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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 20  |  Issue : 3  |  Page : 106-114

Evaluation of different graft material in type 1 tympanoplasty


1 Department of ENT, ENT Hospital, Amravati, Maharashtra, India
2 Department of ENT, Maharshi Markendeshwar Institute of Medical Science and Research, Mullana, Ambala, Haryana, India
3 Department of ENT, Jawaherlal Nehru Medical College, DMIMS, Sawangi (Meghe), Wardha, Maharashtra, India

Date of Web Publication16-Jul-2014

Correspondence Address:
Nitish Baisakhiya
F-8, MMU Campus, Mullana, Ambala - 133 207, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-7749.136844

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  Abstract 

Aims and Objective: The present study was undertaken to compare the results of various autogeneous tissues temporalis fascia, tragal perichondrium, and fascia lata as graft materials for the type 1 tympanoplasty. Materials and Methods: A total of 120 cases with large, subtotal and total perforation were considered in the study. Of the 120 cases, temporalis fascia graft was used in 60 cases (Group-I), tragal perichondrium graft in 40 cases (Group-II), and fascia lata graft in 20 cases (Group-III). The results were evaluated in the form of rate of graft success, hearing gain, and mean residual air-bone gap with respect to the graft materials. Results and Observation: A nonsignificant association was observed between the groups, that is, temporalis fascia (Group-I), tragal perichondrium (Group-II), and fascia lata (Group-III) and the graft uptake. (P = 0.96 > 0.05) and air bone closure (χ2 = 2.908, P = 0.059 > 0.05). Conclusion: The graft take-up rate and Hearing improvement are similar for the different graft materials used. Size of the perforation doesn't significantly influence the success rate of tympanoplasty as per our study. Normal translucent appearance of neotympanum in the postoperative period was seen only with temporalis fascia, while in tragal perichondrial and fascia lata grafts the neotympanum was whitish, thicker, and translucent to opaque.

Keywords: Fascia lata, Perichondrium, Temporal fascia, Tympanoplasty


How to cite this article:
Patil K, Baisakhiya N, Deshmukh P T. Evaluation of different graft material in type 1 tympanoplasty. Indian J Otol 2014;20:106-14

How to cite this URL:
Patil K, Baisakhiya N, Deshmukh P T. Evaluation of different graft material in type 1 tympanoplasty. Indian J Otol [serial online] 2014 [cited 2019 Apr 22];20:106-14. Available from: http://www.indianjotol.org/text.asp?2014/20/3/106/136844


  Introduction Top


Chronic otitis media is the chronic inflammation of mucoperiosteal lining of the middle ear cleft characterized by ear discharge, a permanent perforation of the tympanic membrane and impairment in hearing. It is one of the most common ear diseases encountered in developing countries due to poor socio-economic standards, poor nutrition, lack of health education and unhygienic habits. [1],[2],[3] It is a major cause for deafness in India. [4] Tympanoplasty is now an established surgery for tympanic membrane perforations being carried out routinely by otorhinolaryngologists. [5] Autologous graft materials such as, temporalis fascia, tragal perichondrium, cartilage, fat, and fascia lata have stood the test of time in repairing tympanic membrane perforations. Such abundance of materials implies that there is no clear cut favorite and the choice of graft material depends on individual surgeon's preference. [6],[7] However, due to its anatomic proximity, translucency, and suppleness, temporalis fascia is the most preferred grafting materials among the otologists and successful closure is anticipated in approximately 90% of primary tympanoplasties. Failure rates are higher in larger perforations with temporalis fascia as a graft material. [8],[9] Graft displacement, improper placement, [10] autolysis, infection, hemorrhage,  Eustachian tube More Details dysfunction are the known contributing factors for the failure of closure of perforation. Thus, consistent achievement of good hearing is still a challenge and one of the most difficult tasks of otology surgery. Keeping all these factors in mind and in the light of good results, the present comparative study of different graft materials, that is, temporalis fascia, tragal perichondrium, and fascia lata in underlay tympanoplasty was undertaken to evaluate the postoperative graft take-up and hearing improvement.

