Fate of cartilage material used in middle ear surgery light and electron microscopy study

Comparison of temporalis muscle fascia and cartilage grafts for primary type 1 tympanoplasty: a meta-analysis of randomized controlled trials

PURPOSE

To compare the efficacy and safety of temporalis fascia (TF) with cartilage grafts for primary type 1 tympanoplasty in chronic otitis media (COM) patients.

METHODS

Computerized search was performed in MEDLINE, Embase, and CENTRAL. Eligible for inclusion were randomized controlled trials (RCTs) comparing TF and cartilage grafts in individuals with non-cholesteatoma COM and intact ossicles requiring type 1 tympanoplasty. Primary outcomes were graft success and hearing improvement, measured by the air-bone gap (ABG) closure. The secondary outcome was the occurrence of complications. Standardized mean differences (SMD) and odds ratios (OR) with 95% confidence intervals were calculated.

RESULTS

Eighteen RCTs that enrolled 1273 participants were found eligible. Data were reported at follow-up periods ranging from 6 weeks to 24 months. The pooled effect estimate revealed a higher and statistically significant graft success favoring cartilage grafts at 12 months (OR = 2.24, 95% CI 1.33-3.78) and 24 months (OR = 2.96, 95% CI 1.18-7.43). There was no significant difference between both grafts in post-operative ABG closure across all follow-up periods (6 weeks to 12 months).

CONCLUSIONS

Compared to TF, primary type 1 cartilage tympanoplasty offers better graft uptake rates and comparable postoperative hearing outcomes for COM patients.

Endoscopic full-thickness cartilage-perichondrium double graft myringoplasty in adhesive perforation: retrospective case series

BACKGROUND

The adhesive perforation could be the sequela of adhesive otitis media, that partial tympanic membrane remnant is bound completely to the medial wall of the middle ear by fibrous adhesions. However, few studies have reported on the repairing of adhesive perforation.

OBJECTIVES

To evaluate the long-term outcome of endoscopic full-thickness cartilage-perichondrium double graft myringoplasty for adhesive perforation.

MATERIALS AND METHODS

In total, 26 patients with unilateral adhesive perforation associated with chronic otitis media who underwent full-thickness cartilage-perichondrium double graft myringoplasty were included. Outcomes were evaluated in terms of the hearing gain and graft success rate at 12 and 24 months.

RESULTS

The graft success rate was 96.15% (25/26) at 12 months and 88.46% (23/26) at 24 months. The neovascularization and epithelium covering the lateral surface of the cartilage graft were seen at preoperative 4 weeks, the superficial cartilage graft got complete epithelialization within 4-6 months. CT revealed the well-pneumatized middle ear and mastoid cells at postoperative 24th months in all the patients, no middle ear cholesteatoma formation and keratin pearls were found during the period of follow up.

CONCLUSIONS

Endoscopic full-thickness cartilage-perichondrium double graft myringoplasty without the tympanomeatal flap elevation is a feasible method for repairing adhesive perforations, with a higher graft success rate and satisfactory hearing results.

Full-thickness cartilage graft myringoplasty combined with topical application of bFGF for repair of perforations with extensive epithelialization

OBJECTIVE

The objective of this study is to evaluate the long term outcome of endoscope full-thickness cartilage graft myringoplasty combined with topical application of basic fibroblast growth factor (bFGF) for repair of perforations with extensive epithelialization.

MATERIALS AND METHODS

In total, 65 perforations with extensive epithelialization of edges were divided into the endoscope full-thickness cartilage graft myringoplasty with (bFGF treatment group) and without topical application of bFGF (control group) groups. The outcomes were evaluated in terms of the hearing gain and graft success rate at 12 and 24 months post-surgery.

