Endoscopic cartilage versus temporalis fascia grafting for anterior quadrant tympanic perforations — A prospective study in a tertiary care hospital

doi:10.1016/j.anl.2018.01.002

Auris Nasus Larynx

Volume 45, Issue 5, October 2018, Pages 936-942

https://doi.org/10.1016/j.anl.2018.01.002 Get rights and content

Abstract

Objective

Management of anterior perforations of tympanic membrane is a surgical challenge. The objective of this study is to analyse and compare the results of composite cartilage perichondrium island (CCPI) graft and temporalis fascia graft by endoscopic technique in anterior quadrant perforations.

Methods

A prospective study was conducted in a tertiary care centre from 2012–16. A total of 187 ear drums(n) in 168 patients with perforations involving anterior quadrant were included in the study. All the patients were operated completely by endoscopic technique. Tragal Composite cartilage perichondrium island (CCPI) graft was used in 87 ears and temporalis fascia in 100. Each group was categorised into A and B depending on perforation size. The outcome parameters assessed include graft success with regard to perforation size, pre- and postoperative ABG, mean improvement in ABG, ABG closure ratio and graft medialisation/lateralisation status.

Results

Cartilage group had 91.95% (80/87) success rate overall, while fascia had 79% (79/100). In category 1, the success rate for cartilage and temporalis fascia were 89.6% (26/29) and 68.9% (20/29) respectively (p = 0.51788). In category 2, the success rates were 93.1% (54/58) and 83.1% (59/71) respectively (p = 0.86356). The mean improvement in ABG for both groups were 17.52 ± 3.84 dB and 15.26 ± 5.56 dB respectively (p = 0.04). ABG closure ratio for both the groups were 62.84 ± 11.87 % and 53.6 ± 19.6 % respectively (p = 0.0008).

Conclusion

Endoscopic composite cartilage perichondrium island graft is an effective technique in managing perforations of anterior quadrant barring the expertise required for endoscopic ear surgeries.

Introduction

Temporalis fascia, perichondrium, cartilage, vein, fat and skin are commonly used autografts for reconstructing the tympanic membrane perforations [1]. Fascia is still the preferred graft material barring few circumstances. Advantages of fascia are low basal metabolic rate, availability from same incision and sufficient quantity [2]. In contrast, cartilage grafts are preferred in difficult circumstances like poor eustachian tube function, retraction pockets, infection, anterior perforations and revision surgeries [3], [4].

Since the beginning of cartilage grafts use in middle ear by Utech [5] in 1959 and description of various techniques by Tos [6], cartilage has gained more popularity in last two decades with more and more techniques being described and studied in literature. Palisades, mosaic, composite island, shield and butterfly grafts [7], [8], [9] are few cartilage tympanoplasty techniques described in literature.

Closure of anterior quadrant perforations of tympanic membrane is considered challenging. The reasons for poor surgical outcomes include reduced vascular supply, limited anterior margin, poor visualization, and inadequate graft stabilization [10], [11], [12].

Microscopy is still the preferred tool for any ear surgery though endoscopic ear surgery is gaining more popularity in recent years. The advantages of endoscopes are wider field of view and better depth perception, thereby avoiding canalplasty and posterior meatotomy in selected cases. The wider view also enables the surgeon to visualize the anterior margins clearly which may be compromised with microscopes [13], [14]. There are not many literature evidences that describe the role of endoscopes in cartilage tympanoplasty. This study is designed to evaluate the role of endoscopic cartilage tympanoplasty by composite cartilage perichondrium island graft technique and its comparison with temporalis fascia in repairing perforations involving anterior quadrant.

Section snippets

Study design

A prospective interventional randomised case series study was conducted from 2012 to 2016 in a tertiary care hospital. A total of 187 ears in 168 patients who satisfied the inclusion and exclusion criteria were enrolled in the study. The inclusion and exclusion criteria were as follows,

A.
Inclusion criteria

1.
The patients requiring type 1 tympanoplasty.
2.
Central perforations involving anterior quadrant, which may range from small to subtotal in size.
3.
Minimum follow up of 1 year.

B.
Exclusion criteria

Results

A total of 187 ears were operated during the study period with 87 having had cartilage and 100 had temporalis fascia as their grafting materials.

The mean age of the study population in cartilage and temporalis fascia group were 31.3 ± 4.9 years and 30.2 ± 4.2 years respectively (range, 12–58 years) (p = 0.65).

Women were the majority in both the groups constituting 68.9% and 64% respectively (p = 0.31).

The mean operating time taken for cartilage and fascia tympanoplasty were 45.33 ± 7.43 min and 41.2 ± 6.54 min

Discussion

Type 1 tympanoplasty is one of the most common otological procedures performed. The primary aim of type 1 tympanoplasty is to give a dry ear and restore hearing mechanism. This could be achieved only by creating a near normal tympanic membrane irrespective of underlying pathology and location of the defect.