Aims and objective

The present study was undertaken to compare the results of various autogeneous tissues as graft materials for the repair of the tympanic membrane perforation. The study comprised of autogeneous materials like temporalis fascia, tragal perichondrium, and fascia lata, which are easily available in adequate amount, have good contour, can be thinned down and possess good survival capacity. Being mesodermal in origin, they are free from the possibility of postoperative cholesteotoma.

The aims and objectives of this study were:

  • To compare the graft take-up following type-I tympanoplasty with the use of graft materials temporalis fascia, tragal perichondrium, and fascia lata materials
  • To compare the hearing improvement following type-I tympanoplasty with the use of these graft materials
  • To compare the graft take-up following type-I tympanoplasty in different age groups
  • To study the age and sex distribution of the tubo-tympanic, that is, safe type of chronic otitis media
  • To study the degree of hearing loss in tubo-tympanic, that is, safe type of chronic otitis media.



  Materials and Methods Top


Since the main objective of the study was to assess the graft materials for tympanoplasty with respect to long-term anatomical and functional restorations, cases were selected for the study based on following criteria:

Inclusion criteria

  • Unilateral chronic otitis media of safe or tubo-tympanic type having large, subtotal or total central perforation
  • Conductive hearing loss
  • All the ears were dry for at least 6 weeks before the surgery
  • Age above 12 years and below 60 years.


Exclusion criteria

  • Patients having active ear discharge
  • Patients having any obvious ossicular dysfunction
  • Patients with sensorineural hearing loss
  • Patients having unsafe or atticoantral disease
  • Patients with complications of chronic suppurative otitis media, any external ear pathology, sinonasal pathology, nasal allergy, or any systemic disorder.


Any septic focus in the form of chronic tonsillitis, sinusitis etc., was treated first. Patients with ear discharge were initially treated conservatively and were included in the study only when their ear became dry for at least 6 weeks.

With this criteria 120 systemically healthy patients aged between 12 and 60 years having safe or tubo-tympanic type of chronic otitis media with central perforation and conductive hearing loss visiting ENT. Out-patient Department of Acharya Vinoba Bhave Rural Hospital and Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha, were found suitable for the study and were selected for the study.

Study design

A prospective study was carried out from July 2007 to September 2009. Type-I tympanoplasty by underlay technique, using postaural approach was done for all the cases selected for the study. Any patients requiring ossiculoplasty were subsequently excluded from the study.

Of the 120 cases, as per the consent obtained for the use of graft materials, temporalis fascia graft was used in 60 cases (Group-I), tragal perichondrium graft in 40 cases (Group-II), and fascia lata graft in 20 cases (Group-III).

Methodology

All patients underwent routine ENT evaluation in addition to general medical examination. Ear findings were noted with emphasis on size, site, and margin of perforation, state of drum remnants, state of middle ear mucosa, presence or absence of ear discharge, and tuning fork tests. All details regarding history examination, investigations, and surgery and follow-up findings were documented on specially prepared proforma.

Clinical investigations

Pure-tone audiometry and otomicroscopy.

  • Radiological investigations
  • X-ray mastoid-schullers view of both mastoids was taken in all cases to rule out any associated mastoid pathology and to look for the pneumatization, i.e., well pneumatized, diploic or sclerotic mastoids
  • X-ray paranasal sinuses were taken in selected cases to rule out sinus pathology.


Routine investigations such as complete blood count, random blood sugar, bleeding time, clotting time, blood grouping, liver and renal function tests, routine and microscopic examination of urine and chest X-ray were done on admission.

Surgical procedure

Patients were underwent tympanoplasty under local anesthesia and if require under general anesthesia. All cases were done by postaural approach and graft was kept by underlay technique. Temporal fascia and tragal perichondrium were taken by the conventional method. Fascia lata were taken by a very small cosmetically accepted incision.

