OTOLOGY

Cartilage ‘‘shield’’ tympanoplasty: an effective and practicaltechnique

Emilia Iacovou • Efthymios Kyrodimos •

Aristides Sismanis

Received: 7 July 2013 / Accepted: 20 August 2013

� Springer-Verlag Berlin Heidelberg 2013

Abstract The aim of the present study is to report our

results with cartilage ‘‘shield’’ tympanoplasty (CST) for total

tympanic membrane perforations. A retrospective chart

review of patients undergoing CST was performed in tertiary

referral centers. One hundred and seventy-seven patients who

had undergone CST were identified. Patients’ age ranged

from 7 to 74 (mean 35) years. The mean postoperative follow-

up was 23 (range 6–73) months. The main outcome measures

were Graft take, pre and postsurgery audiologic evaluation.

Graft take was 97.2 %. Three patients developed recurrent

cholesteatomas, one an anterior pinhole perforation, and one a

minimal graft anterior lateralization. The average pre and

postoperative pure-tone air-bone gaps (PTA-ABG) were

32.06 ± 11.21 and 18.69 ± 10.53 dB, respectively. The

overall average ABG improvement was 13.37 ± 9.34 dB.

An overall postoperative ABG of 25 dB or less was achieved

in 140 of the 177 patients (79.1 %). Hearing improvement

was statistically significant in all cases (p \ 0.0001). Carti-

lage shield tympanoplasty is a very reliable procedure. Graft

take is excellent and hearing improvement is significant.

Keywords Cartilage ‘‘shield’’ tympanoplasty �Hearing results � Graft take

Introduction

Tympanoplasty aims firstly to eradicate middle ear disease

and secondly to create a healthy aerated middle ear and to

restore the sound conduction mechanism. Success in

tympanoplasty is defined by the graft take rate, absence of

lateralization and hearing results. Since the introduction of

tympanoplasty in the early fifties by Zoellner [1] and

Wullstein [2], numerous grafting materials and techniques

have been developed for repair of the tympanic membrane

perforations. Skin, fascia, vein, perichondrium, and dura

mater have been used as grafting materials [3–9]. Pres-

ently, the most commonly used materials are temporalis

fascia and cartilage. Cartilage tympanoplasty in particular

is a well-recognized technique and is strongly recom-

mended for high risk failure cases, such as patients with

borderline eustachian tube function, atelectatic middle

ears, revision cases, smokers, and defects of the entire

tympanic membrane. Cartilage can be harvested easily

from the concha cymba or tragus and is well tolerated in

the middle ear. Numerous variations of the cartilage

tympanoplasty techniques have been reported, which have

recently been summarized in detail by Tos [10, 11] and

Yung [12].

The purpose of this communication is to report our

experience with cartilage ‘‘shield’’ tympanoplasty (CST)

for total tympanic membrane perforations.

Materials and methods

After approval by the Virginia Commonwealth University

Medical Center and the Hippokrateion University Hospital

institutional review board, a chart review of patients who

underwent CST between January 1998 and January 2011

E. Iacovou � E. Kyrodimos � A. Sismanis

Department of Otolaryngology Head and Neck Surgery,

Hippokrateion Hospital, University of Athens, Athens, Greece

E. Iacovou (&)

Department of Otolaryngology, Larnaca General Hopital,

Larnaca, Cyprus

e-mail: iacovouemilia@hotmail.com

A. Sismanis

Department of Otolaryngology Head and Neck Surgery, Virginia

Commonwealth University Medical Center, Richmond, VA,

USA

123

Eur Arch Otorhinolaryngol

DOI 10.1007/s00405-013-2679-6

was performed. Successful graft take was defined as having

no perforation, graft retraction, or lateralization.

Outcome measures used were pure-tone average air-

bone gap (PTA-ABG), and speech discrimination scores

(SDS). The PTA-ABG for each audiogram was evaluated

by calculating the mean ABG at 500, 1,000, 2,000 and

4,000 Hz. Hearing improvement was defined as the dif-

ference between the pre and postoperative ABG.

Data analysis was performed using SPSS for Windows

version 16 and Student’s t test for paired samples was used

for statistical comparisons. A p value of less than 0.05 was

considered statistically significant.

