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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 21  |  Issue : 4  |  Page : 233-237

Tympanometric patterns in patients undergoing cartilage tympanoplasty of 0.6 mm thickness


1 Department of Otorhinolaryngology and Head and Neck Surgery, King Saud Medical City, Riyadh, KSA
2 Department of Otorhinolaryngology, King Saud Medical City, Riyadh, KSA
3 Department of Otolaryngology, King Saud Medical City, Riyadh, KSA

Date of Web Publication16-Oct-2015

Correspondence Address:
Bandar Al Qahtani
Department of Otorhinolaryngology and Head and Neck Surgery, King Saud Medical City, Riyadh
KSA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-7749.167408

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  Abstract 

Background: Tympanoplasty has been reported as early as in 1640 by Marcus Banzer, since then many different techniques have been developed for this procedure. The aim of this study is to analyze the tympanometric findings in those patients who underwent cartilage tympanoplasties of 0.6 mm thickness and in order to check different tympanometric patterns obtained in these patients. Materials and Methods: A prospective study was conducted on 60 patients diagnosed clinically with chronic suppurative otitis media in outpatient clinic between 2010 and 2013, in which a cartilage tympanoplasty of 0.6 mm thickness was planned. These patients were evaluated clinically and by pure tone audiograms and tympanograms for cartilage uptake and any late complications. Results: A total of 26 patients were included in our study. The male to female ratio was 3:1 and mean age was 36.1 years. The mean external canal volume of these patients was 0.928, and all of them had a closed air-bone gap. Ten patients had Type As tympanogram which represented 41.6%, 8 of these patients were females. The mean external canal volume of the patients with Type As tympanogram was 1.61. Only one patient had Type A tympanogram with external canal volume of 1.9 and a closed air-bone gap, he was a case of left cartilage tympanoplasty. Type B tympanogram was also found in only one patient who had left cartilage tympanoplasty, with external canal volume of 1.3 and a closed air-bone gap. No patients had Type C or Type Ac. Conclusion: Use of cartilage of 0.6 mm thickness in tympanoplasty for tympanic membrane perforation repair results in excellent outcomes and most common pattern of tympanogram is non-A, B, C postoperatively.

Keywords: Cartilage tympanoplasty, Chronic suppurative otitis media, Tympanogram


How to cite this article:
Al Qahtani B, Al Tuwaijri M, Al Tamimi F, Al Majed A, Wasi M, Al Jabber A. Tympanometric patterns in patients undergoing cartilage tympanoplasty of 0.6 mm thickness. Indian J Otol 2015;21:233-7

How to cite this URL:
Al Qahtani B, Al Tuwaijri M, Al Tamimi F, Al Majed A, Wasi M, Al Jabber A. Tympanometric patterns in patients undergoing cartilage tympanoplasty of 0.6 mm thickness. Indian J Otol [serial online] 2015 [cited 2019 Jan 21];21:233-7. Available from: http://www.indianjotol.org/text.asp?2015/21/4/233/167408


  Introduction Top


Dealing with perforation of tympanic membrane was first reported in 1640 by Marcus Banzer who inserted a small ivory tube covered with a pig's bladder as a lateral graft.[1] Later on, Yearsley in 1841 mentioned using of a ball of cotton wool moisturized by glycerin applied against the tympanic membrane.[2] Improvement in hearing was reported by Toynbee in 1853 who used a rubber disk attached to silver wire over the tympanic membrane.[3] In 1876, Roosa managed tympanic membrane perforation with chemical cautery by silver nitrate to promote healing of perforation.[4] Using trichloroacetic acid as cauterizing agent was started by Okuneff in 1895 which is still used now. Blake used paper patches to cover perforations in 1877.[5] Zoellner [6] and Wullstein and Wullstein [7] introduced tympanoplasty in 1952, and with time different grafts were used with different techniques of tympanic membrane reconstruction, skin, vein, fascia, and dura were used as grafts in such procedures.[8],[9],[10],[11],[12],[13] In middle ear reconstruction Prof. Mirko Tos, one of the most influential otologists, uses harvested cartilage from the concha and tragus, hence the name cartilage tympanoplasty which is now a worldwide recognized procedure.[14] Liden et al. (1970) reported that tympanometry is a method for simultaneously evaluating the integrity of the tympanic membrane, the ossicles and their attachments, and the air cushion of the tympanic cavity. Four tympanometric characteristics were compared in his article. The classification used nowadays was developed by him and Jerger.[15]

This current study was performed to assess the postoperative tympanometric findings in patients undergoing cartilage tympanoplasties of 0.6 mm thickness and to check different tympanometric patterns obtained in these patients.


  Materials and Methods Top


A prospective study conducted on 60 patients diagnosed clinically with chronic suppurative otitis media in our outpatient clinic between March 2010 and March 2013, in whom a cartilage tympanoplasty was planned by the primary surgeon in King Saud Medical City. Preoperative assessment included a pure tone audiogram and a tympanogram.

