|Year : 2018 | Volume
| Issue : 1 | Page : 23-27
Temporalis fascia graft versus composite graft in chronic suppurative otitis media with subtotal and total perforations
Manas Ranjan Rout, Deeganta Mohanty, Chintagunta Pakeer Das, P Vittal Prasad
Department of ENT, ASRAM Medical College, Eluru, Andhra Pradesh, India
|Date of Web Publication||24-May-2018|
Dr. Manas Ranjan Rout
Department of ENT, ASRAM Medical College, Eluru, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Temporalis fascia graft is the most commonly used graft material for reconstruction of the tympanic membrane in chronic suppurative otitis media. However, the success rate is low in case of subtotal and total perforations. We have used both cartilage and the temporalis fascia for the repair with greater success. Aims and Objectives: The aim and objective of the study was to compare the result of temporalis fascia graft and composite graft (temporalis fascia and cartilage) in the repair of subtotal and total perforation of tympanic membrane with respect to graft take-up rate and hearing improvement. Materials and Methods: A total of 300 patients were selected for the study. One hundred and fifty cases we used only temporalis fascia (tympanoplasty with temporalis fascia graft [TTG] group) and another 150 cases both temporalis fascia and cartilage (Composite graft, tympanoplasty with composite graft [TCG] group) were used. The result was assessed after 6 months of surgery. Results: Graft take-up rate in TTG group is 82.67% and in TCG group is 95.34%. More remnant and re-perforations were found in TTG group. It was found that, in TTG group out of 124 patients, hearings improved in 104 patients (83.87%), remain same in 15 patients (12.09%), and deteriorated in 5 patients (4.032%). In TCG group out of 143 patients, hearings improved in 116 patients (81.118%), remain same in 19 patients (15.322%), and deteriorated in 8 patients (6.451%). Discussion and Conclusion: Composite graft is a better graft in comparison to temporalis fascia graft for the repair of the subtotal and total perforation.
Keywords: Air-bone gap, myringoplasty, tympanic membrane, tympanoplasty
|How to cite this article:|
Rout MR, Mohanty D, Das CP, Prasad P V. Temporalis fascia graft versus composite graft in chronic suppurative otitis media with subtotal and total perforations. Indian J Otol 2018;24:23-7
|How to cite this URL:|
Rout MR, Mohanty D, Das CP, Prasad P V. Temporalis fascia graft versus composite graft in chronic suppurative otitis media with subtotal and total perforations. Indian J Otol [serial online] 2018 [cited 2019 Aug 22];24:23-7. Available from: http://www.indianjotol.org/text.asp?2018/24/1/23/233129
| Introduction|| |
Chronic suppurative otitis media (CSOM) is a long-standing infection of a part or whole of the middle ear cleft characterized by ear discharge and a permanent perforation in the tympanic membrane. Hence, the permanent perforation is a hallmark of CSOM.
Temporalis fascia graft is the commonly used graft material for repair of tympanic membrane in CSOM. The result is poor in subtotal and total perforation. In the present study, we have used a composite graft (both temporalis fascia and cartilage) with good postoperative result. Literature shows that success rate of myringoplasty in subtotal perforation is low.
| Materials and Methods|| |
The present study has been approved by the Institutional Ethical Committee vide Regd. No. IEC/ASRAM/003/2017.
Aims and objectives
The aim and objective of the study was to compare the result of temporalis fascia graft and composite graft (temporalis fascia and cartilage) in the repair of subtotal and total perforation of tympanic membrane with respect to graft take-up rate and hearing improvement.
It is a retrospective study conducted over a period of 4 years (from January 2012 to December 2015).
The present study has been conducted in the Department of ENT, in a tertiary care hospital.
A total of 300 patients were selected for the study from the Department of ENT.
This a retrospective study conducted in the Department of ENT. All the patients with CSOM with subtotal and total perforations were selected for the study. All the data taken from medical record department were analyzed and the patients who have undergone the tympanic membrane reconstruction were selected.
Record showed that almost all the patients were examined by otoscopy and microscopy. Hearing was evaluated by pure tone audiometry. Patients having normal ossicular chain were offered Type 1 tympanoplasty and selected for the study.
