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Primary cartilage tympanoplasty: our technique and results

Mubarak M. Khan MBBS, DLO, DNB(ent), a, , 

and Sapna R. Parab MS,

DNB(ent)a 

aDepartment of Otorhinolaryngology, MIMER Medical College, Pune, India

Received 18 April 2010.

Available online 15 September 2010.

Abstract

Cartilage has shown to be a promising graft material to close tympanic membrane perforations.

However, due to its rigid quality, doubts are raised regarding its sound conduction properties.It has been suggested that acoustic benefit may be obtained by thinning the cartilage.

We describe our innovative method for harvesting tragal cartilage from the same endaural

incision and also describe preparation of the graft by slicing it. We present our 3-year experience

of shield cartilage type 1 tympanoplasty using sliced tragal cartilage –  perichondriumcomposite graft.

Aim

The aim of this study was to prove the success rate of our technique of shield cartilage 

tympanoplasty  using sliced tragal cartilage graft in terms of functional and anatomic results.

Study design

Retrospective analysis of  type 1  cartilage tympanoplasties using sliced tragal

cartilage was carried out in MIMER Medical College and Sushrut ENT Hospital during May

2005 to January 2008 with a minimum follow-up of 2 years.

Method and materials

A total of 223 ears were operated by our technique.

Results

The overall success rate of our technique was 98.20% in terms of perforation closure and air  bone gap closure within 7.06 ± 3.39 dB. The success rates in the various age group are as

follows: 11 to 20 years, 97.67%; 21 to 40 years, 99.12%; and 41 to 60 years, 96.96%.

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Conclusion

Our technique of  type 1  cartilage tympanoplasty achieves good anatomic andfunctional results.

Article Outline

1.Introduction 2.

Materials and methods 

2.1. Study population 

2.2. Anaesthesia 2.3. Infiltration 

2.4. Procedure of sliced shield cartilage tympanoplasty 2.5. Postoperative monitoring 2.6. Follow-up protocol 

3.

Results 4.

Discussion 

4.1. Age – sex distribution 

4.2. Anatomic closure of the perforations 4.3. Air Bone Gap (ABG) closure 

5.

Conclusion References 

1. Introduction

Temporalis fascia remains the most frequently used graft material with closure of the tympanic

membrane in 70% to 90% of primary tympanoplasties in different hands. However, insome situations such as advanced middle ear pathology, retraction pockets, and atelectatic ears,

temporalis fascia tends to undergo atrophy in the subsequent postoperative period regardless of  placement techniques [1]. Our dissatisfaction with the temporalis fascia with a higher incidence

of recurrent perforations compelled us to use a tougher material that would not only preventreperforation but also prevent retractions. Cartilage has shown to be a promising graft material toclose perforations in the tympanic membrane. Although it is similar to temporalis fascia, its more

rigid quality tends to resist resorption, retraction, and reperforation, even in the milieu of 

continuous eustachian tube dysfunction [2]. 

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Of the 23 well-defined cartilage tympanoplasty  methods, Tos [3] has classified them

into 6 groups:

1. Underlay palisade method of Heermann

2. Onlay palisade method

3. Method of broad palisades

4. Method of underlay stripes

5. Method of onlay stripes

6. Dornhoffer mosaic cartilage tympanoplasty  

The tragal cartilage is yellow fibroelastic cartilage. The cartilage is a relatively avascular tissue.

The presence of cartilage canals through which blood vessels may enter cartilage is well

documented. Each canal contains a small artery surrounded by numerous venules and capillaries.

Cartilage cells receive their nutrition by diffusions from vessels. Cartilage cells – chondrocytes liein spaces (lacunae) present in matrix. Ground substance is made of complex molecules

containing proteins and carbohydrates (proteoglycans). These molecules form a meshwork that is

filled by water and dissolved salts. The carbohydrates are chemically glycosaminoglycansincluding chondroitin sulfate, keratan sulfate, and hyaluronic acid. The core protein is aggrecan.

The proteoglycan molecules are tightly bound. Along with the water content, these molecules

form a firm gel that gives cartilage its firm consistency [4]. 

This rigidity of the cartilage that prevents reperforations is, however, considered to interfere with

the sound conduction properties of the tympanic membrane. We describe our innovative methodfor harvesting tragal cartilage from the same endaural incision and also describe the preparation

of the graft by slicing it so as to obtain acoustic benefits.

2. Materials and methods

A retrospective study of  type 1  cartilage tympanoplasties operated by both

the authors in MIMER Medical College and Sushrut ENT Hospital from May 2005 to January2008 was carried out.

2.1. Study population

All cases of Safe Chronic Suppurative Otitis Media were included in the study. The patients in

the study group ranged from 11 to 57 years. Only cases in which ossicular chain was intact andno mastoid surgery was performed were included in the study. The number of ears operated was

268. However, 15 patients failed to follow up after 3 months, 16 failed to follow up after 6

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months, and 14 failed to follow up after   1  year and hence were excluded from the

study. Hence, the number of ears included in the study was 223.

