Eustachian tube patency and function in tympanoplasty with cartilage palisades or fascia after cholesteatoma surgery.

OBJECTIVE: To compare the Eustachian tube patency and function after tympanoplasty with either cartilage palisades or fascia grafting after one-stage surgery in children with tensa cholesteatoma. STUDY DESIGN: In children operated for tensa cholesteatoma, cartilage palisade tympanoplasty was performed in 32 ears and fascia tympanoplasty in 29 ears. The patency of the Eustachian tube was evaluated by the Valsalva maneuver before the operation, 1 to 3 months after the operation, and at a follow-up examination 46(1/2) months later (median). Eustachian tube function was evaluated by the nine-step inflation/deflation tympanometric test and the Toynbee test at the follow-up examination. Otomicroscopy and hearing evaluation were performed before and after surgery as well as at the follow-up. MAIN OUTCOME MEASURES: Eustachian tube patency and function. Hearing, postoperative eardrum perforation/retraction, and cholesteatoma recurrence. RESULTS: The Valsalva maneuver was positive in 30% of the ears before the operation, in 65% primarily after the operation, and in 78% at the follow-up examination. A poor tubal function was found in 57% at follow-up. Overall, the late functional hearing results were better in ears with a positive Valsalva maneuver. There were no differences in tubal patency or function in relation to graft material, cholesteatoma, and tympanoplasty type. In ears with a poor tubal function, the hearing results were significantly better in the palisade group (63% success), compared with the fascia group (17% success). All of the four perforations, most of the retractions, and a single moist eardrum were found in the fascia group at the reevaluation. We found no correlation between the condition of the eardrum and the Eustachian tube function at the last evaluation. However, in ears with a poor tubal function, a nonretracted, nonperforated drum was found with higher frequency in the palisade group. Decision matrix analysis showed that the last postoperative Valsalva maneuver was the best predictor of the drum condition at the reevaluation. CONCLUSIONS: The Eustachian tube patency frequently improves after tympanoplasty after cholesteatoma surgery in children, regardless of graft material. The patency and function of the Eustachian tube seem to be without relation to graft material, cholesteatoma, or tympanoplasty type. Cartilage palisade tympanoplasty may be a better reconstruction technique after cholesteatoma surgery, especially in ears with a poor tubal function.     

A tympanometric comparison of tympanoplasty with cartilage palisades or fascia after surgery for tensa cholesteatoma in children

OBJECTIVE: The aim of the present study is to compare the tympanometric and functional findings of cartilage palisade tympanoplasty with those of tympanoplasty with temporalis fascia grafting after one-stage surgery in children with tensa cholesteatoma. STUDY DESIGN: In children aged 5 to 15 years (mean, 9.5 years) with tensa cholesteatoma, cartilage palisade tympanoplasty was performed in 32 ears and fascia tympanoplasty in 29 ears. Tympanometry was performed in 31 ears with cartilage palisade tympanoplasty (the palisade group) and 28 ears with fascia tympanoplasty (the fascia group) at follow-up a median of 48 months after surgical removal of the cholesteatoma (range, 3-75 months). MAIN OUTCOME MEASURES: Postoperative perforations, tympanometric parameters (tympanogram type, compliance, tympanometric width), and hearing. RESULTS: All postoperative re-perforations occurred in the fascia group. However, there was no difference between the palisade group and the fascia group in terms of tympanometric parameters, nor between the two groups when dividing into tensa retraction and sinus cholesteatoma subgroups. When comparing the types of tympanoplasty, the type II group reconstructed with cartilage palisades contained a higher number of ears with a normal compliance (0.2-1.6 mL) but a higher number of ears with a tympanometric width of more than 150 mmH2O. Regarding the number of ears with normal tympanometries, there was no significant difference between the palisade and the fascia group. The late functional hearing results were better in ears reconstructed with cartilage palisades, with functional success in 71%, compared with 54% in the group with fascia grafting. This difference in functional results was particularly pronounced in ears with an abnormal tympanogram (68% vs. 29%). CONCLUSION: Compared to fascia grafting, the present study showed better late functional hearing results after drum reconstruction using cartilage palisades, despite comparable tympanometric findings. Cartilage palisade reconstruction seems to provide better functional results, especially in ears with a poor tubal function, which is the common situation after cholesteatoma surgery.     

