Abstract
The purpose of this study was to assess closure rates in tympanic membrane perforations of various dimensions using the tragal cartilage-perichondrium composite graft and its effect on hearing values and also to present our own experiences.
Materials and methods
Sixty-one patients presenting to our clinic in 2014–2015 and diagnosed with tympanic membrane perforation were included in the study. Otomicroscopic and otoendoscopic examinations were performed preoperatively and at the 12th month postoperatively. Patients were divided into three groups depending on perforation diameter. Pure tone audiometry was performed at 500, 1000, 2000, and 4000 Hz (Hz) preoperatively and at the 12th month postoperatively, air-bone values were recorded, and air-bone gap (ABG) was calculated. Surgery was performed under local anesthesia usıng the transcanal, push-through (transperforation) technique. Perichondrium supported by thinned cartilage graft obtained from the tragal cartilage was used for tympanic membrane repair.
Results
Graft acceptance levels after 12 months in small, medium, and large perforations were 100%, 93.5%, and 93.75%, respectively, and 95% on average. Preoperative air-bone gap values were 18.64 ± 9.63 decibel (dB), 22.51 ± 9.66 dB, and 28.43 ± 11.36 dB, respectively, and 23.18 ± 11.36 dB on average, while 12th month postoperative air-bone gap values were 9.14 ± 8.27 dB, 11.25 ± 6.73 dB, and 17.37 ± 9.22 dB, respectively, and 12.37 ± 8.28 dB on average. The difference between pre- and postoperative 12th month air-bone gap values was statistically significant ( p < 0.005).
Conclusion
The use of thinned cartilage-supported perichondrial grafts in patients with all sizes of tympanic membrane perforation is safe and effective in terms of both anatomical healing and restoration of hearing and can represent a first-choice technique that is easy to perform and involves minimal morbidity.
1
Introduction
Tympanic membrane perforation is a clinical condition that can result from chronic otitis media and trauma and that has an adverse impact on patients’ quality of life. The primary approach for surgical reconstruction is type 1 tympanoplasty, otherwise known as myringoplasty, first described by Wullstein and Zollner .
Various surgical techniques and large numbers of graft materials are today used in myringoplasty surgery. Grafts used for myringoplasty include the temporal muscle fascia, perichondrium, periosteum, and cartilage tissue. The most popular grafts are fascia and cartilage grafts. The characteristics of the graft to be selected represent the most important factors in successful outcomes in both anatomical and auditory terms. The graft must be easy to harvest, durable, preserve membrane stability in the long term, compatible with normal body tissues, and contribute to hearing . The surgical technique to be used must be minimally traumatic with minimal morbidity. Other factors that can affect the success of the operation in addition to these surgical factors include the condition of the ear to be operated, Eustachian tube function, and the experience and ability of the surgeon. Many studies have shown that operations using cartilage graft in repair of tympanic membrane perforations are effective in terms of both graft stability and auditory outcomes and involve minimal morbidity .
The purpose of this study was to investigate the auditory and anatomical healing success of the thinned tragal cartilage-supported perichondrial graft in tympanic membrane perforations.
2
Materials and methods
The study was performed in 2014–2015 following receipt of our hospital ethical committee approval. Patients with tympanic membrane perforation and conductive-type or mixed-type hearing loss, with dry ears and no ear discharge for at least 3 months, and with normal middle ear mucosa and no ossicular chain defect were included in the study. Detailed ear, nose, and throat examinations were performed, and detailed anamnesis was taken. Complete blood count, full biochemistry and hepatitis, HIV and syphilis tests were performed on all patients. Patients with suppurative otitis and ossicular chain pathology, poor mastoid aeration in the temporal bone tomography, with a history of disease that might delay healing such as anemia, granulomatous diseases, tuberculosis, malignancy, aged below 15 or over 70, or with a previous history of ear surgery were excluded. Sixty-one patients, 37 female and 24 male, were enrolled. Patients were divided into three groups on the basis of preoperative perforation diameters, those with perforations smaller than 1/3 of the area of the tympanic membrane, those between 1/3 and 2/3 of the area of the tympanic membrane, and those with perforations larger than 2/3 of the area of the tympanic membrane.