In all patients, a detailed history was taken. A thorough clinical examination of ear, nose, and

throat was done with special reference to the ear. Otomicroscopic examination was done in allcases. Hearing was assessed with Tuning Fork. Preoperative and postoperative pure toneaudiogram was done in all patients. Preoperative investigations included hemogram, bleeding

and clotting time, urine for routine, and microscopy, HIV testing and hepatitis B surface antigen

test. In patients older than 40 years, electrocardiogram and chest x-ray were done. All details of the patients including name, age, sex, address, mobile number, preoperative findings, and pure

tone audiogram were entered in case sheets. In all patients, preoperative and postoperative video-

otoendoscopic recording was done for documentation. All patients were assessed preoperatively

 by an anesthesiologist and were fit for surgery in American Society of Anesthesiologist (ASA)grade I or II. All patients were explained about the operative procedures failure rates along with

the postoperative care to be taken. Written consent was taken in all patients.

2.2. Anaesthesia

All patients were operated under local anesthesia with adequate sedation except children whowere operated under general anesthesia. Premedication included pentazocine lactate injection

Indian Pharmacopoeia (IP) 30 mg/midazolam injection British Pharmacopoeia (BP)  1  mg/mL.

2.3. Infiltration

Two percent lidocaine with 1:200 000 adrenaline was used.

2.4. Procedure of sliced shield cartilage tympanoplasty  

With proper aseptic precautions, Lempert's endaural incision is taken. Tragal cartilage graft is

harvested via the same incision, that is, by sharp dissection into vertical limb of Lempert's

incision (Fig. 1). The cartilage with its attached perichondrium is dissected from overlying skinand soft tissue by a pair of sharp scissors in a plane that is easily developed superficial to the

 perichondrium on both sides (Fig. 2). It is necessary to make an inferior cut as low as possible to

maximize the length of the harvested cartilage graft (Fig. 3). The superior cut is made leaving 5-

mm strip of cartilage in the dome of the tragus for cosmesis (Fig. 4). The cartilage is then

grasped with plain forceps and retracted, and final cut is given on the fourth side (first side beingthe free edge along the incisura terminalis), which delivers a piece of cartilage measuring

approximately 15 × 15 mm (Fig. 5).

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Full-size image (47K)

Fig. 1.

Tragal cartilage graft via the same endaural incision.

Full-size image (53K)

Fig. 2.

Cartilage dissected from overlying skin.

Full-size image (48K)

Fig. 3.

An inferior cut on tragal cartilage.

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Full-size image (45K)

Fig. 4.

The superior cut on tragal cartilage.

Full-size image (50K)

Fig. 5.

A piece of cartilage of 15 × 15 mm.

The thickness of the tragal cartilage is approximately  1  mm, and it has been suggested

that thinning the cartilage to 0.5 mm could attain acoustic benefit. The thickness of the normal

tympanic membrane is 0.1 mm. Hence, to achieve this acoustic benefit, we thin the cartilage withthe help of a Cartilage Splitter (Kalelkar Surgical, Mumbai, India). The cartilage splitter is an

assembly consisting of blade fixation instrument and other for cartilage stabilization (Fig. 6). The

 peculiarity of the Cartilage Splitter is that it can produce cartilage slices of varied thickness

ranging from 0.1 to 0.5 mm. Edges of the perforation in the pars tensa are freshened with thehelp of a sickle knife (Fig. 7). Tympanomeatal flap is elevated after giving 6 o'clock and 12

o'clock incision. This can be extended up to 2 o'clock on anterior canal wall (considering right

ear) leaving 6-mm canal skin from annulus tympanicus laterally. The whole elevated

tympanomeatal flap is parked in attic area superiorly (Fig. 8). Ossicular mobility and continuityare assessed. The handle of malleus is denuded. The tragal cartilage is firmly held with the help

of cartilage splitter (Fig. 9). The tragal cartilage is sliced with the help of cartilage splitter knife

(Fig. 10). The composite sliced cartilage-perichondrium shield graft of 0.5-mm thickness (Fig.

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11) is now placed by underlay technique in a meticulous manner after filling the middle ear with

gel foam (Fig. 12). Tympanomeatal flap is reposited back. Gel foam is placed over the graft.

Meatal pack is placed. Endaural incision is sutured. Mastoid bandage is tied.

Full-size image (46K)

Fig. 6.

Cartilage splitter set for slicing tragal cartilage.

Full-size image (40K)

Fig. 7.

Subtotal perforation in right tympanic membrane.

Full-size image (51K)

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Fig. 8.

Elevated tympanomeatal flap is parked in attic.

