Butterfly inlay tympanoplasty: A study in Indian scenario

Popularly myringoplasty is done by an underlay or an onlay technique using mostly temporalis fascia graft. A new technique of inlay tympanoplasty using composite cartilage perichondrium graft is applied in the present study of 20 patients, for closure of small to medium sized perforations. The results have been analysed in terms of graft take up rate and hearing improvement.     

Fat graft myringoplasty: a cost-effective but underused procedure

OBJECTIVES: The objective of this study was to evaluate the success of fat graft myringoplasty and to discuss the utilities and advantages of a fat graft in primary versus revision myringoplasties. METHODS: Eighteen patients who had not had previous otological surgery, and twelve patients whose tympanic membrane perforations have persisted despite myringoplasty with temporalis fascia were included in this prospective clinical trial. All patients were treated by fat graft myringoplasty and followed up for one year. RESULTS: Successful closure of the perforation was obtained in 82.4 per cent of the ears at the final follow up. The success rate in the group of patients who had not had previous otological surgery was higher than those of revision cases. CONCLUSIONS: Adipose tissue provides the basic requirements for grafting of the tympanic membrane, with its own favourable characteristics. Fat graft myringoplasty is a cost-effective alternative in small perforations of the tympanic membrane, including revision cases.     

软骨软骨膜在鼓膜修补中的应用

目的探讨鼓膜大穿孔采用软骨-软骨膜修补的方法及临床疗效。方法36例（40耳）鼓膜大穿孔（软骨-软骨膜组）采用软骨-软骨膜行鼓膜修补术并与同期46例（46耳）颞肌筋膜鼓膜修补术（颞肌筋膜组）进行比较。软骨-软骨膜组采用耳后切口,切取耳廓软骨-软骨膜,然后将软骨切成2～3条,将其相互部分重叠修复穿孔,修补鼓膜,同期行听骨链重建。结果随访1年,软骨-软骨膜组鼓膜穿孔愈合率为95.0%（38/40）;筋膜组鼓膜穿孔愈合率为89.1%（41/46）,两组相比无统计学意义（χ2=0.288,P=0.592）。颞肌筋膜组17耳鼓膜有钙化斑中,5耳穿孔未愈,占29.4%（5/17）;软骨-软骨膜组20耳鼓膜有钙化斑,其中1耳穿孔未愈,占5.0%（1/20）。两组鼓膜有钙化斑的病例鼓膜穿孔愈合率相比有统计学意义（χ2=4.031,P=0.045）。术后1年复查软骨-软骨膜组纯音听力平均气导听阈为36.9dB,平均骨气导差为17.8dB;筋膜组纯音听力平均气导听阈为35.5dB,平均骨气导差为15.9dB。两组比较无统计学意义（t=2.103,P=0.85）。结论软骨-软骨膜修补鼓膜穿孔是一种可靠的方法,其在修补鼓膜大穿孔和鼓膜伴有钙化斑的患者中有一定的优势。     

内镜下鼓膜成形术

目的评价内镜下修补干性鼓膜中、小穿孔的效果并与传统的烧灼法作对照。方法按完全随机法将鼓膜干性中央性中、小穿孔130耳分为两组,第一组100耳接受内镜下同种异体颞肌筋膜鼓膜成形术(内镜组),另30耳采用传统的40%三氯醋酸烧灼法进行修补(对照组)。比较两组间术后3个月鼓膜穿孔完全愈合的耳数以及术后6个月的语言频率纯音听阈的差异。结果术后3个月,内镜组鼓膜穿孔完全愈合率为91/100,较对照组的20/30高(P<0.01),术后6个月,两组鼓膜穿孔完全愈合者的骨-气导差在10dB以内的占90.1%。结论使用内镜修补鼓膜穿孔具有明显的优势,可代替手术显微镜且更容易通过狭窄或弯曲的外耳道,该手术是一种简单易行、安全有效的方法。     

Myringoplasty: update on onlay pedicle skin flap and temporalis fascia sandwich graft

The technique of onlay sandwich grafting of tympanic membrane perforations fashioned by the use of pedicle flap raised from the posterior deep meatal skin and autologous temporalis fascia is described. The results of a series of 124 ears operated between 1987 and 1999 are the basis of this report. Of these 106 patients had myringoplasty for the first time. The operation was successful in 102 (96.23 per cent) patients. Eighteen patients had revision myringoplasty, with a successful result in 14 (77.78 per cent). None of the patients developed complications usually associated with onlay grafting. A preliminary report of this work was presented at the XVI World Congress of Otolaryngology Head and Neck Surgery at Sydney in 1997.     

