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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 24  |  Issue : 3  |  Page : 168-171

Comparison of tragal perichondrium and temporal fascia grafts in tympanoplasties


Department of Ear, Nose and Throat and Head and Neck Surgery, University Hospital Center, Zagreb, Zagreb, Croatia

Date of Web Publication11-Jan-2019

Correspondence Address:
Dr. Selma Hodzic-Redzic
Department of Ear, Nose and Throat and Head and Neck Surgery, University Hospital Center Zagreb, Zagreb, Kispaticeva 12, Zagreb 10000
Croatia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/indianjotol.INDIANJOTOL_119_16

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  Abstract 


Objective: The objective of this study was to compare the anatomic and functional outcomes of the different graft materials used in tympanoplasty. Settings and Design: This was an observational, cross-sectional study. Patients and Methods: The study included 243 patients operated at Tertiary Care University Hospital, from January 2011 to December 2015. The study excluded patients who had previous ear surgery and patients with cholesteatoma and nose and paranasal sinuses diseases. Tympanoplasty was done under general anesthesia. The retroauricular approach was primarily used. All grafts were placed using the underlay technique. Audiological testing of all patients was done preoperatively and postoperatively. Statistical Analysis Used: All data were entered into Excel and analyzed using MedCalc Statistical Software version 15.8 (MedCalc Software bvba, Ostend, Belgium). Descriptive statistics was used. Audiological findings were compared using a paired t-test. The value of P < 0.05 was considered statistically significant. Results: The temporal fascia was used as the graft material in 160 patients, and tragal perichondrium was used in 83 patients. Improvement of audiological outcome in patients with temporal fascia amounted 62.5% and in patients with perichondrium amounted 60.24%. The graft success rate 3 months postoperatively was 92.5% in the fascia group whereas it was 95.18% in the perichondrium group. Conclusion: Improvement of audiological outcome was slightly better (62.5%) in the fascia group while graft acceptance in the postoperative period was slightly better (95.18%) in the perichondrium group.

Keywords: Temporal fascia graft, tragal perichondrium graft, tympanic membrane perforation, tympanoplasty


How to cite this article:
Hodzic-Redzic S, Kovac-Bilic L, Branica S. Comparison of tragal perichondrium and temporal fascia grafts in tympanoplasties. Indian J Otol 2018;24:168-71

How to cite this URL:
Hodzic-Redzic S, Kovac-Bilic L, Branica S. Comparison of tragal perichondrium and temporal fascia grafts in tympanoplasties. Indian J Otol [serial online] 2018 [cited 2019 Jan 18];24:168-71. Available from: http://www.indianjotol.org/text.asp?2018/24/3/168/249865




  Introduction Top


Tympanoplasty is used to treat chronic suppurative otitis media[1] with the aim of closing the defect of the eardrum and restoration of function impairment.[2] It can be combined with canal wall up or wall down mastoidectomy[3] and includes in addition to solving the pathology of the mastoid cavity, solving pathology of the facial nerve, and the  Eustachian tube More Details. This includes different approaches to the problem, so that the surgery depends on the underlying pathology, and is individual for each patient. Myringoplasty implies closure of the eardrum defect, without exploration of the middle ear. Tympanoplasty, in addition to the closure of the eardrum defect, implies exploration of the middle ear with or without reconstruction of the ossicular chain.[4]

The audiological outcome of the tympanoplasty amounts to 80%–90%, and a good result is considered if improvement of the air-bone gap amount 15 dB or more.[3] The audiological outcome depends on the condition of the middle ear, the presence or absence of the cholesteatoma and depends also on the condition of the ossicular chain and the degree of the aeration of the middle ear.[5],[6],[7] Since all of these factors can impact the audiological outcome, there are various techniques used to improve the surgical procedure, primarily in terms of the material used to close the eardrum defect. Materials for the closure of the defect can be autologous, which include temporal fascia, fascia lata, perichondrium, cartilage with or without perichondrium, veins, fat, and skin.[8],[9] Allograft materials include dura mater, epicard, temporal fascia, amniotic membrane, skin, cornea, peritoneum, veins, and aortic valve. Of late, alloplastic grafts such as paper, gelatin, and acellular dermal matrix are often used. There are several ways used to close the eardrum defect. Three basic types of surgery are overlay technique,[10] underlay technique,[11] and through (over underlay) technique of tympanoplasty.[12] Other techniques are modifications of those three.