The patients were booked for surgery on routine basis and prepared accordingly. Upon admission, they were consented for cartilage tympanoplasty either right or left and harvesting of the temporalis fascia cartilage graft from the concha with a thickness of 0.6 mm and technique used were underlay technique and lateral to the hand of malleus (in fashion of fascia then cartilage and then handle of malleus) supported by gel foam on both sides. After recovering from the postoperative period and ruling out any immediate complications, they were discharged with outpatient follow-up. In the clinic, those patients were evaluated clinically [Figure 1] and [Figure 2] and by pure tone audiograms and tympanograms for cartilage uptake and any late complications, then the same evaluation was repeated after 2 months. Patients who failed cartilage tympanoplasty or lost follow-up in the clinic were excluded from the study. The minimum follow-up period was 4 months.
Figure 1: Postcartilage tympanoplasty

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Figure 2: Postcartilage tympanoplasty (well-taken thick graft)

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The data about demographic (name, age, and gender) preoperative assessment as mentioned above, operative findings and postoperative tympanometric findings were collected on a specially designed proforma. The tympanogram patterns which did not fit in any known type were labeled as none A, B, and C [Figure 3] and [Figure 4]. These data were entered and analyzed with the aid of statistical package SPSS (IBM Inc., Chicago, Illinois, USA). The frequency and percentage were calculated for qualitative variables (gender, type of tympanograms, and side of operation) and mean ± standard deviation was measured for quantitative variables (age, external canal volume). Findings were presented in tables.
Figure 3: Non-A, B, C tympanometric pattern

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Figure 4: Non-A, B, C tympanometric pattern

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  Results Top


In this prospective study, 40 patients underwent cartilage tympanoplasty; in which 14 patients were excluded and 7 of them had middle ear pathology (cholesteatoma, fibrosis, and tympanic sclerosis). Five patients lost their follow-up in the clinic and two patients had failed surgeries. A total of 26 patients were included in our study. The male to female ratio in our population was 3:1, the mean age was 36.1 years; 16 years and 65 years were the youngest and the oldest age, respectively. Five patients had bilateral disease; one of these patients had bilateral surgeries with 1 year period between the two surgeries. The left and the right cartilage tympanoplasty patients were equal, 12 in each group as shown in [Table 1]. Two patients were revision cases and both of them were right sided surgeries.
Table 1: Demographic and clinical profile of study population

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The majority of the patients (11 patients) had a non-A, B, C [Figure 3] and [Figure 4] tympanometric pattern which represented 45.83% of the population as shown in [Table 2]. The mean age of these patients was 36.9 years, 10 of them were females. Seven of the non-A, B, C tympanograms were right ears and 5 were left ears. The mean external canal volume of these patients was 0.928, and all of them had a closed air-bone gap. 10 patients had Type As tympanogram which represented 41.6%, the mean age of this group was 33.8 years, 8 of these patients were females and 2 of them were males. Left cartilage tympanoplasty was done in 6 of these patients and the right side was operated in 4 of them. The mean external canal volume of the patients with Type As tympanogram was 1.61. All patients had a closed air-bone gap except one with a gap of 35 db, this patient was found to have tympanosclerosis. Only one patient had Type A tympanogram with external canal volume of 1.9 and a closed air-bone gap, he was a case of left cartilage tympanoplasty. Type B tympanogram was also found in only one patient who had left cartilage tympanoplasty, with external canal volume of 1.3 and a closed air-bone gap. No patients had Type C or Type Ac.
Table 2: Patterns of postoperative tympanograms after cartilage tympanoplasty

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  Discussion Top


The long-term goals of tympanic membrane repair are to create an intact or "safe" tympanic membrane and restore hearing. Since Wullstein [16] and Zollner [17] described their tympanoplasty techniques using split-thickness and full-thickness skin grafts, numerous materials have been used to reconstruct the tympanic membrane. Perichondrium and fascia are the current tissues of choice used by most otologic surgeons for tympanic membrane repair in either an overlay or underlay technique.[18] We used overlay technique in the subjects of our study.

The advantages of cartilage over fascia are numerous. The thickness of cartilage creates stiffness that is more resistant than fascia to the anatomic deformation caused by negative middle ear pressure, thus improving long-term anatomic integrity.[19] A cartilage graft also acts as a tissue buffer for total or partial ossicular replacement prostheses. This prosthesis tissue interface allows for better long-term hearing results and decreases the extrusion rate of the implant.[20]

It must be noted that many of the studies do not use the same criteria to assess hearing outcome compared to that of the current study. There are several different kinds of myringoplasty techniques which are often adapted by surgeons according to their resources and clinical presentation of the patients; which differ from country to country. Thus, making the results yielded in the current study not fully comparable to that of other similar studies. There are various techniques of myringoplasty with their own corresponding results.[21] However, still there is no consensus about the optimal technique, which is often employed on the basis of surgeon's preference and skills.[21]

In our study, we used cartilage tympanoplasty and harvesting the temporalis fascia the cartilage graft from the concha with a thickness of 0.6 mm by using underlay technique. Numerous studies have shown cartilage tympanoplasty superior to other techniques.[1],[22],[23],[24]

Our study included 26 individuals who had undergone tympanoplasty and where postoperatively evaluated for external canal volume and bone air gap. The male to female ratio in our study was 3:1, the mean age was 36.1 years, 16 years and 65 years were the youngest and the oldest age, respectively. These findings are in accordance with the findings of Holmquist,[25] in their study they also had male predominance. In contrast to our study, Gierek et al.[26] had a female predominance. It is of importance to note that majority of the participants in the current sample were male and thus a repeated study of a more even distribution of male and female patients may have yielded different results. These findings highlight the importance of demographic information that may potentially affect the results of a study and indicate that one should consider gender when comparing hearing outcome postmyringoplasty surgery.