Postoperative follow-up

Thereafter, all patients were called for regular follow-up once weekly for 1 month and fortnightly for 3 months, then after 6 months and 1 year. Hearing assessment with tuning fork tests and pure-tone audiometry was repeated once the tympanic membrane healed (at 4-6 weeks). Thereafter, the status of the healed neotympanum was recorded and pure-tone audiometry was done to access the auditory status after 8 th week, 3 months, 6 months and 1 year to see if there are any changes.

Statistical analysis

The results were evaluated in the form of graft uptake, hearing outcome and complications. Healed neo-tympanic membrane, which move on seiglization was taken as successful graft take-up, while any residual perforations or retraction of neo-tympanum were taken as failures. Postoperative and preoperative pure-tone audiograms were compared. Hearing gain and mean residual gaps were evaluated in speech frequencies of 500, 1000, and 2000 Hz.

The collected data were tabulated and statistical analysis was performed by estimating rates, means and standard deviations. Statistical analysis with the Student's t-test, Chi-square test, and F-test for large sample size was used to examine these parameters with regards to graft take-up and hearing improvement and comparisons were made between the three patient groups. The criteria for statistical significance were set at P < 0.05.


  Observation and Results Top


The primary aim of this study was to compare the rate of success of the different graft materials in terms of graft take-up and hearing improvement. To meet these goals, in this study of 120 cases of tubo-tympanic chronic otitis media with conductive hearing loss who underwent tympanoplasty, primarily we have observed and analyzed the rate of graft success, hearing gain, and mean residual air-bone gap (ABG) with respect to the graft materials temporalis fascia, tragal perichondrium, and fascia lata following surgery. During the study, we have also observed distribution of the age, sex, etiology, size of perforation, its relation to hearing loss and graft success rate.

For the purpose of analysis, these 120 patients selected for the study, having similar pathology (benign large, subtotal, or total central perforations with conductive hearing loss with intact and mobile ossicular chain) were divided into groups according to the graft material used for tympanoplasty as per the consent obtained from the patient for the use of different graft materials. Thus in Group-I, 60 patients underwent tympanoplasty using temporalis fascia, in Group-II, 40 cases underwent tympanoplasty using tragal perichondrium and in Group-III, 20 cases underwent tympanoplasty using fascia lata. These patients were operated in the same surgical setup, by senior staff members of the department.

Maximum number of patients, that is, 41 (34.16%) were from the age group of 12-20 years, followed by 29 (24.16%) in 21-30 years, 23 (19.16%) patients in 31-40 years, 17 (14.16%) patients in 41-50 years, and 10 (8.33%) patients in 31-40 years. The mean age of all the cases together was 29.8 years with a standard deviation of 12.94 years. Due to the large standard deviation the median age was calculated as 28 years. The age of the youngest Patient was 12 years and the oldest was 59 years as shown in [Table 1]. In the present study, male and female population were compared and it was found that out of 120 patients, 68 patients (56.66%) were males and 52 patients (43.33%) were females as shown in [Table 2]. Examining the relationship between the cause and the disease it was observed that most of the tympanic perforation, that is, 110 (91.67%) were infective in origin while 10 (8.33%) cases were traumatic in origin. In our study, we have divided the perforations of the tympanic membrane into three categories depending on the size of the perforation, i.e., large, subtotal and total central perforation involving about 50-75%, 75-100%, and 100% of the tympanic membrane respectively as shown in the figure. Small and moderate size perforations are not included in our study to avoid bias. Maximum number of cases had subtotal perforation, that is, 59 cases (49.17%), followed by large central perforation in 51 cases (42.5%), while 10 cases (8.33%) had total perforation as in [Table 3] and [Figure 1].
Figure 1: Size of the perforations of the patients included in this study

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Table 1: Age wise distribution of patients in this study (n)

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Table 2: Sex distribution patients in this study (n)

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Table 3: Distribution of size of the perforation (n)

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In our study, the preoperative hearing loss with respect to the various sizes of perforations was also studied. The average preoperative air conduction (AC) and bone conduction (BC) thresholds at speech frequencies 500, 1000, and 2000 Hz were taken into consideration.

