Miringoplastia con injerto doble medial y lateral

Comparative study of endoscopic underlay myringoplasty with or without tucking of the attached perichondrium graft when repairing large central dry perforations

OBJECTIVE

To compare the graft success rates and hearing outcomes of underlay myringoplasty with or without perichondrium tucking of the attached perichondrium, graft perforation margins when repairing chronic large central dry perforations.

STUDY DESIGN

Randomized controlled trial.

MATERIAL AND METHODS

Chronic large central dry perforations were prospectively randomized to tucking perichondrium graft underlay (TPGU) and no-tucking perichondrium graft underlay (NTPG) groups. The graft outcomes and complications were compared between the two groups at 12 months postoperatively.

RESULTS

In total, 61 patients with large central dry perforations were included. All patients completed 12-month follow-ups. Residual perforations occurred in 0.0 % of the TPGU group and in 12.9 % of the NTPG group (P = 0.129), and re-perforations occurred within 6 months in 0.0 % and 3.2 % of the two groups, respectively (P = 0.987). The graft success rates were 100.0 % (30/30) and 83.9 % (26/31) (P = 0.067). No significant between-group differences were observed in terms of preoperative (P = 0.547) or postoperative (P = 0.612) air bone gaps (ABGs) or mean ABG gains (P = 0.597). No graft-related complications were observed in either group during follow-up. No patients exhibited significant graft blunting or medialization; graft lateralization was noted in one patient of the NTPG group.

CONCLUSIONS

Endoscopic cartilage with tucking of the attached perichondrium perforation margins during underlay myringoplasty may improve the graft success rate compared to that of the cartilage push-through technique when repairing large central dry perforations; however, the hearing improvements were comparable in the two groups.

Effects of no perforation margin trimming and EAC packing in cartilage underlay myringoplasty for chronic large perforations in children

OBJECTIVE

Trimming of perforation margins and external auditory canal (EAC) packing are basic procedures in underlay myringoplasty for repairing chronic perforations. The objective of this study was to compare the operation time, graft outcome, hearing improvement, and complications of endoscopic cartilage underlay myringoplasty with and without trimming of perforation margins and EAC packing in children.

STUDY DESIGN

Prospective, randomized study.

SETTING

Tertiary referral center.

MATERIAL AND METHODS

Pediatric patients older than 12 years with chronic perforations were randomly divided into two groups: myringoplasty with trimming of perforation margin and EAC packing (TPME) group or no trimming of perforation margin and EAC packing (NTPME) group. The operation time, graft success rate, hearing improvement, and complications were compared between the two groups.

RESULTS

Fifty-two patients were ultimately included in the study. The mean operation time was 31.4 ± 4.2 min in the TPME group and 23.6 ± 1.7 min in the NTPME group; the difference was significant (P < 0.01). The rate of aural fullness significantly differed between the TPME and NTPME groups (P = 0.000). All participants were followed up for 12 months; the graft success rate did not significantly differ between the groups (88.5% vs. 96.2%; P = 0.603). No patients developed adhesive otitis media. Between the preoperative and postoperative measurements, the mean air-bone gap improved by 10.2 ± 2.8 dB in the TPME group and 11.6 ± 0.7 dB in the NTPME group; this was significant (P < 0.001) in both groups.

CONCLUSIONS

Endoscopic cartilage underlay myringoplasty NTPME shorted the operation time and avoided aural fullness and EAC discomfort compared with the TPME technique; however, graft success and hearing improvement were comparable between the two techniques for repairing large perforations in children.

Comparison of two endoscopic perichondrium-cartilage graft underlay myringoplasty for large perforations: a randomized controlled trial

OBJECTIVE

The objective of this study was to compare the graft outcomes and complications of two endoscopic perichondrium-cartilage graft techniques for repairing large perforations.

STUDY DESIGN

Single center blinded randomized controlled trial.

MATERIALS AND METHODS

61 large perforations more than 50% of TM area were prospectively randomized to undergo the free perichondrium and free cartilage graft group (FPFC, n = 31) or perichondrium partial attachment the cartilage graft group (PPAC, n = 30). The primary outcome measures were the operation time; secondary outcome measures were the graft success rate and hearing gain at 12 months postoperatively and postoperative complications.