RESULTS

All patients were followed up at 24 months. Graft success rate was 97.2% in postoperative 12th month and 97.2% in postoperative 24th month in the bFGF group, whereas graft success rate was 100.0% in postoperative 12th month and 86.2% in postoperative 24th month in the control group. The re-perforation wasn't evident in any patients in the bFGF group while re-perforation in 4 (13.8%) patients in the control group, with statistical significance (P = 0.023).Comparing the two groups, there was no difference regardless of in preoperative or postoperative 12 months mean ABG or ABG closure. CT images revealed the well pneumatized middle ear and mastoid cells at postoperative 24th months in both groups, no middle ear cholesteatoma and keratin pearls were found during the period of follow up.

CONCLUSIONS

The cartilage-perichondrium double graft combined with bFGF are a feasible and effective method for providing the long-term graft success rate of the perforations with extensive epithelialization.

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.

A Comparative Study of Type-I Underlay Tympanoplasty with Temporalis Fascia Graft Alone and with Conchal Cartilage

Tympanoplasty which is the repair of the tympanic membrane using temporalis fascia, has been done worldwide and has stood the test of time. However in cases of reperforation or large/subtotal perforations, we are often left in need of some sturdy material for grafting. To compare the graft uptake and hearing improvement in patients undergoing type I tympanoplasty using temporalis fascia alone and temporalis fascia along with conchal cartilage. The current research is a prospective study of 60 patients with chronic suppurative otitis media (Tubo tympanic type), undergoing type I tympanoplasty, using temporalis fascia alone and temporalis fascia along with conchal cartilage. The graft uptake and hearing improvement was much better using temporalis fascia along with conchal cartilage graft as compared to cartilage alone. The use of temporalis fascia along with conchal cartilage graft is beneficial for patients with chronic suppurative otitis media (tubotympanic type) undergoing type I tympanoplasty than using temporalis fascia alone.

Comparative Study of Hearing Improvement of Type 1 Tympanoplasty Using Temporalis Fascia and Conchal Cartilage as Graft Material

Tympanic Membrane perforation is a common cause of hearing loss. Various surgical techniques with different types of graft materials have been described for the treatment of perforations. The conchal cartilage and temporalis fascia graft are most widely used. We conducted a prospective Randomized control trial at Sri Guru Ram Das Institute of Medical Sciences and Research to compare the post operative hearing outcomes between the patients of safe CSOM (n = 40) using temporalis fascia (n = 20) and conchal cartilage (n = 20). It was found that the AB gap closure at 2 months post-operatively was 11.55 ± 8.173 for conchal perichondrium group as compared to 10.49 ± 9.069 for temporalis fascia group. At 6 months the AB gap closure was 14.98 ± 9.915 for conchal cartilage group as compared 11.41 ± 8.288 db for temporalis fascia group. Thus hearing improvement was better for conchal cartilage group both at 2 and 6 months but the comparison of the AC gain at the end of 6 months and subjective improvement in hearing between the two techniques was not statistically significant owing to the small sample size of the study. Both Temporalis fascia and conchal cartilage with perichondrium were acceptable graft material for successful closure of tympanic membrane perforation, hearing improvement was better with conchal cartilage group.

Endoscopic Tympanoplasty Using Nasal Septal Cartilage Allograft

The purpose of the study was to analyze the morphological and functional outcomes in a series of 60 patients for whom Type I tympanoplasty was done using alcohol preserved nasal septal cartilage allograft through endoscopic permeatal route. The study was a prospective, interventional (surgical) study of 60 patients between October 2012 and September 2014. Patients were operated using 0°, 4 mm, 18 cm long Hopkin's rod endoscope through permeatal route. 70% ethyl alcohol preserved allogeneic nasal septal cartilage with thickness of around 0.5 mm was used for grafting. At the end of 6 months, final assessment of morphological outcome i.e. intact tympanic membrane and functional outcome i.e. reduction in Air Bone gap, was done. At the end of 6 months, 57 patients (95%) had intact tympanic membrane. Mean ABG in postoperative patients was 11.83 dB. The operative time taken in 42 patients (70%) was 30-45 min. 42 patients (70%) returned to normal activity in 3-5 days. Endoscopic cartilage tympanoplasty using allogenic nasal septal cartilage can be safely and effectively used for Type I tympanoplasty with good anatomical and audiological results with benefits of reduced operating time, morbidity, pain and 'No scar'.