According to our study as shown in [Table 4], the mean preoperative AC threshold was found to be maximum for cases with total perforations which were 49.15 ± 7.34 dB, followed by subtotal perforations of 35.38 ± 10.10 dB and for large perforations it was 31.73 ± 9.84 dB. The overall preoperative, mean preoperative AC was 34.72 ± 10.4 dB. The mean preoperative ABG was found to be maximum for cases with total perforations which was 24.56 ± 5.77 dB, followed by subtotal perforations of 20.44 ± 5.39 dB and for large perforations it was 19.5 ± 5.6 dB. The overall mean preoperative ABG was 20.38 ± 5.62 dB. Thus hearing loss is increased with an increase in the size of perforation. For temporalis Fascia (Group-I), 52 of the 60 cases (86.67%) showed successful graft uptake, while seven cases showed residual perforation while one case showed retracted graft accounting to eight failures (13.33%). For tragal perichondrium (Group-II), 35 out of 40 cases (87.50%) showed successful graft uptake while eight cases (12.50%) had residual perforations; and for fascia lata (Group-III), 17 of the 20 cases (85%) showed successful graft uptake, while two cases showed residual perforation and graft was retracted in one case, accounting to three failures (15%) as shown in [Table 5]. Thus Overall out of 120 patients undergoing tympanoplasty, in 104 (86.67%) patients grafts were accepted successfully, while 16 (13.33%) patients had residual perforations.
Table 4: Preoperative hearing loss in relation to perforation size

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Table 5: Results of tympanoplasty with respect to graft material

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A nonsignificant association was observed between the groups, i.e., temporalis fascia (Group-I), tragal perichondrium (Group-II), and fascia lata (Group-III) and the Graft uptake. (P = 0.96 > 0.05) revealing that the pattern of graft take-up was same statistically in all the three groups.

Healing was faster in tragal perichondrium (Group-II) and took about 2-3 weeks, followed by temporalis fascia which took about 2-4 weeks. Fascia lata took longer time to take-up about 4-5 weeks and looked pale white and thicker in early postoperative period and neovascularization was seen only after 1 month postoperatively.

In this study, we have observed that after healing, normal translucent appearance of neotympanum in the postoperative period was seen only with temporalis fascia while with tragal perichondrial and fascia lata grafts the neotympanum was whitish, thicker and translucent to opaque, which may compromises the discovery of recurrence of disease and iatrogenic cholesteatoma formation.

As a difference in graft success with respect to the graft materials (groups) was not significant statistically, we also studied surgical outcome for these graft materials (groups) with respect to the size of the perforation. A nonsignificant association was observed between the graft success in groups and the size of perforation (P > 0.05) revealing that the pattern of graft take-up was same statistically in all the three groups, indicating that the successful graft take-up with respect to graft materials (groups) doesn't depend on the size of the perforation also.

Among the temporalis fascia (Group-I) patients, graft take-up rate of large central perforations was 85.19% (23/27 cases), subtotal perforations was 88.89% (24/27 cases), and total perforations was 83.33% (5/6 cases).

Among the tragal perichondrium (Group-II) patients, graft take-up rate of large central perforations was 94.74% (18/19 cases), subtotal perforations was 83% (15/18 cases), and total perforations was 67% (2/3 cases) as in [Table 6].
Table 6: Graft success/failure with respect to size of perforation

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Among the fascia lata (Group-III) patients, graft take-up rate of large central perforations was 100% (5/5 cases), subtotal perforations was 78.5% (11/14 cases), and total perforations was 100% (1 case).

Overall the cases of large central perforations faired well with successful graft take-up in 90.2% (46/51 cases), subtotal perforations had a successful graft take-up in 84.75% cases (50/59 cases), total perforations had successful graft take-up in 80% cases (8/10 cases).

A nonsignificant association was observed between the graft materials (groups) and the age groups (χ2 = 10.796, P = 0.2135) revealing that the pattern of distribution of scores of various age groups was same in the three groups statistically.