Late results of surgery in different cholesteatoma types

Our series of 740 cholesteatomas, operated during the period 1969 to 1980, were seen at follow-up several times with a median observation period of 9.2 years (range 3-21 years). There were; 273 attic cholesteatomas with retraction (perforation) of Shrapnell's membrane; 271 sinus cholesteatomas with superioposterior retraction (perforation) of pars tensa, and 196 tensa retraction cholesteatomas extending from a retraction of the whole pars tensa. The late results were analyzed for each type separately, and compared. The recurrence rate was lowest (6.6%) in attic cholesteatoma and highest (13.3%) in tensa retraction cholesteatoma. In all three types no residual cholesteatomas were detected after the 4th postoperative year, whereas recurrent cholesteatomas occurred up to 10 years after surgery. The reoperation rate was lowest (15%) in attic cholesteatoma and almost the same (21%) in sinus and tensa retraction cholesteatoma. The hearing results were best in attic cholesteatoma and poorest in tensa retraction cholesteatoma. It is concluded that cholesteatoma surgery should be individualized and that both the canal wall up and canal wall down methods have their place in cholesteatoma surgery.     

Combined Heermann and Tos (CHAT) technique in cholesteatoma surgery: surgical technique and preliminary results

The combined Heermann and Tos (CHAT) technique is the combination of Heermann's 'cartilage palisade tympanoplasty' and Tos's 'modified combined approach tympanoplasty = modified intact canal wall mastoidectomy'. The first author (Cem Uzun) performed the CHAT technique as a one-stage operation in 15 ears of 15 patients with cholesteatoma. Two patients (one with a follow up of less than six months and one who did not show up at the final re-evaluation) were excluded from the study. Median age in the remaining 13 patients was 37 years (range: 14-57 years). Cholesteatoma type was attic, sinus (Tos tensa type 1) and tensa retraction (Tos tensa type 2) in six, five and two ears, respectively. Cholesteatoma stage was Saleh and Mills stage 1, 2, 3, 4 and 5 in one, three, four, four and one ear, respectively. The eustachian tube was not involved with cholesteatoma in any ear. After drilling of the superoposterior bony annulus, transcanal atticotomy with preservation of thin bridge and cortical mastoidectomy with intact canal wall, the cholesteatoma was removed, and the eardrum and atticotomy were reconstructed with palisades of auricular cartilage. Type I tympanoplasty was performed in two ears, type II in nine ears and type III (stapes absent) in two ears, with either autologous incus (eight cases), cortical bone (two) or auricular cartilage (one). No complication occurred before, during or after surgery. Oto-microscopy and audiometry were done before and at a median of 13 months after surgery (mean 14 months, range 7-30 months). There was no sign of residual or recurrent cholesteatoma in any patient during the follow-up period. At the final examination, all ears were dry and had an intact eardrum except one with a small, central hole, which had been seen since the early post-operative period. Clean and stable attic retraction with a wide access was observed in two ears. Post-operative hearing at the final evaluation was better (change > 10 dB) than the pre-operative one in nine ears and did not change in the remaining four. Pre- and post-operative mean hearing values were, pure-tone average 47 and 35 dB (p = 0.01) and air-bone gap 30 and 20 dB (p = 0.02), respectively. With the CHAT technique, cholesteatoma can be completely and safely removed from the middle ear, and a durable and resistant reconstruction of the middle ear with reasonable hearing can be achieved. However, a further study should analyse long-term results of a larger patient group.     

Retraction pockets of pars tensa in pediatric patients: Clinical evolution and treatment

Objective

To assess outcome in pediatric patients after treatment for retraction pockets of pars tensa in relation to retraction grade, site, occurrence of complications, and patient age.

Methods

Outcomes in 45 ears of 37 children medically or surgically treated for retraction pockets were compared to a control group of 40 untreated children over a follow-up period of at least 24 months. Grade I and II retractions were treated with medical therapy or ventilation tube insertion; in III or IV grade retractions, excision and tympanic reinforcement with cartilage grafting and in some cases ossiculoplasty were performed.