Due to its anatomical characteristics, transparency, and flexibility, temporal fascia, and tragal perichondrium are two most commonly used grafts.[13]

Which one of them is better, which allows better audiological outcome, i.e., better hearing, and which lasts longer and allows better anatomical outcome is still controversial.

In this study, we try to solve this confusion and present our experience in the underlay tympanoplasty with temporal fascia and tragal perichondrium grafts, their impact on the audiological outcome, as well as the ability of closure of the eardrum defect.


  Patients and Methods Top


The study was observational and included patients of both sexes operated at the Tertiary Care University Center from January 2011 to December 2015. There were 243 patients operated during the regular program by three different surgeons who used the same technique of operation. Two of them used only temporal fascia graft, and one of them used only tragal perichondrium graft. Indication for surgery was made by these three experienced surgeons by otomicroscopic examination. Patients were randomly assigned to the groups by the way they appeared by the certain doctor in the certain ambulance.

Included were only patients with perforation and dry middle ear and patients with ear infection were conservatively treated first and were surgically treated afterward.

Included were patients for whom this was the first surgery.

The study excluded patients with cholesteatoma and those with nose and paranasal sinuses diseases (such as chronic rhinosinusitis, with or without polyps).

All patients were preoperatively examined by otomicroscopy. Tympanoplasty was done under general anesthesia. The retroauricular approach was primarily used. Transmeatal and endaural approaches were used in isolated cases. Temporal fascia or tragal perichondrium grafts were used to close the defect. All grafts were placed using underlay technique.

Main outcome measures were the audiological outcome and anatomical outcome, i.e., the result of graft uptake 3 months postoperatively.

Audiological testing of all patients was done preoperatively and postoperatively. Average value of hearing was found as the mean of four frequencies: 500, 1000, 2000, and 4000 Hz. Improvement of the air-bone gap that amounted 15 dB or more was considered as the good result.

Postoperatively, patients were examined 1 and 3 months after the surgery. Based on the otomicroscopic findings, patients were classified into two groups as follows: patients who needed new surgery and those with normal postoperative otomicroscopic findings.

Statistics

All data were entered into Excel and analyzed using MedCalc Statistical Software version 15.8 (MedCalc Software bvba, Ostend, Belgium). Descriptive statistics was used. Audiological findings were compared using a paired t-test. The value of P < 0.05 was considered statistically significant.


  Results Top


There were 243 patients operated with a minimum age of 17 and maximum age of 81. The median of age was 51. The result was measured by accepting graft 3 months postoperatively, and improving audiology findings by reducing the air-bone gap at least for 15 dB. The results are shown in [Table 1], [Table 2], [Table 3], [Table 4].
Table 1: Sex and age distribution

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Table 2: Graft distribution and audiological finding

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Table 3: Audiological improvement

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Table 4: Anatomical improvement

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  Discussion Top


Otitis media is an inflammatory disease of the middle ear and represents an important public health problem. It is caused by several interrelated factors, such as infection, dysfunction of the Eustachian tube, allergies, and barotrauma. Chronic otitis media is an advanced form of the disease and is associated with some irreversible pathological changes of the middle ear, such as the occurrence of granulation tissue, changes of ossicles, tympanosclerosis, perforation of the tympanic membrane, and cholesteatoma.[13]

Perforations of the tympanic membrane are a huge problem. They can be caused by chronic otitis, as well as by trauma. Perforations are classified according to the duration to the acute and chronic, which lasts more than 3 months, according to the presence or absence of secretion to the wet and dry perforations.[14] Time needed for perforation to heal depends mostly on the type of perforation. Perforations which are wet and acute close spontaneously after a few weeks in 76%–94% of cases using only topical antibiotic therapy.[15],[16] The closing of chronic perforations requires surgical treatments: myringoplasty or tympanoplasty.[15],[17],[18]

The ideal material for the closure of the tympanic membrane should have a low rate of rejection, it should be sufficient in quantity, have a sufficient strength, have the ability to conduct similar to the tympanic membrane, and it should be easily accessible. Membranous grafts such as temporal fascia and perichondrium meet these criteria and lead to the closure of 95% treated ears. On the other hand, in situations where there is a total perforation, chronic mucosal dysfunction, recurrent perforation, atelectatic ear, and cholesteatoma, the better choice is the cartilage.[19],[20],[21]

