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ORIGINAL ARTICLE
Year : 2015  |  Volume : 21  |  Issue : 3  |  Page : 183-185

Nonspecific otalgia: Indication for cartilage tympanoplasty


Department of Otorhinolaryngology and Head Neck Surgery, Government Medical College, Srinagar, Jammu and Kashmir, India

Date of Web Publication17-Jul-2015

Correspondence Address:
Zafarullah Beigh
Marouf Colony, 90 Feet Road, Bachapora, Srinagar - 190 020, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-7749.159707

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  Abstract 

Introduction: Myringoplasty and tympanoplasty are commonly performed otologic surgical procedures. The aim of this study was to analyze the influence of nonspecific otalgia on the successful autologous conchal cartilage and temporalis fascia graft take up in type-1 tympanoplasty. Materials and Methods: A total of 250 adult patients who met the inclusion criteria were enrolled for this study. Patients were placed in two groups (otalgia and nonotalgia group) depending upon the history of otalgia. Patients in both groups were operated (type-1 tympanoplasty) using randomly either temporalis fascia or conchal cartilage as the graft material. Follow-up of patients was done after 3 weeks, 6 weeks, and 3 months of surgery to check the status of graft take up. Result: Our study shows that patients in otalgia group in which autologous temporalis fascia was used as the graft material, the majority of patients had graft necrosis by 3 months after surgery (9.6% success only). Whereas patients of the same group in which autologous conchal cartilage was used as the graft material, successful graft take up was in 93.5% patients after 3 months of surgery. Our study shows that there was not much difference in using autologous temporalis fascia or autologous conchal cartilage on successful graft take up in nonotolgia group of patients, with success rate of 97.89% and 97.84%, respectively.

Keywords: Cartilage, Otalgia, Tympanoplasty


How to cite this article:
Ahmad R, Beigh Z. Nonspecific otalgia: Indication for cartilage tympanoplasty. Indian J Otol 2015;21:183-5

How to cite this URL:
Ahmad R, Beigh Z. Nonspecific otalgia: Indication for cartilage tympanoplasty. Indian J Otol [serial online] 2015 [cited 2019 Nov 22];21:183-5. Available from: http://www.indianjotol.org/text.asp?2015/21/3/183/159707


  Introduction Top


Myringoplasty is an operative procedure used in the reconstruction of a perforated tympanic membrane, whereas tympanoplasty is the reconstruction of the hearing mechanism along with the eradication of any pathology within the middle ear cleft. [1] Long standing perforation leading to recurrent ear discharge needs surgical corrections like myringoplasty or tympanoplasty. Different authors have described different factors and technical elements to modify the outcome of tympanoplasty. Despite several known prognostic factors that may affect the surgical outcome, failures have been reported in the literature. [2],[3],[4],[5],[6],[7]

This study was conducted to analyze the influence of nonspecific otalgia on the successful autologous conchal cartilage and temporalis fascia graft take up in type-1 tympanoplasty in our patients.


  Materials and Methods Top


This study was conducted in Department of Otorhinolaryngology and head neck surgery Government Medical College, Srinagar. After clearance from Institutional Ethical Committee, 250 adult patients who met the inclusion criteria of dry tympanic membrane perforation of any size with the conductive hearing loss of 10-40 dB were enrolled for this study. General and otorhinolaryngological examination of all patients was done. After completion of the examination, patients were placed in two groups (otalgia and nonotalgia group) depending upon the history of otalgia. All patients were informed about the procedure of the study and written consent was taken from them. Patients in both groups were operated (type-1 tympanoplasty) under general anesthesia using randomly either temporalis fascia or conchal cartilage as the graft material. All operations were carried out by one surgeon (Dr. Rauf Ahmad) to avoid any variations in surgical competence and operative procedures. Follow-up of patients was done after 3 weeks, 6 weeks, and 3 months of surgery to check the status of graft take up.

Exclusion criteria

  • Ears with any pathology in the external auditory canal
  • Ears with any pathology requiring mastoid exploration or ossiculoplasty
  • Ears with any bacterial or fungal infection identified by the culture within 3 months prior to the surgery
  • Immunosuppressed patients or patients taking immunosuppressive medications
  • Patients with comorbidities like diabetes mellitus or chronic renal disease that could influence wound healing or recovery.



  Results Top


Our study includes a total of 250 patients. 62 patients gave a history of otalgia, for which no specific cause was found on examination and many patients in this group had received anti-depressants and other medications for otalgia. 188 patients did not give any history of otalgia and were put in nonotalgia group. Majority of patients in otalgia group were females from a rural area in the age group of 26-35. On the other hand, majority of patients in nonotalgia group were males from a rural area [Table 1].
Table 1: Demographics of two groups of patients

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Our study shows that patients in otalgia group in which autologous temporalis fascia was used as the graft material, majority of patients had graft necrosis by 3 months after surgery (9.6% success only). Whereas patients of the same group in which autologous conchal cartilage was used as the graft material, successful graft take up was in 93.5% patients after 3 months of surgery. Our study shows that there was not much difference in using autologous temporalis fascia or autologous conchal cartilage on successful graft take up in nonotolgia group of patients, with success rate of 97.89% and 97.84%, respectively [Table 2].
Table 2: Follow - up of patients showing status of graft take up

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  Discussion Top


Among published, reasons for the closure failure following myringo⁄tympanoplasty, [8]  Eustachian tube More Details dysfunction has been the "dumping ground" diagnosis for unidentified failures even though this dysfunction cannot be proved. However, the mechanism for closure failure has not been evaluated previously or proved rigorously. The aim of our study was to determine the role of nonspecific otalgia in successful graft take up.