Results

Medical treatment or ventilation tube insertion resolved grade I and II retractions in 94% of cases. In grade III or IV retractions the anatomic success rate was 75.8%. Normal hearing (air-bone gap <10 dB) was restored in 31 (68.8%) cases. Surgical failures and complications (recurrence, tympanic membrane perforation, progression to cholesteatoma) were higher in posterior retractions. In the control group, only 35% of retractions healed spontaneously; in the remaining cases the condition progressed to more serious retractions or complications.

Conclusion

A wait and see approach or conservative therapy is indicated only in mild-to-moderate retraction pockets owing to their benign prognosis. Pocket excision and tympanic reinforcement are absolutely indicated in advanced retractions with complications and/or bilateral conductive hearing loss to avert progression to more serious pathologies.     

Pathogenesis of sinus cholesteatoma

The aim of the present study was to provide evidence for the establishment of sinus cholesteatoma, defined as postero-superior pars tensa retraction extending into the posterior tympanum and tympanic sinuses. Background: There is clinical evidence for formation of a retraction, but there is a lack of explanation for the transition from a retraction pocket to an active and expanding sinus cholesteatoma. Epidemiological studies on incidence of postero-superior retractions of pars tensa and follow-up studies on patients with similar pars tensa retractions were performed. Additionally, expression of proliferation marker and analysis of basement membrane were studied in samples of sinus cholesteatoma. The prevalence of pars tensa pathology was between 9.2 and 24% of investigated ears. In children with manifest secretory otitis there were some sinus cholesteatomas and 5–6% severe retractions, some of those became pre-cholesteatomas, requiring treatment and controls. Immunohistochemistry of sinus cholesteatomas showed that proliferating keratinocytes were very often found within epithelial cones growing towards the underlying stroma. These growth cones exhibit focal discontinuities of the basement membrane especially in areas of intense subepithelial inflammation. As a possible explanation based on clinical and immunohistochemical findings, we propose a four-step concept for pathogenesis of sinus cholesteatoma combining the retraction and proliferation theory: (1) The retraction pocket stage. (2) The proliferation stage of the retraction pocket, subdivided in (a) Cone formation, (b) Cone fusion. (3) Expansion stage of attic cholesteatoma. (4) Bone resorption.     

Treatment of sinus cholesteatoma. Long-term results and recurrence rate

We classified cholesteatomas as attic cholesteatoma, developing from Shrapnell's membrane; tensa cholesteatoma, originating in pars tensa, which is subdivided into tensa retraction cholesteatoma involving the entire pars tensa, and sinus cholesteatomas, developing from a posterosuperior retraction (perforation). From 1964 to 1980, one-stage operations were carried out on 271 ears with sinus cholesteatomas. Follow-up included 90% of the patients, and the median observation time was 9.75 years. The recurrence rate was 10%. The recurrence rate was found to be independent of the mastoidectomy type employed. The best hearing results were obtained in ears with intact ossicular chain. We conclude that, wherever possible, sinus cholesteatoma should be removed through the auditory canal without mastoidectomy just as an intact ossicular chain should be preserved. "Canal wall up" and "canal wall down" appear to be equally valuable mastoidectomy types, and both methods must be employed to obtain optimum results.     

Tensa retraction cholesteatoma: treatment and long-term results

To obtain the best possible results of treatment of acquired cholesteatoma, we made a subdivision of cholesteatoma types into attic and pars tensa cholesteatomas, and subdivided the latter further into tensa retraction cholesteatoma and sinus cholesteatomas. Tensa retraction cholesteatoma is defined as arising from a retraction or perforation of the whole pars tensa, whereas sinus cholesteatoma is defined as arising from a retraction or perforation of the postero-superior part of the tensa. We present the long-term results obtained in tensa retraction cholesteatomas treated with one stage surgery from 1964 to 1980. Median observation time was 9 years, range 2 to 19 years. Sixty-one ears were treated without mastoidectomy, whereas 71 ears had canal wall-up mastoidectomy and 64 ears had canal wall-down mastoidectomy. The total recurrence rate was 13.3 per cent; 17 ears had residual cholesteatoma, and nine ears had recurrent cholesteatoma. The best results were obtained in ears with an intact ossicular chain where mastoidectomy was not performed. In 49 per cent of the cases, the cholesteatoma was confined to the tympanic cavity without reaching the aditus, antrum or mastoid process. About one-third to one-quarter of the ears had tympanoplasty only, with removal of the cholesteatoma through the ear canal.     

