|Year : 2015 | Volume
| Issue : 3 | Page : 165-169
Temporalis muscle fascia and cartilage palisade technique of type 1 tympanoplasty: A comparison
Kumar Subhanshu, Rohit Sharma, Vinit K Sharma
Department of ENT, Head and Neck Surgery, SRMS Institute of Medical Sciences, Bareilly, Uttar Pradesh, India
|Date of Web Publication||17-Jul-2015|
Department of ENT, Head and Neck Surgery, SRMS Institute of Medical Sciences, Ram Murti Puram, Bareilly - 243 202, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: Chronic suppurative otitis media is one of the common causes of deafness in india and occupies a considerable amount of clinic and operating time of otolaryngologists. Materials and Methods: This was a prospective study containing 50 patients, which was further divided into two groups of 25 patient each. One group was cartilage palisade technique group and other was temporalis fascia technique group (TFT group). Detailed history and examination along with pure tone audiometry was performed. Pre- and postoperative hearing results and graft uptake were compared. All surgeries were performed through the post aural approach. Cartilage was harvested from cymba concha and fascia from temporalis muscle. Results: Hearing improved significantly when either of the technique was used. Though this was slightly better, but stastically insignificant in TFT. there was no significant difference in the graft uptake rates, but it was better in cases of Eustachian tube dysfunction when cartilage palisades were used. Conclusion: There was no statistically significant difference in results in terms of success and auditory function but cartilage palisade technique gave better results in specific conditions like Eustachian tube dysfunction.
Keywords: Cartilage palisade, Temporal fascia, Tympanoplasty
|How to cite this article:|
Subhanshu K, Sharma R, Sharma VK. Temporalis muscle fascia and cartilage palisade technique of type 1 tympanoplasty: A comparison. Indian J Otol 2015;21:165-9
|How to cite this URL:|
Subhanshu K, Sharma R, Sharma VK. Temporalis muscle fascia and cartilage palisade technique of type 1 tympanoplasty: A comparison. Indian J Otol [serial online] 2015 [cited 2020 Jul 2];21:165-9. Available from: http://www.indianjotol.org/text.asp?2015/21/3/165/161015
| Introduction|| |
A tympanic membrane (TM) perforation is any defect in the TM resulting in exposure of the middle ear. TM perforation occurs as a result of chronic suppurative otitis media (CSOM), which is one of the common causes of deafness in India and occupies a considerable amount of clinic and operating time of otolaryngologists. Other causes include acute otitis media with TM rupture, trauma, or surgical interventions like the placement of a pressure equalization tube (PET). The large majority of perforations heal spontaneously, but some do not for reasons that are not known. A TM with a PET that is retained for over 1 year is a significant risk for developing a chronic perforation. Most agree that a TM perforations that show no signs of healing at 3 months is unlikely to close spontaneously and can at that point be considered a chronic perforation, making the surgical repair an appropriate step. ,
Since Wullstein and Zoellner popularized tympanoplasty in the 1950s, various materials have been used for the procedure including fascia, skin, vein, dura, and cartilage. Currently, temporalis muscle fascia is the most frequently used grafting material in tympanoplasty. In atelectatic ears, the fascia, and perichondrium have been shown to undergo atrophy and subsequent failure in the postoperative period. Thus, it would be better to choose a grafting material that can resist the continuous negative middle ear pressure. Cartilage is used increasingly for myringoplasty, however, there is some controversy regarding its use; although many surgeons recommend the use of cartilage specially in large perforations and revision cases. ,,,,,
The aim of the present study was to compare hearing results, as well as graft takes for commonly preferred reconstruction techniques of the TM (i.e., temporalis fascia vs. cartilage) in type 1 tympanoplasty.
| Materials and Methods|| |
The proposed prospective study was carried out in the Department of ENT and Head and Neck Surgery from April 2013 to June 2014 at our institute after approval by the Research/Ethics Committee.
In this study, total 50 patients were included those were suffering from CSOM and had been dry for at least 1 month with a large central perforation involving more than 50% of TM.
Two groups of 25 each were made - Temporalis fascia technique (TFT group) and cartilage palisade technique (CPT group). Detailed history and examination were carried out. The patient having a history of previous ear surgery, mixed hearing loss, and having any middle ear pathology apart from central perforation were excluded. The patients having pure conductive hearing loss were posted for type 1 tympanoplasty.