The mean postoperative ABG for Group-I (temporalis fascia) was 10.5 ± 4.35 dB, for Group-II was 10.97 ± 6.63 dB, for Group-III was 12.1 ± 4.33 dB with an overall postoperative ABG of 10.14 ± 4.74 dB. The mean gain in hearing for Group-I (temporalis fascia) was 9.36 ± 3.63 dB, for Group-II was 10.92 ± 5.82 dB, for Group-III was 12.10 ± 4.33 dB with an overall gain in hearing of 10.34 ± 4.68 dB as shown in [Table 7].

A nonsignificant association was observed between the graft materials (groups) and the Air-bone closure (χ2 = 2.908, P = 0.059 > 0.05) revealing that the pattern of distribution of scores of different categories of air-bone closure was same in the three groups statistically. However, a highly significant difference was observed between preoperative and postoperative air-bone closures, indicating that most of the cases had air-bone closures and thus gain in hearing. Also a nonsignificant association was observed between the graft materials (groups) and the gain in hearing (P > 0.05) revealing that the pattern of distribution of scores of gain in the hearing was same in the three groups statistically indicating uniform hearing improvement for all the three Graft materials (groups) as displayed in [Figure 2].
Figure 2: Age distribution of the patients included in this study (n)

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Table 7: Improvement in ABG with different graft materials

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{Figure 2}


  Discussion Top


Surgical repair of the tympanic membrane and tympanic membrane grafting have travelled a long way after initial reports of the tympanic membrane grafting filtered out of Germany in 1950s. These years have been filled with numerous technical advances that have improved surgery for tympanic membrane repair to high level of accuracy. A critical problem early in the development of tympanoplasty was finding a suitable material for tympanic membrane grafting. This evolution of the tympanic membrane grafting has been based on biological tissues of mesodermal origin which contain collagen matrix. [9] Temporalis fascia and perichondrium remains by far the commonly employed material today.

Age distribution

The possible predisposition of age towards disease was assessed and it was found that most of the cases, that is, 41 (34.16%) were in the age group of 12-20 years and least, that is, 10 cases (8.33%) in the age group of 51-60 years [Table 1] and [Figure 1]. The mean age of all the cases together was 29.8 years with a median age of 28 years (range: 12-59 years). Similar findings were noted in the study of Singh et al., [11] in which the mean age was 28.9 years (range: 13-48 years) and in the study of Dornhoffer [12] in which the mean age was 28 years (range: 9-57 years).

Sex distribution

Of the 120 patients, 68 patients (56.66%) were males and 52 (43.33%) were females [Table 2] and [Figure 2]. The bias probably may be attributed to the fact that only male patients gave consent for the use of fascia lata as a graft material for tympanoplasty. Similar findings were noted in the study of Dornhoffer [12] in which tragal perichondrium tympanoplasties were performed on 55% males and 45% on females patients. In the study of Strahan et al., [13] 62% were males and 38% were females.

Distribution of size of perforations

All the perforations were central perforations. In the present study, we have considered only large, subtotal and total central perforation involving about 50-75%, 75-100%, and 100% of the tympanic membrane area, respectively. The maximum number of cases, that is, 59 cases (49.17%) had subtotal perforation, followed by large central perforation in 51 cases (42.5%), while 10 cases (8.33%) had total perforation [Table 4]. Similar selection criteria regarding the size of perforation was used in the study of Indorewala [14] and Roychaudhuri [15] to have a consistency in the outcome and to avoid bias in the analysis of the results of surgery.

Preoperative hearing loss

The hearing loss is found to be increased with an increase in the size of perforation. The large perforations had a mean AC threshold of 32.12 dB, BC of 11.56 dB and mean ABG of 19.89 dB. The Subtotal perforations had AC of 35.38 dB, BC of 14.26 dB and ABG of 20.83 dB. Total perforations showed an AC of 44.47 dB, BC of 23.65 dB and mean ABG of 20.82 dB. Overall, the mean preoperative pure-tone AC threshold was 34.75 dB, BC was 13.89 dB and ABG was 20.43 dB [Table 5].