Hearing results after primary cartilage tympanoplasty

OBJECTIVES/HYPOTHESIS: Cartilage-perichondrium grafting of the tympanic membrane has been used in an effort to reduce recurrence or progression of middle ear disease. The rigidity of cartilage has obvious benefit in preventing tympanic membrane retraction, but concern has been raised regarding its sound conduction properties Few studies in the literature address hearing results after cartilage tympanoplasty. The purpose of this study was to investigate the hearing results after primary cartilage tympanoplasty and compare them with results after primary tympanoplasty with temporalis fascia. STUDY DESIGN: A retrospective review of all ear surgeries using cartilage between 1994 and 1999 was performed. METHODS: Only primary cases in which the ossicular chain was intact and no mastoid surgery was performed were included. Indications for surgery included tympanic membrane perforation, retraction, and cholesteatoma Pre- and postoperative speech reception thresholds and air-bone gaps at 500 Hz, 1,000 Hz, 2,000 Hz, and 4,000 Hz were compared. RESULTS: Eleven patients comprised the cartilage study group, and there were 11 age- and temporally matched control subjects. The mean improvement in speech reception threshold for both the study group and the control group was 10 dB. The majority of patients in both groups had ABG closure to within 10 dB at all frequencies examined. There were no statistically significant differences in speech reception threshold improvement or air-bone gap closures between the two groups. CONCLUSIONS: These results demonstrate that hearing results after cartilage tympanoplasty are comparable to those after temporalis fascia tympanoplasty. Therefore, when indicated, a cartilage-perichondrium graft can be used for prevention of disease recurrence or progression without fear of impairing hearing.     

Comparison of different tympanic membrane reconstruction techniques in type I tympanoplasty

The objective of the study was to assess the functional results after type I tympanoplasty with temporal muscle fascia, perichondrium/cartilage island and cartilage palisades. The records of 120 patients who underwent type I tympanoplasty operation between January 2003 and June 2007 were retrospectively reviewed. This study aimed to comprise a homogeneous group of patients to make the comparisons as accurate as possible. For this purpose, primary tympanoplasty cases with subtotal perforations, intact ossicular chain, dry ear for a period of at least 1 month, and normal middle ear mucosa were included in the study. Patients younger than 15 years of age and patients with cholesteatoma were excluded. Temporal muscle fascia was used in 67 (55.8%), perichondrium/cartilage island flap was used in 34 (28.3%), and cartilage palisades were used in 19 (15.8%) of the patients. Pre- and postoperative otoscopic examinations, pure-tone averages, and air-bone gaps were compared pre and postoperatively. Concerning all of the cases, the graft take rate was 85% (102/120). In the perichondrium/cartilage island flap group, the graft take rate was 97.7%, whereas the graft take rates for the fascia group and cartilage palisades group were 80.6 and 79.0%, respectively. In the perichondrium/cartilage island flap group, the pure-tone average was 36.36 dB, whereas the pure-tone averages for the fascia group and cartilage palisades group were 36.07 and 39.79 dB, preoperatively. The postoperative pure-tone averages were 24.54 dB fort he perichondrium/cartilage island flap group, 24.51 dB for the fascia group and 23.23 dB for the cartilage palisades group. Cartilage grafting is not only more enduring against infection and negative middle ear pressure but also it has low re-perforation rates on long-term follow-up. Thus, cartilage may be preferred more often for primary tympanoplasties with high graft rate and hearing improvement.     