Cartilage palisade technique and TFT of tympanoplasty were used in alternate patients. Both tympanoplasty techniques were performed by a postaural approach by the same surgeon having experience of around 15 years in middle ear surgeries. Xylocaine sensitivity was performed in all patients prior to surgery under L.A. About 2% xylocaine with adrenaline (1:200,000) was used as the local anesthetic agent and 4% xylocaine with adrenaline used as topical anesthetic agent.
In patients who underwent palisade cartilage tympanoplasty, conchal cartilage was used in all cases. The perichondrium was removed from the convex side of the cartilage, and the cartilage was then cut into several slices with, on average, four or five palisades. The gel foam bed was formed, followed by two or three palisades placed anterior to the malleus handle and two or three placed posteriorly. Gel foam was placed over it followed by aural pack, and the closure of the wound was done in two layers followed by mastoid dressing.
In patients who underwent tympanoplasty where the temporalis muscle fascia was used as a grafting material, the graft was harvested from the ipsilateral deep temporal muscle fascia and gel foam bed was formed, and the graft was placed medial to the long process of the malleus and medial to (under) the drum remnant and anterior annulus. The gel foam were filled then over it, followed by placing medicated aural pack and the wound was closed in 2 layers, and mastoid dressing was done.
Postoperatively patients were given oral antibiotics in the form of co-amoxiclav (amoxiclav - 500 mg and clavulanic acid 125 mg) twice a day along with oral nasal decongestants (phenylephrine - 10 mg/cetirizine - 10 mg) once a day and topical nasal decongestants (xylometazoline hydrochloride and sorbitol - 0.1%) thrice a day. Suture and pack were removed on 7 th postoperative day.
| Observation and Results|| |
The primary aim of the study was to compare the rate of success of the graft materials used in large central perforations in terms of graft take-up and hearing improvement. To meet these goals, the study was done on 50 patients equally divided into two groups. TFT group and CPT group [Figure 1],[Figure 2] and [Figure 3].
|Figure 2: Cartilage harvested from cymba concha and cut into the palisades|
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|Figure 3: Pre-and post-operative picture of cartilage palisade technique|
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The age of the patients ranged from 10 to 60 years with most of them (38%) were between 10 and 30 years age group. Overall, 54% patients recruited in our study were males. Eustachian tube More Details (E.T.) patency test (valsalva manoeuvre) was carried out in all the patients, but E.T. dysfunction did not preclude surgery.
Rinne's was negative in all the ears preoperatively in both groups. Tuning fork test was performed at 6 th and 10 th week postoperatively in both groups. About 84% of patients show Rinne's positive at the 10 th week in TFT group and 60% in CPT group.
Pure tone audiometry at 6 th and 10 th week postoperatively showed significant improvement in both study groups. However, in comparison to cartilage palisade tympanoplasty, the TFT had better mean air conduction values though statistically insignificant [Table 1].
|Table 1: Pure tone audiometry (dB) results with temporal fascia and cartilage palisade tympanoplasty|
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Graft success rate was compared with the techniques of tympanoplasty used. Successful TM closure was observed in 23 ears with temporal fascia graft and 21 ears with cartilage palisades [Figure 4].
|Figure 4: Overall graft success rates with the type of tympanoplasty technique were used|
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None of the cases with E.T., dysfunction had residual perforation when cartilage palisade tympanoplasty was performed, but two had residual perforation with TFT [Table 2].
| Discussion|| |
A TM perforation is any defect in the TM resulting in exposure of the middle ear. TM perforation occurs as a result of CSOM, which is one of the common causes of deafness in India and occupies a considerable amount of clinic and operating time of otolaryngologists. Other causes include acute otitis media with TM rupture, trauma, or surgical interventions such as the placement of a PET. ,
Most agree that a TM perforations that show no signs of healing at 3 months is unlikely to close spontaneously and can at that point be considered a chronic perforation, making the surgical repair an appropriate step.