Full-size image (36K)

Fig. 9.

Tragal cartilage firmly held in cartilage splitter.

Full-size image (40K)

Fig. 10.

Cartilage is sliced by cartilage knife.

Full-size image (36K)

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Fig. 11.

Sliced cartilage-perichondrium shield graft.

Full-size image (43K)

Fig. 12.

Sliced cartilage kept as underlay graft.

2.5. Postoperative monitoring

Patient is monitored closely for a minimum of 4 hours and is encouraged to eat by lunchtime.

Patient is usually discharged within 6 hours of surgery if the vital signs are stable and adequate

control of pain with oral analgesics (ibuprofen + paracetamol). All patients are put on

 prophylactic broad-spectrum antibiotics (amoxicillin + clavulanic acid) and analgesics(ibuprofen + paracetamol) and Antihistaminics (fexofenadine) for 7 days postoperatively.

2.6. Follow-up protocol

First postoperative visit is after 48 hours for meatal pack and mastoid bandage removal. Patientis advised about ear care and use of topical antibiotic — steroid ear drops (neomycin + polymyxin

B + hydrocortisone). Subsequent postoperative visits are at weekly intervals for   1month and thereafter monthly for 6 months. At the end of 3 months, pure tone audiometry(average threshold at 500, 1000, 2000, and 3000 Hz) is done to evaluate air bone gap (ABG)

closure. Patients are evaluated functionally at the end of 6 months,  1 year, and 2 years.

3. Results

The data of the operated patients are tabulated in [Table 1], [Table 2] and [Table 3]. 

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Table  1. Age and sex distribution

Age group (y) Male Female Total

10 – 20 25 18 43

21 – 

40 70 44 114

41 – 60 34 32 66

Total 129 94 223

Table 2. Age and sex-wise distribution of perforations

Age group (y) Residual Recurrent Total

10 – 20  –  1 [M] 1  

21 – 401  [M]

 –  1  

41 – 601  [F] 1 [M]

2

Total 2 2 4

M indicates male; F, female.

Table 3. Preoperative and postoperative ABG

Average preoperative

ABG

Postoperative ABG

6 mo Postoperative ABG  1

 y

Postoperative ABG

2 y

30.68 ± 4.77 6.79 ± 2.52 7.13 ± 3.27 7.06 ± 3.39

4. Discussion

It has been shown in both experimental and clinical studies that cartilage is well tolerated bymiddle ear, and long-term survival is the norm [5], [6], [7] and [8]. The greatest advantage of the

cartilage graft has been thought to be its very low metabolic rate. However, in addition, it can

receive its nutrients by diffusion; it is very easy to work with because it is pliable and resistsdeformation from pressure variations and becomes well incorporated in the tympanic membrane

[9]. Human and animal studies [10] and [11] have found that although some softening occurs

with time, the matrix of the cartilage remains intact, but with empty lacunae, showing

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degeneration of the chondrocytes [2]. In our study group, a total number of 223 ears underwent

type 1  cartilage tympanoplasty using shield sliced tragal cartilage-

 perichondrium composite graft.

4.1. Age – 

sex distribution

In our study, patients ranged from 11- to 57-year age group. The total number of males is 129,

and for females, it was 94. The success rate in terms of perforation closure in 11- to 20-year agegroup was 97.67%; 21- to 40-year age group. 99.12%, and 41- to 60-year age group, 96.96%.

We had comparable success rates in all the age groups, which is in contradiction to the study by

Raine and Singh [12], who demonstrated a significant higher rate of failures in 8- to 12-year age

group in a retrospective analysis of 114 tympanoplasties. They advocated deferringsurgery till 12 years for achieving better results, whereas Strahan and Ward [13] documented that

incidence of graft failure was higher in older age group.

4.2. Anatomic closure of the perforations

In our study, graft uptake was in 219 patients, recurrent perforations (Fig. 13) in 2 years follow-

up was in 2 patients, and residual perforation (Fig. 14) in 2 patients, of a total number of 223 ears

operated. The success rate with our technique was 98.20% in terms of perforation closure. The

number of residual perforations is 2 and that of recurrent perforations is 2. The success ratewould be higher, if the incidence of residual perforations had to be nil. There was no

 postoperative retraction in the study group. In our study group, we did not encounter any

complications (eg, perichondritis, otitis externa, or cosmetic deformity of tragus).

Full-size image (35K)

Fig. 13.

Recurrent perforation after   1  year.

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Full-size image (36K)

Fig. 14.

Residual perforation, improperly fitting cartilage.

