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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
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[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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