In this study, 54% patients were male. This was compared with a report by Rao and Reddy, and Vijaya and Nagarathnamma were it shows that incidence of CSOM is found to be higher in males approximately 55% to 60% and in females approximately 35% to 40%, which co-relates with the male predominance. It may be because of their more exposed way of life and probably in our rural society males access medical facilities earlier as compared to females. ,
Age ratio shows approximately 38% patients were between the age group 10 and 30. It appeared that the onset of CSOM was more in younger age group and also that more of them opted for tympanoplasty. Similar reports are made from other developing countries including Pakistan and Bangladesh. , Other study by Fakir et al., and Hossain et al., shows that younger age group suffer more as because of cellular mastoid, the horizontal position of E.T. and enlarge adenoid. , However, in other studies by Gupta et al., and Loy et al., it was stated that age has not much relation to CSOM, but it is common in people with poor socioeconomic status. ,
Chopra et al., and Collins et al., show better results of palisade cartilage tympanoplasty for blocked E.T Tubes. In our study cartilage, palisade tympanoplasty was performed in 10 patients having E.T. dysfunction, and it was successful in all of them. Whereas, TFT was used in 9 patients with E.T. dysfunction, but two of them had a residual perforation. This indicates that CPT may give better results in patients with blocked E.T. However, Tos reported that E.T. function, seemed to have no importance for reperforations. ,,
Hearing assessment was done in the form of tuning fork test and pure tone audiometry at 6 th and 10 th week after surgery. Preoperatively all the patients were Rinne's negative but at 10 th week 84% patient had changed to Rinne's positive in TFT group and 60% in CPT group. On audiometry, the improvement was statistically significant in both groups at 6 th and 10 th week but slightly higher in the TFT group. In one study by Cabra and Moñux, no relevant differences between the functional results of the two procedures were observed (palisade cartilage and fascia tympanoplasty). 
In 2004, Gierek et al., performed 112 cases with cartilage and 30 cases with temporalis fascia. They observed that there was no significant hearing difference between the two groups. 
Temporalis fascia is ideal in the aspect of the primary hearing improvement; it is softer than normal TM, which suggests that it is far more likely to be retracted or reperforated after tympanoplasty. 
Couloinger et al. observed 59 cartilage graft tympanoplasties and 20 temporalis fascia graft tympanoplasties in 2005, and they reported no postoperative hearing difference between the two groups. 
On reviewing the literature for graft uptake rates, it was obvious that this was quite variable. In our study, graft success rate of TFT group and CPT group was 92% and 84%, respectively.
Yung et al., found no significant difference in graft take or hearing gain between cartilage (with or without perichondrium) and fascia graft in perforations larger than 50%. 
The results of Zahnert et al., and couple or other authors stated no significant difference between cartilage and fascia graft uptake. ,, In comparison, some authors had better graft uptakes in palisade cartilage tympanoplasty. Neumann et al., reviewed 84 cases of the patient, who underwent cartilage palisade tympanoplasty and found an overall graft acceptance rate of 97.6%.  Uzun et al., achieved 100% TM closure with palisade cartilage tympanoplasty, whereas an 84.2% success rate was observed in temporalis fascia grafting.  Nevertheless with time, bigger sample sizes will provide more reliable results.
| Conclusion|| |
Chronic suppurative otitis media is a leading health problem in India causing significant social handicap in terms of hearing loss. Various grafts and techniques have been used for closure of TM perforations. Tympanoplasty by cartilage palisade and TFTs yielded similar graft uptake rates. Improvement in hearing was slightly better, when temporal fascia was used as a graft material though this difference was not significant. CPT requires slight more practice and perfection, but it may be specifically used as a grafting material in cases with E.T. dysfunction and also in more advanced pathological conditions, such as recurrent perforation and TM atelectasis.
| Acknowledgments|| |
- Audiologists of ENT Department, SRSMS IMS for technical help
- SRMS Trust for material support.
| References|| |
Mishra RN, Bhatia ML, Bhatia BP. Investigations of hearing in school children in Lucknow. Indian J Otol 1961;13:107-27.
Mitchell RB, Pereira KD, editors. Pediatric Otolaryngology for the Clinician. New York City: Humana Press, A Part of Springer Science + Business, Media, LLC; 2009.
Wullstein HL. Functional operations in the middle ear with split-thickness skin graft. Arch Othorhinolaryngol 1953;161:422-35.
Zollner F. The principles of plastic surgery of the sound-conducting apparatus. J Laryngol Otol 1955;69:637-52.
Van Rompaey V, Farr MR, Hamans E, Mudry A, Van de Heyning PH. Allograft tympanoplasty: A historical perspective. Otol Neurotol 2013;34:180-8.
Mohamad SH, Khan I, Hussain SS. Is cartilage tympanoplasty more effective than fascia tympanoplasty? A systematic review. Otol Neurotol 2012;33:699-705.
