Medial or medio-lateral graft tympanoplasty for repair of tympanic membrane perforation

Objective

To describe and evaluate the medio-lateral graft tympanoplasty¹ for the reconstruction of anterior or subtotal tympanic membrane (TM) perforation and medial graft tympanoplasty for posterior TM perforation.

Methods

Retrospective study of 200 patients who underwent medio-lateral graft tympanoplasty (100 cases) and medial graft tympanoplasty (100 cases) at community and tertiary care medical centers from 1995 to 2006. All patients underwent preoperative and postoperative audiograms. In the medial graft tympanoplasty, the graft is placed entirely medial to the remaining TM and malleus. First, margin of TM perforation is denuded removing ring of squamous tissue. Tympanomeatal flap is elevated. Temporalis fascia is harvested, semidried, and grafted medial to the TM perforation and malleus with Gelfoam packing supporting the graft. In the medio-lateral graft technique, posterior tympanomeatal flap is elevated same as in the medial graft tympanoplasty first. Anterior-medial canal skin is elevated down to the annulus. At the annulus only squamous epithelial layer of TM is elevated up to anterior half of the TM perforation. Temporalis fascia is grafted medial to posterior half of the perforation and lateral to anterior half of the de-epithelialized TM perforation up to the annulus. Anterior canal skin is rotated to cover the fascia graft and TM perforation as a second layer closure. Patients were followed for at least six months. Outcome was considered successful if TM is healed and intact.

Results

There were four failures (96% success rate) in medial graft method for posterior TM perforation due to infection and re-perforation. In the medio-lateral graft tympanoplasty, there were three failures (97% success rate) due to a postoperative infection, anterior blunting and recurrent cholesteatoma.

Conclusion

The medial graft tympanoplasty works well for posterior TM perforation. The medio-lateral graft method is an excellent method for the reconstruction of large anterior or subtotal TM perforation. This new method should help otologic surgeons to improve outcome of tympanoplasty for anterior or subtotal TM perforation.     

Island cartilage vs temporalis fascia in type 1 tympanoplasty: A prospective study

Objective

(1) To compare the results of graft take-up and audiological outcome of temporalis fascia versus island cartilage graft in type 1 tympanoplasty. (2) To compare the rate of postoperative retraction of neotympanum in both.

Revision tympanoplasty using scar tissue graft.

OBJECTIVE: To evaluate the success rate of subcutaneous postsurgical scar tissue as graft material for revision tympanoplasty operations. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center. PATIENTS: Thirty-five patients who underwent revision tympanoplasty with or without mastoidectomy procedures and 36 patients undergoing primary operations who had all the data necessary for the study and a minimum follow-up of 6 months. The mean follow-up period was 12 months (range, 6-18 mo). Mean age, perforation size, cholesteatoma presence, time required for harvesting, and adjunctive mastoidectomies were similar between the two groups. INTERVENTION: The patients undergoing revision tympanoplasty had graft material harvested from the subcutaneous scar tissue. In the control group, temporalis fascia graft was used as graft tissue. MAIN OUTCOME MEASURES: The rate of perforation closure and postoperative hearing change was measured. RESULTS: In the scar tissue tympanoplasty group, 32 of 35 patients (91%) had successful closure of the tympanic membrane perforation, whereas in the control group, the success rate was 92% (p > 0.05). Mean postoperative pure-tone average improvement was 21 dB in the scar tissue tympanoplasty group and 18 dB in the control group (p > 0.05). CONCLUSION: Subcutaneous scar tissue is as successful in perforation closure and hearing improvement as temporalis fascia graft. The use of subcutaneous scar tissue graft is advantageous to other graft materials used in revision tympanoplasty operations in that it can be harvested through the same incision, does not add to the operative time, and does not carry the cost or risk of acellular dermis.     

Results of revision tympanoplasty for chronic non-cholesteatomatous otitis media

Objective

To evaluate the success rate for revision tympanoplasty using different graft materials, to compare results of primary and re-tympanoplasty using the same technique and to analyse the effect of potential influencing factors on closure of tympanic membrane (TM) and hearing outcome.

