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Year : 2018  |  Volume : 24  |  Issue : 3  |  Page : 179-183

A prospective study of outcome of boomerang-shaped chondroperichondrial graft in Type i tympanoplasty

Department of ENT, JLN Medical College and Hospital, Ajmer, Rajasthan, India

Date of Web Publication11-Jan-2019

Correspondence Address:
Dr. Digvijay Singh Rawat
Department of ENT, JLN Medical College and Hospital, Ajmer, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/indianjotol.INDIANJOTOL_31_18

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Context: Cartilage has proven to be an excellent graft material inside the middle ear. The use of cartilage for tympanic membrane grafting may provide additional benefits in some difficult situations. Aims: The study was planned to evaluate the graft uptake and hearing after placement of “boomerang-shaped chondroperichondrial graft” in Type I tympanoplasty. Settings and Design: The prospective study was conducted on 40 patients having chronic suppurative otitis media with no active disease at least for last 6 weeks in a tertiary care center of North India. Patients having cholesteatoma and ossicular erosion/or necrosis were excluded from the study.Subjects and Methods: Those patients underwent tympanoplasty Type I by postaural approach and underlay grafting using “boomerang-shaped chondroperichondrial graft” from tragal cartilage and were followed up for 3 months. Hearing evaluation was performed preoperatively and postoperatively after 3 months. Statistical Analysis Used: The mean, range, and standard deviation of air conduction and air-bone gap were calculated and compared with preoperative findings. Results: The mean age of study group was 26.23 ± 12.46 years. Ear discharge (100%) and hearing impairment (87.5%) were the chief presenting complaints. The mean duration of ear discharge was 6.67 ± 6.75 years. Type I tympanoplasty was performed in all cases using “boomerang-shaped chondroperichondrial graft” harvested from tragal cartilage. Graft was taken up at the 3rd month in all patients. The preoperative mean air conduction was 43.21 ± 7.17 dB, which at the 3rd month improved to 36.49 ± 6.60 (P = 0.00004). Preoperative mean air-bone gap was 25.45 ± 8.44 dB which was improved to 19.31 ± 8.18 dB postoperatively at the 3rd month (P = 0.0014). Conclusions: Boomerang-shaped chondroperichondrial graft has excellent “take rate” in Type I tympanoplasty.

Keywords: Boomerang-shaped chondroperichondrial graft, cartilage tympanoplasty, chondroperichondrial graft

How to cite this article:
Pareek YK, Rawat DS, Aseri Y, Tailor MK, Verma PC, Singh BK. A prospective study of outcome of boomerang-shaped chondroperichondrial graft in Type i tympanoplasty. Indian J Otol 2018;24:179-83

How to cite this URL:
Pareek YK, Rawat DS, Aseri Y, Tailor MK, Verma PC, Singh BK. A prospective study of outcome of boomerang-shaped chondroperichondrial graft in Type i tympanoplasty. Indian J Otol [serial online] 2018 [cited 2020 Sep 23];24:179-83. Available from: http://www.indianjotol.org/text.asp?2018/24/3/179/249871

  Introduction Top

The aim in tympanoplasty is to achieve a healthy ear with reconstructed tympanic membrane (TM), which is well aerated and has a good hearing function.[1] Most frequently used grafting material is temporal fascia graft due to the ease of its accessibility at the surgical site and the successful closure of the TM in most of the normally ventilated middle ears.[2],[3] However, in situations such as persistent middle ear pathology, large perforations, or retraction pockets, the use of temporalis fascia causes higher failure rates due to the effect of negative pressure in the middle ear.[3]

Cartilage is being used in the middle ear for several decades for reconstruction of TM and ossicular reconstruction.[4],[5],[6] The perichondrium cartilage island flap technique is preferred for the management of the atelectatic ear and the high-risk perforation. The palisade technique demonstrates durable and resistant reconstruction of the TM with reasonable hearing in subtotal and total perforations.[7] Boomerang-shaped chondroperichondrial graft has currently gained acceptance in the literature.[8] The study was planned to evaluate the graft uptake and hearing after placement of boomerang-shaped chondroperichondrial graft in Type I tympanoplasty.

  Subjects and Methods Top

The study was conducted in a tertiary care center from August 2016 to July 2017. Target population was patients of chronic suppurative otitis media with no active disease at least for the past 6 weeks, who were willing to undergo middle ear surgery. Patients having cholesteatoma and ossicular erosion/or necrosis were excluded from the study. The study design was a prospective longitudinal study, and ethical approval was obtained from the Ethical Research Committee of the institute. Target population patients were provisionally selected and evaluated. A written fully explained consent stating the voluntary participation of subjects in the study was taken before the enrollment of the subjects. All cases selected were evaluated using preformed proforma. Out of those patients who fulfilled the inclusion criteria and none of the exclusion criteria was detected pre-operatively or intra-operatively, constituted the study group. A study group sample size of 40 patients considered to compensate for patients who might be lost in follow-up.