Lee JC, Lee SR, Nam JK, Lee TH, Kwon JK. Comparison of different grafting techniques in type I tympanoplasty in cases of significant middle ear granulation. Otol Neurotol 2012;33:586-90.
Zhang ZG, Huang QH, Zheng YQ, Sun W, Chen YB, Si Y. Three autologous substitutes for myringoplasty: A comparative study. Otol Neurotol 2011;32:1234-8.
Rao BN, Reddy MS. Chronic suppurative otitis media - A prospective study. Int J Otolaryngol Head Neck Surg 1994;3:72-7.
Vijaya D, Nagarathnamma T. Microbiological study of chronic suppurative otitis media. Indian J Otol 1998;4:172-4.
Chaudhri MA, Alaudin M. Comparative study between tubotympanic and atticoantral types of chronic suppurative otitis media. Bangladesh Med Res Counc Bull 2002;28:36-44.
Memon MA, Matiullah S, Ahmed Z, Marfani MS. Frequency of unsafe chronic suppurative otitis media in patients with discharging ear. J Liaquat Univ Med Health Sci 2008; 7:102-5.
Fakir AY, Hanif A, Ahmed KU, Haroon AA. intracranial complications of CSOM - A study of 40 cases. Bangladesh J of otorhinolaryngology, 1999;5(1);9(1/2):11-14.
Hossain MM, Kundu SC, Hoque MR, Shamsuzzaman AKM, Khan MK Haider KK. Extracranial complications of chronic suppurative otitis media. A study on 100 cases. Mymensing Med J 2006;Jan 15:4-9.
Gupta V, Gupta A, Sivarajan K. Chronic suppurative otitis media; An aerobic microbiological study. Indian J Otol 1998;4:79-82.
Loy AH, Tan AL, Lu PK. Microbiology of chronic suppurative otitis media in Singapore. Singapore Med J 2002;43:296-9.
Chopra H, Gupta S, Munish M. Correlation between Eustachian tube functions and result of myringoplasty. Int J Otolaryngol Head Neck Surg 1994;3:149-51.
Collins WO, Telischi FF, Balkany TJ, Buchman CA. Pediatric tympanoplasty: Effect of contralateral ear status on outcomes. Arch Otolaryngol Head Neck Surg 2003;129:646-51.
Tos M, Stangerup SE, Orntoft S. Reasons for reperforations after tympanoplasty in children. Acta Otolaryngol 2000;543:143-46.
Cabra J, Moñux A. Efficacy of cartilage palisade tympanoplasty: Randomized controlled trial. Otol Neurotol 2010;31:589-95.
Gierek T, Slaska-Kaspera A, Majzel K, Klimczak Gotqb L. Results of Myringoplasty and Type I Tympanoplasty with the Use of Fascia, Cartilage and Perichondrium Grafts. Otolaryngologia Polska 2004;3:529-33. (In Pol- ish).
Jesic SD, Dimitrijevic MV, Nesic VS, Jotic AD, Slijepcevic NA. Temporalis fascia graft perforation and retraction after tympanoplasty for chronic tubotympanic otitis and attic retraction pockets: Factors associated with recurrence. Arch Otolaryngol Head Neck Surg 2011;137:139-43.
Couloigner V, Baculard F, El Bakkouri W, Viala P, Francois M, Narcy P, et al
. Inlay Butterfly Cartilage Tympanoplasty in Children. Ontology Neurotology 2005;26:247-51.
Yung M, Vivekanandan S, Smith P. Randomized study comparing fascia and cartilage grafts in myringoplasty. Ann Otol Rhinol Laryngol 2011;120:535-41.
Zahnert T, Bornitz M, Hüttenbrink KB. Acoustic and mechanical properties of tympanic membrane transplants. Laryngorhinootologie 1997;76:717-23.
Sheehy JL, Anderson RG. Myringoplasty. A review of 472 cases. Ann Otol Rhinol Laryngol 1980;89(4 Pt 1):331-4.
Dornhoffer J. Cartilage tympanoplasty: Indications, techniques, and outcomes in a 1,000-patient series. Laryngoscope 2003;113:1844-56.
Neumann A, Hennig A, Schultz-Coulon HJ. Morphological and functional results of palisade cartilage tympanoplasty. HNO 2002;50:935-9.
Uzun C, Cayé-Thomasen P, Andersen J, Tos M. A tympanometric comparison of tympanoplasty with cartilage palisades or fascia after surgery for tensa cholesteatoma in children. Laryngoscope 2003;113:1751-7.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]