A total of 300 patients were selected for the study. They were divided into two groups. One hundred and fifty patients, for whom tympanoplasty was done using only temporalis fascia, were kept in one group and named as tympanoplasty with temporalis fascia graft (TTG). Another 150 patients, for whom both temporalis fascia and cartilage was used as graft material, were kept in another group and named as tympanoplasty with composite graft (TCG).
Our standard procedure was postauricular approach (by Wild's incision) in all the cases and temporalis fascia was harvested. Cartilage was taken from either concha or tragus of the pinna for composite graft. Tympanomeatal flap was elevated by giving 6 o'clock and 12 o'clock incisions. Fibrous annulus was elevated and tympanic membrane lifted. In all the cases, we did tympanoplasty by underlay technique. A tunnel was created in the anterior meatal wall, and anterior tucking was done in all the cases by dragging the temporalis fascia graft through it. In TTG group, we have used temporalis fascia only for the reconstruction [Figure 1]. In TCG group, we have used both temporalis fascia and cartilage (conchal or tragal). First of all, temporalis fascia graft was positioned. Cartilage was sliced to make thin and cut into small pieces and placed all around the middle ear above the gel foam up to the level of lower end of handle of malleus. Some cases we have sliced the cartilage into long strips and placed in the form of palisade inferior to handle of malleus (cartilage palisade tympanoplasty) [Figure 2]. Then, temporalis fascia graft with tympanomeatal flap was repositioned. Gel foam pack given above the graft filling the external auditory canal. Wound was sutured in layers using 3-0 Vicryl for soft tissue and 3-0 silk for skin. Mastoid bandage was applied.
Patients' records were followed up monthly and 6-month records were evaluated for graft take-up, remnant, and re-perforations. Preoperative hearing loss and postoperative hearing loss after 6 months were collected.
Samples were collected randomly.
- Patients with subtotal and total perforations with intact ossicular chain
- Patient treated with Type 1 tympanoplasty either using temporalis fascia graft or composite graft
- Patient's record with clear data is available in medical record department
- Patients came for regular follow-up.
- Proper patient's records not available
- Patient lost follow-up
- Patient with CSOM having ossicular erosion
- Patient with unsafe type of perforation.
Postoperative data were analyzed by Chi-square test for graft take-up and by Z-test for hearing improvement.
| Results|| |
A total of 300 patients were divided into two groups (150 in each group). In one group, tympanic membrane grafting was done using temporalis fascia graft and named as TTG. In another group, tympanic membrane grafting was done using composite graft, i.e., both temporalis fascia and cartilage and named as TCG.
[Table 1] shows the age distribution of all 300 patients with respect to group. It shows that, in TTG group out of 150 patients, 68 were in the age group of 15–30 years, 52 were in the age group of 30–45 years, and 30 were in the age group of 45–60 years. In TCG group, 65 patients were in the age group of 15–30 years, 53 were in the age group of 30–45 years, and 32 were in the age group of 45–60 years. Hence, a maximum number of the patients in our study were in the age group of 15–30 years, i.e., 44.34% and a minimum number of patients were in the group of 45–60 years, i.e., 20.67%.
[Table 2] shows the sex distribution of the patients in our study. It shows that, in TTG group, 92 patients were male and 58 were female. In TCG group, 90 patients were male and 60 were female. Hence, as a whole, 60.67% (182) of patients were male and 39.34% (118) of patients were female.
Out of 300 patients, general anesthesia was used in 252 cases and rest 48 cases we used local anesthesia for surgery.
After 6 months of surgery, all the data were collected for graft take-up rate. [Table 3] shows the postoperative result after 6 months. It was seen that, in TTG group, out of 150 patients, graft was taken up in 124 cases (82.67%), and in TCG group, graft was taken up in 143 cases (95.34%). Out of 300 cases, a total of 33 cases failed with either remnant perforations or re-perforations. It shows that, in TTG group, there were 20 remnant perforations (13.34%) and 6 re-perforations (4%). In TCG group, there were five remnant perforations (3.34%) and two re-perforations (1.34%). By applying the Chi-square test, Chi-square value was 12.21 and degree of freedom was 2, P < 0.005 (highly significant).