Temporalis fascia is still the most commonly utilized graft material for tympanic membrane reconstruction [2]. The success rate of fascia graft ranges from 70 to 95% from various literature

Limitations and recommendations

The obvious limitations of study are relative short follow up. As drum retractions and reperforations have been reported even years later, a longer follow up with a larger sample size is recommended. The authors have not included the middle ear mucosal status in results. This could be a confounding factor affecting the graft success, leading to lack of standardisation of results.

Conclusion

Endoscopic composite cartilage perichondrium island graft is an effective technique in managing perforations of anterior quadrant. The technique described can nullify the difficulties faced and improve the outcomes in such cases, barring the long and tough learning curve required to expertise the one handed endoscopic ear surgery.

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Window shade tympanoplasty for anterior marginal perforations

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(2005)

Cited by (25)

Minimally invasive tympanoplasty: review of outcomes and technical refinements
2021, Operative Techniques in Otolaryngology - Head and Neck Surgery
Citation Excerpt :
He noted further a total exposure of the anterior angle with the endoscope in all cases compared to the microscope and GIR of 96% one year after surgery. Mohanty et al (2018) were the first to compare endoscopic cartilage vs temporalis fascia grafting for anterior quadrant perforations in a prospective randomized setting.23 The overall GIR was not stated, as the evaluation was performed separately for perforations sizes of <50% and >50%.
This review is intended to provide an overview of endoscopic techniques for tympanic membrane closure procedures with focus on prospective randomized studies and latest surgical trends in endoscopic tympanic membrane closure. Minimally invasive endoscopic procedures for tympanic membrane closure are safe and suitable techniques. Endoscopic techniques offer similar postoperative outcomes in terms of graft intake rate and air bone gap closure compared to microscopic approaches. The endoscopic approach provides favorable cosmetic outcomes, less postoperative pain and shorter surgical time. Therefore, endoscopic ear surgery has evolved into a promising, minimally invasive alternative to the microscopic technique for closing tympanic membrane perforations evidenced by an increasing number of scientific publications with comparable, if not superior outcomes for the endoscopic technique.
Which graft should be used for the pediatric transcanal endoscopic type 1 tympanoplasty? A comparative clinical study
2019, International Journal of Pediatric Otorhinolaryngology
Citation Excerpt :
A tympanoplasty is a quite frequently performed surgical procedure in the pediatric settings at otology clinics. Tympanoplasties are intended for the closure of the perforated tympanic membranes and the correction of the emergent hearing losses [1]. In the literature, the first surgical procedure to intervene a tympanic membrane perforation was performed by Berthold [2] in 1878.
To compare the functional and anatomical success rates of the fascial versus perichondrial grafts in pediatric endoscopic type 1 tympanoplasties.
This retrospective clinical study was conducted on 40 pediatric patients (23 females and 17 males; mean age: 10.0 ± 1.7 years; the age range: 6–13) who were operated with a transcanal endoscopic type 1 tympanoplasty. The study participants were assigned to two groups by graft types. The patients were assigned to either the tragal cartilage perichondrium group (Group A) or the fascia of the temporal muscle (Group B). The groups were compared according to the pre- and postoperative air-bone gaps and to the status of the tympanic membrane.
There were not any statistically significant differences between the groups in terms of the distribution of age, gender, the operation sites, the duration of the operation, MERI scores or the size of the perforation (all p values > 0.05). The graft retention success rates were 94.7% and 90.5% in Group A and Group B, respectively. There were no statistically significant differences between the two groups in terms of the graft retention success rates (p = 0.609). The functional (audiological) success rate was statistically higher in Group B compared to Group A (p = 0.044).
Perichondrium and fascia grafts were found out to be acceptable for use in pediatric endoscopic tympanoplasties. The functional success rates were higher in the fascia group. We also recommended the fascia as a graft in pediatric transcanal endoscopic type 1 tympanoplasties.
Comparison of temporal muscle fascia and tragal cartilage perichondrium in endoscopic type 1 tympanoplasty with limited elevation of tympanomeatal flap
2020, Brazilian Journal of Otorhinolaryngology
Citation Excerpt :
There was no statistically significant difference between the groups in terms of graft retention success (p = 0.166) (Table 3) (Fig. 3). Developments related to tympanoplasty, one of the most common otologic surgical procedures in otology clinics, still continue.1,3 Otologists are exploring new techniques and methods to increase tympanoplasty success and to reduce the incidence of revision surgery.
Elevation of tympanomeatal flap is one of the basic steps of tympanoplasty. A satisfactory level of anatomic and functional success can be achieved by using different grafts with limited tympanomeatal flap elevation.
We aimed to compare the anatomic and functional success of tragal cartilage perichondrium and temporal muscle fascia in cases of endoscopic type 1 tympanoplasty performed with limited tympanomeatal flap elevation.
In total, 81 cases (33 females, 48 males, mean age 22.1 ± 10.1 years, interval 18–49 years) which underwent transcanal endoscopic type 1 tympanoplasty with limited elevation of tympanomeatal flap were included the present study. All cases were divided into two groups as tragal cartilage perichondrium (group A) and temporal muscle fascia (group B). The comparison of the groups were made considering the pre- and postoperative air-bone gap and the tympanic membrane status.
There was no statistically significant difference between Group A and Group B in preoperative and in postoperative air-bone gap values (p = 0.608 and 0.529, respectively). In Group A and B, postoperative air-bone gap values demonstrated significant decrease compared to the preoperative values (p = 0.0001). Group A and group B did not demonstrate significant differences between postoperative improvements of air-bone gap values (p = 0.687). Graft retention success was 92.6% in group A while it was 90.0% in group B. There was no statistically significant difference between the groups in terms of graft retention success (p = 0.166).
In accordance with the results of this study, we believe that both tragal cartilage perichondrium and temporal muscle fascia, and also in limited tympanomeatal flap elevation in endoscopic tympanoplasty are all eligible for result in safe and successful surgery.
O descolamento do retalho timpanomeatal é uma das etapas básicas da timpanoplastia. Um nível satisfatório de sucesso na restauração anatômica e funcional pode ser alcançado com o uso de diferentes enxertos e descolamento limitado do retalho timpanomeatal.
Comparar os resultados anatômicos e funcionais entre o uso de pericôndrio de cartilagem tragal e de fáscia do músculo temporal em timpanoplastias endoscópicas tipo 1 feitas com descolamento limitado do retalho timpanomeatal.
Foram incluídos no estudo 81 pacientes (33 mulheres, 48 homens, média de 22,1 ± 10,1 anos, variação de 18-49 anos), submetidos a timpanoplastia endoscópica transcanal tipo 1 com descolamento limitado do retalho timpanomeatal. Todos os casos foram divididos em dois grupos: pericôndrio da cartilagem tragal (grupo A) e fáscia do músculo temporal (grupo B). Na comparação dos grupos consideraram-se o gap aéreo-ósseo, pré e pós-operatório e a condição da membrana timpânica.
Não houve diferença estatisticamente significante entre os grupos A e B no pré e pós-operatório (p =  0,608 e 0,529, respectivamente). Nos grupos A e B, os valores do gap aéreo-ósseo no pós-operatório demonstraram redução significante em relação aos valores pré-operatórios (p =  0,0001). Os grupos A e B não demonstraram diferenças significantes entre as medidas pré e pós-operatórias dos valores dos gaps (p =  0,687). O sucesso da retenção do enxerto foi de 92,6% no grupo A, enquanto no grupo B foi de 90,0%, não ocorreu diferença estatisticamente significante entre os grupos (p =  0,166).
De acordo com os resultados deste estudo, acreditamos que tanto o pericôndrio da cartilagem tragal como a fáscia do músculo temporal, usados com descolamento limitado do retalho timpanomeatal na timpanoplastia endoscópica, são elegíveis para uma cirurgia segura e bem-sucedida.
Over-under cartilage tympanoplasty: Technique, results and a call for improved reporting
2020, Journal of Laryngology and Otology
Comparison of temporalis muscle fascia and cartilage grafts for primary type 1 tympanoplasty: a meta-analysis of randomized controlled trials
2023, European Archives of Oto-Rhino-Laryngology
Tympanoplasty in the Setting of Complex Middle Ear Pathology: A Systematic Review
2023, Annals of Otology, Rhinology and Laryngology