In comparison with other studies, we observed that the majority of the patients had a non-A, B, C tympanometric pattern which represented 45.83% of the population, slightly less than half of the study population. Our study showed mean age of these patients was 36.9 years, showing that middle age group is dominant in our study. This middle age dominance can explain our findings on the bases of gender and other variables.

Approximately, half of our patients (41.6%) had Type As tympanogram, the mean age of this group was 33.8 years, and majority of this group were females.

In our study, all of the subjects had closed air-bone gap except one with a gap of 35 db. This patient was found to have tympanosclerosis. Only one patient had Type A tympanogram with external canal volume of 1.9 and a closed air-bone gap, he was a case of left cartilage tympanoplasty. Only one patient had Type B tympanogram, underwent left cartilage tympanoplasty, with an external canal volume of 1.3 and a closed air-bone gap. In our study, we found no patient with Type C tympanogram in contrast to the study conducted by Booth.[27]

In summary, we note that the use of cartilage in tympanoplasty for tympanic membrane perforation repair results in excellent outcomes that are comparable to the best-case outcomes that have been reported in the adult population. The results obtained in the current study are of particular interest to ear, nose, and throat specialists as well as audiologists. Moreover, further studies should be conducted to ascertain the effects of demographic characteristics on audiological outcomes after cartilage tympanoplasty.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Gerber MJ, Mason JC, Lambert PR. Hearing results after primary cartilage tympanoplasty. Laryngoscope 2000;110:1994-9.  Back to cited text no. 9
    
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Tabb HG. Closure of perforations of the tympanic membrane by vein grafts. A preliminary report of twenty cases. Laryngoscope 1960;70:271-86.  Back to cited text no. 10
    
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13.
Yetiser S, Tosun F, Satar B. Revision myringoplasty with solvent-dehydrated human dura mater (Tutoplast). Otolaryngol Head Neck Surg 2001;124:518-21.  Back to cited text no. 13
    
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Arriaga MA. Cartilage tympanoplasty: Classifications of methods—techniques-results. Otol Neurotol 2010;31:861-1012.  Back to cited text no. 14
    
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Liden G, Peterson JL, Bjorkman G. Tympanometry. Arch Otolaryngol Head Neck Surg 1970;92:248.  Back to cited text no. 15
    
16.
Wullstein H. Functional operations in the middle ear with the help of free split flap graft. EurArch Otorhinolaryngol 1952;161:422-35.  Back to cited text no. 16
    
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Zollner F. The principles of plastic surgery of the sound-conducting apparatus. J Laryngol Otol 1955;69:637-52.  Back to cited text no. 17
    
18.
Rizer FM. Overlay versus underlay tympanoplasty. Part I: historical review of orical review of the literature. Laryngoscope. 1997;107(12 Pt 2):1.  Back to cited text no. 18
    
19.
Brace MD, Horwich P, Kirkpatrick D, Bance M. Tympanic membrane manipulation to treat symptoms of patulous eustachian tube. Otol Neurotol 2014;35:1201-6.  Back to cited text no. 19
    
20.
Altenau MM, Sheehy JL. Tympanoplasty: Cartilage prostheses – A report of 564 cases. Laryngoscope 1978;88:895-904.  Back to cited text no. 20
    
21.
Sergi B, Galli J, De Corso E, Parrilla C, Paludetti G. Overlay versus underlay myringoplasty: Report of outcomes considering closure of perforation and hearing function. Acta Otorhinolaryngol Ital 2011;31:366-71.  Back to cited text no. 21
    
22.
Elasfour AA, Zaghloul HS. Cartilage tympanoplasty: Audiological and otological outcome. Int Congr Ser 2003;1240:73-9.  Back to cited text no. 22
    
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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.  Back to cited text no. 23
    
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Carr MM, Poje CP, Nagy ML, Pizzuto MP, Brodsky LS. Success rates in paediatric tympanoplasty. J Otolaryngol 2001;30:199-202.  Back to cited text no. 24
    
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Holmquist J. Eustachian tube function and tympanoplasty. Acta Otorhinolaryngol Belg 1991;45:67-9.  Back to cited text no. 25
    
26.
Gierek T, Slaska-Kaspera A, Majzel K, Klimczak-Golab L. Results of myringoplasty and type I tympanoplasty with the use of fascia, cartilage and perichondrium grafts. Otolaryngol Pol 2004;58:529-33.  Back to cited text no. 26
    
27.
Booth JB. Tympanometry in tympanoplasty. Acta Otorhinolaryngol Belg 1974;28:510-7.  Back to cited text no. 27
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]


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[Pubmed] | [DOI]



 

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