After 6 months of surgery, all the patients for whom graft has taken well were evaluated for hearing result. It was found that, in TTG group out of 124 patients, hearings improved in 104 patients (83.87%), remain same in 15 patients (12.09%), and deteriorated in 5 patients (4.032%). In TCG group out of 143 patients, hearings improved in 116 patients (81.118%), remain same in 19 patients (15.322%), and deteriorated in 8 patients (6.451%) [Figure 3].
|Figure 3: Hearing result, tympanoplasty with temporalis fascia graft versus tympanoplasty with composite graft|
Click here to view
[Table 4] shows the hearing result in the form of improvement in air-bone gap (ABG) in both the groups where graft has taken well, i.e., 124 patients in TTG group and 143 patients in TCG group. In all patients, preoperative ABG and postoperative ABG after 6 months of surgery were taken into consideration. It shows that, in TTG group out of 124 patients, ABG improved 25 dB in 10 patients (8.064%), 20 dB in 26 patients (20.967%), 15 dB in 38 patients (30.645%), 10 dB in 18 patients (14.516%), 5 dB in 12 patients (9.677%), and 0 dB in 15 patients (12.096%) and deteriorated by 5 dB in 5 patients (4.032%). Hence, in TTG group, significant hearing improvement (≥10 dB) occurred in 92 out of 124 (74.19%) cases. In TCG group out of 143 patients, ABG improved 25 dB in 13 patients (9.09%), 20 dB in 30 patients (20.979%), 15 dB in 41 patients (28.671%), 10 dB in 20 patients (13.986%), 5 dB in 12 patients (8.391%), and 0 dB in 19 patients (13.286%) and deteriorated by 5 dB in 8 patients (5.594%). Hence, in TCG group, significant hearing improvement occurred in 104 cases out of 143 (72.72%) cases. Average improvements in ABG were calculated in both the groups. The value in TTG is 12.54 dB, whereas in TCG, it is 12.30 dB. By applying the Z-test, Z = 0.228, which is insignificant (value >1.96 is significant).
| Discussion|| |
CSOM is of two types; tubotympanic type and atticoantral type. Tubotympanc type is called the safe type of CSOM because there is very rare chance of serious complications and it is associated with a central perforation and subtotal perforation of the tympanic membrane. Atticoantral type of CSOM is called unsafe type or dangerous type because it is associated with the pathology such as cholesteatoma, granulation tissue, and osteitis causing bone erosion and serious complications.
Sometimes, the safe type of CSOM may be dry or active. Due to perforation in the tympanic membrane, there is a chance of repeated infection of the middle ear cleft. The perforation can give rise to conductive hearing loss. The loss still increases when it involves the ossicular chain. In long-standing cases, there is a chance of sensory neural hearing loss due to the involvement of inner ear. Involvement of inner ear is supposed to be due to diffusion of toxins, antibodies, and antibiotics from the middle ear, through the round window membrane.
Conductive hearing loss is the main finding in case of tympanic membrane perforation. Severity of hearing loss depends on the size and site of the perforation. Hearing loss is more if the perforation size is bigger. Moreover, hearing loss is more in case of posterior perforation in comparison to anterior one.
Tympanoplasty is a microsurgical operative procedure perform to eradicate the disease from the middle ear and to reconstruct the hearing mechanism. Repair of the tympanic membrane, while the ossicular chain is intact, is called Type 1 tympanoplasty. Various graft materials were used in the past and also used now for the reconstruction of tympanic membrane such as temporalis fascia, cartilage, perichondrium, fat, vein, and skin. Previously, some of the graft materials used, which are not used nowadays, are skin, cadaver durameter, etc. Temporalis fascia is the best graft material because of its low basal metabolic rate, morphology like a normal tympanic membrane, good graft take-up rate, and excellent hearing result. However, in few cases, use of cartilage gives a better result than temporalis fascia, such as atelectatic tympanic membrane due to chronic Eustachian tube More Details dysfunction, subtotal and total perforation of the tympanic membrane, and revision cases.
Successful repair of the tympanic membrane depends on various factors such as size of the perforation, function of the eustachian tube, disease clearance from the middle ear cleft, and experience of the surgeon. Success rate is inversely proportional to the size of the perforation. Literature shows that the success of myringoplasty in experts' hand ranges from 95% to 97%, whereas in trainees' hand, it is 78%. Success decreases grossly in revision cases (60%). Success rate of myringoplasty in subtotal perforation is also low, i.e., 92.5% in experts' hand.