Temporalis Fascia and Cartilage-Perichondrium Composite Shield Grafts for Reconstruction of the Tympanic Membrane

Objectives

We sought to compare the long-term functional results of tympanic membrane reconstruction with temporalis fascia and cartilage shield grafting.

Methods

This study includes 113 patients who had tympanoplasty type I tympanic membrane reconstruction between 1997 and 2007, 47 with tragal cartilage and 66 with temporalis fascia. Fourteen patients in the cartilage group and 9 patients in the temporalis fascia group also had mastoidectomy. The average follow-up was 3.2 years. The hearing threshold was calculated as the mean value of the thresholds for 500, 1,000, 2,000, and 3,000 Hz. A paired-samples t-est was used for comparison of the preoperative and postoperative air and bone conduction hearing thresholds and air-bone gaps.

Results

Significant recovery was found in the postoperative air conduction threshold and air-bone gap in both the temporalis fascia and cartilage groups as compared to those before surgery (p < 0.001). However, the average air and bone conduction thresholds and air-bone gap were found to be statistically different after surgery in the cartilage group as compared to those in the temporalis fascia group. There was no significant difference in hearing parameters before and after surgery in patients with or without mastoidectomy in either the cartilage group or the temporalis fascia group.

Conclusions

The hearing gain in patients with cartilage shield grafting was better than that in those who had temporalis fascia tympanoplasty, although experimental analysis shows loss of acoustic energy for thick and large shield cartilage grafts.

The audiological and take results of perichondrium attached cartilage island graft in tympanoplasty: PACIT

Cartilage is one of the most preferable grafts for tympanoplasty (TPL). The anatomical and audiological results and take rates of perichondrium attached cartilage island graft in tympanoplasty (PACIT) are presented herein. One hundred ninety four ears of 191 patients (108 male, 83 female) were evaluated retrospectively in terms of the type of surgery, graft take rate and hearing results. Type I, II, and III TPL were performed in 127 (65.46%), 45 (23.20%), and 22 (11.34%) ears, respectively. The overall mean preoperative pure tone average-air bone gaps (PTA-ABGs) for TPL types were 33.74 ± 9.60, 52.58 ± 9.07, and 56.58 ± 10.27 dB HL, respectively; postoperative mean values for TPL groups were 18.55 ± 9.25, 31.21 ± 4.36, and 44.84 ± 12.45 dB HL. Postoperative hearing results showed an improvement (≥ 10 dB) in 76.81% of ears with a mean gain of 20 dB HL (range 10-40 dB). However, 19.07% of ears showed no change (< 10, ≥ 0 dB) in hearing, and hearing worsened in 4.12% of ears (< 0 dB) postoperatively. Overall, graft take was 91.24% at least 13 months (mean 68.64) after surgery with a graft failure rate of 8.76%. Graft take was successful in TPL groups. Postoperative PTA-ABG results demonstrated significant improvement. The long-term eligibility of perichondrium attached cartilage island graft in TPL is emphasised with this study.

Comparative study of sliced tragal cartilage and temporalis fascia in type I tympanoplasty

OBJECTIVE

To compare anatomical and audiological results using sliced tragal cartilage and temporalis fascia in type I tympanoplasty.

METHOD

A retrospective review was undertaken of primary tympanoplasties using sliced tragal cartilage and temporalis fascia from May 2005 to January 2008. In total, 223 ears were operated on using sliced tragal cartilage graft and 167 using temporalis fascia. Statistical analysis of the outcome data was performed.