In this study, the results of using temporal fascia and tragal perichondrium using underlay technique were compared. Both of these grafts are available in the operating field, available in sufficient quantity, have excellent contour, can be compressed to one point and trimmed as necessary, and have an excellent ability to survive. In addition, as they both are mesodermal in origin, there is no possibility of postoperative cholesteatoma.[13]

In total, 243 patients had complete data for analysis. There was a slight predominance of women (56.79%), which may be due to the fact that women are generally more conscious of their health than men. In other studies, there was a predominance of men.[13]

Most of the patients had over 51 years, 44.54%, there was 38.27% patients in the age of 31–50, and 17.28% patients who had <30 years. This is due to the fact that chronic otitis is most often present in people over 51 years.

There was statistically significant difference between preoperative and postoperative audiological finding in the fascia and in the perichondrium group.

Improvement of audiological outcome in patients with the fascial graft amounted 62.5% and in the study Dabholkar et al. in 2007 that percentage amounted 76%.[13]

Hearing improvement of the patients with tragal perichondrium graft amounted 18.41 dB, and in the study of Haisch et al. from 2013, hearing improvement amounted 10.8 dB,[22] which represents a better result of this study. In percentage, this improvement amounted 50%, and in the study Dabholkar et al. in 2007, this improvement amounted 75%.[13] In the study of Racić and Sprem, hearing improvement with tragal perichondrium graft amounted to 69% (compared to 42% with the fascia).[23]

There was no statistically significant difference in postoperative otomicroscopic finding in fascia and in the perichondrium group.

The graft success rate was 92.5% for the fascia group compared with 95.18% for the tragal perichondrium group.

According to the study Dabholkar et al., graft success rate for the fascia group was 84%, and graft success rate for the tragal perichondrium was 80%.[13] In the study of Haisch et al., graft success rate of tragal perichondrium was 85%,[22] while in the U study of Racić and Sprem, there was 84% graft uptake of fascia and 80% graft uptake of the tragal perichondrium.[23]

Thus, in this study, both audiological outcomes were approximately similar, but both graft persistence were better than the above-mentioned studies. The tragal perichondrium graft uptake was slightly better than the fascia, but the hearing outcome was slightly better with temporal fascia graft (62.5%) than with tragal perichondrium graft (60.24%).

Temporal fascia and tragal perichondrium remain ideal materials for closing uncomplicated tympanic membrane perforation. They provide a good audiological outcome, and the ability of graft uptake is excellent.

The future is to form new grafts that reproduce the mechanical and acoustic properties of the tympanic membrane. Furthermore, we expect the use of biomolecules with proliferative and angiogenic effects, such as epidermal growth factor, insulin, and serum, which can improve the outcome in the tympanic membrane perforation.[18]


  Conclusion Top


There was the statistically significant difference between preoperative and postoperative audiological finding in the fascia and in the perichondrium group.

Improvement of audiological outcome was slightly better (62.5%) in the temporal fascia group than in tragal perichondrium group (50%). Graft acceptance in the postoperative period was slightly better (95.18%) in the perichondrium group than in the temporal fascia group (92.5%).

There was no statistically significant difference in postoperative otomicroscopic finding in fascia and in the perichondrium group.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Athanasiadis-Sismanis A. Tympanoplasty: Tympanic membrane repair. In: Gulya AJ, Minor LB, Poe DS, editors. Glasscock-Shambaugh Surgery of the Ear. 6th ed. Shelton: People's Medical Publishing House; 2010. p. 465-88.  Back to cited text no. 1
    
2.
Committee on Conservation of Hearing of the American Academy of Ophthalmology and Otolaryngology. Standard classification for surgery for chronic ear infection. Arch Otolaryngol Head Neck Surg 1965;81:204-5.  Back to cited text no. 2
    
3.
Shetty S. Pre-operative and post-operative assessment of hearing following tympanoplasty. Indian J Otolaryngol Head Neck Surg 2012;64:377-81.  Back to cited text no. 3
    
4.
Hirsh BE. Myringoplasy and tympanoplasty. In: Myers EN, editor. Operative Otolaryngology Head and Neck Surgery. Philadelphia: Elsevier; 2008. p. 1246-61.  Back to cited text no. 4
    