Methods

Study included all patients, who underwent tympanoplasty (n = 617) and re-tympanoplasty (n = 94) for chronic otitis media without cholesteatoma in the period between September 1998 and 2007. The data of all patients on preoperative disease, perforation size and localization, middle ear status, surgical approach, graft material, adjunctive procedures, pre- and postoperative morphological (otomicroscopy) and functional (hearing examination evaluating pure-tone audiogram) results were analyzed. All operations were performed using an underlay technique and either the retroauricular or transcanal approach. The temporal fascia, perichondrium or cartilage-perichondrium composite grafts were used for the reconstruction of TM. Ossiculoplasty was performed as needed. The interrelation between multiple pre-operative parameters and post-operative morphological (closure of the perforation) and functional (hearing level) outcomes was analysed.

Results

Successful closure rates of the TM perforation were 93.6% and 90.2% of the patients in the primary and revision tympanoplasty groups, respectively. Graft take rate and hearing results did not depend on graft material. Structural changes were found more frequently in the re-tympanoplasty group (63.4% comparing to 29.5% of primary cases). Ossiculoplasty was performed more often in revision cases (24.4% comparing to 11.4% of primary cases). Successful hearing (ABG within 20 dB) for primary tympanoplasties was achieved in 81.1%, and for retympanoplasty - in 69.5% of the cases. (p < 0.01). There were no interrelation between any estimated parameters and the graft take rate for either primary or revision tympanoplasty.

Conclusions

There is no evidence of increased risk of graft failure in re-tympanoplasty cases when compared to primary tympanoplasty operations. Hearing results depend on structural changes in the middle ear (ossicular abnormalities and tympanoscerosis) which in revision cases are found more often. No differences were found between fascia, perichondrum or cartilage-perichondrium grafts in terms of graft healing and hearing results.     

Surgical and hearing results of the circumferential subannular grafting technique in tympanoplasty: a randomized clinical study

Purpose

Circumferential elevation of the anullus away from its bony seat and extension of the graft onto the anterior bony canal increase the bed of the graft anteriorly but may be associated with anterior blunting, and so, a significant conductive hearing loss may result. The purpose of this study was to compare the surgical and audiologic success rates of circumferential subannular grafting with the conventional underlay tympanoplasty.

Materials and Methods

A randomized clinical study was conducted from September 2007 to December 2010 at a tertiary referral center. Thirty-eight patients underwent circumferential subannular grafting (group A), and 25 patients underwent conventional underlay tympanoplasty with extension of the anterior edge of the graft forward against the lateral wall of the Eustachian tube, and therefore, the anterior sharp tympanomeatal angle remained unbroken (group B). All patients underwent preoperative and postoperative audiogram. Blunting and lateralization of the graft were evaluated 6 months after the surgery.

Results

The surgical success rate was 97% in group A and 100% in group B patients. Improvement of the air conduction thresholds in all frequencies and closure of the mean air-bone gap were significant and similar among the 2 groups. There were no cases of significant blunting and tympanic membrane lateralization in the 2 groups.

Conclusion

This study showed underlay tympanoplasty with elevation of the annulus away from the sulcus tympanicus in the anterior sharp tympanomeatal angle and placement of the graft between it and anterior bony canal is not associated with increased risk of blunting and lateralization of the graft, if that sharp angle is adequately restored.     

The use of sodium hyaluronate-carboxymethylcellulose to prevent postoperative mastication pain from harvesting of temporalis fascia

Objective

To evaluate the anti-adhesive and anti-inflammatory effects of sodium hyaluronate-carboxymethylcellulose (HA-CMC) in reducing postoperative pain after temporalis fascia harvest during tympanomastoid surgery.

Materials and methods

Between January and December 2009, 27 patients underwent tympanoplasty and open cavity mastoidectomy involving the harvesting of temporalis fasciae (more than 3 × 4 cm). At the end of surgery, patients were injected with 1.5 g HA-CMC or normal saline around the fascia harvest area. Beginning immediately postoperatively and for 2 months after surgery, patients scored their pain in the temporal area on a visual analogue scale (VAS).

