Sutureless tympanoplasty using acellular dermis

Objective

A prospective randomized unblinded controlled trial was conducted by comparing acellular dermis with temporalis fascia as graft materials in tympanoplasty (type 1) in terms of operative time, postoperative pain, graft success rate, and audiologic outcome.

Study design

Forty-two patients with (inactive) chronic suppurative otitis media of tubotympanic type were randomized, matched, and divided equally into 2 groups of 21 each. One group underwent tympanoplasty (type 1) via transcanal route using temporalis fascia graft and the other using acellular dermis. Both groups were compared for operative time, postoperative pain, graft success rate, and audiologic improvement in hearing.

Results

There was a statistically significant reduction in operative time (P < .05) and postoperative pain (P < .05) in the acellular dermis group. However, there was no statistical difference in graft success rate (P > .05) and hearing improvement (P > .05) between both the groups.

Conclusion

Results of tympanoplasty using acellular dermis as graft material are comparable to that using temporalis fascia in terms of graft uptake and hearing improvement. However, tympanoplasty using acellular dermis has the advantage of shorter operative time and lesser postoperative pain.     

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.     

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.     

Three-point fix tympanoplasty

Conclusion: The three-point fix tympanoplasty procedure is a stable and effective technique – with a high degree of graft take and satisfactory hearing results – for reconstruction of most tympanic membrane (TM) perforations. Objective: It is difficult to repair a TM perforation, including subtotal perforation, involving the anterior part of the annulus. Reperforation can occur when an underlay graft technique is used. An overlay graft technique may result in anterior blunting/lateralization. We introduce a three-point fix tympanoplasty procedure, which can provide additional support to yield a stable graft. Methods: The study enrolled a total of 234 patients who underwent a three-point fix tympanoplasty procedure from November 2005 to June 2011. Anatomic success was defined as an intact, repaired TM, while functional success was defined as a significant decrease in the air–bone gap at the end of follow-up compared with preoperative hearing (air–bone gap). The complication rate was also analyzed. Results: The anatomic success rate was 93.2% (218/234 patients). The functional success rate after an average of 1 year was 73.5%. The postoperative average pure-tone air–bone gap (15.4 ± 11.4 dB) decreased successfully in comparison with the preoperative average air–bone gap (20.6 ± 12.1 dB). There were few postoperative complications (7.7%).     

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.     

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.

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.     

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.

How I do it: Anterior pull-through tympanoplasty for anterior eardrum perforations

Conclusions This technique is offered as a convenient and reliable method for cases with anterior TM perforation and inadequate anterior remnant. Objectives Chronic otitis media surgery is one of the most common procedures in otology. Anterior tympanic membrane (TM) perforation with inadequate anterior remnant is associated with higher rates of graft failure. It was the goal of this series to evaluate the anatomical and functional outcomes of a modified underlay myringoplasty technique—the anterior pull-through method. Materials and methods In a retrospective clinical study, 13 patients with anterior TM perforations with inadequate anterior remnants underwent tympanoplasty with anterior pull-through technique. The anterior tip of the temporalis fascia was pulled through and secured in a short incision lateral to the anterior part of the annulus. Data on graft take rate, pre-operative, and post-operative hearing status were analyzed. Results A graft success rate of 84.6% (11 out of 13) was achieved, without lateralization, blunting, atelectasia, or epithelial pearls. The air–bone gap was 21.5?±?6.8?dB before intervention and 11.75?±?5.7?dB after surgery (p?=?0.003).     

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.

Bacterial cellulose graft versus fat graft in closure of tympanic membrane perforation

Object

To compare between results of bacterial cellulose graft myringoplasty and fat graft myingoplasty in patients had mild or moderate size safe perforation.

3-flap tympanoplasty — A simple and sure success technique

Objective Three-flap tympanoplasty, a simple method for tympanic membrane repair, is recorded as an alternative method, which probably has advantages over other procedures and its efficacy evaluated Patients Four hundred and fifty patients with subtotal or large central perforations with either an anterior bony overhang or vers small anterior rim of the perforation who underwent 3-flap tympanoplasty were included in this study Follow up period was 24 months Technique After removing the margin of the tympanic membrane remnant, three flaps (Superior, anterior and posterior) were elevated from the external auditory canal wall The temporalis fascia graft was then placed over the handle of malleus and all the three flaps were repositioned over the graft Main outcome measures The graft take over rate and hearing improvement postoperatively were the main outcome measures Results Four hundred and twenty-five patients (94 44%) had successful grafts Both subjective and objective hearing improvement with a compliant tympanic membrane was seen in all of these patients postoperatively Mediatisation or lateralisation of the intact tympanic membrane did not occur Twenty-five patients had graft rejection, which was noted about 4 weeks after surgery and was due to infections Conclusion 3-flap tympanoplasty is a simple technique with a very good success rate It is a useful method for busy practioners and junior otolaryngologists     