Otological and audiological outcomes five years after tympanostomy in early childhood

OBJECTIVE: Ventilation tubes in the treatment of otitis media in young children remain controversial. Despite abundant research, few prospective long-term follow-up studies have included even a minority of patients under 1 year old. We investigated long-term otological and audiological outcomes in children with recurrent acute otitis media and otitis media with effusion, who were treated early with ventilation tubes. STUDY DESIGN: Prospective follow-up. METHODS: Three hundred five children under 17 months of age received a primary tympanostomy in the Central Hospital of Central Finland (Jyv?skyl?, Finland), and those 281 (92.1%) who were monitored prospectively for 5 years made up the study group. At the final examination, pneumatic otoscope and otomicroscope were used and pure-tone audiometric thresholds of air and bone conduction were measured to define the hearing levels (mean of 0.5, 1.0, and 2.0 KHz thresholds). RESULTS: Of ears, 67.3% were healed, 7.1% had a retraction of tympanic membrane in pars flaccida and 9.6% in pars tensa, 7.5% had an ongoing otitis media with effusion, 3.9% had a ventilation tube in place, and 4.6% had a tympanic membrane perforation with mean hearing levels of 7.6, 9.0, 16.0, 18.5, 10.5, and 17.7 dB, respectively. CONCLUSIONS: Hearing in general was well preserved, and no ear presented with adhesive otitis media or cholesteatoma. Adverse otological and audiological outcomes of these young children did not exceed those presented by others for older counterparts. Tympanic membrane perforations, ongoing otitis media with effusion, and pars tensa retractions were causes of mild conductive hearing loss. Because one third of ears continued to have middle ear disease or sequelae, we emphasize the proper follow-up and restoration of middle ear ventilation with repeat ventilation tubes if not otherwise achieved.     

The extraordinary healing properties of the pediatric tympanic membrane: a study of atelectasis in the pediatric ear

OBJECTIVES: Traumatic perforations of the eardrum are generally treated conservatively as they tend to heal spontaneously. Retraction pockets of the eardrum, leading to atelectasis of the middle ear and often ultimately though unpredictably, to cholesteatoma formation, are treated in a variety of ways including complex grafting procedures. On the premise that a surgically resected retraction pocket is in essence a traumatic perforation, we examined the results of spontaneous healing of the resected retraction pocket. METHODS: Retrospective case note study. PATIENTS: A group of 86 ears in 62 patients who had undergone simple excision of the atrophic segment of the eardrum and who had no grafting procedure of the resultant defect, were followed at 6 days, 6-7 weeks and then every 6 months to determine the incidence of spontaneous healing of the eardrum. Audiograms were taken preoperatively, at 7 weeks and between 7 and 15 months postoperative. RESULTS: 94.2% of the eardrums (81 out of 86 ears) healed spontaneously without any form of grafting within 7 weeks. Air bone gap showed improvement in 53 patients. Only one of the four ears that failed to achieve closure had postoperative ear discharge. There were no other complications. In 17 ears (19.8%) there was a recurrence of the atelectasis. CONCLUSION: Excision of retraction pockets in pediatric ear atelectasis, in principle does not require grafting, as the great majority will heal spontaneously. The spontaneous healing in this study is comparable to reported studies of spontaneous healing of traumatic perforations. Irrespective of the size of the atrophic part of the membrane, recurrence rates for the atelectasis after simple excision is similar to that described in other studies. Retraction pockets may be excised and allowed to heal without risk to the hearing.     

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.     

Surgical management of the atelectatic ear

OBJECTIVE: The surgical management of the atelectatic ear is controversial because the natural course toward cholesteatoma development cannot be predicted, and hearing acuity remains normal until later in the disease course. Consequently, surgery is often delayed until there is a clear indication, such as hearing loss or frank cholesteatoma development, but such delay often necessitates more extensive surgery. Because earlier intervention appears to be in the best interest of the patient but is often avoided because of near normal hearing levels at this stage, the author proposes a staging system for classification and management of the atelectatic ear. Hearing results and complications in patients undergoing tympanoplasty with or without ossicular reconstruction are reported for patients with type III and IV retractions. STUDY DESIGN: A retrospective study using a computerized otologic database to identify patients who meet the inclusion criteria. SETTING: A tertiary referral center. PATIENTS: A total of 55 patients (63 ears) aged 5 to 78 years underwent cartilage tympanoplasty with or without ossicular reconstruction. INTERVENTIONS: Elevation of the ear drum, followed by cartilage reconstruction of the tympanic membrane, with ossicular reconstruction as indicated. MAIN OUTCOME MEASURES: Postoperative pure tone average air-bone gap for four frequencies (500, 1000, 2000, 4000 Hz) compared with preoperative levels. RESULTS: There was a statistically significant improvement in hearing (p < 0.05). CONCLUSIONS: This staging system offers an effective treatment algorithm for pars tensa retractions and management of type III and IV retractions via cartilage tympanoplasty with or without ossicular reconstruction and is a proven treatment modality.     