Results

There were no significant postoperative complications, such as bleeding or hematoma, in either control group. VAS scores of both groups decreased over time and were negligible after 2 months. VAS scores of the HA-CMC and control groups differed significantly (p < 0.001 by repeated measures ANOVA for all VAS scores).

Conclusion

HA-CMC can decrease immediate postoperative pain arising from tissue adhesion and inflammation, thus reducing postoperative mastication pain.     

脱细胞真皮基质与颞肌筋膜在Ⅰ型鼓室成形术中的临床疗效分析

目的 探讨脱细胞真皮基质(acellular dermal matrix,ADM)与颞肌筋膜在Ⅰ型鼓室成形术中的临床疗效.方法 回顾分析2014年1月～2015年1月广州军区广州总医院收治的慢性化脓性中耳炎静止期患者60例(60耳),局麻下显微镜下耳内切口,内植法完成Ⅰ型鼓室成形术,其中32例(32耳)采用ADM,28例(28耳)采用颞肌筋膜.比较分析两组患者手术时间,术后疼痛程度,鼓膜愈合情况及术后听力恢复效果.结果 两组患者手术时间和术后疼痛比较,差异有显著性统计学意义(t=-21.78和-8.920,P均<0.05),鼓膜愈合成功率和术后听力提高均无显著统计学意义(P>0.05).结论 使用ADM修复鼓膜与颞肌筋膜修复疗效相当,但是使用ADM患者手术时间短,术后疼痛轻,避免开创2次手术区域,值得临床推广应用.     

Inlay “butterfly” cartilage tympanoplasty

Objectives

The aim of this study was to analyze the outcome of inlay “butterfly” cartilage tympanoplasty.

Methods

The files of 42 patients (24 were male, 18 were female) who underwent primary or revision inlay butterfly cartilage tympanoplasty in 2005 to 2011 at a tertiary medical center were reviewed. Patients were regularly observed by otoscopy and audiometry.

Results

The mean patient age was 27 years (range, 14–75 years), and the mean duration of follow-up was 24 months (range, 3–36 months). The postoperative period was uneventful. The technical (anatomical) success rate was 92% at 1 year. There was a significant decrease in the mean air-bone gap in 32 patients (preoperatively, 49.6 dB; postoperatively, 26.2 dB; P = .006). Results were suboptimal in 3 patients with persistent small perforations of the operated ear.

Conclusion

Inlay butterfly cartilage tympanoplasty appears to be effective in terms of defect closure and improved hearing, comparable with temporalis fascia graft tympanoplasty. Follow-up is necessary for at least 1 year when some perforation may reappear.     

Audiological and graft take results of cartilage reinforcement tympanoplasty (a new technique) versus fascia

Our objective is to compare hearing and graft take results of temporal muscle fascia tympanoplasty and cartilage reinforcement tympanoplasty. Seventy seven patients are classified into two groups: Group 1 included 37 patients for whom cartilage graft, harvested from symba concha, is used as reinforcement under temporalis muscle fascia anteriorly and Group 2 included 40 patients for whom only temporalis muscle fascia is used in type 1 tympanoplasty. A pure-tone audiometry is done within 1 week prior to surgery and at 6 months postoperatively. There is statistically significant difference between postoperative graft take results among groups. In both groups postoperative anterior TM perforation is encountered most commonly. Success rate of cartilage reinforcement tympanoplasty in revision patients is 100% but temporal muscle fascia tympanoplasty’s is 66%. There is no statistically significant difference between preoperative and postoperative air conduction gain of TM intact patients. The results indicated that Cartilage reinforcement myringoplasty technique under anterior of the temporal muscle fascia significantly increases the graft take ratios in high-risk perforations and it also does not affect hearing levels. Therefore, the authors suggest usage of cartilage reinforcement tympanoplasty technique under anterior of the temporal muscle fascia which is an easy and applicable technique to increase graft take ratios, particularly in patients with preoperative anterior and subtotal TM perforations.     

Inlay butterfly cartilage tympanoplasty in children.