RESULTS

At the two-year and four-year follow ups, successful closure of the tympanic membrane was achieved in 98.20 per cent and 97.75 per cent, respectively, of the cartilage group compared with 87.42 per cent and 82.63 per cent, respectively, of the temporalis fascia group. At the four-year follow up, the average air-bone gap was 7.10 ± 3.01 dB in the cartilage group and 8.05 ± 3.22 dB in the temporalis fascia group.

CONCLUSION

The overall success rate for primary cartilage tympanoplasty is higher when using sliced cartilage than with temporalis fascia grafting.

Tragal cartilage shield tympanoplasty: our technique and results in 612 cases

CONCLUSION

This study reveals that tragal cartilage tympanoplasty is a reliable technique, it has a high degree of graft take, and the tympanic re-aeration and hearing results are satisfactory.

OBJECTIVE

Cartilage is the grafting material of choice in advanced pathologies of the middle ear while the indications for its routine use remain controversial. The purpose of this study was to report our long-term experience with the 'tragal cartilage shield' tympanoplasty.

METHODS

This was a retrospective case series. The study was conducted on 612 adult patients from January 2003 until January 2012. We evaluated graft take, pure-tone average air-bone gap (PTA-ABG), postoperative aeration, and complications. The mean postoperative follow-up was 68 months.

RESULTS

Sex, age, and tobacco smoke did not have any impact on postoperative results. Graft take was achieved in 99.35% of patients; there were no immediate postoperative complications. The overall average preoperative PTA-ABG was 44.95 ± 7.77 dB, whereas 1 year after surgery it was 10.66 ± 5.41 dB (p < 0.0001). Statistically significant improvement was observed up to 10 years after surgery. Moreover, we obtained a good tympanic ventilation (1 year after surgery, the average aeration score was 9.09 ± 1.93), which was stable up to 10 years.

Cartilage graft or fascia in tympanoplasty in patients with low middle ear risk index (anatomical and audological results)

The aim of this study was to compare anatomic and audiological results of cartilage graft with temporal fascia graft in type 1 tympanoplasty patients with low middle ear risk index (MERI). In this retrospective study, 63 patients that underwent type 1 tympanoplasty with chondroperichondrial island graft between July 2009 and November 2010 were compared with 45 patients in whom temporal muscle fascia was used. Patients in both groups had low MERI values varying between 1 and 3. Five and nine patients underwent masteidectomy in cartilage and fascia group, respectively. Mean duration of follow-up was 11.9 ± 3.7 (5-17) months. Mean value was calculated at pre-operative and post-operative hearing threshold 0.5, 1, 2, 4 kHz, and air bone gap (ABG) gain was compared in both cartilage and fascia groups. when pre-operative and post-operative ABG gain were compared, significant decrease was seen in ABG levels (p < 0.001). However, no significant difference was seen in ABG gain values (p = 0.608), which was 10.1 ± 7.00 dB in cartilage group and 10.8 ± 5.38 dB in fascia group. In both groups, age, sex, and the addition of mastoidectomy procedure had no significant effect on ABG gain and success. Cartilage is a graft material that may be preferred without concern about the effects on hearing results, especially, in patients with low MERI values. The addition of mastoidectomy had no impact on the outcome of operation and audiological results. However, further studies with larger case series may be carried out to further clarify the issue.

Long-term histologic changes and effects of perichondrium preservation of auricular cartilage grafted in rabbit tympanic bullae

INTRODUCTION

This study evaluated the long-term histologic changes of grafted auricular cartilage in rabbit tympanic bullae.

MATERIALS AND METHODS

Auricular cartilage with or without perichondrium was prepared and cut into small pieces to obliterate the rabbit tympanic bullae. The histologic changes of the grafted cartilage in both groups were compared 20 months after surgery.