RESULTS

All patients completed follow-up of 12 months. The mean operation time was 38.2 ± 2.3 min in the FPFC group and 37.4 ± 5.6 min in the PPAC group (P = 0.658). At postoperative 3 months, the graft success rates were 96.7% in the FPFC group and 93.3% in the PPAC group (P = 0.976). At postoperative 12 months, the graft success rates were 96.7% in the FPFC group and 83.3% in the PPAC group (P = 0.182). However, the residual and re-perforation rate with no infection was 0.0% (0/31) in the FPFC group and 16.7% (5/30) in the PPAC group (P = 0.056). No significant between-group differences were observed pre- (P = 0.842) or post- (P = 0.759) operative air bone gap (ABG) values or mean ABG gain (P = 0.886). However, granular myringitis has been noted in 6.5% in the FPFC group and in 3.3% in the PPAC group.

CONCLUSIONS

This study suggested that 12-month graft success and hearing gain were comparable between the perichondrium free and partial attachment the cartilage graft techniques, nevertheless, partial attachment technique could increase residual and re-perforations.

Comparison of Endoscopic Modified and Typical Myringoplasty: A Randomized Controlled Trial

OBJECTIVE

Here, we aimed to compare the operation time, postoperative pain score, graft healing, graft success rate, cholesteatoma incidence, audiometric outcomes, and complications between endoscopic modified myringoplasty (EMM) and endoscopic typical myringoplasty (ETM).

METHODS

Patients with unilateral chronic tympanic membrane (TM) perforations undergoing myringoplasty were prospectively randomized to undergo EMM (n = 44) or ETM (n = 45). The operation time, postoperative pain score, graft healing, graft success rate, cholesteatoma incidence, audiometric outcomes, and complications were compared between these groups.

RESULTS

In total, 89 patients with unilateral chronic perforations were included (EMM group, 44; ETM group, 45). There were significant differences between the EMM and ETM groups in mean pain scores on the day after surgery (1.32 ± 0.56 vs. 2.58 ± 1.16, p < 0.001) and in the mean operation time (18.18 ± 2.43 vs. 51.53 ± 8.28 min, p < 0.001). There were no significant differences in graft success rates (93.18% vs. 88.89%, p = 0.735), pre- or postoperative air conduction pure-tone averages or air bone gaps (ABGs), or changes in ABGs between the groups. However, the difference in graft healing was significant at postoperative week 2 (33/44 vs. 24/45, p = 0.033) but was nonsignificant at postoperative week 4 and month 6. Computed tomography revealed the middle ear and mastoid to be well pneumatized at 12 months in all patients.

CONCLUSION

While 12-month graft and audiometric outcomes were comparable between EMM and ETM techniques, patients who underwent EMM had less postoperative pain, shorter operative times, faster healing, and a lower incidence of complications.

LEVEL OF EVIDENCE

1 Laryngoscope, 133:2779-2785, 2023.

Comparison of Cartilage Reinforcement and Push-Through Techniques for the Treatment of Large Perforations

Objective: To compare the graft success rate and hearing outcomes of endoscopic cartilage reinforcement perichondrium-cartilage composite graft and push-through techniques for the treatment of large marginal perforations. Study Design: Randomized controlled trial. Materials and Methods: A total of 57 large marginal perforations were prospectively randomized to cartilage reinforcement (n = 29) and cartilage push-through technique (n = 28) groups. The graft success rate, audiometric outcomes, and complications were compared between the 2 groups at 6 months. Results: All patients completed 6 months of follow-up. The graft success rate in the cartilage reinforcement group was significantly higher compared to that in the push-through group (100.0% vs 78.6%, P < .01). Residual perforation was observed in 5 (17.9%) patients, and re-perforation in 1 (3.6%) patient, in the push-through group. The preoperative air-bone gap (ABG) was 17.6 ± 3.5 dB in the cartilage reinforcement group and 16.8 ± 8.4 dB in the push-through group (P > .05). Postoperatively, although the postoperative ABG in the cartilage reinforcement group was higher than that in the push-through group, no significant difference was observed (11.8 ± 4.3 dB vs 8.9 ± 2.5 dB, P > .05). Additionally, no significant difference was found in ABG closure between the 2 groups (6.6 ± 1.9 dB vs 7.9 ± 4.7 dB, P > .05). Conclusion: Cartilage reinforcement myringoplasty is a simpler and more useful technique to achieve graft success compared to cartilage-perichondrium push-through for the treatment of large marginal perforations, and it does not affect hearing levels.