In a study conducted by Yung [13] (1983) large size perforations had a mean AC threshold of 30 dB, BC of 9.7 dB and mean ABG of 20 dB. Subtotal perforations had a mean AC of 43 dB, BC of 14.4 dB and mean ABG of 28.6 dB total perforations showed a mean AC of 48.5 dB, BC of 17 dB and ABG of 32 dB. Dornhoffer [12] reported mean preoperative ABG of 17.9 dB. Singh et al., [11] reported mean preoperative AC threshold of 32.3 dB, BC of 8.3 dB and ABG of 27.6 dB. Our results were comparable with the above studies for large and total perforations and the mean preoperative ABG.

Subtotal and total perforations had greater air and BC thresholds than large perforations. This can be attributed to direct exposure of round window, rendering the internal ear more vulnerable for damage. In addition, there is also loss of phase difference effect between the round window and oval window. In subtotal and total perforations, there is a greater loss of the ear drum surface with further reduction in areal ratio, than the large perforations.

When success rate of the tympanic membrane closure with different graft materials was compared, successful graft take-up rate of 86.67% was achieved for temporalis fascia (Group-I), 87.5% for tragal perichondrium (Group-II) and 85% for fascia lata (Group-III) with overall successful graft take-up rate of 86.67%. However, this difference in graft success was not significant statistically. Thus, our results suggest that type of graft material doesn't influence the successful graft take-up.

Our results are comparable with study of Strahan et al., [13] in which take-up rate of 87.5% was achieved using temporalis fascia and 86% by tragal perichondrium by underlay technique. Eviatar [16] noted that graft take rate with tragal perichondrium by underlay technique was 88% at the end of 1 year follow-up. Dornhoffer [12] achieved graft uptake success rate of 85% using tragal perichondrium by underlay technique. Rizer [17] achieved a success rate of 88.8% using temporalis fascia by underlay technique. Dabholkar et al., [7] compared temporalis fascia with Tragal Perichondrium in underlay tympanoplasty and achieved a graft success rate of 84% for Temporalis fascia and 80% for tragal perichondrium. Our results were comparable with the above studies.

In contrast to the present study Herman and Tang [10] achieved graft uptake success rate of 95.3% and Mathai [18] achieved graft uptake rate of 95% using by temporalis fascia. Sperm et al., [19] in a comparative study of different graft materials found a take-up rate of 91% with temporalis fascia and 92% using tragal perichondrium. Singh et al., [11] also found a graft success rate of 95% for temporalis fascia and 90% for tragal perichondrium. Results of these studies are higher than our study.

Indorewala [14] compared outcome of temporalis fascia with that of fascia lata and found a successful take-up rate of 89.19% for temporalis fascia and 96% for fascia lata for central perforations. The results of fascia lata in this study are higher than our study. In a study by Gupta et al., [20] they found a successful take-up rate of 92% for temporalis fascia, 91% for tragal perichondrium which is higher than our study and 75% for fascia lata which is less than our study. Al Lackany et al., [21] compared different graft materials in tympanoplasty and achieved a successful take-up rate of 80% with temporalis fascia, which is less than our study, and 92% with tragal perichondrium which is higher than our study.

We also studied results for graft materials with respect to size of the perforation. Among the temporalis fascia (Group-I) patients, graft take-up rate for large central perforations was 85.19%, subtotal perforations was 88.89%, and total perforations was 83.33%. Among the tragal perichondrium (Group-II) patients, graft take-up rate for large central perforations was 95%, subtotal perforations was 83%, and total perforations was 67%. Among the fascia lata (Group-III) patients, graft take-up rate for large central perforations was 100%, subtotal perforations was 78.5%, and total perforations was 100% (1/1 case). However, there was no significant statistical difference between these graft materials in relation to the size of the perforation.