RESULTS

Remarkable spongy bony trabeculae of mature lamellar bone with red bone marrow formation were observed in the perichondrium-preserved group. Parts of the grafted cartilage pieces were invaded and replaced by bone and bone marrow. The grafted cartilage pieces grossly maintained their original polygonal shapes, and no osteochondral tissue regeneration was observed in the perichondrium-removed group. The viable chondrocyte ratios were 46.21 ± 5.58 versus 27.80 ± 4.81%, and the minimal resorption ratios were 10.31 ± 3.27 versus 2.98 ± 1.48% in the perichondrium-preserved (n = 14) and -removed groups (n = 12, p < 0.05). The tissue ratios were cartilage: 38.18 ± 8.76 versus 52.97 ± 9.30%; lamellar bone: 18.49 ± 5.31 versus 0.82 ± 0.43%; bone marrow: 20.72 ± 6.27 versus 0.00 ± 0.00%; fibrous tissue: 10.13 ± 2.74 versus 5.81 ± 2.20%, and adipose tissue: 12.01 ± 4.48 versus 40.70 ± 7.83% in the perichondrium-preserved and -removed groups. The differences were all statistically significant (p < 0.05).

CONCLUSION

A space-filling mass effect with minimal resorption of the cartilage pieces was observed in the perichondrium-removed group. In addition to this mass effect, the progenitor cells in the preserved perichondrium allowed active bone tissue regeneration and cartilage resorption in the perichondrium-preserved group.

Primary cartilage tympanoplasty: our technique and results

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-perichondrium composite 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%.

CONCLUSION

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

[Myringoplasties. A retrospective analysis of our surgical outcomes]

OBJECTIVE

The aim of this study was to present, myringoplasty case results in our department. Different factors were studied to confirm their prognostic value.

MATERIALS AND METHODS

A total of 126 myringoplasties from 2006 until 2010 were reviewed, collecting patient-related details, descriptions of the anatomical defect and the most interesting surgical aspects.

RESULTS

Subtotal perforations (35.7%) were the most frequently observed. In 89.7% of the operations, the transcanal approach was preferred. The medial technique (underlay) to the tympanic membrane was the most performed (97.6%). Cartilage was the principal graft used (82.5%). Complete closure of the perforation was obtained in 71.1% of the cases at 6 months follow-up. Recurrences of the perforations were of minimal size in 11.9% of the cases, partial in 11.1% and with a cartilage fragment gap in 4.8%. The mean time in which these defects were registered was 3.82 months. The mean post-operative auditory gain was 12.8 decibels at 6 months.

CONCLUSIONS

Myringoplasty is an appropriate technique for restoring tympanic integrity and obtaining functional benefit. Dried middle ear mucosa and posterior perforations seem to be related with better functional results.

Efficacy of cartilage palisade tympanoplasty: randomized controlled trial

OBJECTIVES

To calculate the efficacy (evaluating both morphologic and functional results) of cartilage palisade tympanoplasty (CPT) in comparison with tympanoplasty involving a temporalis muscle fascia (FT) graft.

STUDY DESIGN

Randomized controlled trial.

SETTING

General Hospital.

PATIENTS

One hundred twenty-three patients with chronic otitis media who were recruited for the study between the years 1997 and 2002.

INTERVENTION(S)

Sixty-four patients were randomly allocated to the group receiving CPT and the remaining 59 to the group undergoing tympanoplasty with FT.

MAIN OUTCOME MEASURE

The primary endpoint was defined as "morphological success," a composite variable that includes the absence of perforation, atelectasis, atrophy, lateralization, otorrhea, and blunting. The secondary endpoints were defined as functional hearing results.

RESULTS

Both treatment groups were homogeneous with regard to the main baseline characteristics studied. Morphologic success at 24 months in the CPT group was 51 of 62 (82.26%), whereas in the FT group, it was 38 of 58 (64.41%; p = 0.03; relative risk = 1.28; 95% confidence interval (CI) = 1.02-1.60). The relative risk for morphologic success, adjusted for a multivariate model, was 1.36 (95% CI = 1.11-1.38), whereas the adjusted NNT was 5 (95% CI = 4-15). No statistically significant differences were found between the functional results of both treatment groups.