Perichondrium-Cartilage Inlay Butterfly Myringoplasty: An Office-Based Procedure for Closing Small- to Medium-Sized Tympanic Membrane Perforations

Objective: The objective of this study was to assess the graft and functional outcomes of inlay butterfly cartilage-perichondrium graft myringoplasty in an office setting. Material and Methods: Adult patients with chronic perforations underwent inlay butterfly cartilage-perichondrium graft myringoplasty under local and topical anesthesia. The graft and functional outcomes, intraoperative pain score, and complications were evaluated at 6 months postoperatively. Results: A total of 39 patients (39 ears) were included in this study. All patients completed 6 months of follow-up. The mean operation time was 26.5 ± 3.2 (ranged from 21 to 32) minutes. The intraoperative mean pain score was 0.61 ± 0.28. The graft success rate was 97.4% (38/39) at 6 months postoperatively. The mean preoperative air-bone gap (ABG) was 19.18 ± 4.01 dB, while the mean postoperative ABG at 6 months was 10.56 ± 2.27 dB (P < .05; Paired-Samples T Test). The functional success rate was 100.0% (38/38). Endoscopic examination showed that the transplanted perichondrium graft gradually atrophied, flattened, and became indistinguishable from the surrounding tympanic membrane 2 to 3 months following surgery, the superficial layer of perichondrium graft formed the crust and migrated into the external auditory canal at 3 to 6 months postoperatively. Conclusions: Perichondrium-cartilage inlay butterfly myringoplasty is a highly successful and minimally invasive procedure well tolerated by adults for closure of small- and medium-sized perforations in an office setting.

Endoscopic perichondrium-cartilage button technique for repairing chronic large perforations in teenagers

OBJECTIVE

The objective of this study was to evaluate the graft outcome and complications of endoscopic perichondrium-cartilage button technique for repairing chronic large perforations in teenagers.

STUDY DESIGN

Prospective case series.

MATERIALS AND METHODS

56 patients with chronic large perforations more than 50% of the TM who underwent endoscopic perichondrium-cartilage button technique. The graft success rate, hearing outcome, and complications were evaluated at postoperative 3, 6 and 12 months.

RESULTS

Of the 56 ears, 3 (5.4%) patients lost follow-up, 53 (94.6%) patients were finally included in this study. The mean operation time was 37.2 ± 5.4 min. The retrograde tympanomeatal flap elevation was performed in 16 (30.2%) patients. The graft success rate was 96.2% (51/53) at postoperative 3 months and 94.3% (50/53) at postoperative 12 months. The mean preoperative ABG was 25.0 ± 3.7 dB, while the mean postoperative ABG postoperatively 6 months was 12.8 ± 3.1 dB; the difference between these values was significant. No graft-related complications (e.g., graft lateralization, significant blunting, and graft medialization) were encountered during the follow-up period. However, graft keratin pearl was noticed in 5.7% (3/53) patients, which occurred in the handle of malleus in 2 and antero-inferior margin in one. All the graft pearls were endoscopically removed in the outpatient setting.

CONCLUSIONS

Endoscopic perichondrium-cartilage button technique can be achieved in every teenager patient with chronic large perforation without cholesteatoma, and, is a safe and efficient procedure.

Endoscopic modified perichondrium-cartilage sandwich graft for repairing chronic subtotal and total perforations

OBJECTIVE

The objective of this study was evaluate the short-and long-term graft outcome and complications of endoscopic modified perichondrium-cartilage sandwich graft for repairing chronic subtotal and total perforations.

STUDY DESIGN

Prospective case series.

MATERIALS AND METHODS

135 patients with chronic subtotal and total perforations who underwent endoscopic modified perichondrium-cartilage sandwich graft technique. The graft success rate, hearing outcome, and complications were evaluated at postoperative 6 and 24 months.