5.
Sismanis A. Tympanoplasty. In: Glasscock ME, Gulya AJ, editors. Glasscock-Shambaugh Surgery of the Ear. 5th ed. Ontario: BC Decker Inc.; 2003. p. 473.  Back to cited text no. 5
    
6.
Goldenberg RA. Hydroxylapatite ossicular replacement prostheses: A four-year experience. Otolaryngol Head Neck Surg 1992;106:261-9.  Back to cited text no. 6
    
7.
Kolo ES, Ramalingam R. Hearing results post tympanoplasty: Our experience with adults at the KKR ENT hospital, India. Indian J Otolaryngol Head Neck Surg 2014;66:365-8.  Back to cited text no. 7
    
8.
Mohamad SH, Khan I, Hussain SS. Is cartilage tympanoplasty more effective than fascia tympanoplasty? A systematic review. Otol Neurotol 2012;33:699-705.  Back to cited text no. 8
    
9.
Van Rompaey V, Farr MR, Hamans E, Mudry A, Van de Heyning PH. Allograft tympanoplasty: A historical perspective. Otol Neurotol 2013;34:180-8.  Back to cited text no. 9
    
10.
House WF. Myringoplasty. AMA Arch Otolaryngol 1960;71:399-404.  Back to cited text no. 10
    
11.
Shea JJ Jr., Vein graft closure of eardrum perforations. J Laryngol Otol 1960;74:358-62.  Back to cited text no. 11
    
12.
Kartush JM, Michaelides EM, Becvarovski Z, LaRouere MJ. Over-under tympanoplasty. Laryngoscope 2002;112:802-7.  Back to cited text no. 12
    
13.
Dabholkar JP, Vora K, Sikdar A. Comparative study of underlay tympanoplasty with temporalis fascia and tragal perichondrium. Indian J Otolaryngol Head Neck Surg 2007;59:116-9.  Back to cited text no. 13
    
14.
de Juan E, Walsh A, Rader S, Shelley TH, Lamborne AN, Niparko JK. Tympanic Membrane Prosthesis with Mechanical Fixation. US Patent; 2001.  Back to cited text no. 14
    
15.
Teh BM, Marano RJ, Shen Y, Friedland PL, Dilley RJ, Atlas MD, et al. Tissue engineering of the tympanic membrane. Tissue Eng Part B Rev 2013;19:116-32.  Back to cited text no. 15
    
16.
Zhang Q, Lou Z. Impact of basic fibroblast growth factor on healing of tympanic membrane perforations due to direct penetrating trauma: A prospective non-blinded/controlled study. Clin Otolaryngol 2012;37:446-51.  Back to cited text no. 16
    
17.
Hong P, Bance M, Gratzer PF. Repair of tympanic membrane perforation using novel adjuvant therapies: A contemporary review of experimental and tissue engineering studies. Int J Pediatr Otorhinolaryngol 2013;77:3-12.  Back to cited text no. 17
    
18.
Villar-Fernandez MA, Lopez-Escamez JA. Outlook for tissue engineering of the tympanic membrane. Audiol Res 2015;5:117.  Back to cited text no. 18
    
19.
Buckingham RA. Fascia and perichondrium atrophy in tympanoplasty and recurrent middle ear atelectasis. Ann Otol Rhinol Laryngol 1992;101:755-8.  Back to cited text no. 19
    
20.
Milewski C. Composite graft tympanoplasty in the treatment of ears with advanced middle ear pathology. Laryngoscope 1993;103:1352-6.  Back to cited text no. 20
    
21.
Chhapola S, Matta I. Cartilage-perichondrium: An ideal graft material? Indian J Otolaryngol Head Neck Surg 2012;64:208-13.  Back to cited text no. 21
    
22.
Haisch A, Harder J, Hopfenmüller W, Sedlmaier B. Functional and audiological results of tympanoplasty type I using pure perichondrial grafts. HNO 2013;61:602, 604-8.  Back to cited text no. 22
    
23.
Racić G, Sprem N. The fascia and perichondrium in reconstructive surgery of the middle ear. Laryngol Rhinol Otol (Stuttg) 1986;65:496-8.  Back to cited text no. 23
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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