency that will be applied to the patient’s tympanic membrane using a 
cotton tip swab. 
 
After the five of the initial patients are treated we will review the treatment outcomes. Should all five 
fail to receive any benefit from the PRP treatment or if some other unanticipated serious adverse events 
emerges during the study the study team will consider the utility of moving forward. Given the history of 
the routine use of PRP in multiple other subspecialties including otolaryngology facial plastics surgery 
we do not anticipate any systemic or local reactions or problems. While this study is not without risks, 
patients are already scheduled for surgery at the time of enrollment. Participation in the study does not 
delay routine care in this patient population as surgery is universally scheduled 5-8 weeks after initial 
consultation. The likelihood of failure and/or success is not known and therefore stopping the study 
after 5 patients may prevent us from seeing the positive impact of this treatment. Prevention of even 
one out of 10 patients proceeding to surgery would be financially justifiable given the expense of 
surgery and the relative low cost of PRP treatment. After 10 patients are enrolled and treated the study 
team will again revisit the utility of proceeding with the study. At that point if no patients have any 
measurable benefit from the treatment the study will be stopped and carefully reviewed for futility.  

Adverse events will all be documented using the CTCAE 4.0 Protocol and the PI will assess the 
association with the study drug. Any adverse events will be reviewed with the independent safety 
monitor who will have the authority to stop the study if the adverse events are associated with the 
investigational treatment and deemed a significant risk likely to occur in future participants. The 
standard serious adverse events of death, life-threatening complication, inpatient hospitalization or 
prolongation, or persistent or significant disability will all be considered events worthy of stopping the 
study. Again, this is an autologous therapeutic and there is no evidence of serious adverse events or 
adverse events beyond placebos or alternative therapies reported in the PRP literature for any of the 
approved uses. 
Protocol for Preparation: 
Each kit will contain the following:  Double syringe, double syringe luer cap, tourniquet (disposable and 
latex free), alcohol pad, angel wing infusion set 19G, Gauze sponge (2x2in), Band-Aid (latex free), and 
patient label.  All samples will be processed at KUMC in the ENT clinic. 
 
Step 1: Prior to withdrawing, prime the outer and inner syringes by pulling each plunger completely back 
and forward before starting the process.  Withdraw approximately 1.5ml ACD-A into the syringe.  
However, if the ACP is going to be used within 30 minutes of blood withdrawal, the use of ACD-A is not 
required. 
Step 2: Blood withdraw. Place the tourniquet along the proximal arm and prep the skin where the 
desired vein to withdraw blood is located.  Slowly withdraw by pulling back on the wings that are 
colored red. Fill the syringe with a maximum of 16cc of venous blood at a rate of 1cc every 2 seconds 
and seal the syringe with the red cap.  Of note, blood will be collected with a single uninterrupted 
venipuncture with minimal damage to and manipulation of the donor’s tissue.  The 19 gauge butterfly 
needle will be used to withdraw blood, which is located in the kit. 
 
Step 3: The centrifuge will be located in the clinic. Gently rotate the syringe in order to mix the blood 
and the ACD-A.  Place the syringe into a bucket and an appropriate size counterbalance in the opposite 
bucket of the centrifuge. For the sake of this study, we will centrifuge the blood immediately upon 
collection. Recommendations are that it is done within 4 hours and stored at a temperature of 20 to 24 
degrees Celsius. 
 
Step 4: Run the centrifuge at 1500 rpm for 5 minutes.  Remove the syringe, taking care to keep it in an 
upright position to avoid mixing the plasma and red blood cells. 
 
Step 5: Transfer 4-7ml of the ACP from the larger outer syringe into the small inner syringe that comes 
with the kit.  Slowly push down the outer syringe’s red wings, while slowly pulling up the plunger of the 
small inner syringe.  Final concentration of platelets is estimated around 600 x 103 / ul. 
 
Step 6: Unscrew the small inner syringe.  The ACP is ready for use at the point of care. The ACP can also 
be transferred into a sterile cup on the sterile field and transferred into a 10ml syringe for use.  The ACP 
should be used within 4 hours after blood draw.  For this procedure, we will use immediately after 
isolating. 
 
Step 7: one the ACP is isolated and ready to use it will be applied directly to the small tympanic 
membrane perforation with the use of the otomicroscope. 
 

Patient follow up.  We will ask patients to remain in the clinic for 30 minutes after the injection to assure 
the safety in the acute post-treatment period including bleeding, vertigo, ear fullness, pain, erythema, 
swelling, or other signs of inflammation or infection. We will conduct a phone interview between 3-5 
days after application of PRP. During this phone interview conducted by study team members, we will 
again evaluate any concerning side effects with questions about the same issues mentioned above and 
any worsening of hearing loss or discomfort. Each subsequent follow-up visit will evaluate the safety of 
the treatment with the same endpoints and additionally include an assessment of efficacy.  
 