RESULTS

124 patients were finally included in this study. The graft success rate was 96.3% in subtotal perforation and 97.7% in total perforation (P = 0.874), with an overall success rate of 96.8% at postoperative 6 months. The graft success rate was 95.8% (68/71) in subtotal perforation and 94.9% (37/39) in total perforation (P = 0.795), with an overall success rate of 95.5% (105/110) at postoperative 24 months. The mean ABG improved from 28.0 ± 5.3 dB preoperatively to 14.9 ± 4.8 dB postoperatively 12 months (P < 0.05) for subtotal perforations; from 33.4 ± 7.4 dB preoperatively to 16.1 ± 2.4 dB postoperatively 12 months (P < 0.05) for total perforations. No graft-related complications (e.g., graft lateralization, significant blunting, graft medialization) were encountered during the follow-up period. Of the 110 patients, temporal bone CT revealed well pneumatization of the middle ear and mastoid region. However, graft keratin pearl was noticed in 1.8% (2/110) patients.

CONCLUSIONS

Endoscopic modified perichondrium-cartilage sandwich graft for repairing subtotal and total perforations had excellent short and long-term graft success rate with less time-consuming and minimal complications.

Endoscopic inlay cartilage and perichondrium myringoplasty for repairing large perforations in teenagers

OBJECTIVE

This study compared the long-term graft success rates and hearing outcomes of overlay-underlay and underly cartilage myringoplasty for repairing large perforations in Teenagers.

STUDY DESIGN

prospective, randomized study.

SETTING

Tertiary referral center.

METHODS

Pediatric patients older than 12 years with chronic perforations were randomly divided into two groups:intervention group (n = 39) and control group (n = 41). The graft success rate, hearing improvement, and complications were compared between the two groups.

RESULTS

A total of 80 patients were included in this study. The graft success rate was 100% in the intervention group and 95.1% in the control group at postoperative 3 months, the difference wasn't significant (P = 0.496). Also, the graft success rate was not significantly different between the two groups at 12 months postoperatively (100.0% vs 87.8%, p = 0.073). However, the difference of graft success rate was significant between the two groups at 24 months postoperatively (97.4% vs 75.6%, p = 0.012). CT examination revealed well-pneumatized middle ears 24 months after surgery in both group. However, epithelial pearls near the umbo were seen at 31 months postoperatively in one patient in the observation group.

CONCLUSIONS

Compared to the endoscopic cartilage with perichondrium composite graft underlay technique, endoscopic perichondrial graft overlay and cartilage underlay had a better long-term graft success rate and lower rate of long-term re-perforation in teenagers. However, the graft technique had no effect on hearing outcome.

Excising or preserving perforation margins in endoscopic transtympanic cartilage myringoplasty does not affect surgical success

OBJECTIVE

To compare the outcome of endoscopic transtympanic cartilage myringoplasty with and without removal of perforation edges for repairing chronic perforations with mucosal chronic otitis media (COM).

STUDY DESIGN

Quasi-randomised clinical trial.

SETTING

Tertiary referral centre.

MATERIALS AND METHODS

Patients with chronic perforations and mucosal COM undergoing endoscopic transtympanic cartilage myringoplasty were allocated to a control group for whom the perforation edges were preserved (n = 40) and an intervention group for whom the edges were removed (n = 39). Mean operation time, graft success rate, mean scores of graft neovascularisation and epithelialisation, and hearing were compared between the groups at 4 weeks and/or 6 months postoperatively.

RESULTS

Graft success rate was 95% (38/40) in the control group and 97% (38/39) in the intervention group at 6 months postoperatively; the difference was not significant. Mean graft neovascularisation scores 4 weeks postoperatively were 2.52 ± 0.59 in the control group and 2.58 ± 0.55 in the intervention group; the difference was not significant. Mean graft epithelisation scores 4 weeks postoperatively were 1.48 ± 0.57 in the control group and 1.68 ± 0.51 in the intervention group; the difference was not significant and remained nonsignificant 6 months postoperatively (2.5 ± 0.55 vs. 2.76 ± 0.36). Audiological outcomes at 6 months did not differ between the groups.

CONCLUSION

Endoscopic, transtympanic cartilage underlay myringoplasty with preservation of the perforation margins did not affect graft neovascularisation, epithelialisation or success. Longer-term outcomes and risk of cholesteatoma require further study.

Transcanal Endoscopic Cartilage and Perichondrium Graft Myringoplasty for Large Tympanic Membrane Perforations

OBJECTIVES

The objective of this study was to evaluate the outcomes following transcanal endoscopic cartilage and perichondrium double-layer myringoplasty for subtotal and total tympanic membrane (TM) perforations.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary referral center.