Technique

The CST technique, a modification of the one reported by

Duckert et al. [13], has been previously reported by our

group [14, 15] and in brief has as follows: Under general

anesthesia a vascular strip incision is made in the ear

canal, followed by a postauricular incision. Areolar tissue

overlying the temporalis fascia is harvested, a T-shaped

incision over the mastoid cortex periosteum is made, and

the periosteum is elevated off the mastoid bone. The

vascular strip is elevated out of the ear canal and kept in

the postauricular area using a self-retaining retractor.

Through the postauricular approach, the edges of the

perforation are properly denuded and the tympanic mem-

brane remnants involved with tympanosclerosis are com-

pletely removed.

The middle ear is explored and any pathology present is

removed. Using sharp and blunt dissection, a circular piece

of cartilage measuring approximately 9–10 mm is har-

vested from the posterior aspect of the cymba concha. The

perichondrium is stripped from both sides, a wedge piece

of cartilage is excised to accommodate the manubrium of

the malleus, and the graft is trimmed to accommodate the

size of the defect. The middle ear space is packed with

Gelfoam� and ossicular reconstruction is performed when

necessary. The cartilage graft is placed medial to the

manubrium of the malleus and the tympanic membrane

remnants or fibrous annulus.

In cases of absent fibrous annulus, the graft is placed at

the level of the tympanic sulcus. The previously harvested

areolar tissue is then placed over the cartilage and medial

to the edges of the perforation extending to the posterior

bony canal wall. Pledgets of Gelfoam are placed over the

graft for stabilization.

The vascular strip is returned to its original position and

two Pope Ear Wicks� impregnated in antibiotic ointment

are placed in the ear canal. The postauricular incision is

closed in two layers and a mastoid dressing is applied for

24 h.

Results

One hundred and seventy-seven patients (37 children and

140 adults) who underwent CST were included in the

study. All patients had adequate follow-up and hearing

results. Patients’ ages ranged from 7 to 77 (mean age 36)

years. The mean postoperative follow-up was 23 (range

6–73) months with the mean audiogram being obtained at

least 6 months following surgery.

There were no immediate postoperative complications

such as hematoma, or sensorineural hearing loss. There was

one case of wound infection, which responded to oral

antibiotics. In three cholesteatoma cases, although grafting

was initially successful, revision surgery became necessary

due to recurrences. One patient developed an anterior

pinhole perforation, and one developed a minimal graft

anterior lateralization. In both patients no further surgical

intervention was required. Overall successful graft take

was 97.2 %.

One hundred and nineteen cases were primary proce-

dures and 58 were revisions. Underlying otologic pathol-

ogies of the primary and revision cases are summarized in

Table 1. Overall, 91 procedures (51.4 %) were performed

for tympanic membrane perforations without active middle

ear disease, 39 (22.03 %) for cholesteatomas, 16 (9.04 %)

for atelectatic middle ears, 14 (7.91 %) for perforations

with granulomatous/polypoid middle ear disease, 9 (5.1 %)

for atresias and 8 (4.52 %) for lateralized grafts of previous

tympanoplasties.

In conjunction with the tympanoplasty, an intact canal

wall (ICW) mastoidectomy was performed in 63 patients

(35.6 %) and an atticotomy in 4 (2.3 %). A partial ossicular

replacement prosthesis (PORP) was used in 4 patients

(2.3 %), a total ossicular replacement prosthesis (TORP) in

9 patients (5.1 %) and a type III tympanoplasty was per-

formed in 45 patients (25.4 %).

Audiometric data

The overall average preoperative PTA-ABG was

32.06 ± 11.21 dB, whereas the postoperative was

18.69 ± 10.53 dB. The overall improvement was

13.37 ± 9.34 dB which was found statistically significant

(p \ 0.0001). An overall postoperative ABG of 25 dB or

less was achieved in 140 of the 177 patients (79.1 %).

Table 2 depicts overall hearing results. Table 3 depicts

overall hearing results according to specific frequencies.

Speech discrimination score levels did not reveal any

statistically significant difference [94.5 % preoperatively

versus 95.2 % postoperatively (p [ 0.05)]. Hearing results

according to the underlying pathology are depicted in

Fig. 1.

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123

In cases with associated ICW mastoidectomy the pre

and postoperative air-bone gaps (ABGs) were 33.1 ± 12.6

and 21.57 ± 13.14 dB, respectively (p \ 0.0001). In cases

without mastoidectomy pre and postoperative ABGs were

31.41 ± 10.28 and 16.74 ± 8.15 dB, respectively (p \0.0001), whereas in cases with atticotomy were 33.75 ±

14.58 and 18.13 ± 11.3 dB, respectively (p \ 0.02).