Written consent forms were obtained from all patients. All patients were operated under local anesthesia using an otomicroscope by the transcanal route. Patients were discharged on the 1st day postoperatively. Ear tampons were removed on the 7th day. Otomicroscopic and otoendoscopic examinations were performed before surgery and on the 12th month postoperatively. Simultaneous 500–4000 Hz pure tone audiograms were requested. Air-bone hearing values were recorded, and air-bone gap (ABG) values calculated. Patient records were established using these data. At the end of the study, anatomical success was defined as graft healing without perforation, retraction, lateralization, or medialization. Auditory success was defined using statistical analysis of the difference between preoperative ABG values and those at the 12th month postoperatively.
2.1
Statistical analysis
We performed all statistical analyses on SPSS for Windows, version 17.0, software. Unless otherwise stated, results are expressed as mean ± SD. We used the Mann–Whitney U test or independent sample t test for comparisons between two subject groups and also the Pearson correlation test or Spearman correlation test, as appropriate. We used multiple regression analysis to exclude possible confounding effects of other variables in the results from each correlation analysis and considered a result of p < 0.05 as statistically significant.
2.2
Surgical technique
All patients were operated under local anesthesia following sedoanalgesia. Following preoperative preparation with a sterile covering, anesthesia was administered with 2 ml/100.000 subcutaneous lidocaine and adrenalin to the tragal cartilage and four quadrants of the skin of the outer ear passage of the ear to be operated. We then waited for 10 min. The tympanic membrane was visualized with an aural speculum under an otomicroscope. An otoendoscope was used for areas difficult to visualize with a microscope, and the perforated membrane was de-epithelialized with a pick. The diameter of the perforation was calculated approximately using a Rosen round-tipped knife. An incision of approximately 1 cm was made to the skin of the tragal cartilage, and a graft with its convex face covered by perichondrium equivalent to the diameter of the perforation was harvested. A portion of approximately 4 mm was left in order to avoid compromising the cosmetic appearance of the tragal cartilage dome. The graft with one layer of perichondrium was left to dry by stripping the perichondrium. A 2-mm triangular section matching the manubrium malleus on the cartilage portion was removed, and the flexibility of the cartilage was increased with gentle thinning. Absorbable sponge was inserted into the middle ear in order to improve contact between the graft and the remnant membrane. The cartilage graft was held with the help of an alligator forceps, and underlay was inserted medially to the tympanic membrane remnant and the annulus fibrosus by adjusting the section that would coincide with the malleus manubrium by the transcanal and transperforation route. The skin of the external ear canal in those parts of the marginal perforation with no annulus fibrosus and the remnant of the tympanic membrane was elevated and inserted at the level of the tympanic sulcus. The prepared perichondrium was placed as underlay such as to support the remnant membrane not in contact with the cartilage. In cases in which the cartilage was placed at the level of the tympanic sulcus, the margins of the perichondrium were tucked beneath the skin of the external ear passage. Complete closure was thus achieved ( Figs. 1, 2 ). The cutaneous incision in the tragal region was then sutured. No canaloplasty or general anesthesia was required in any case. A tampon was inserted into the outer ear passage. This was removed 1 week later. Prophylactic amoxicillin + clavulanic acid therapy was given to all patients for 1 week.