In the present study, the graft take-up rate in case of using only temporalis fascia is 124 out of 150 patients, i.e., 82.67%. This result is comparable to other studies. Pradhan et al. studied the result of temporalis fascia in subtotal and large perforations in 30 cases, and the result was 80%. Patil et al. studied 120 cases and found that the graft take-up rate is 85.19% in large perforation, 88.89% in subtotal perforation, and 83.33% in total perforations. Yegin et al. have shown only 65% result with the use of temporalis fascia in pediatric cases. Demirpehlivan et al. in 2011 reported 80.6% result  with temporalis fascia. Ulkü in 2010 reported the result of 88.2% with the same graft.
In our study, we have used both cartilage and temporalis fascia for reconstruction of the subtotal and total perforations. We have got the success rate of 95.34%. This is also comparable to other studies. Pradhan et al. have shown the success rate with cartilage as 96.7%. Kulkarni et al. have described the success rate of 98.3% using cartilage and temporalis fascia in Type 1 tympanoplasty. Mundra et al. studied 94 patients using temporalis fascia/perichondrium with slices of cartilage and found the graft take-up rate as 98.94%.
In our study, we have evaluated the hearing improvement in each group after 6 months of surgery. We have found that significant hearing improvement (≥10 dB) occurred in 74.19% cases in temporalis fascia group and 72.72% in cartilage and temporalis fascia group. Some authors have shown still better hearing improvement in their studies. Pradhan et al. have shown that significant hearing improvement was found in 90% cases in temporalis fascia group and 88% in cartilage group. Kulkarni et al. have shown that the hearing improvement in cartilage tympanoplasty was within 13.35 ± 5.22 dB of ABG closure. Mundra et al. concluded that, in 95.74% of patients, different types of tympanoplasty achieved hearing level of 30 dB or less.
| Conclusion|| |
Composite graft (both temporalis fascia and cartilage) is a better graft in comparison to temporalis fascia graft for the repair of the subtotal and total perforation of the tympanic membrane and that is also statistically significant when graft take-up rate is taken into consideration.
The authors would like to thank Dr. N. Partha Sarathy, Professor and HOD Community medicine, for technical help.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Dhingra PL. Cholesteatoma and Chronic Suppurative Otitis Media; Disease of Ear, Nose and Throat. 3rd
ed. Noida: Elsevier Publication; 2004. p. 87-96.
Frootko NJ. Reconstruction of Middle Ear; Scott-Brown's Otolaryngology. 6th
ed. New Delhi: Butterworth-Heinemann Publication; 1997. p. 1-30.
Yung MW. Myringoplasty for subtotal perforation. Clin Otolaryngol Allied Sci 1995;20:241-5.
Pradhan P, Anant A, Venkatachalam VP. Comparison of temporalis fascia and full-thickness cartilage palisades in type-I underlay tympanoplasty for large/subtotal perforations. Iran J Otorhinolaryngol 2017;29:63-8.
Patil K, Baisakhiya N, Deshmukh PT. Evaluation of different graft material in type 1 tympanoplasty. Indian J Otol 2014;20:106-14. [Full text]
Yegin Y, Çelik M, Koç AK, Küfeciler L, Elbistanlı MS, Kayhan FT, et al.
Comparison of temporalis fascia muscle and full-thickness cartilage grafts in type 1 pediatric tympanoplasties. Braz J Otorhinolaryngol 2016;82:695-701.
Demirpehlivan IA, Onal K, Arslanoglu S, Songu M, Ciger E, Can N, et al.
Comparison of different tympanic membrane reconstruction techniques in type I tympanoplasty. Eur Arch Otorhinolaryngol 2011;268:471-4.
Ulkü CH. Cartilage tympanoplasty with island technique for reconstruction of tympanic membrane perforation: Anatomic and audiologic results. Kulak Burun Bogaz Ihtis Derg 2010;20:7-12.
Kulkarni S, Kulkarni V, Burse K, Sancheti V, Roy G, Cartilage support for fascia graft in type – 1 tympanoplasty. Indian J Otolaryngol Head Neck Surg 2014;66:291-6.
Mundra RK, Sinha R, Agrawal R. Tympanoplasty in subtotal perforation with graft supported by a slice of cartilage: A study with near 100% results. Indian J Otolaryngol Head Neck Surg 2013;65:631-5.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]