OBJECTIVE: To assess the results of inlay butterfly cartilage tympanoplasty in children. STUDY DESIGN: Before-and-after trial; follow-up duration, 26.6 +/- 19.9 months (mean +/- standard deviation). SETTING: Tertiary referral center. PATIENTS: Fifty-nine pediatric cases of tympanic membrane perforation. INTERVENTION: Inlay butterfly cartilage tympanoplasty was performed under general anesthesia according to the technique originally described by Eavey and modified by Lubianca-Neto (i.e., without any associated split-thickness skin graft). MAIN OUTCOME MEASURES: Percentage of perforation closures, surgical complications, preoperative and postoperative puretone hearing thresholds; the results of inlay butterfly cartilage tympanoplasty were compared with those obtained in a retrospective series of 29 underlay fascia temporalis myringoplasties. RESULTS: The 71% "take rate" of inlay butterfly cartilage tympanoplasty was not significantly different from the 83% take rate obtained with underlay fascia temporalis tympanoplasty (p = 0.23, chi test). The anatomic results were improved when the graft diameter was at least 2 mm larger than the size of the perforation (81% take rate) (p = 0.009, chi test). No iatrogenic cholesteatoma was observed. Pure-tone hearing thresholds were improved at 0.5, 1, and 2 kHz, and stable at 4 kHz. Hearing levels were not different from those obtained with underlay fascia temporalis tympanoplasty. CONCLUSION: Inlay butterfly cartilage tympanoplasty is a safe, efficient, time-saving, and easy technique of tympanoplasty in children. Anatomic results may be improved by associating a split-thickness skin graft and/or by trimming a tragal graft much larger than the size of the perforation.     

Clinical advantages of cartilage palisades over temporalis fascia in type I tympanoplasty

Objective

To compare the post-operative outcomes in using temporalis fascia and full thickness broad cartilage palisades as graft in type I tympanoplasty.

Methods

This study, conducted at a tertiary referral institute, included 90 consecutive patients with mucosal type chronic otitis media requiring type I tympanoplasty with a 60/30 distribution of cases with fascia and cartilage palisades, respectively. The fascia group consisted of primary cases in adults and excluded revision cases, near-total or total perforations and pediatric cases. The cartilage group included pediatric, revision cases and near-total or total perforations. The fascia group utilized the underlay technique for grafting, whereas the cartilage group used tragal full thickness broad cartilage palisades with perichondrium attached on one side placed in an underlay or over-underlay manner. Post-operative graft take-up and hearing outcomes were evaluated after 6 months and 1 year with subjective assessment and pure tone audiometry.

Results

The graft take-up rate was 83.3% in the fascia group and 90% in the cartilage palisade group. The mean pure tone air–bone gaps pre- and post-operatively in the fascia group were 30.43 ± 5.75 dB and 17.5 ± 6.94 dB, respectively, whereas for the cartilage group, these values were 29 ± 6.21 dB and 7.33 ± 3.88 dB, respectively.

Conclusion

Cartilage grafting with full thickness palisades is more effective than fascia as graft material, particularly in “difficult” tympanoplasties fraught with higher failure rates otherwise.     

Comparison of temporalis fascia and tragal cartilage grafts in type 1 tympanoplasty in elderly patients

Objective

To investigate the success rates and hearing outcomes of temporalis fascia and tragal cartilage grafts used for type-1 tympanoplasty in the elderly (³65 years)

Tympanic membrane grafting with alloderm

OBJECTIVE/HYPOTHESIS: The purpose of this work is to evaluate the performance of an acellular dermal allograft (AlloDerm; LifeCell Corp., The Woodlands, TX) in tympanic membrane (TM) grafting. STUDY DESIGN: A retrospective review of 20 consecutive tympanoplasty surgeries using temporalis fascia and 20 consecutive procedures using AlloDerm. METHODS: The charts of 20 consecutive adults who underwent tympanoplasty surgery were reviewed to evaluate graft take and hearing results. Similarly, 20 consecutive patients who had TM grafting with AlloDerm were reviewed. Pre- and postoperative air-bone gaps (ABG) at 500 Hz, 1000 Hz, 2000 Hz, and 4000 Hz were compared. RESULTS: There were no graft failures in either the temporalis fascia group or the AlloDerm group. No statistically significant difference was noted in hearing results when comparing the residual conductive loss in both postoperative groups. CONCLUSIONS: AlloDerm is a suitable material for TM grafting. This product is especially valuable in revision surgery in which the availability of appropriate autologous grafting material is limited.     