Figure 2 depicts hearing results according to the type of

associated mastoid surgery.

In type I tympanoplasty cases pre and postoperative

ABGs were 31.26 ± 9.81 and 16.68 ± 9.86 dB, respec-

tively (p \ 0.0001). In type III tympanoplasty cases, the

pre and postoperative PTA-ABGs were 32.36 ± 13.97 and

22.06 ± 10.6 dB, respectively (p \ 0.0001). The pre and

postoperative ABGs in cases with ossicular reconstruction

were for PORPs 32.19 ± 5.44 and 18.13 ± 8.51 dB

(p \ 0.09), respectively, and for TORPs 41.11 ± 12.55

and 28.75 ± 11 dB (p \ 0.007), respectively.

Figure 3 depicts hearing results according to the type of

tympanoplasty and ossicular reconstruction.

Table 1 Summary of

underlying otologic pathologiesMiddle ear pathology Primary

cases

Revision

cases

Tympanic membrane perforation without active middle ear disease 70 (58.8 %) 21 (36.2 %)

Cholesteatoma 23 (19.3 %) 16 (27.6 %)

Tympanic membrane perforation with granulomatous/polypoid middle ear

disease

9 (7.6 %) 5 (8.6 %)

Atelectatic ear 10 (8.4 %) 6 (10.35 %)

Atresia 7 (5.9 %) 2 (3.45 %)

Graft lateralization of graft of previous tympanoplasty 0 (0 %) 8 (13.8 %)

Total 119 58

Table 2 Overall hearing results

PTA-ABG Preoperative cases (%) Postoperative cases (%)

0–10 dB 2 (1.1) 43 (24.3)

11–25 dB 58 (32.8) 97 (54.8)

[25 dB 117 (66.1) 37 (20.9)

Table 3 Overall hearing results according to specific frequencies

500 Hz 1000 Hz 2000 Hz 4000 Hz

Preoperative PTA-ABG

(dB)

33.11 35.99 30.62 28.56

Postoperative PTA-ABG

(dB)

22.01 20.46 15.85 16.44

Improvement of PTA-

ABG (dB)

11.53 15.9 15.06 12.43

PTA pure-tone average, ABG air-bone gap

Fig. 1 Hearing results according to otologic pathology

Fig. 2 Hearing results according to type of associated mastoid

surgery

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123

Discussion

The use of cartilage in tympanic membrane repair dates

back to 1960 when Utech [16] first described the

interposition of cartilage in ossiculoplasty. Soon after,

Jansen also reported the use of auricular and nasal septal

cartilage to reconstruct the ossicular chain in ears without a

stapes suprastructure [17]. Soon after, Salen [18] and

Jansen [17, 19] reported the use of cartilage for recon-

struction of the ossicular chain in ears without stapedial

suprastructure and for tympanic membrane perforations.

However, the one who popularized the use of cartilage in

tympanoplasty was Heermann [20]. He claimed to have

used the cartilage palisade technique for middle ear and

mastoid cavity reconstruction since 1960, in over 13,000

cases [21].

As cartilage is resistant to infection and has considerable

stiffness, it is considered to be a more reliable and stable

grafting material [14, 22, 23]. On the contrary, temporalis

fascia lacks stability and may shrink during healing [24].

Compared to tragal cartilage, conchal cartilage has similar

acoustic properties as shown by Zahnert et al. [25].

Fig. 3 Hearing results according to the type of tympanoplasty and

ossicular reconstruction

Table 4 Summary of the literature on cartilage tympanoplasty

Study Graft type Number of cases Surgical

Technique

Mean F/up Graft

take rate

(%)

Hearing results

Current Cymba

concha

cartilage

177 Cartilage

shield

23 months 97.2 Type I pre-/postoperativeABG:

31.26 ?/9.81 dB/16.68 ± 9.86 dB

Type III pre-/postoperative ABG:

32.36 ± 13.97 dB/

22.06 ± 10.6 dB

PORP pre-/postoperative ABG:

32.19 ± 5.44 dB/18.13 ± 8.51 dB

TORP pre-/postoperative ABG:

41.11 ± 12.55 dB/28.75 ± 11 dB

Duckert

et al. [13]

Cymba

concha

cartilage

294 (24 % type I, 51 % type III

PORP, 25 % type III TORP)

Cartilage

shield

Minimum

F/up

6 months

97 Closure of the ABG within:

10 dB in 82 % of type I,

20 dB in 80 % of PORP and

30 dB in 85 % of TORP cases

Dornhoffer

[26]

