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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 30  |  Issue : 1  |  Page : 1-4

A comparative study of audiological and surgical results in partial versus complete strip cartilage reinforcement tympanoplasty


1 Lecturer of Otolaryngology, E.N.T. Department, Faculty of Medicine, Ain Shams University, Egypt
2 Lecturer of Audiology, E.N.T. Department, Faculty of Medicine, Ain Shams University, Egypt

Date of Submission16-Mar-2013
Date of Acceptance25-Aug-2013
Date of Web Publication17-Feb-2014

Correspondence Address:
Hesham A AbdelKader
MD, Flat 743, Tower B, Bat ElEzz Towers, 35/45 Ibn Alhakm Square
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1012-5574.127183

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  Abstract 

Hypothesis
Different techniques used in cartilage tympanoplasty are palisade technique, shield graft, in-lay butterfly graft, and island flap cartilage.
Purpose
The aim of the study was to compare audiological and graft take results in partial versus complete strip cartilage reinforcement tympanoplasty.
Materials and methods
A total of 60 patients with central perforation of the tympanic membrane and age ranging from 18 to 40 years were selected. They were divided into two equal study groups of 30 patients each. The first group underwent complete strip cartilage reinforcement tympanoplasty and the second group underwent partial strip cartilage reinforcement tympanoplasty.
Results
The overall success rate was 83.3% in the complete strip technique and 86.66% in the partial strip technique. In both study groups, there was statistically significant difference between the audiological results before and after operation. Furthermore, audiological and graft take results were better in the partial strip technique but with no statistically significant difference.
Conclusion
The overall results of partial strip tympanoplasty are better than complete strip tympanoplasty regarding graft take and audiological results.

Keywords: Cartilage tympanoplasty, complete strip, graft medialization, graft take, partial strip


How to cite this article:
AbdelKader HA, Khafagy AG, Abdel Rahman TT. A comparative study of audiological and surgical results in partial versus complete strip cartilage reinforcement tympanoplasty. Egypt J Otolaryngol 2014;30:1-4

How to cite this URL:
AbdelKader HA, Khafagy AG, Abdel Rahman TT. A comparative study of audiological and surgical results in partial versus complete strip cartilage reinforcement tympanoplasty. Egypt J Otolaryngol [serial online] 2014 [cited 2020 Apr 7];30:1-4. Available from: http://www.ejo.eg.net/text.asp?2014/30/1/1/127183


  Introduction and rationale Top


Since Wullstein and Zoellner popularized tympanoplasty in the 1950s, various materials have been used for the procedure, including fascia, skin, vein, dura, and cartilage [1]. Currently, temporalis muscle fascia is the most frequently used grafting material in tympanoplasty [2], but unfortunately in atelectatic ears the fascia and perichondrium have been shown to undergo atrophy and subsequent failure during the postoperative period. Thus, it would be better to choose a grafting material that can resist the continuous negative middle ear pressure. Cartilage might be a better choice than fascia to resist the negative middle ear pressure because it is rigid and more stable [3],[4].

Cartilage contributes minimally to an inflammatory tissue reaction and is well incorporated with the tympanic membrane layers; it also provides firm support to prevent retraction. The greatest advantage of the cartilage graft has been thought to be its very low metabolic rate. It receives its nutrients by diffusion, is easy to work with because it is pliable, and it can resist deformation from pressure variations. Perichondrium and cartilage share with fascia the quality of being mesenchymal tissue, but they are thicker and stiffer. However, they mechanically reduce the vibratory pattern of the tympanic membrane, contributing to some impairment in the functional results, especially in the higher tones [5].

Different techniques used in cartilage tympanoplasty are palisade technique, shield graft, in-lay butterfly graft, and island flap cartilage.

The aim of this study was to compare between the complete and partial strip tympanoplasty regarding the audiological and graft take results.


  Materials and methods Top


Participants

A total of 60 patients were selected, with central perforation of the tympanic membrane. These 60 patients (with age ranging from 18 to 40 years) were divided into two equal study groups of 30 patients each. The first group underwent complete strip cartilage reinforcement tympanoplasty and the second group underwent partial strip cartilage reinforcement tympanoplasty with homograft cartilage between 2012 and 2013 in Demerdash Hospital, Ain Shams University, with 6 months follow-up. Tragal cartilage and perichondrium were used as graft material.

The sampling method was convenience sampling, and participants were comprised of patients who were hospitalized with chronic otitis media and who underwent homograft cartilage tympanoplasty. The exclusion criteria were patients with membrane retraction pocket, with severe atelectasis, patients who underwent middle ear intact canal cholesteatoma surgery, patients with air-bone gap (ABG) more than 35 dB, and patients who refused to come for the follow-up visits.

The study protocol was approved by the Ethics Committee of Ain Shams University Hospital, Ain Shams University, and informed consents were obtained from all patients after explaining the study protocol and aims.


  Methods Top


All patients were subjected to the following:

  1. Complete history taking and otological examination were carried out.
  2. Basic audiological evaluation: Pure-tone audiometry including air and bone conduction and speech audiometry including speech reception threshold using bisyllabic words and speech discrimination using Arabic phonetically balanced words were carried out (Soliman, 1976) [6].
  3. Successful graft take was defined as having no perforation, retraction, lateralization, or medialization.


Surgical procedure

All procedures were performed by the senior author according to the well-established principles of ear surgery; the ear must be free of disease before the reconstruction of the hearing mechanism.

A postauricular approach was used under general anesthesia supplemented with local infiltration of 2% lidocaine with 1 : 100 000 epinephrine.