Comparison between clinical and audiological results of tympanoplasty with modified sandwich technique and underlay technique

Introduction

Surgical repair of the tympanic membrane, termed a type one tympanoplasty is a tried and tested treatment modality. Overlay or underlay technique of tympanoplasty is common. Sandwich tympanoplasty is the combined overlay and underlay grafting of tympanic membrane.

Long-term results of type I tympanoplasty with perichondrium reinforced cartilage palisade vs temporalis fascia for large perforations: A retrospective study

Objective:To compare the rate of graft uptake and postoperative hearing outcomes of Type I tympanoplasty with perichondrium reinforced cartilage palisade to temporalis fascia for large tympanic membrane(TM)perforations over 5 years follow-up period.Materials and methods:This was a retrospective comparative study involving patients with chronic otitis media with large TM perforations.The patients underwent type I tympanoplasty using either perichondrium reinforced cartilage palisade(CP group)or temporalis fascia(TF group)as the graft via a transmeatal approach and under local anesthesia.Morphological and functional results were recorded at three-and five years follow-up.Demographic profiles including age and sex,surgery side,contralateral disease and graft uptake rate,as well as hearing outcomes,were compared between the two groups.Results:At three years follow-up,graft uptake was 94.87%for perichondrium reinforced cartilage palisade and 80.7%for fascia,respectively,(p?0.67).At five years follow-up,the uptake rate dropped to 87.17%in the CP group,but to 66.6%in the TF group(p?0.019).Hearing improved after surgery in both groups,and showed no significant difference between the two groups.Conclusion:Over long-term,perichondrium reinforced palisade showed a statistically significant better outcome regarding graft uptake than temporalis fascia in type Itympanoplasty for large TM perforations with comparable audiometric results.     

Endoscopic versus microscopic approach to type 1 tympanoplasty in children

Objectives

We investigated the outcomes of the endoscopic versus microscopic approach to type 1 tympanoplasty in pediatric patients.

Methods

In this retrospective study, the outcomes of 61 ears of 60 pediatric patients (33 male and 27 female) who underwent type 1 tympanoplasty were evaluated. One patient underwent a bilateral operation. The age range of the patients was 7–16 years. Group 1 underwent tympanoplasty with an endoscopic technique (n = 32), and Group 2 underwent tympanoplasty with the conventional microscopic technique (n = 29). A boomerang-shaped chondroperichondrial graft was used in both groups. The outcomes were analyzed in terms of the hearing gain, duration of surgery, and graft success rate.

Results

In both groups, the postoperative air–bone gap (ABG) was significantly lower than the preoperative ABG. There were no significant differences between the preoperative and postoperative ABG values (in dB) in either group. The mean operative duration in Group 1 was significantly lower than that in Group 2 (51.37 vs. 67.03 min, respectively). In the preoperative evaluation, 65.6% of patients in Group 1 had larger perforations and 34.4% had smaller perforations. In Group 2, 58.6% and 41.3% of patients had larger and smaller perforations, respectively. Perforations were detected in two (6.25%), four (12.50%), and four (12.50%) of the patients in Group 1 at postoperative months 1, 6, and 12, respectively. Perforations were detected in two (5.71%) patients in Group 2 at postoperative months 1, 6, and 12. At 12 months postoperatively, there were smaller perforations in four (12.5%) of the children in Group 1 and in two (5.71%) of the children in Group 2. The difference between the perforation conditions (larger vs. smaller) was not significant in either group. The preoperative and postoperative increases in the ABG were associated. The operative duration was shorter in Group 1 than in Group 2.

Conclusion

In pediatric patients undergoing type 1 tympanoplasty, especially if the external ear canal is narrow and the anterior canal wall is prominent, the endoscopic and microscopic approaches appear to give equal results in terms of easy visualization of the entire tympanic membrane and no requirement for extra intervention to evaluate the ossicular system. A shorter operative duration is an advantage of the endoscopic tympanoplasty technique.     