Cholesteatoma in children--the experience at The Red Cross War Memorial Children's Hospital in South Africa 1988-1996.

This review of experience with cholesteatoma in children, describes the presentation and features of the disease from a tertiary institution in a 'developing country'. A total of 24 out of 96 cholesteatomas in 81 children (M:F = 44:37) aged 2-12 years initially presented with mastoiditis, with intracranial complications in seven children. Three of the cholesteatomas were congenital, 56 arose from retraction pockets-11 pars flaccida, 45 pars tensa 21 were associated with either a central perforation or total atelectasis and one originated at a ventilation tube site. Open cavity surgery was undertaken in all cases-atticotomy in 14, open mastoid cavity in 82 ears. It was not always possible to preserve reasonably normal pre-operative hearing nor was it possible to improve hearing loss. Twenty-six out of 81 children did not return for follow-up. Even with open cavity surgery, recurrence of cholesteatoma occurred. Late diagnosis, extensive disease, a high rate of complications and poor follow-up are the features of this disease in 'developing' countries.     

The mechanical reduction of early acquired cholesteatomas in children: indications and limitations

The standard treatment for acquired cholesteatoma involves surgical removal of the lesion and reconstruction of the tympanic membrane. In some children, these lesions can be treated more conservatively. We conducted a retrospective study of 29 ears in 24 children who had been treated for early acquired cholesteatoma with mechanical reduction and a tympanostomy tube. Outcomes measures included hearing status, the postoperative appearance of the tympanic membrane, and the need for additional surgery. We found that anterior and inferior pars tensa lesions, with or without squamous debris, can be successfully reduced, but that posterosuperior retractions respond less well when the ossicular chain has been eroded. None of the children who responded to mechanical reduction required major reconstructive surgery later. We conclude that mechanical reduction of retraction pocket cholesteatomas with tympanostomy tube placement is sufficient to restore normal hearing and a normal tympanic membrane appearance in selected children with early lesions. We also identified several important prognostic features, including the patient's age, the specific location of the retraction pocket on the tympanic membrane, the extent of the pocket, ossicular chain involvement, and the patient's adenoid status.     

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.     

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.     

A study of recurrence of retraction pockets after various methods of primary reconstruction of attic and mesotympanic defects in combined approach tympanoplasty

The major drawback of combined approach tympanoplasty (CAT) is a relatively high rate of cholesteatoma recurrence compared to open-cavity techniques, which is thought to occur primarily by recurrence of retraction pockets. In this series of 63 CATs carried out by one surgeon, scutum reconstruction to prevent recurrent attic retraction was carried out in 43 cases. Repair with bone pate proved much more successful in achieving this (20.7%; 6/29 recurrent retraction pockets) compared to tragal cartilage (57.1%; 8/14) (Fisher's exact test, P = 0.0205) and was found to be a result of the greater incidence of cartilage resorption. Recurrence of retraction in pars tensa defects was more common as the only material used was a simple temporalis fascia graft. The mean time to development of recurrences was 21.1 months and that has important implications for follow-up. We conclude that the use of bone pate for scutum reconstructions reduces the incidence of attic retraction pockets, and therefore the risk of cholesteatoma recurrence following CAT.     

软骨栅—软骨膜鼓膜成形术

目的 探讨用自体软骨栅－软骨膜行鼓室成形术的疗效. 方法 用自体条栅状软骨行豉室成形术对66耳鼓膜穿孔（面积＞50％）的患者进行鼓膜修补,并与同期用颞肌筋膜修补的60耳相同病变进行比较。结果 软骨－软骨膜组的近期鼓膜穿孔愈合率为92．4％,颞肌筋膜组为80％。两组的听力结果差异无显著性。结论 软骨－软骨膜特别适用于修补鼓膜大穿孔及粘连性中耳炎。条栅状软骨－软骨膜鼓膜成形术是一种很好的修补鼓膜大穿孔的方法。