Fluorescence angiography is the only valid technique for studying the graft vascularization and take up but its clinical use remains limited. Therefore, direct inspection under operating microscope and⁄or otoscope is the only way in clinical situations. In our study, we used otoscopic examination during the preoperative period and in postoperative follow-up to examine graft take up.

In some cases of graft failure, cause may be attributed to avascular necrosis (AVN) of the graft due to a progressive deterioration of blood supply from the periphery of the tympanic membrane. [9] In many series, 32-40% of the graft failures were attributed to this kind of atrophy of the graft. [9] Vartiainen's study attributes atrophy of the graft as the most common cause of late failure. [10] In the early stages of AVN, patients may not have any symptoms. Eventually, pain will develop. Pain usually develops gradually and may be mild or severe. One hallmark of AVN is severe night pain.

Avascular necrosis is caused when the blood supply is interrupted and enough blood does not get to the tympanic membrane. Blood travels to the tympanic membrane through blood vessels. Enough blood cannot get to membrane/graft if blood vessels get blocked by fat or air if they become too thick or too small or if they get too weak. This theory of AVN is supported by the fact that all those patients in our otalgia group who failed to take up graft reported to have otalgia in postoperative period consistent with graft necrosis. While as those patients whose graft was taken up successfully did not complain of otalgia in the postoperative period. Many things can cause this to happen. Corticosteroids in high doses and radiations to the ear may be contributing factors though we do not completely understand why. Unfortunately, it is not always possible to determine exactly what caused the problem.

This process of AVN can be reason for nonspecific otalgia in dry tympanic membrane perforations and subsequent failure of autologous temporalis fascia graft take up, but does not explain why autologous conchal cartilage graft does not get affected by this process of AVN.


  Conclusion Top


Large randomized controlled studies at molecular level is required to study the cause of nonspecific otalgia in CSOM patients with inactive mucosal disease (dry tympanic membrane perforations) and role of this otalgia on successful tympanoplasty procedures using various graft materials. This study clearly shows that nonspecific otalgia is a cause of temporalis fascia graft failure in type-1 tympanoplasty and is an indication for cartilage tympanoplasty.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Hirsch BE. Myringoplasty and tympanoplasty. In: Myers EN, editor. Operative Otolaryngology/Head and Neck Surgery. 2 nd ed. Philadelphia: Saunders; 2008. p. 1246-61.  Back to cited text no. 1
    
2.
Becvarovski Z, Kartush JM. Smoking and tympanoplasty: Implications for prognosis and the Middle Ear Risk Index (MERI). Laryngoscope 2001;111:1806-11.  Back to cited text no. 2
    
3.
Onal K, Uguz MZ, Kazikdas KC, Gursoy ST, Gokce H. A multivariate analysis of otological, surgical and patient-related factors in determining success in myringoplasty. Clin Otolaryngol 2005;30:115-20.  Back to cited text no. 3
    
4.
Albera R, Ferrero V, Lacilla M, Canale A. Tympanic reperforation in myringoplasty: Evaluation of prognostic factors. Ann Otol Rhinol Laryngol 2006;115:875-9.  Back to cited text no. 4
    
5.
Emir H, Ceylan K, Kizilkaya Z, Gocmen H, Uzunkulaoglu H, Samim E. Success is a matter of experience: Type 1 tympanoplasty: Influencing factors on type 1 tympanoplasty. Eur Arch Otorhinolaryngol 2007;264:595-9.  Back to cited text no. 5
    
6.
Lin AC, Messner AH. Pediatric tympanoplasty: Factors affecting success. Curr Opin Otolaryngol Head Neck Surg 2008;16:64-8.  Back to cited text no. 6
    
7.
Pinar E, Sadullahoglu K, Calli C, Oncel S. Evaluation of prognostic factors and middle ear risk index in tympanoplasty. Otolaryngol Head Neck Surg 2008;139:386-90.  Back to cited text no. 7
    
8.
Alkan S, Baylancicek S, Sözen E, Basak T, Dadas B. Effect of the use of dry (rigid) or wet (soft) temporal fascia graft on tympanoplasty. J Otolaryngol Head Neck Surg 2009;38:126-32.  Back to cited text no. 8
    
9.
MacKinnon DM. Relationship of pre-operative eustachian tube function to myringoplasty. Acta Otolaryngol 1970;69:100-6.  Back to cited text no. 9
[PUBMED]    
10.
Vartiainen E. Findings in revision myringoplasty. Ear Nose Throat J 1993;72:201-4.  Back to cited text no. 10
    



 
 
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Introduction
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