嵌入法鼓膜成形术的临床应用

目的 探讨嵌入法鼓膜成形术的临床应用。方法 选择2002年3月～2009年12月就诊于我科的中央型中小鼓膜穿孔患者107 例111 耳,分为3个手术组：嵌入法脂肪鼓膜成形术组(脂肪组)42例44耳,嵌入法蝶形软骨鼓膜成形术组(软骨组)32例32耳,内植法软骨膜鼓膜成形术组(对照组)33例35耳。手术均在耳内镜下进行。结果 术后6个月随访,3组的愈合率分别为90.9 %、93.8%、91.4%,无统计学差异(P>0.05);听力复查示平均气导提高>10dB及平均气骨导差<10dB的发生率亦无统计学差异(P>0.05)。对已愈合患者随访12～38个月,脂肪组及软骨组无鼓膜再穿孔,对照组再穿孔2耳。结论 耳内镜下嵌入法脂肪鼓膜成形术及嵌入法蝶形软骨鼓膜成形术是简单、成功率高的微创技术。     

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.     

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.     

Treatment of tympanic membrane retraction pockets by excision. A prospective study.

The treatment of tympanic membrane retraction pockets by simple excision is described in 66 ears in 50 patients. After one operation 65 per cent of the retraction pockets were successfully treated (mean follow up 14.1 months). Persisting perforations occurred in five patients after one excision. Retrotympanic cholesteatoma was found in one patient, after two retraction pocket excision operations. The number of myringotomies with grommet insertion and the presence of bilateral disease does not predict the outcome of the procedure. Simple excision should be considered in the first instance, rather than reinforcement tympanoplasty using temporalis fascia or cartilage graft, in the treatment of tympanic membrane retraction pockets.     

内外植法与内植法鼓膜成形术的近期对比分析

目的:探讨内外植法修补鼓膜的成功率和对听力的影响.方法:回顾性分析2002年以来行内植法鼓膜成形术且术后随访6个月以上的74例(77耳)患者,A组44例(45耳)采用传统的内植法,B组30例(32耳)将移植膜放置在残余鼓膜与锤骨柄之间(内外植法),比较2组患者术后3个月时的听力.结果:A组鼓膜1次修补成功40耳(89.0%),语言区平均听阈改善≥10 dB者23耳,手术成功率57.5%.B组鼓膜修补1次愈合28耳(87.5%),语言区平均听阈改善≥10 dB者23耳,手术成功率71.9%.并发症:A组再穿孔2耳(5.9%),鼓膜内陷8耳(17.8%);B组再穿孔2耳(6.25%),钝角愈合3耳(9.38%),鼓膜内陷2耳(6.25%).结论:将移植膜放置在残余鼓膜与锤骨柄之间可避免术后鼓膜和锤骨柄脱离,减少移植膜与鼓岬发生粘连.对鼓膜较大穿孔患者听力的改善明显优于移植膜放置在锤骨柄内侧者.     

A comparative study of different graft materials used in myringoplasty

Two hundred twenty cases of unilateral chronic suppurative otitis media (CSOM) with dry central perforation were chosen for this study and myringoplasty were done. Age group ranged from 13 to 48 years. Four types of autogenous tissues were used as graft material. Grafting was done by underlay technique when temporalis fascia, tragal perichondrium, areolar tissue were used as graft material and when fat graft was used the ear lobule fat was placed directly into perforation through transcanal route. Postoperative follow-up was carried out up to 6 months. In this study, it was found that the younger age group has less impairment of hearing and better chance of tympanic membrane perforation closure than the older age group in CSOM with central perforation. Anterior perforations has less impairment of hearing and better result in successful closure of tympanic membrane than posterior perforation group. It was also observed that larger the size of perforation greater is the hearing impairment preoperatively and postoperative hearing gain is also less compared to small perforation. Best hearing improvement occurred using temporalis fascia. Failure occurred may be due to postoperative infection, respiratory tract infection, neglected post-operative advice etc.     

Fat tissue in the treatment of tympanic membrane perforations

Adipose myringoplasty is presented as a simple and effective technique in managing tympanic membrane perforations. A review of 34 fat plug myringoplasties performed in 28 patients with drum perforations over a 4-year period was done. Twenty-two myringoplasties were postinflammatory, five--posttraumatic and three--postinflammatory in temporalis fascia. Criteria for selection, operative technique and results are discussed.     

