Abstract
Objectives
The aim of this study was to analyze the outcome of inlay “butterfly” cartilage tympanoplasty.
Methods
The files of 42 patients (24 were male, 18 were female) who underwent primary or revision inlay butterfly cartilage tympanoplasty in 2005 to 2011 at a tertiary medical center were reviewed. Patients were regularly observed by otoscopy and audiometry.
Results
The mean patient age was 27 years (range, 14–75 years), and the mean duration of follow-up was 24 months (range, 3–36 months). The postoperative period was uneventful. The technical (anatomical) success rate was 92% at 1 year. There was a significant decrease in the mean air-bone gap in 32 patients (preoperatively, 49.6 dB; postoperatively, 26.2 dB; P = .006). Results were suboptimal in 3 patients with persistent small perforations of the operated ear.
Conclusion
Inlay butterfly cartilage tympanoplasty appears to be effective in terms of defect closure and improved hearing, comparable with temporalis fascia graft tympanoplasty. Follow-up is necessary for at least 1 year when some perforation may reappear.
1
Introduction
Tympanoplasty was introduced in the 1950s by Zollner and Wullstein , who used numerous graft materials and tissues to close tympanic membrane perforations. Since then, both the underlay and overlay approaches have been found to be reliable , depending on the surgical indications, technical variants, and patient follow-up . The most common grafting materials are the temporalis fascia and perichondrium , which are associated with a successful tympanic membrane closure rate of about 90% and improved hearing in about 60% of patients . However, both require incision of the canal skin, which poses a risk of morbidity and need for postoperative care . To simplify the procedure, several studies have proposed refreshing the perforation edges and then inserting a graft, such as cartilage, fat , or a synthetic device, through the perforation . This makes the graft easy to apply and reduces operating and recovery time, leading to lower costs. The newer techniques can also be done under local anesthesia on an ambulatory basis and may be applicable even for myringosclerotic tympanic membranes. Furthermore, they eliminate the need for tympanomeatal flap elevation and postoperative ear packing, as well as the risk of cartilage atrophy .
The aim of the present study was to analyze the outcome of one of these alternative techniques, inlay “butterfly” cartilage tympanoplasty, first reported in 1998 by Eavey , in which the graft is harvested from the tragal cartilage.
2
Materials and methods
The study sample included 42 patients (42 ears) who underwent primary or revision inlay butterfly cartilage tympanoplasty between January 2005 and March 2011 at the Department of Otolaryngology–Head and Neck Surgery of a major tertiary hospital. At our center, pure-tone average audiometric examination is routinely conducted before tympanoplasty. Only ears that have been dry for at least 3 months and tympanic membrane perforations that are fully visible threw the external auditory canal are considered eligible for inlay cartilage technique, all other situations undergo a “normal” tympanoplasty. Surgery is performed under general anesthesia with endotracheal intubation. Patients are usually hospitalized for 1 day. Postoperatively, they are observed regularly at the clinic on postoperative day 5, for removal of the external gauze, and at 1 and 6 months for otoscopy and audiometry. A third otoscopic evaluation is performed at 1 year.
2.1
Surgical technique
Patients are prepared and draped for a sterile procedure. The meatal surface of the tragus and the external ear canal are injected with 1 to 3 mL of a local anesthetic mixture (9 mL lidocaine 1% and 0.6 mL adrenaline). The operations were performed through an aural speculum. If the edge of the perforation is obscured by a bony canal overhang, the anterior canal skin is elevated to expose the overhang and a drill is used to widen the canal. The dimensions and shape of the perforation are then estimated using a surgical hook, and the perforation edges are refreshed with a pick. As described by Eavey , the tragal cartilage graft is harvested making a linear incision on the tragal skin, removing the cartilage, followed by carving of the cartilage to the desired size and shape of the perforation and preserving the perichondrium on both surfaces. The graft should measure 1 to 2 mm more in every dimension than the actual perforation. We try to leave at least 5 mm of tragal cartilage for cosmesis. A No. 11 surgical blade is used to incise the thin cartilage edge between the 2 sheets of perichondrium. The cartilage is then inserted throughout the perforation, yielding a butterfly configuration, with one “wing” remaining in the lateral position and the other wing lying medial to the perforated ear drum. Several small pieces of self-absorbing Gelfoam (Pfizer, New York, NY, USA) are placed in the external ear canal and the external ear is covered with a gauze pad. No packing is placed in the middle ear, and no stitches are necessary for the tragal incision, which is closed by secondary intention. The gauze is removed on the fifth postoperative day.
2.2
Data collection
For the present study, data on background variables, surgical approach, complications, and anatomical and functional outcome were collected from the patients’ medical charts. Technical (anatomical) success was defined as a finding of an intact repaired tympanic membrane repair at the end of the follow-up period. Functional success was defined as a significant decrease in the air-bone gap at the end of follow-up compared with baseline (> 10 dB).
The significance of the change in air-bone gap was analyzed using the Pearson χ 2 test.
2
Materials and methods
The study sample included 42 patients (42 ears) who underwent primary or revision inlay butterfly cartilage tympanoplasty between January 2005 and March 2011 at the Department of Otolaryngology–Head and Neck Surgery of a major tertiary hospital. At our center, pure-tone average audiometric examination is routinely conducted before tympanoplasty. Only ears that have been dry for at least 3 months and tympanic membrane perforations that are fully visible threw the external auditory canal are considered eligible for inlay cartilage technique, all other situations undergo a “normal” tympanoplasty. Surgery is performed under general anesthesia with endotracheal intubation. Patients are usually hospitalized for 1 day. Postoperatively, they are observed regularly at the clinic on postoperative day 5, for removal of the external gauze, and at 1 and 6 months for otoscopy and audiometry. A third otoscopic evaluation is performed at 1 year.
2.1
Surgical technique
Patients are prepared and draped for a sterile procedure. The meatal surface of the tragus and the external ear canal are injected with 1 to 3 mL of a local anesthetic mixture (9 mL lidocaine 1% and 0.6 mL adrenaline). The operations were performed through an aural speculum. If the edge of the perforation is obscured by a bony canal overhang, the anterior canal skin is elevated to expose the overhang and a drill is used to widen the canal. The dimensions and shape of the perforation are then estimated using a surgical hook, and the perforation edges are refreshed with a pick. As described by Eavey , the tragal cartilage graft is harvested making a linear incision on the tragal skin, removing the cartilage, followed by carving of the cartilage to the desired size and shape of the perforation and preserving the perichondrium on both surfaces. The graft should measure 1 to 2 mm more in every dimension than the actual perforation. We try to leave at least 5 mm of tragal cartilage for cosmesis. A No. 11 surgical blade is used to incise the thin cartilage edge between the 2 sheets of perichondrium. The cartilage is then inserted throughout the perforation, yielding a butterfly configuration, with one “wing” remaining in the lateral position and the other wing lying medial to the perforated ear drum. Several small pieces of self-absorbing Gelfoam (Pfizer, New York, NY, USA) are placed in the external ear canal and the external ear is covered with a gauze pad. No packing is placed in the middle ear, and no stitches are necessary for the tragal incision, which is closed by secondary intention. The gauze is removed on the fifth postoperative day.
2.2
Data collection
For the present study, data on background variables, surgical approach, complications, and anatomical and functional outcome were collected from the patients’ medical charts. Technical (anatomical) success was defined as a finding of an intact repaired tympanic membrane repair at the end of the follow-up period. Functional success was defined as a significant decrease in the air-bone gap at the end of follow-up compared with baseline (> 10 dB).
The significance of the change in air-bone gap was analyzed using the Pearson χ 2 test.
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