In a study conducted by Indorewala, [14] temporalis fascia achieved graft success of 95% for large and 83% for subtotal perforations, while fascia lata achieved graft success of 98% for large and 95% for subtotal perforations. Al Lackany et al., [21] found that temporalis fascia achieved graft success of 86.7% for large and 82.3% for subtotal perforations and 66.6% for total perforations; while tragal perichondrium achieved graft success of 95% for large and 83.4% for subtotal perforations and 83.7% for total perforations. Our results were comparable with the above studies for large and subtotal perforations.

In our study, successful graft take-up of 87.8% was achieved in 12-20 years age group, 89.65% in 21-30 years age group, 81.81% in 31-40 years, 88.88% in 41-50 years age group, and 80% in 51-60 years age group. However, this difference was found to be statistically nonsignificant indicating that the graft success doesn't depend on the age of the patient [Table 8]. It was found that successful graft take-up rate in the age group of 12-15 years was 82.35% while in 15-20 years age group it was 91.66%. Chopra and Grover [22] found a higher success rate of 50% success in 9-11 years age group as opposed to 83.34% success in 12-14 years age group. Gupta and Mishra [23] found similar results (90.24%) in 12-15 years age group as compared to 8-11 years age group (81.8%). The probable explanation of high incidence of failure in younger children is due to increased incidence or upper respiratory tract infection and immature Eustachian tube function. They advocate deferring the surgery till 12 years of age for achieving better results. Singh et al., [11] achieved graft success of 93% in 11-20 years age group, 95% in 21-30 years, 87% in 31-40 years, 77% in 41-50 years age group. Strahan et al., [13] documented that the incidence of graft failure to restore hearing were higher in older age group. Our results were comparable with the above studies.
Table 8: Graft success in relation to the age groups

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In our study mean gain in ABG was not significantly different between the different graft materials used. The mean gain for temporalis fascia was 9.36 dB, tragal perichondrium was 10.92 dB, and for fascia lata was 12.10 dB [Table 7]. Similar findings were noted by Dornhoffer, [12] where in it was 10.2 dB for tragal perichondrium. In contrast to our study, Indorewala [14] noted a higher gain of 15 dB for fascia lata and 17 dB for temporalis fascia. Singh et al., [11] achieved mean gain of 9.3 dB for temporalis fascia, which are similar to this study and 8.5 dB for tragal perichondrium, which is lesser than our study.

In our study with temporalis fascia graft, good hearing results, that is, closure rate of ABG within 10 dB was found in 57.7% cases [Table 9] which is comparable to Singh et al., [11] (63%), Herman and Tang [10] (75%) and Dabholkar et al., [7] (76%), but is less than studies conducted by Strahan et al., [13] (82%) and Gupta and Mishra [23] (92%). Average hearing results, i.e., closure between 11 and 20 dB was found in 38.5% cases which is more than Dabholkar et al., [13] (24%). With tragal perichondrial graft, closure of ABG within 10 dB was found in 54.3% cases which is comparable to Singh et al., [11] (55.5%), but is less than Strahan et al., [13] (90%), Dornhoffer [12] (77%), Dabholkar et al., [13] (75%) and Gupta and Mishra [23] (83%). The closure between 11 and 20 dB was found to be 45.7% which is more than Dabholkar et al., [13] (25%). With fascia lata graft, the closure of ABG within 10 dB was found to be 70.6% which is comparable to Gupta and Mishra [23] (75%).
Table 9: Comparison of take rate of graft materials in different studies

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It was also observed that tragal perichondrium and fascia lata are thicker and stiffer than temporalis fascia and need not be dried and can be placed as wet graft and are easier to manipulate in the middle ear. Similar findings were noted by Singh et al., [11] Indorewala [14] and Gupta and Mishra. [23]

In this study we have observed that after healing, normal translucent appearance of neotympanum in the postoperative period is achieved only in temporalis fascia while in tragal perichondrial and fascia lata grafts the neotympanum was whitish and translucent to opaque which may compromises the discovery of recurrence of disease and iatrogenic cholesteatoma formation.


