Cartilage Tympanoplasty: Classification of Methods -- Techniques -- Results

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Comparisons of pre and postoperative air bone gap on pure tone audiometry. Chronic suppurative otitis media is a very common condition in the practice of otolaryngology both in developed as well as developing countries.

The common sequel of chronic suppurative otitis media is perforation of the tympanic membrane which results in recurrent otorrhea and hearing loss. Every otolaryngologist must know how to repair a tympanic membrane perforation. A commonly used graft is the temporalis fascia which may be used in an underlay or onlay technique. In current surgical practice, the tragal cartlage with perichondrium graft has gained popularity, more so after the technique was described by Eavey.

The cartilage tympanoplasty offers an otologist another reliable material in his armamentarium for tympanic membrane reconstruction. The choice of technique largely depends on the surgeon's preference. Eavey 4 first used tragal cartilage with perichondrium on both sides for myringoplasty for small tympanic membrane perforation in children. The logic for this technique was that since the children have repeated upper respiratory infections, and the cartilage graft type I tympanoplasy will resist reperforations subsequent to these infections.

He also placed a split thickness skin graft on the cartilage. However, in our patients we used neither skin or any other graft over the cartilage. Cartilage tympanoplasty has many advantages in situations such as recurrent, residual, total perforations, chronic mucosal dysfunction or severely atelectatic tympanic membranes, where facia and perichondrium undergo atrophy and subsequent failure. Further, it has a low metabolic rate to survive long and is well accepted in the middle ear.

However, cartilage has been criticized due to concern regarding hearing results because of its thickness. The results were comparable to temporalis fascia. They advocated that a cartilage perichondrium graft is useful to prevent recurrence or progression of postoperative retraction pockets. Recent studies by Mohamad, et al. Group A the tympanic membrane is repaired using many full thickness strips of cartilage with perichondrium on canal side.

Six different methods are included in this group. Group B consists of cartilage tympanoplasty with several foils, thin and thick plates of bare cartilage without perichondrium.

Classification of Methods - Techniques - Results

Four different methods are included in this group. Group C consists of a cartilage perichondrium composite island graft where perichondrium suspends and fixates the cartilage island.

In this group also four different methods are included. Group D, a total pars tensa perforation is reconstructed using a large cartilage perchondrium graft. There different methods of reconstruction were used in this group. Group E, anterior, inferior and subtotal perforations were repaired using a cartilage perichondrium composite graft.

In this group, four methods were used including two inlay and two onlay techniques. Group F, the cartilage disc is placed under the perforation and perichondrium on top of the tympanic membrane on the denuded margins of perforation. Butterfly cartilage tympanoplasty is included in this group. We performed cartilage tympanoplasty in healthy young patients.

Only smoking was found to have an adverse effect on graft uptake. They specially recommended butterfly cartilage tympanoplasty in older patients or who had no other comorbidities. Results of cartilage tympanoplasty, even in large perforations, was found to be good. Cartilage tympanoplasty is described to be of utmost value in large size perforations which include revision surgery, anterior, marginal or even a draining perforation at the time of surgery, subtotal or total perforation and bilateral perforation.

The cartilage thickness of the tragus and cymba is the same in children as in adults, however, the perichondrium is more adherent in children. Hence while making a groove or if the perichondrium is to be removed from one side, one must be careful while making a butterfly cartilage graft in children.

Cartilage should be held between the finger and thumb and not in tooth forceps to avoid breakage. Tragal cartilage is ideal since it is thin flat and in a reasonable quantity to reconstruct even the entire tympanic membrane Dornhoffer. The concept of cartilage tympanoplasty is not a new one, and it has only been used in few cases till recently.

Previously, it was believed that there will be some degree of conductive loss after cartilage myringoplasty because of its thickness and rigidity as compared to the commonly used temporalis fascia. However, Milewski reported that this is not so. It is nourished by diffusion and gets well incorporated in the tympanic membrane.

On the contrary, cartilage graft tympanoplasty is beneficial, since the cartilage graft maintins some degree of rigidity which resists resorption and retraction that can occur in some stubborn cases. Recently, Ayache described butterfly cartilage tympanoplasty by a transcanal endoscopic procedure. Furthermore, there were no cases of anterior blunting and lateralization and the procedure was minimally invasive.

Myringoplasty using septal cartilage. Fascia and cartilage palisade tympanoplasty. Tragal perichondrium and cartilage in tympanoplasty. Classification of Methods -- techniques -- Results. Thieme Stuttgart New York. Functional results of temporalis fascia versus cartilage tympanoplasty in patients with bilateral chronic otitis media. Epub Oct Otolaryngol Clin North Am. Chin Med J Engl. Fascia and perichondrium atrophy in tympanoplasty and recurrent middle ear atelectasis.

Ann Otol Rhinol Laryngol. Composite graft tympanoplasty in the treatment of ears with advanced middle ear pathology. Epub Mar 3. Cartilage tympanoplasty for management of retraction pockets and cholesteatomas. Acoustic properties of different cartilage reconstruction techniques of the tympanic membrane.

Cartilage Tympanoplasty

Middle ear mechanics of cartilage tympanoplasty evaluated by laser holography and vibrometry. Hearing results after primary cartilage tympanoplasty. Is cartilage tympanoplasty more effective than fascia tympanoplasty? Predictors of surgical and hearing long-term results for inlay cartilage tympanoplasty.