CONCLUSION

Cartilage palisade tympanoplasty is a more effective technique for reconstructing the tympanic membrane than FT for the population studied.

Cartilage tympanoplasty: Indications, techniques, and outcomes in A 1,000-patient series

OBJECTIVES/HYPOTHESIS

The purpose of this study was to analyze the anatomical and audiologic results in more than 1,000 cartilage tympanoplasties that utilized a logical application of several techniques for the management of the difficult ear (cholesteatoma, recurrent perforation, atelectasis). Our hypothesis was that pathology and status of the ossicular chain should dictate the technique used to achieve optimal outcome.

STUDY DESIGN

Retrospective clinical study of patients undergoing cartilage tympanoplasty between July 1994 and July 2001. A computerized otologic database and patient charts were used to obtain the necessary data.

METHODS

A modification of the perichondrium/cartilage island flap was utilized for tympanic membrane reconstruction in cases of the atelectatic ear, for high-risk perforation in the presence of an intact ossicular chain, and in association with ossiculoplasty when the malleus was absent. A modification of the palisade technique was utilized for TM reconstruction in cases of cholesteatoma and in association with ossiculoplasty when the malleus was present. Hearing results were reported using a four-frequency (500, 1,000, 2,000, 3,000 Hz) pure-tone average air-bone gap (PTA-ABG). The Student t test was used for statistical comparison. Postoperative complications were recorded.

RESULTS

During the study period, cartilage was used for TM reconstruction in more than 1,000 patients, of which 712 had sufficient data available for inclusion. Of these, 636 were available for outcomes analysis. In 220 cholesteatoma cases, the average pre- and postoperative PTA-ABGs were 26.5 +/- 12.6 dB and 14.6 +/- 8.8 dB, respectively (P <.05). Recurrence was seen in 8 cases (3.6%), conductive HL requiring revision in 4 (1.8%), perforation in 3 (1.4%), and post- and intraoperative tube insertion in 11 (5.0%) and 18 ears (8.2%), respectively. In 215 cases of high-risk perforation, the average pre- and postoperative PTA-ABGs were 21.7 +/- 13.5 dB and 11.9 +/- 9.3 dB, respectively (P <.05). Complications included recurrent perforation in 9 ears (4.2%), conductive HL requiring revision in 4 (1.9%), postoperative and intraoperative tube insertion in 4 (1.9%) and 6 ears (2.8%), respectively. In 98 cases of atelectasis, the average pre- and postoperative PTA-ABGs were 20.2 +/- 10.9 dB and 14.2 +/- 10.2 dB, respectively (P <.05). Complications included 1 perforation (1.0%), conductive loss requiring revision in 2 cases (2.0%), and post- and intraoperative tube insertion in 7 (7.1%) and 12 ears (12%), respectively. In 103 cases to improve hearing (audiologic), the average pre- and postoperative PTA-ABGs were 33.6 +/- 9.6 dB and 14.6 +/- 10.1 dB, respectively (P <.05). Complications included 1 perforation (1.0%), conductive loss requiring revision in 11 (11%), and post- and intraoperative tube insertion in 6 (5.8%) and 2 (1.9%), respectively.

CONCLUSIONS

Cartilage tympanoplasty achieves good anatomical and audiologic results when pathology and status of the ossicular chain dictate the technique utilized. Significant hearing improvement was realized in each pathological group. In the atelectatic ear, cartilage allowed us to reconstruct the TM with good anatomic results compared to traditional reconstructions, which have shown high rates of retraction and failure. In cholesteatoma, cartilage tympanoplasty using the palisade technique resulted in precise reconstruction of the TM and helped reduce recurrence. In cases of high-risk perforation, reconstruction with cartilage yielded anatomical and functional results that compared favorably to primary tympanoplasty using traditional techniques. We believe the indications for cartilage tympanoplasty (atelectatic ear, cholesteatoma, high-risk perforation) were validated by these results.