Myringoplasty in Children: Predictive Factors of Outcome

Objectives: To assess the results of myringoplasty in children and to determine which factors independently influence the postoperative results. Study Design: Retrospective study of the anatomic and functional results of 231 consecutive myringoplasties performed in 188 children between 1988 and 1992. Multivariate analysis of poor prognostic factors by cross-sectional comparison 1 year after surgery. Methods: Myringoplasties were performed via an endaural approach with a fascia temporalis underlay graft. Results: In 216 of 231 ears (93.5%) the tympanic membrane was closed. A good anatomic outcome was considered to have been achieved in 188 ears (81.6%), although in 18 ears (7.8%) seromucous otitis media occurred, in 8 ears (3.5%) a progressive retraction pocket was encountered, and in 2 ears significant lateralization was present. One hundred thirty-nine (67.5%) of the 206 ears tested in the postoperative period had a postoperative air-bone gap of 10 dB or less. On average, mean bone conduction remained unaltered. The age of the patient and the size and the location of the perforation did not affect the outcome. Three prognostic factors for an abnormal postoperative tympanic membrane were found, with 95% confidence intervals: inflammatory changes in the middle ear mucosa (P < .05), contralateral tympanic perforation (P < .05), and contralateral cholesteatoma (P < .01). Conclusions: Myringoplasty with underlay grafting of the fascia temporalis in children gives good anatomic and functional results. Inflammatory changes within the middle ear mucosa, contralateral tympanic perforation, and contralateral cholesteatoma independently influence the risk of an abnormal postoperative tympanic membrane. The presence of one of these factors preoperatively should lead to the consideration of alternative, more durable graft material, such as autologous cartilage.     

Butterfly cartilage graft inlay tympanoplasty for large perforations

OBJECTIVE: Butterfly graft inlay tympanoplasty is a well-established technique for the repair of small perforations. However, the efficacy of the technique for medium and large tympanic membrane perforations remains unknown. STUDY DESIGN: Retrospective case series. METHODS: Postauricular tympanoplasty and tympanomastoidectomy using a large butterfly cartilage inlay graft (>4 mm diameter to total drum replacement) were analyzed in 90 pediatric patients (99 ears). RESULTS: Patient ages ranged from 2 to 20 years; mean follow-up duration was 27.6 months. Successful closure occurred in 92% of the ears. No graft lateralized nor displaced into the middle ear. No retraction pocket occurred during the follow-up period. In 62 cases, intact canal wall or canal wall window tympanomastoidectomy was performed; Fifty-one (82.2%) of the patients having mastoidectomy procedures had chronic otitis media with cholesteatoma. The mean preoperative to postoperative four-tone air-bone gap improved from 23 to 21 dB; the number of patients with 0 to 10 dB hearing results increased from 16 ears preoperatively to 32 ears postoperatively. Postoperative suboptimal results included eight patients with postoperative perforations in the residual tympanic membrane adjacent to an intact cartilage graft; two of these patients were the only individuals who exhibited otorrhea. CONCLUSIONS: Cartilage butterfly graft inlay tympanoplasty is effective in the vast majority of patients with moderate to large perforations. The closure rate exceeded 90% with no graft displacement, postoperative adverse events were respectably low, and hearing results improved or remained stable despite the need for concurrent mastoidectomy in the majority of patients.     

内植法鼓膜修补术——自制鼓膜刮匙的应用及长期效果观察

目的探讨用自制刮匙刮除鼓膜穿孔缘鳞状上皮行内植法鼓膜修补术的临床效果。方法共对386例（398耳）用自制的鼓膜内层上皮刮匙刮除鼓膜穿孔缘残留鳞状上皮或掀起耳道深部皮肤，取颞肌筋膜行内植法鼓膜修补术。结果经2年以上随访，11耳再度穿孔，387耳穿孔修补成功。术后1至3个月纯音测听示听力改善率达97．2％。结论用自制刮匙刮除鼓膜穿孔缘残留鳞状上皮行内植法鼓膜修补术效果满意。     

Lateral graft type 1 tympanoplasty using AlloDerm for tympanic membrane reconstruction in children