METHODS

Adult patients who underwent transcanal endoscopic double-layer myringoplasty for subtotal and total TM perforations between January 2015 and December 2017 were included. The graft success rate, hearing outcomes, and complications were evaluated postoperatively. Temporal bone computed tomography or magnetic resonance imaging was performed at 24 months postoperatively.

RESULTS

The mean follow-up period was 28.2 ± 6.1 (range, 24-36) months. The graft success rate was in 95.7% (45/47) at 6 months, 93.6% (44/47) at 12 months, and 87.2% (41/47) at 24 months, respectively. The mean ABG improved from 32.89 ± 5.31 dB preoperatively to 10.89 ± 4.78 dB postoperatively 12 months (p < 0.05) for subtotal perforations; from 33.41 ± 7.41 dB preoperatively to 11.45 ± 2.41 dB postoperatively 12 months (p < 0.05) for total perforations. No graft-related complications (e.g., graft lateralization, significant blunting, graft atelectasis, graft adhesions, or effusion) were encountered during the follow-up period. Postoperative temporal bone imaging revealed a pneumatized middle ear and mastoid in all cases with no evidence of cholesteatoma.

CONCLUSIONS

Transcanal endoscopic myringoplasty for large TM perforations using a double-layer perichondrium and cartilage graft is feasible with comparable rates of closure to more invasive approaches.

Endoscopic myringoplasty: comparison of double layer cartilage-perichondrium graft and single fascia grafting

Objective

To compare surgical results of endoscopic myringoplasty using double layer cartilage-perichondrium grafts versus single fascia grafts.

Study design

Prospective, randomized, controlled.

Setting

University-affiliated teaching hospital.

Subjects and methods

In total,134 patients who underwent endoscopic myringoplasty were included in this study. Patients in group A received a double layer tragal cartilage-perichondrium graft and those in group B received a temporal muscle fascia graft. The groups were compared with respect to the pre- and postoperative air-bone gap (ABG) and the graft success rate.

Results

The graft success rate was 98.5% (66/67) in the Group A and 94.0% (63/67) in the Group B at 6 months, the difference wasn’t statistically significant (p = 0.362). However, the graft success rate was 97.0% (65/67) in the Group A and 85.1% (57/67) in the Group B at 12 months, the difference was statistically significant (p = 0.034).

In addition, only one patient (1.49%) had small keratin pearls in the Group A, no patients developed cholesteatoma of middle ear in either group.

Conclusions

The endoscopic double layer perichondrium-cartilage graft technique is feasible for repairing medium or larger perforations, it has a better long-term graft success rate and less operative time compared with the single layer fascia graft technique. However, long-term hearing outcomes were the same for the single and double layer closure techniques.

Use of Endoscopic Cartilage Graft Myringoplasty Without Tympanomeatal Flap Elevation to Repair Posterior Marginal Perforations

OBJECTIVE

We evaluated the graft success rate and hearing outcomes of endoscopic cartilage graft myringoplasty without tympanomeatal flap elevation used to repair posterior marginal perforations.

STUDY DESIGN

A prospective case series.

MATERIALS AND METHODS

A total of 31 patients with posterior marginal perforations who underwent endoscopic cartilage graft myringoplasty were included. The outcomes were the hearing gain and graft success rate at 6 and 24 months.

RESULTS

The graft success rate was 96.7% (30/31) at 6 months and 90.3% (28/31) at 24 months; 1 patient exhibited composite graft extrusion and lateralization in the region of the anterior annulus; a residual perforation was apparent. Reperforation occurred in 2 patients. The mean preoperative air-bone gap (ABG; 28.61 ± 3.14 dB) was significantly greater than the mean postoperative ABG (12.15 ± 3.98 dB; P < .05) at 6 months; however, there was no statistically significant difference between the post-6 months and post-24 months with regard to ABG values (P = .871), ABG gain (P = 0.648), or functional success rate (P = .472). No significant graft blunting or atelectasis was noted during follow-up. The free perichondrium became fully integrated with the skin of the external auditory canal; the perichondrium could not be clearly distinguished endoscopically 4 to 8 weeks postoperatively. Computed tomography revealed well-pneumatized middle ear and mastoid cavity at postoperative 24 months.

CONCLUSION

Endoscopic cartilage graft myringoplasty without tympanomeatal flap elevation reliably repairs posterior marginal perforations. The short- and long-term graft success rate is high, and the hearing results are satisfactory; the technique is minimally invasive.