2
Materials and methods
The study was performed in 2014–2015 following receipt of our hospital ethical committee approval. Patients with tympanic membrane perforation and conductive-type or mixed-type hearing loss, with dry ears and no ear discharge for at least 3 months, and with normal middle ear mucosa and no ossicular chain defect were included in the study. Detailed ear, nose, and throat examinations were performed, and detailed anamnesis was taken. Complete blood count, full biochemistry and hepatitis, HIV and syphilis tests were performed on all patients. Patients with suppurative otitis and ossicular chain pathology, poor mastoid aeration in the temporal bone tomography, with a history of disease that might delay healing such as anemia, granulomatous diseases, tuberculosis, malignancy, aged below 15 or over 70, or with a previous history of ear surgery were excluded. Sixty-one patients, 37 female and 24 male, were enrolled. Patients were divided into three groups on the basis of preoperative perforation diameters, those with perforations smaller than 1/3 of the area of the tympanic membrane, those between 1/3 and 2/3 of the area of the tympanic membrane, and those with perforations larger than 2/3 of the area of the tympanic membrane.
Written consent forms were obtained from all patients. All patients were operated under local anesthesia using an otomicroscope by the transcanal route. Patients were discharged on the 1st day postoperatively. Ear tampons were removed on the 7th day. Otomicroscopic and otoendoscopic examinations were performed before surgery and on the 12th month postoperatively. Simultaneous 500–4000 Hz pure tone audiograms were requested. Air-bone hearing values were recorded, and air-bone gap (ABG) values calculated. Patient records were established using these data. At the end of the study, anatomical success was defined as graft healing without perforation, retraction, lateralization, or medialization. Auditory success was defined using statistical analysis of the difference between preoperative ABG values and those at the 12th month postoperatively.
2.1
Statistical analysis
We performed all statistical analyses on SPSS for Windows, version 17.0, software. Unless otherwise stated, results are expressed as mean ± SD. We used the Mann–Whitney U test or independent sample t test for comparisons between two subject groups and also the Pearson correlation test or Spearman correlation test, as appropriate. We used multiple regression analysis to exclude possible confounding effects of other variables in the results from each correlation analysis and considered a result of p < 0.05 as statistically significant.
2.2
Surgical technique
All patients were operated under local anesthesia following sedoanalgesia. Following preoperative preparation with a sterile covering, anesthesia was administered with 2 ml/100.000 subcutaneous lidocaine and adrenalin to the tragal cartilage and four quadrants of the skin of the outer ear passage of the ear to be operated. We then waited for 10 min. The tympanic membrane was visualized with an aural speculum under an otomicroscope. An otoendoscope was used for areas difficult to visualize with a microscope, and the perforated membrane was de-epithelialized with a pick. The diameter of the perforation was calculated approximately using a Rosen round-tipped knife. An incision of approximately 1 cm was made to the skin of the tragal cartilage, and a graft with its convex face covered by perichondrium equivalent to the diameter of the perforation was harvested. A portion of approximately 4 mm was left in order to avoid compromising the cosmetic appearance of the tragal cartilage dome. The graft with one layer of perichondrium was left to dry by stripping the perichondrium. A 2-mm triangular section matching the manubrium malleus on the cartilage portion was removed, and the flexibility of the cartilage was increased with gentle thinning. Absorbable sponge was inserted into the middle ear in order to improve contact between the graft and the remnant membrane. The cartilage graft was held with the help of an alligator forceps, and underlay was inserted medially to the tympanic membrane remnant and the annulus fibrosus by adjusting the section that would coincide with the malleus manubrium by the transcanal and transperforation route. The skin of the external ear canal in those parts of the marginal perforation with no annulus fibrosus and the remnant of the tympanic membrane was elevated and inserted at the level of the tympanic sulcus. The prepared perichondrium was placed as underlay such as to support the remnant membrane not in contact with the cartilage. In cases in which the cartilage was placed at the level of the tympanic sulcus, the margins of the perichondrium were tucked beneath the skin of the external ear passage. Complete closure was thus achieved ( Figs. 1, 2 ). The cutaneous incision in the tragal region was then sutured. No canaloplasty or general anesthesia was required in any case. A tampon was inserted into the outer ear passage. This was removed 1 week later. Prophylactic amoxicillin + clavulanic acid therapy was given to all patients for 1 week.