The objective study outcomes will be in terms of success of healing of tympanic membrane, and pictures 
taken in clinic will be the data collected.  The pictures taken of the perforation will be standardized to 
the size of the malleus in order to compare images between different visits. 
 
Patients who do not have complete closure of the tympanic membrane will proceed to surgery as 
originally planned and resume routine follow-up. Should any patients achieve full closure and healing 
they will have their surgery cancelled and resume routine follow-up. 
 
A full schedule of events for each study visit is included below. 

Schedule of Events 
 
Treatment Visit 
Post injection 
Follow up phone 
Call 
Follow up Visit 1 
Follow up Visit 2 
Final Follow  
 
Day 0 
Day 3-5 
Day 14 
Day 28 
Day 42 
Visits 
1 
N/A 
2 
3 
4 
 
 
 
 
 
 
Medical History and Current Medications 
X 
 
 
 
 
Ringing in the Ear Evaluation 
X 
X 
X 
X 
x 
Overall Exam 
X 
 
X 
X 
x 
Blood Samples 
X 
 
 
 
 
Questionnaires 
X 
X 
x 
X 
X 
Hearing Test 
X 
 
 
 
X 
Ear Exam 
X 
 
X 
X 
X 
Eardrum Mobility Test 
X 
 
 
 
X 
Balance Testing 
X 
 
X 
X 
X 
Study Treatment Application 
X 
 
 
 
 
Review Current Medications and Side Effects 
X 
 
X 
X 
X 
Signs of Infection, edema, or Inflammation 
X 
X 
X 
X 
X 
Photographs of Eardrum 
X 
 
X 
X 
X 
Approximate Study Visit Length (in hours) 
2 hours 
5-10 minutes 
0.25 hour 
0.25 hour 
0.25 hour 

While the principal investigator, Dr. Staecker, has had limited exposure to the use of PRP we as ENT 
residents have use it on a consistent basis during our facial plastics procedures.  More specifically we 
apply it after rhytidectomy (face lift) to help with healing and decrease post-operative hematomas.  We 
perform about 15-20 rhytidectomies a year.   Furthermore, we will not have a control arm because 
those subsets of patients already exists in a day to day basis in the Neurotology clinic.  The control arm 
would be standard patients that do not wish to participate in the study and simply with to schedule 
surgery for tympanoplasty.  Our aim with this initial study is to understand and evaluate the potential 
efficacy of platelet enriched plasma (PRP) as a treatment for patients with chronic tympanic membrane 
perforation.  If preliminary data does suggest PRP may be beneficial, our next step is to perform a larger 
randomized prospective study. 
 
Data Management and Security 
To ensure the privacy and confidentiality of data collected from patients, data will be stored in REDCap, 
a password protected database accessible only by the relevant study personnel. No identifying 
information such as medical record number, date of birth or social security number will be collected.  
 
Monitoring and Reporting Unanticipated Problems 
The attached questionnaire will be utilized to identify any problems with the study that may be causing 
patient discomfort of problems. The results of these questionnaires will be discussed at regular 
meetings with the study personnel to determine to continue or discontinue the study. Any adverse 
events noted during the follow-up will also be reviewed. Any problems identified will be promptly 
reported according to the requirements of the KU Human Subjects Committee standard operating 
procedures. 
 
This study will only be stopped prior to consenting all patients if there is a serious adverse event 
deemed to be connected with the application of the PRP.  Patient’s will be followed closely, including  a 
follow up phone call 3-5 days post application, at the pre-arranged clinic visits, or at any point if a 
patient has significant concerns or symptoms.  Multiple large systematic reviews and Cochrane data 
base reviews have found no associated complications with PRP compared to controls.  However there 
are case reports with possible adverse events, including inflammatory reaction, in patients with 
autoimmune issues such as diabetes type I.  In both the phone interview and clinic follow up we will ask 
and examine for any signs of excessive inflammation or reaction; specifically looking for erythema, 
drainage, swelling, edema, pruritus, or other inflammatory symptoms.  After five subjects have been 
enrolled, we will look at cumulative adverse events and the number of subjects needed to proceed.  We 
have appointed Dr. James Lin, a Neurotologist, who will serve as an independent safety monitor to 
review any adverse events.  If after five subjects or any other point the study is deemed unsafe or 
delaying standard of care, we will terminate the study. 
 
Statistical Analysis Plan and Sample Size 
Chi-square and Fischer exact tests will be used to test for whether or not patients were able to avoid 
surgery. Time to healing analysis will also be completed. Statistical significance will be based on an a 
priori designation of p<= 0.05. Demographic variables and clinical variables will be summarized using 
descriptive statistics.  
 
A minimum of 10 patients will be enrolled in this pilot study. Patients will not be randomized as a part of 
this study. Due to the pilot nature of this study and the absence of any prior data to build sample size 
calculations, this exploratory group should provide data for future studies and justify future sample size 
calculations. 

 
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