We would like to comment on the manuscript entitled “A retrospective study of EGF and ofloxacin drops in the healing of human large traumatic eardrum perforation” by Yang et al. . This work is interesting and excellent. The authors first compared the healing of traumatic tympanic membrane perforation (TMP) using epidermal growth factor (EGF) and ofloxacin drops (FLOX). They found that the closure rates and times were similar in the EGF and FLOX groups . Therefore, FLOX may completely replace EGF for treating traumatic TMP. FLOX is convenient and inexpensive, and is available in otorhinolaryngology departments worldwide, because it is usually used to treat acute and chronic suppurative otitis media. Therefore, FLOX will provide an excellent treatment choice for traumatic TMP. However, some issues remain to be clarified.

First, it is necessary to examine the factors influencing TMP healing. The authors did not describe their inclusion criteria in detail, so we do not know whether patients with coexisting myringosclerosis or inverted edges were included or excluded. Previous studies suggested that coexisting myringosclerosis affects the blood supply and prolongs healing time . Lou et al. found that pre-existing myringosclerosis was the most prominent cause of spontaneous healing failure in traumatic TMP. In another study of FGF-2 for traumatic TMP, Lou et al. also found that coexisting myringosclerosis was a significant risk factor for non-healing of TMP. Other studies showed that inverted edges usually result in centrifugal migration of the proliferation epithelium, thereby delaying spontaneous eardrum healing or resulting in failure to close . However, the presence of curled edges did not seem to affect the outcome of fibroblast growth factor (FGF) treatment or patching . Therefore, the authors should compare the healing outcomes of patients with coexisting myringosclerosis or inverted edges among different treatments using EGF, FLOX, and simple observation.

Comparing the treatment dosage of EGF and FLOX is difficult. The authors applied the same volume, 0.1–0.15 mL, of the EGF and FLOX solutions to keep the eardrum moist. However, they wrote that the patients themselves applied the EGF or ofloxacin otic drops once a day until perforation closure was confirmed by a physician. “The dose of eardrops kept the residual TM moist (not excessively wet or dry). The patients were followed-up 2 or 3 days after treatment commencement so that the physician could determine whether the dose of eardrops was correct and whether purulent otorrhea developed”. This procedure is theoretically feasible, but is difficult operationally. The authors did not describe whether all of the perforation edges remained moist when the EGF and FLOX eardrops were applied. First, the dosages were not in accordance with literature recommendations, but instead were based on the authors’ experience. Patients cannot easily determine whether the eardrum is moist. The degree of moistness of the perforation edges will not always be identical even if the same numbers of eardrops are applied, because the structure of the external auditory canal differs among individuals. Second, the location of the perforation also affects the eardrum status; the same number of eardrops may render lower perforations wet, but upper perforations either moist or dry. Ideally, the EGF or FLOX drops should have been applied by a physician throughout treatment. In addition, the perforation edge should have been observed endoscopically on a daily basis, thereby optimizing the assessment of healing outcomes.