Arch Otolaryngol Head Neck Surg. Otolaryngol Head Neck Surg. In cases where TMF was used as a graft material, the graft was harvested from the ipsilateral temporalis muscle. The cartilage grafts were harvested from the tragus or cavum concha or cymba 8, 6 and 4, respectively. The perichondrium on one surface of the cartilage was preserved. The perichondrial surface was placed lateral. The size of the cartilage was reduced considering the size of the perforation and the cartilage graft was cut with a no.

Approximately 2 mm width cartilage resection was done vertically from the center of the cartilage for malleus handle and the lateral process by preserving perichondrium.

Account Options

The graft was under the tympanic membrane remnants or fibrous annulus. Absorbable hemostatic gelatin sponges was used to support the graft. Evaluation of middle ear revealed that ossicular chain was mobile and intact, thus reconstruction was not required. Audiometric examinations were performed in quiet rooms with an Interacoustics AC—40 clinical audiometer Assens, Denmark according to the standards of the company, and all of the tests were carried out by the same audiometrist.

Audiologic data were reported in accordance with the recommended methods of the Hearing Committee of the American Academy of Otolaryngology, Head and Neck Surgery, which endorsed a new minimal standard for reporting hearing results in clinical trials[ 6 ]. The audiological evaluation was performed before the operation and on the 3th postoperative month. Bone and air conduction pure-tone average thresholds PTA were obtained using , , Hz and the mean of Hz taken as the Hz hearing thresholds, and air-bone gaps ABG were calculated. The condition of the membrane graft was recorded in the 3 rd month follow up or later with otoendoscopy and recorded on patient follow-up database.

Сведения о продавце

Our study was approved by the local ethics committee and conducted in accordance with the ethical principles described by the Declaration of Helsinki. Informed consent form was obtained from all participants before the study Project No: Student's t test and paired sample t test were used for the two-group comparisons of quantitative data with a normal distribution. Fisher's Exact test was used for the comparison of qualitative data. A level of p Results There were a total of 43 patients consisting of 25 males and 18 females included the study.

The patients were divided into two groups according to graft material used. Group I consisted of 18 patients 10 males and 8 females who underwent type I tympanoplasties using cartilage grafts and group 2 consisted of 25 patients 15 males and 10 females who were operated using TMF grafts. The mean ages of the group 1 and the group 2 were We obtained same results when comparing successful hearing levels and ABG between the groups with intact grafts Table 2.

Discussion The term tympanoplasty was introduced in by Wullstein to describe surgical techniques for the reconstruction of the middle-ear hearing mechanism that had been impaired or destroyed by chronic ear disease[ 7 ]. Using the classification system designed by Wullstein, a type I tympanoplasty is similar to a myringoplasty in that the goal of the procedure is to address only a TM perforation, although the middle ear is entered by lifting of a tympanomeatal flap[ 8 ].

Tympanic membrane perforations result mainly from infectious and traumatic etiologies. When the decision has been made to perform the repair, there are numerous surgical techniques and graft materials available, and most commonly used graft material is TMF because of it convenient location and resistant to infection. However, patient's characteristics such as adhesive TM, revision surgery, eustachian tube dysfunction and retraction pockets play significant roles in the failure of TMF grafting. In that case cartilage graft a maybe better choices in tympanoplasty procedure. Because of its innate structural stability, rigidity, viability and endurance against infections, it is a more predictable graft material than that of TMF.

However there have been concerns that these may affect acoustic transfer and hearing adversely[ 9 ]. The ideal tympanoplasty procedure aims to restore hearing, resulting in an intact tympanic membrane with an intact or a reconstructed ossicular chain[ 10 ]. There are various studies reporting various results using TMF and cartilage grafts[ 11 , 12 ]. The cause of these differences may be the result of different criteria for reporting the success of those procedures[ 13 , 14 ].

In one study, the authors reported that there is no difference in postoperative hearing results when comparing cartilage and TMF grafts in tympanoplasty. Despite the thickness of the cartilage, the hearing results are acceptable[ 15 , 16 ]. On the other hand, there are concerns that the thickness of cartilage is an important point in terms of good hearing results.

In a recent study, authors showed that reducing the thickness of cartilage to a thickness of 0. They concluded that cartilage grafting may be preferred more often for primary tympanoplasties with low risk[ 20 ]. Other studies have shown that hearing results are comparable between cartilage grafts and temporalis fascia grafts[ 21 - 23 ]. Furthermore, some authors reported better hearing results in the cartilage group compared to TMF[ 24 , 25 ]. In our study, we reduced the thickness of cartilage to a thickness of 0. Consistent with the literature, the hearing results and graft take rates of our cartilage graft group was good when compared with the TMF group.

On the other hand, the audiologic results and graft take rates were better in TMF group compared to the cartilage group with 3 months follow up but did not differ significantly Table 1 and 2. However, these early results may differ in the following months such like the cartilage may become thinner and regain a more effective conductive capacity.

In our study, we did not use the middle ear risk index MERI which generates a numeric indicator of the severity of the middle ear disease to categorize patients according to the severity of the disease[ 26 ]. This may also explain our early results as well as the fact that our groups were not homogeneous. Another limitation of our study is that the number of patients were small on both groups. The third and the most important limitation is the short follow up period precluding to draw definite conclusions. Conclusion In this study, we aimed to compare the graft take rates and hearing improvements in patients treated with TMF or cartilage grafts.

Both cartilage and fascia showed good clinical outcomes in terms of anatomic success and hearing results and can be safely used in the reconstruction of tympanic membrane perforations as graft materials in type I tympanoplasties. Reference 1 Wullstein H. Theory and practice of tympanoplasty.

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