Cartilage tympanoplasty

This chapter describes two techniques for cartilage reconstruction of the tympanic membrane: the perichondrium/cartilage island flap, which uses tragal cartilage, and the palisade technique, which uses cartilage from the tragus or cymba. The perichondrium/cartilage island flap is preferred for management of the atelectatic ear and the high-risk perforation. The palisade technique is preferred in cases of cholesteatoma and when ossicular reconstruction is needed in the malleus-present situation. Descriptions of the modifications that should be taken in response to specific surgical indications are also provided and include the high-risk perforation, the ear requiring ossiculoplasty, the atelectatic ear, cholesteatoma, and pervasive Eustachian tube dysfunction.

Endoscopic Transtympanic Tympanoplasty in the Treatment of Conductive Hearing Loss: Early Results

OBJECTIVE

We describe our initial experience with endoscopic transtympanic tympanoplasty and evaluate whether this approach is adequate and minimally invasive in the treatment of conductive hearing loss.

STUDY DESIGN

Prospective trial.

SETTING

University hospital.

PATIENTS

Nine patients underwent endoscopic transtympanic tympanoplasty, with an average follow-up period of 17 months. Presurgical diagnosis was made by transtympanic endoscopy through a perforation made by OtoScan laser-assisted myringotomy in the outpatient clinic.

METHODS

With clean endoscopic visualization, ossiculoplasty was performed by inserting a trimmed tragal cartilage through the myringotomy perforation made by laser-assisted myringotomy. Two types of ossiculoplasty were performed: columella reconstruction and interposition. The tympanic membrane was covered with a chitin membrane or sealed with a small piece of perichondrium from the tragal cartilage.

MAIN OUTCOME MEASURES

Perioperative and postoperative complications and preoperative and postoperative hearing.

RESULTS

Endoscopic transtympanic tympanoplasty with columella and endoscopic transtympanic tympanoplasty with interposition were performed in seven and two patients, respectively. Insertion of the cartilage was performed without conversion to a conventional otomicroscopic technique. The average hearing level before the operation was 59 dB. After the endoscopic transtympanic tympanoplasty, the average improved to the level of 27 dB, with an average air-bone gap of 11 dB. The myringotomy perforation was closed within 2 to 3 weeks.

CONCLUSION

As opposed to conventional methods, this procedure does not require surgical exposure such as otosclerosis drilling and skin incision, and avoids the substantial risk of unnecessary injury to the chorda tympani. Endoscopic transtympanic tympanoplasty for a disrupted ossicular chain is an adequate and minimally invasive procedure and should prove to be a useful surgical procedure in future endoscopic tympanoplasty.

Trommelfellrekonstruktion mit Knorpel

Autogenous cartilage-perichondrium-composite-grafts have become essential and well established transplant materials in reconstructive middle ear surgery. They have proven to be particularly appropriate for surgical situations which benefit from the bradytrophy and stiffness of the cartilage (adhesive otitis, retraction pockets, subtotal tympanic membrane defects, revision tympanoplasty). Of the numerous techniques available, the perichondrium-island technique and the palisade-cartilage technique are described in detail in this review, also regarding modifications and comments in the literature. Both methods show good functional and morphological results and should be chosen according to individual surgical requirements. The data of experimental investigations are involved in the decision which technique should be favored.

[Tympanoplasty using cartilage: 3 years of experience]

We present our results in a timpanoplasty technique using autologous cartilage, in a retrospective study of 71 cases within 3 years. We used this technique in revision surgery, large perforations, severe retractions, and atrophic membranes. 32% of cases needed ossicular chain reconstruction. A complete closing of the membrane was obtained in 86% of cases, while 14% remained re-perforated or discontinued between cartilage pieces. These results are comparable to other studies using cartilage graft with several techniques. These results encourage us to continue using this technique in order to acquire more experience and a better knowledge about the efficacy of this technique.