Tragal

cartilage

Cymba

concha

cartilage

636 (226 type I, 252 PORP, 158

TORP)

Cartilage

Palisades

Perichondrium/

cartilage island

2.7 years 97.8 Type I pre-/postoperative ABG:

16.1 ± 11 dB/11.3 ± 9.2 dB

PORP pre-/postoperative ABG:

26.7 ± 12.5 dB/14.5 ± 8.7 dB

TORP pre-/postoperative ABG:

34.4 ± 11.9 dB/16.6 ± 10.5 dB

Cavaliere

et al. [27]

Tragal

cartilage

306 (100 type I, 130 type III, 40

type III PORP, 36 type TORP)

Cartilage

shield

37 months 99.35 TypeI pre-/postoperative ABG:

36.80 ± 1.94 dB/

6.40 ± 2.20 dB

Type III pre-/postoperative ABG:

44.55 ± 4.98 dB/

11.45 ± 3.50 dB

PORP pre-/postoperative ABG:

45.00 ± 5.06 dB/

11.60 ± 3.97 dB

TORP pre-/postoperative ABG:

53.89 ± 3.19 dB/

14.25 ± 7.27 dB

Eur Arch Otorhinolaryngol

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According to these authors, testing of the frequency

response function of tragal and conchal cartilage plates,

using a laser Doppler interferometer, revealed no statistical

difference in the acoustic transfer characteristics. Although

the rigidity of the cartilage graft has obvious benefits in

preventing retraction of the tympanic membrane, it has

been suspected to potentially compromise its sound con-

duction properties. However, this has not been substanti-

ated based on clinical and audiological outcome reports

[26, 27].

We prefer the use of cymba concha cartilage because it

is within the surgical field and no additional incision is

required, has an average thickness of 0.8 mm, and its

concave contour resembles the conical shape of the normal

tympanic membrane [15]. Furthermore, it has a similar

average thickness with fossa triangularis cartilage (mean

thickness 0.775 mm), and is thinner than tragal cartilage

(mean thickness 1.016 mm) [28].

Overall our hearing results showed a significant

improvement between pre and postoperative PTA-ABGs.

Our experience reveals that CST with cymba concha is a

reliable technique, resulting in a high degree of graft take

and satisfactory hearing results. Furthermore, we found that

conchal cartilage is a very satisfactory grafting material

because of its accessibility, adaptability, stability and

resistance to negative middle ear pressure and absorption.

The 97.2 % overall graft take rate and hearing results in

our patients are comparable to the results of other studies.

Literature review on cartilage tympanoplasty by Dornhof-

fer revealed a 97.8 % graft take [26]. Duckert et al. [13]

achieved a graft take rate of 97 % in a similar study with

ours using conchal cartilage. Cavaliere et al. [27] reported a

graft take rate of 99.35 % and a mean postoperative ABG

of 10.43 ± 5.25 dB using tragal cartilage in CST. Table 4

is a summary of the literature on cartilage tympanoplasty.

A potential disadvantage of this procedure is the graft

opacity, which may conceal a recurrent or residual cho-

lesteatoma as well as collection of middle ear effusion. To

compensate for the possibility of recurrent or residual

cholesteatoma, we recommend a second look procedure

12 months following the initial procedure when complete

cholesteatoma removal is uncertain, and especially for

those cases with involvement of the sinus tympani and

pediatric patients with well-pneumatized temporal bones.

A high-resolution computerized tomography or magnetic

resonance imaging of the temporal bones might be another

noninvasive method of detecting recurrent or residual

cholesteatomas in such cases. Jindal et al. in a review of the

literature reported that diffusion-weighted (DW) magnetic

resonance imaging scan can reliably detect residual or

recurrent cholesteatoma after mastoid surgery [29]. In

cases of suspected middle ear effusion, a myringotomy is

indicated. Another drawback is the additional 10–15 min

required to obtain the graft.

Conclusions

Cartilage ‘‘shield’’ tympanoplasty is a very reliable and

effective technique for tympanic membrane reconstruction.

Use of cymba concha cartilage has resulted in excellent

graft take and significant hearing improvement with mini-

mal complications. Due to its resistance, cartilage is a

grafting material of choice for patients at high risk for

failure such as eustachian tube dysfunction cases, atelec-

tatic ears, extensive tympanosclerosis, cholesteatomas, and

total tympanic membrane perforations. We highly recom-

mend this technique to others.

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