The edges of the perforation were scrupulously denuded to promote good capillary blood flow. All tympanic membrane remnants with tympanosclerosis were removed. The middle ear was explored and any pathologic material was removed. A cut through the skin and cartilage was made on the medial side of the tragus, leaving 2 mm of cartilage in the dome of the tragus for cosmesis.

The tragal cartilage was harvested together with the perichondrium. This cartilage is ideal as it is thin, flat, and in sufficient quantities to permit reconstruction of the entire tympanic membrane. Typically, the piece of cartilage is 15 mm in length and 10 mm in width in children and somewhat larger in adults.

The tragal perichondrium was placed lateral to the cartilage and medial to the edges of the perforation and extended posteriorly onto the canal wall, when present (underlay technique). Next, a complete strip of cartilage 2 mm in width was removed vertically from the center of the cartilage (extending from upper edge to inferior one) to accommodate the entire malleus handle versus partial strip (extending from superior edge to midway between superior and inferior edge) to accommodate part of the malleus. In both methods, the outer perichondrium toward the external auditory canal was left intact. The postauricular incision was closed in two layers and pieces of gelfoam impregnated in antibiotic ointment were placed in the ear canal [Figure 1].
Figure 1:

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Postoperative care

Patients were given water precautions and caution against vigorous nose blowing. Sutures were removed 1 week after surgery, and the gelfoam was suctioned from the ear canal 3 weeks postoperatively. Antibiotic steroid-containing drops were used for further 2 weeks to clear the ear of residual gelfoam, which can lead to granulation and fibrous tissue formation if not completely removed from the tympanic membrane.

An audiogram was performed 2 months after surgery, and the tympanic membrane was examined. If the hearing result was good and the tympanic membrane was clear, the ear was examined after 6 months.

Statistical analysis

The data were analyzed using SPSS for Windows (version 18; SPSS Inc., Chicago, Illinois, USA). The pure-tone average (PTA)-ABG for each audiogram, preoperative and postoperative PTA-ABG, and graft take results were compared between the two study groups using the χ2 -test and the Mann-Whitney U-tests. P-value of less than 0.05 was considered statistically significant for analyses.


  Results Top


There were 60 patients in this study; these patients underwent tympanoplasty with homograft cartilage and their follow-up period was 6 months. The study population was divided into two groups: group 1 (complete strip) and group 2 (partial strip) [Table 1],[Table 2],[Table 3],[Table 4] and [Table 5].
Table 1: Preoperative air-bone gap in both study groups

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Table 2: Graft take results in both study groups

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Table 3: Postoperative air-bone gap in both study groups

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Table 4: Medialization of the graft in both study groups

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Table 5: Comparison between the two study groups with respect to the degree of improvement of air - bone gap before and after operation using the Mann - Whitney U-test

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  Discussion Top


In our study, there was a significant difference in the mean of PTA-ABG before and after surgery. Closure of the tympanic membrane was achieved at a rate of 83.3% in the complete strip technique and 86.66% in the partial strip technique.

The present data were in agreement with previous studies based on the overall results of cartilage reinforcement tympanoplasty. In both study groups, there was statistically significant difference between audiological results before and after operation. Furthermore, audiological and graft take results were better in the partial strip technique but with no statistically significant difference.

In the study by Dornhoffer [1], the mean of ABG before and after tympanoplasty with homograft cartilage was similar to that in our study. Hashemi et al., in Shiraz University, reported the mean of SRT and air bone gap (ABG) in 4 frequencies of 500, 1000, 2000 and 4000 in patients who had undergone tympanoplasty to be 17, 15, 15 and 18 with perichondrium cartilage and 19, 18, 19 and 23 with fascia [7]. Mokhtarinejad et al. (2012) also showed similar results to our study [8].


  Conclusion Top


The findings of this study demonstrated that partial strip cartilage tympanoplasty was more effective technique for tympanic membrane closure with acceptable hearing results compared with the complete strip technique.





Conflicts of interest

None declared.

 
  References Top

1.Dornhoffer J. Cartilage tympanoplasty: indications, techniques, and outcomes in a 1,000-patient series. Laryngoscope 2003; 113(11):1844-56.  Back to cited text no. 1
    
2.Amedee RG, Mann WJ, Riechelmann H. Cartilage palisade tympanoplasty. Am J Otol 1989; 10(6):447-50.  Back to cited text no. 2
    
3.Duckert LG, Muller J, Makielski KH, Helms J. Composite autograft "shield" reconstruction of remnant tympanic membranes. Am J Otol 1995; 16(1):21-6.  Back to cited text no. 3
    
4.Page C, Charlet L, Strunski V. Cartilage tympanoplasty: postoperative functional results. Eur Arch Otorhinolaryngol 2008; 265(10):1195-8.  Back to cited text no. 4
    
5.Tos M. Cartilage Tympanoplasty. 1st ed. (2009). New York: Thieme; 2009: 7, 147.  Back to cited text no. 5
    
6.Soliman S. Speech discrimination audiometry using Arabic phonetically balanced words. Ain-Shams med. J, 1976; 27:27:30.  Back to cited text no. 6
    
7.Hashemi SB, Sohrabi H, Omranifard H. Comparison of tympanoplasty results with use of perichondrium-cartilage and temporalis facia. Iran J Otorhinolaryngol 2009; 21(56):63-66.  Back to cited text no. 7
    
8.Mokhtarinejad F, Abtahi SH, Noei Alamdary Sh. Postoperative anatomic and functional results of homograft cartilage tympanoplasty. J Res Med Sci 2012; 17(Spec 1):S120-S124.  Back to cited text no. 8
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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Abstract
Introduction and...
Materials and me...
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