Success rates for various graft materials in tympanoplasty – A review

ObjectivesThe aim of this paper is to review how successful each type of grafts is in tympanoplasty.MethodsPubmed, Google and the Proquest Central Database at Kırıkkale University were queried using the keywords “graft”, “success” “tympanoplasty”, “success rate” with the search limited to the period 1955 to 2017.ResultsVarious types of graft materials including temporalis fascia, cartilage, perichondrium, periosteum, vein, fat or skin have been used in the reconstruction of tympanic membrane (TM) perforation. Although temporalis fascia ensures good hearing is restored, there are significant concerns that its dimensional stability characteristics may lead to residual perforation, especially where large TM perforations are involved. The “palisade cartilage” and “cartilage island” techniques have been stated to increase the strength and stability of a tympanic graft, but they may result in a less functional outcome in terms of restoring hearing. Smoking habits, the size and site of a perforation, the expertise level of the operating surgeon, age, gender, the status of the middle ear mucosa and the presence of myringosclerosis or tympanosclerosis are all important in determining how successful a graft is.ConclusionAlthough temporal fascia is the most commonly used graft material for tympanoplasty, poor graft stability may cause failure. This failure is due to the inclusion of connective fibrous tissue containing irregular elastic fibers present in the grafted fascia. Cartilage grafts offer better ability to resist infection, pressure, and cope with insufficient vascular supply. This means that cartilage grafts are suitable for use in revision cases.     

Primary cartilage tympanoplasty: our technique and results

Cartilage has shown to be a promising graft material to close tympanic membrane perforations. However, due to its rigid quality, doubts are raised regarding its sound conduction properties. It has been suggested that acoustic benefit may be obtained by thinning the cartilage. We describe our innovative method for harvesting tragal cartilage from the same endaural incision and also describe preparation of the graft by slicing it. We present our 3-year experience of shield cartilage type 1 tympanoplasty using sliced tragal cartilage-perichondrium composite graft.

Aim

The aim of this study was to prove the success rate of our technique of shield cartilage tympanoplasty using sliced tragal cartilage graft in terms of functional and anatomic results.

Study design

Retrospective analysis of type 1 cartilage tympanoplasties using sliced tragal cartilage was carried out in MIMER Medical College and Sushrut ENT Hospital during May 2005 to January 2008 with a minimum follow-up of 2 years.

Method and materials

A total of 223 ears were operated by our technique.

Results

The overall success rate of our technique was 98.20% in terms of perforation closure and air bone gap closure within 7.06 ± 3.39 dB. The success rates in the various age group are as follows: 11 to 20 years, 97.67%; 21 to 40 years, 99.12%; and 41 to 60 years, 96.96%.

Conclusion

Our technique of type 1 cartilage tympanoplasty achieves good anatomic and functional results.     

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)

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.     

Palisade cartilage tympanoplasty for management of subtotal perforations: a comparison with the temporalis fascia technique

The use of cartilage as a grafting material has been advocated in cases at high risk for failure, such as subtotal perforations, adhesive processes, tympanosclerosis and residual defects after primary tympanoplasties. The cartilage palisade technique, in which the TM is fully reconstructed with palisade-shaped cartilage pieces, was first described by Heermann. Cartilage material has been critized because of concerns regarding hearing results, however, large cartilage plates with thicknesses ≤0.5 mm have been suggested as an acceptable comprise and the graft take of this technique has been reported to be excellent. The purpose of this study was to compare the graft take rates and hearing results of primary type I cartilage tympanoplasty operations with palisade technique with those of primary tympanoplasty using temporalis fascia in a homogenous group of patients. Study design: retrospective chart review. Setting: tertiary medical center. The study population included 51 patients who were operated between January 2000 and 2006 at the Department of Otorhinolaryngology of Ataturk Training and Research Hospital, Izmir, Turkey. Primary tympanoplasty cases with pure subtotal perforations (perforation >50% of the whole TM area), intact ossicular chain, at least more than 1 month dry period and normal middle ear mucosa were included in the study. Palisade cartilage tympanoplasty group included 23 cases, whereas 28 patients were were in the fascia group. Intervention: therapeutic. Graft take rates were noted in 51 patients and pre- and post operative audiograms were compared using the chi-square test with Yates’ continuity correction, Fisher’s exact test, t test and repeated measures ANOVA. Graft take was achieved in 22 patients (95.7%) in palisade cartilage group and in 21 patients (75%) in temporalis fascia group (P = 0.059). Mean speech reception treshold, air–bone gap and pure-tone average scores comparing the gain between both techniques showed no significant changes in the threshold (P > 0.05). However the functional success was achieved with the palisade cartilage technique postoperatively, regarding to mean air–bone gap and speech reception threshold changes. Our experience with palisade cartilage technique demonstrates that subtotal or total perforations at high risk for graft failure, can be treated efficiently and a durable and resistant reconstruction of the TM with reasonable hearing can be achieved. The study was presented as a poster at the Fifth Balkan Congress of Oto-Rhino-Laryngology, Edirne, Turkey, 7–10 September 2006.     