OBJECTIVES: To describe the lateral graft type 1 tympanoplasty technique using AlloDerm for tympanic membrane reconstruction in children and to compare its surgical and audiometric outcomes with the traditional underlay type 1 tympanoplasty. METHODS: The records of 34 consecutive children undergoing type 1 tympanoplasty between 2004 and 2005 were reviewed; 18 received lateral graft tympanoplasty with AlloDerm and 16 received underlay tympanoplasty (8 AlloDerm and 8 temporalis fascia). Pre- and post-surgical audiograms, speech reception threshold, closure rate and complication rate were evaluated using one-way and repeated measures ANOVAs. RESULTS: Children who underwent lateral graft type 1 tympanoplasty pre-operatively had larger tympanic membrane perforations, worse pure tone averages, air bone gaps and speech reception thresholds as compared with children undergoing underlay type 1 tympanoplasty (P<0.001). Pure tone averages and air bone gaps improved significantly with surgery in both lateral and underlay type 1 tympanoplasty groups (P<0.05), with both groups achieving comparable postoperative audiometric outcomes (P>0.01). The lateral graft group demonstrated a higher perforation closure rate (94%) as compared with both underlay groups (88%). Complication rates were virtually non-existent. CONCLUSIONS: Despite larger perforations and worse pre-operative audiometric scores, children who underwent lateral graft type 1 tympanoplasty achieved comparable postoperative audiometric results and perforation closure rates as compared with children who underwent underlay type 1 tympanoplasty. Results suggest that lateral graft type 1 tympanoplasty using AlloDerm is effective for tympanic membrane reconstruction in children and should be used when temporalis fascia is not available or the extent of the perforation limits its use.     

Inlay Tympanoplasty: Cartilage Butterfly Technique

For closure of a nonmarginal tympanic membrane perforation, currently popular techniques utilize either an underlay or an onlay approach. However, both procedures require incising canal skin. A transcanal inlay procedure could provide theoretical advantages of ease, speed, and comfort. Specifically designed cartilage that could facilitate the transcanal approach similar to placement of a solid tube was employed and evaluated. A transcanal cartilage butterfly inlay technique was found to be efficient and effective to close a subgroup of small-to-medium-sized tympanic membrane perforations including cases in which the condition of the tympanic membrane was somewhat hostile. Postoperative patient comfort was an additional benefit.     

Comparative study of underlay tympanoplasty with temporalis fascia and tragal perichondrium

The perforations of the tympanic membrane maybe of traumatic origin or due to chronic suppurative otitis media. If the perforations fail to heal conservatively, they require surgical closure. Autologous graft materials have stood the test of time in repairing tympanic membrane perforations. In our tertiary care institution we conducted a prospective randomized control trial on 50 subjects to evaluate the comparative efficacy of temporalis fascia and tragal perichondrium as grafting material in underlay tympanoplasty. In this study surgical success was evaluated in terms of intact drum membrane during the follow up period and closure of A–B gap within 10 dB. Temporalis fascia achieved a graft uptake of 84% and a satisfactory hearing improvement in 76% of the patients. Tragal perichondrium achieved a success rate of 80% graft uptake and 75% hearing gain. The rates are comparable with no statistical significance of the difference between them.     

Prognostic factors influencing anatomic and functional outcome in myringoplasty

The objectives of myringoplasty are essentially two: restore the eardrum integrity and improve hearing level. We have carried out a retrospective study of myringoplasties performed in our Department, between 1996 to 2000, corresponding to 197 surgical interventions, in 162 patients. The characteristics more frequently seen for operating ears were central localization of tympanic membrane perforation, dry ear, good eustaquian tube function and underlay technique placing fascia graft. Endaural or retroauricular approach were similar in number. We obtained 73.6% of anatomic success, though in some cases we needed to reoperate the patient. When we analysed risk factors of anatomic success, we noticed than only the tympanic perforation site had influence, with better rate in posterior perforations and lower rate in subtotal perforations. We analysed functional results in ears with anatomic success, finding 75.6% of hearing level improvement with a gap of less than 20 dB. Factors influencing hearing improvement were surgeon experience and the presence of middle ear alterations.     

Butterfly cartilage tympanoplasty outcomes: A single-institution experience and literature review

Purpose

In 1998, Dr. Eavey described the trans-canal inlay butterfly cartilage tympanoplasty technique, also known as cartilage button tympanoplasty. Many retrospective studies have since demonstrated its efficacy and decreased operative time when compared to underlay and overlay tympanoplasty techniques. The butterfly cartilage tympanoplasty approach uses only a cartilage graft to repair tympanic membrane perforations. The aim of this study was to review the literature for studies that examined butterfly cartilage tympanoplasty success rates and outcomes and compare them to outcomes from our cohort.