Comparison between clinical and audiological results of tympanoplasty with double layer graft (modified sandwich fascia) technique and single layer graft (underlay fascia and underlay cartilage) technique

Introduction

Surgical repair of the tympanic membrane, termed a type one tympanoplasty is a tried and tested treatment modality. Overlay or underlay technique of tympanoplasty is common. Sandwich Tympanoplasty is the combined overlay and underlay grafting of tympanic membrane.

Screening of SLC26A4, FOXI1 and KCNJ10 genes in unilateral hearing impairment with ipsilateral enlarged vestibular aqueduct

Objective

To investigate the implication of SLC26A4, FOXI and KCNJ10 genes in unilateral hearing impairment associated with ipsilateral inner ear malformation (Enlargement of the vestibular aqueduct and/or Mondini dysplasia).

Methods

We have gathered 25 patients presenting unilateral hearing impairment and ipsilateral enlarged vestibular aqueduct. For each of the patients, we have analyzed SLC26A4, FOXI1 and KCNJ10 genes sequences.

Results

The analysis of SLC26A4 revealed only eight heterozygous SLC26A4 sequence variants, three of them being novel (p.Met147Ile, p.Asn538Asn and p.Leu627Arg). None of the patients carried a second mutation on the other allele. Moreover, the SLC26A4 locus was excluded by segregation analysis in two families. No mutations were present in FOXI1 and KCNJ10 genes.

Conclusions

Together, these data suggest that SLC26A4, FOXI1 and KCNJ10 are not major determinants in unilateral deafness and enlarged vestibular aqueduct compared with their implication in Pendred syndrome and non-syndromic bilateral enlarged vestibular aqueduct.     

Loop overlay tympanoplasty for anterior or subtotal perforations

Objective

To report our experience with “loop overlay” tympanoplasty, a modified overlay technique with a superiorly based skin flap, for the reconstruction of anterior, subtotal or total tympanic membrane (TM) perforations.

Methods

Retrospective review of patients undergoing loop overlay tympanoplasty from March 1998 to February 2007 was performed. Four hundred and twenty-nine patients who underwent loop overlay tympanoplasty and then follow-up visits a minimum of 6 months later were included in this study. Hearing test results were reported using a four-frequency (0.5, 1, 2, and 3 kHz) pure tone average air–bone gap. The outcome was considered successful if the TM was intact without lateralization or anterior blunting after the follow-up visit.

Results

There was a 98.8% success rate. There was no graft lateralization, anterior blunting, neocholesteatoma, or sensorineural hearing loss. The mean preoperative to postoperative four-tone air–bone gap improved from 23.5 to 8.1 dB, which is a mean gain of 15 dB; this was statistically significant (p < 0.001, paired sample t-test).

Conclusion

The loop overlay graft method is a safe and effective technique for reconstruction of anterior, subtotal or total TM perforations, with excellent graft take and significant improvement of hearing. It provides a precise replacement of the flap and a preserved healing plane.     

Use of nasal mucosa graft in tympanoplasty

IntroductionTympanoplasty techniques with different types of graft have been used to close tympanic perforations since the 19th century. Tragal cartilage and temporalis fascia are the most frequently used types of graft. They lead to similar functional and morphological results in most cases. Although little published evidence is present, nasal mucosa has also been shown to be a good alternative graft.ObjectiveSurgical and audiological outcomes at the six-month follow-up in type I tympanoplasty using nasal mucosa and temporalis fascia grafts were analyzed.MethodsA total of 40 candidates for type I tympanoplasty were randomly selected and divided into the nasal mucosa and temporalis fascia graft groups with 20 in each group. The assessed parameters included surgical success; the rate of complete closure of tympanic perforation and hearing results; the difference between post- and pre-operative mean quadritonal airway-bone gap, six months after surgery.ResultsComplete closure of the tympanic perforation was achieved in 17 of 20 patients in both groups. The mean quadritonal airway-bone gap closures were11.9 and 11.1 dB for the nasal mucosa and temporalis fascia groups, respectively. There was no statistically significant difference between the groups.ConclusionThe nasal mucosa graft can be considered similar to the temporal fascia when considering the surgical success rate of graft acceptance and ultimate audiological gain.