Tympanic membrane perforation: size, site and hearing evaluation

Objective

To assess different clinical scales of TM perforation size; to evaluate the effect of the size and the site of a perforation on the hearing level and frequencies.

Methods

Prospective study. Observers had subjectively estimated the size in millimeter and in percentage of a particular perforation; objectively computerized measures of TM perforations area were analyzed. Agreement between different measures was studied. Cases with postoperative intact TM and an air-bone gap (ABG) of 10 dB or less were studied.

Results

Global mean preoperative ABG was 21.8 ± 17 dB. Preoperative ABG was different between small-large and small-total perforations (p = 0.001). Difference of the preoperative ABG was statistically significant between perforations filling up the four quadrants and perforation limited to one quadrant in the postero-inferior, antero-superior and antero-inferior site. No statistically difference between perforation sites was identified for each affected frequency. Difference is statistically significant (p = 0.001) between the 250 Hz and the other frequencies for the medium, large and total perforations. After myringoplasty bone conduction improvement was statistically significant for the frequencies 500 (p = 0.04), 1000 (p = 0.04) and 2000 Hz (p = 0.011). Agreement was large enough when TM perforation size was expressed in percentage and absent when expressed in millimeter.

Conclusion

TM perforation can be clinically estimated quite precisely as a percentage of the TM area. Conductive hearing loss is frequency dependent; with the greatest loss occurring at the lowest sound frequencies. Hearing loss does not depend on the perforation's location.     

Influence of size and site of perforation on fat graft myringoplasty

Objectives

In this retrospective study, we investigated the outcomes of fat graft myringoplasty (FGM) in different perforation sizes and locations. The outcomes were evaluated in terms of closure rates and audiological test results.

Methods

The study population included 172 patients who were operated between 2007 and 2012. 161 had unilateral and 11 had bilateral chronic otitis media; and 183 ears were operated by FGM. The patients were divided into two groups based on size as small and larger (size of ≤30 of TM was defined as small perforations, and size of >30% TM was defined as a medium–large perforations); and two groups based on location of perforation [anterior and other (non-anteriorly located)]. Patients’ follow-ups were performed between 1 and 5 years; and follow-up examinations were performed with otoendoscopy. Air conduction (AC) thresholds and air-bone gap (ABG) were evaluated both preoperative year and postoperative 1st year.

Results

The total perforation closure rate was 84.7%. In this study, we found out that FGM is effective closing medium–large perforations just as small perforations with the success rate of 79.1% and 86.4% respectively (p > 0.05). When audiological outcomes were evaluated in both groups, AC values got lower and ABG values improved postoperatively, whereas regarding AC thresholds and ABG improvement among the size groups, patients with small perforations had significantly better postoperative results (p < 0.05). In terms of perforation location, closure rates were 85.2% in anteriorly perforations and 84.5% in the other located perforations. Audiological outcomes demonstrated that in both groups, AC values got lower and ABG values improved postoperatively; and hearing results were not different in anteriorly located perforations and other locations.

Conclusion

Fat graft myringoplasty (FGM) may be used in all small and medium–large, and anteriorly and other located perforations. Although hearing improvement was detected in each of the small; and medium–large perforations; patients with small perforations had more satisfied audiological outcome than medium–large perforations.     

Autologous perichondrium-cartilage graft in the treatment of total or subtotal perforations of the tympanic membrane

BACKGROUND: In myringoplasty or tympanoplasty, fascia of the temporalis muscle and perichondrium or cartilage-perichondrium composite grafts are most commonly used to reconstruct the tympanic membrane (TM). Primary failures or recurrent perforations in the anterior part of the TM frequently occur in cases of eustachian tube dysfunction or total perforations of the TM. The purpose of this paper is to introduce a perichondrium-cartilage composite graft for closure of total perforations of the TM. Twenty-one patients (17 adults, 4 children) were included in this study, all of whom had a total perforation of the TM. METHODS: An oval shaped piece of cartilage with perichondrium on one side was harvested from the cavum conchae. The cartilage was cut in the shape of a U without removing the inner layer of perichondrium. The inner diameter of the cartilage ring should be nearly the same as the diameter of the tympanic ring. This cartilage framework stabilizes and fixes the perichondrium and prevents the perichondrium from subsiding into the middle ear cavity. Shrinking of the perichondrium is also reduced by the cartilage ring. In all patients introduced in this study, the TM was closed and no residual perforation occurred. The hearing results in tympanoplasty were the same as in other techniques with a residual air-bone gap of about 20 dB. CONCLUSIONS: This technique seems to be a valuable method for the closure of total perforations of the TM. Especially in perforations near the anterior anular region the underlay technique with fascia or perichondrium is an uncertain method. The soft material which is only fixed by adhesion can easily be displaced during wound healing. The hearing results are comparable to that achieved in other techniques. Further studies with greater number of patients are necessary to assess long term results.