  Summary Top


The present prospective study was undertaken to compare the surgical outcome of the graft materials temporalis fascia, tragal perichondrium and fascia lata in type-I tympanoplasty in terms of graft take-up and hearing improvement. The results thus obtained are summarized as:

  • Most of the cases (34.16%) were from the age group of 12-20 years and least (8.33%) from the age group of 51-60 years
  • Males contributed to 56.66% cases and 43.33% were females
  • The most of the tympanic perforation, that is, 91.67% were infective in origin while 8.33% cases were traumatic in origin
  • Subtotal perforations were commonest followed by large central perforations and total perforations
  • Hearing loss was maximum for total perforations, followed by subtotal and large central perforations. The hearing loss is found to be increased with an increase in the size of perforatio
  • Most of the cases of tympanoplasty (82.5%) were operated under local anesthesia
  • Postaural approach and underlay technique was used for all cases
  • Graft success rate was 86.67% for temporalis fascia graft, 87.5% for tragal perichondrium graft and 85% for fascia lata graft with overall graft success rate of 86.67%
  • Graft Success rate for large central perforations was 90.2%, 84.75% for subtotal perforations and 80% for total perforations
  • Successful graft take-up of 87.8% was achieved in 12-20 years age group, 89.65% in 21-30 years age group, 81.81% in 31-40 years, 88.88% in 41-50 years, and 80% in 51-60 years age group
  • Successful graft take-up rate in the age group of 12-15 years was 82.35% while in 15-20 years age group it was 91.66%. Thus the graft success worsened with both extremes of age
  • The mean gain in air conduction threshold for temporalis fascia was 9.36 dB, tragal perichondrium was 10.92 dB, and for fascia lata was 12.10 dB
  • Good hearing result i.e., mean ABG closure within 10 dB was seen in 57.7% cases of temporalis fascia, 54.3% cases of tragal perichondrium and 70.6% cases of fascia lata. Average hearing result i.e., ABG closure between 11 and 20 dB was seen in 38.5% cases of temporalis fascia, 45.7% cases of tragal perichondrium and 29.4% cases of fascia lata, while poor hearing results i.e., ABG closure >20 dB result was seen only in 4% cases of temporalis fascia
  • Tragal perichondrium and fascia lata are thicker and stiffer than temporalis fascia and need not be dried and can be placed as wet graft and are easier to manipulate in the middle ear with ideal handling qualities
  • Healing was faster with tragal perichondrium followed by temporalis fascia. fascia lata graft took longer time of about 4-5 weeks for healing
  • Normal translucent appearance of neotympanum in the postoperative period was seen only with temporalis fascia while in tragal perichondrial and fascia lata grafts the neotympanum was whitish, thicker and transluscent to opaque
  • Graft preparation time for tragal perichondrium was longer as compared to temporalis fascia. While fascia lata needed preparing, painting and draping of a second surgical site which consumed time, thus increasing the overall time of the surgery.



  Conclusion Top


From the present study we may conclude that:

  • Temporalis fascia, tragal perichondrium and fascia lata free grafts provide viable autograft material for tympanoplasty
  • These materials are mesodermal in origin which excludes the risk of iatrogenic cholesteatoma
  • They achieve comparable and excellent graft takes of 86.7%
  • They achieve comparable and good hearing restoration
  • The very fact that the P value is nonsignificant in the graft take-up rate and the hearing improvement for the different graft materials shows that the graft take-up rate and hearing improvement are similar for the different graft materials used
  • Size of the perforation doesn't significantly influence the success rate of tympanoplasty
  • Tragal perichondrium and fascia lata are thicker and stiffer than temporalis fascia. They are easier to manipulate in the middle ear as they do not get folded on itself, thus have ideal handling qualities
  • However, graft preparation time for tragal perichondrium was longer and fascia lata needed preparing, painting, and draping of a second surgical site increasing the overall time of the surgery
  • Normal translucent appearance of neotympanum in the postoperative period was seen only with temporalis fascia while in tragal perichondrial and fascia lata grafts the neotympanum was whitish, thicker, and translucent to opaque
  • Thus with all the things being equal, the graft material doesn't influence the success rate of tympanoplasty in terms of graft take-up and hearing improvement.


 
  References Top

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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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