4.3. Air Bone Gap (ABG) closure

In our study of 223 ears, the average (SD) ABG closure postoperatively was 7.06 ± 3.39 dB. The

average ABG closure of 7 dB is indicative of the effective sound conduction by the sliced

cartilage graft. Hence, slicing cartilage has offset the disadvantage of the thicker cartilage

interfering with the sound conduction. With reference to the study reported by Ben Gamra et al[1], the average ACG (Air Conduction Gain) was 21 ± 11dB, and residual perforation was

observed in 2.2% in the cartilage group, with an average follow-up of 2 years. According to the

study by Dornhoffer  [14], tympanic membrane closure was achieved in all 22 patients, with preoperative and postoperative pure tone average ABG of 21.1 and 6.8 dB, respectively.

The advantages of our innovative technique of cartilage tympanoplasty are as follows:

1.  No extra incision for cartilage harvesting because it is available at operative site

2. Improved results with closure of the tympanic membrane perforations in 98.20%

3. Low recurrence in 2-year follow-up

4. Resistant to repeated infection due to rigidity

5. No retraction and adhesion of tympanic membrane in postoperative follow-up of 2 years

6. Residual perforations can be reduced with meticulous technique

5. Conclusion

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Our technique of  type 1  cartilage tympanoplasty gives good anatomic and

functional results. The highlight of our technique is the harvesting of the graft via the same

endaural incision. By slicing the cartilage, desired acoustic benefit is obtained. We recommendusing sliced cartilage as a first choice for tympanic membrane reconstruction.

References

[1] O. Ben Gamra and C. Mbarek et al., Cartilage graft in type I tympanoplasty:

 audiological and otological outcome, Eur Arch otorhinolaryngol  265 (2008), pp. 739 – 742.Full Text via CrossRef  | View Record in Scopus | Cited By in Scopus (5) 

[2] J.L. Dornhoffer, Cartilage tympanoplasty, Otolaryngol Clin N Am 39 (2006), pp.

1161 – 

1176. Article |  PDF (949 K) | View Record in Scopus | Cited By in Scopus (14) 

[3] M. Tos, Cartilage tympanoplasty methods. Proposal of a classification, Otolaryngol 

 Head Neck Surg  139 (2008), pp. 747 – 758. Article |  PDF (8633 K) | View Record in Scopus 

| Cited By in Scopus (7) 

[4] In: I. Singh, Editor, Textbook of human histology, Jaypee Brothers Medical Publishers, New

Delhi (2004), pp. 89 – 93.

[5] L. Loeb, Auto transplantation & homotransplantations of cartilage in the guinea pig, Am J  Pathol  2 (1926), pp. 111 – 122.

[6] L.A. Peer, The fate of living and dead cartilage transplanted in humans, Surg Gynecol Obstet  

68 (1939), pp. 603 – 610.

[7] A.G. Kerr, J.E. Byrne and G.D. Smyth, Cartilage homografts in the middle ear: a long termhistological study, J Laryngol Otol  87 (1973), pp. 1193 – 1199. View Record in Scopus | Cited By

in Scopus (24) 

[8] A. Don and F.H. Linthicum Jr, The fate of cartilage grafts for ossicular reconstruction in

tympanoplasty,  Ann Otol Rhinol Laryngol  84 (2part  1) (1975), pp. 187 – 191.

View Record in Scopus | Cited By in Scopus (0)

[9] R.M. Levinson, Cartilage-perichondrial composite graft tympanoplasty  in treatment

of posterior marginal and attic retraction pockets, Laryngoscope 97 (1987), pp. 1069 – 1074. ViewRecord in Scopus | Cited By in Scopus (54) 

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[10] E. Yamamoto, M. Iwanaga and M. Fukumoto, Histologic study of homograft cartilages

implanted in the middle ear, Otolaryngol Head Neck Surg  98 (1988), pp. 546 – 550.

[11] M. Hamed, M. Samir and M. El Bigermy, Fate of cartilage material used in middle ear 

surgery: light and electron microscopy study, Auris Nasus Larynx 26 (1999), pp. 257 – 262.

Article |  PDF (1153 K) | View Record in Scopus | Cited By in Scopus (11) 

[12] C.H. Raine and S.D. Singh,  Tympanoplasty  in children: a review of 114 cases, J  Laryngol Otol  97 (1983), pp. 217 – 221. View Record in Scopus | Cited By in Scopus (36) 

[13] R.W. Strahan and P. Ward et al., Tympanic membrane grafting. Analysis of materials and

techniques, Annals of otology 80 (1971), pp. 854 – 860. View Record in Scopus | Cited By inScopus (4) 

[14] J.L. Dornhoffer, Hearing results with cartilage tympanoplasty,  Laryngoscope 107 (1997), pp. 1094 – 1099. Full Text via CrossRef  | View Record in Scopus | Cited By in Scopus

(58) 

This study was not financially supported by external sources.

Corresponding author. Department of Otorhinolaryngology, MIMER Medical College,Pune 410507, India. Tel.: +91 98226 46207(Mobile); fax: +91 2114 223916.

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