View all citing articles on Scopus

View full text

Endoscopic cartilage versus temporalis fascia grafting for anterior quadrant tympanic perforations — A prospective study in a tertiary care hospital

Abstract

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Study design

Results

Discussion

Limitations and recommendations

Conclusion

Otolaryngol Head Neck Surg

Int J Pediatr Otorhinolaryngol

Auris Nasus Larynx

Tympanic membrane plastic with temporal fascia

Hals Nas Ohrenh

Myringoplasty. A review of 472 cases

Ann Otol Rhinol Laryngol

Repair of drum

Iowa Med Soc

Fascia and cartilage palisade tympanoplasty. Nine years experience

Arch Otolaryngol

About diagnostic and therapeutic possibilities of tympanotomy in sound conduction disturbances

J Laryngol Otol

Comparison of three different tympanic membrane reconstruction techniques in type I tympanoplasty

Eur Arch Otorhinolaryngol

Comparison of different grafting techniques in type I tympanoplasty in cases of significant middle ear granulation

Otol Neurotol

Inlay tympanoplasty: cartilage butterfly technique

Laryngoscope

An endoscopic method of tympanic membrane fluorescein angiography

Ann Otol Rhinol Laryngol

Window shade tympanoplasty for anterior marginal perforations

Laryngoscope