A detailed history was taken as to age, sex, socioeconomic status, occupation, nature, and duration of symptoms, etc., All patients undergo thorough history and ENT examination. A battery of investigation including routine blood investigation, urine examination, X-ray mastoids lateral oblique view, X-ray chest, electrocardiography, ototelescopic examination, examination under microscopic, and tuning fork tests performed in all patients.

The pre- and postoperative hearing evaluation was be done by pure-tone audiometry in a soundproof audiometry room. Air- and bone-conduction (with masking) thresholds of all these patients were recorded for 0.5, 1, 2, and 4 kHz preoperatively and in postoperative period after 3 months. The mean, standard deviation, range, and the number of decibels of change in the air-bone gap were calculated.

Patients were explained about the surgical procedure and study. The patients planned for surgery after proper investigations and preanesthetic checkup and clearance. Preanesthetic checkup and lidocaine sensitivity testing of all the patients performed. The procedures were undertaken under local or general anesthesia. The surgical approach was postaural. Status of the middle ear structures and ossicular chain was checked. If the ossicular chain was intact, then the bed for boomerang-shaped chondroperichondrial graft was made. The tympanomeatal flap was elevated 300°, posterosuperiorly from 12 o'clock position to far anteriorly up to 2 o'clock/10 o'clock position. Tragal cartilage was harvested with perichondrium on both the sides, and appropriate size boomerang-shaped cartilage island was made. Template made from aluminum packaging of suture material was used to match the exact size and shape of cartilage suitable to be placed. The composite graft was placed underlay in such a way that the boomerang-shaped cartilage lied at the level of annulus anteriorly, and perichondrium was sandwiched between canal wall and tympanomeatal flap. Gelfoam was placed in external acoustic canal, and ointment/Merocel packing was done. Wound closed in two layers and mastoid dressing was applied. Oral antibiotic amoxicillin with clavulanic acid was prescribed for 7 days. Sutures and external auditory canal packing were removed on the 7th postoperative day. Topical antibiotic with steroids (ciprofloxacin with dexamethasone) was prescribed for 21 days. Patients were followed up at the 1st and 3rd month postoperatively. Patients were evaluated for healing, graft uptake, and hearing. Microscopic examination was performed after the 3rd month to evaluate the condition of the graft. The end points were postoperative hearing threshold levels and “take rate” of graft after 3 months of surgery. All cases were subjected to postoperative pure-tone audiometry by the same audiologist in similar condition as were of preoperative audiometry. Statistical analysis of these results will be done by t-test using OpenEpi software.[9] P < 0.05 was considered statistically significant.

  Results Top

Forty patients were selected for study group fulfilling all inclusion criteria and satisfying all exclusion criteria. In these 40 patients, boomerang-shaped chondroperichondrial graft was placed. The age of the patients included in the study ranged from 10 to 60 years with a mean age of 26.23 ± 12.46 years. In this study, there were 15 (37.5%) males and 25 (62.5%) females; of these, 21 (52.5%) patients were from urban area and 19 (47.5%) from rural area [Table 1].
Table 1: Demographic characteristic of study population

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The most common complaints of patients were ear discharge presented in all patients (n = 40). Mean duration of ear discharge was 6.67 ± 6.75 years. The second common presenting complaint was hearing impairment which was complained by 87.5% of patients. Mean duration of hearing loss was 5.71 ± 6.52 years. There was bilateral disease in 13 patients; the right ear was affected in 15 and the left ear in 12 patients [Table 2]. On the basis of otoscopic and microscopic examination, 22 (32.5%) right ears and 18 (32.5%) left ears were selected for surgery; out of which, 33 (82.5%) patients had central perforation, two (5%) patients had posterosuperior retraction, and five (12%) patients had marginal perforation. Edematous middle ear mucosa was seen in 5 (12.5%) patients. The preoperatively mean air conduction was 43.21 ± 7.17 dB and mean air-bone gap was 25.45 ± 8.44 dB [Table 3].
Table 2: Clinical presentation of study population

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Table 3: Comparison of pre- and postoperative hearing

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Type I tympanoplasty using boomerang-shaped chondroperichondrial graft made up of tragal cartilage was performed in all cases by senior authors. Out of 40, nine procedures were undertaken under general anesthesia. The peri- operative and postoperative period was uneventful with no significant complications. Patients were counseled and motivated for regular follow-up and all completed the 3rd month follow-up. During postoperative follow-up, leftover Gelfoam pieces were removed; after 1 month, the graft was healthy in all patients.

At the 3rd month, all the patients were satisfied and no major complaint reported. Out of the 35 patients presented with hearing loss, 16 reported improvement in hearing and 19 reported not much change. Worsening of hearing was not reported by any of the study patients. Graft was taken up in all the patients. The preoperative mean air conduction was 43.21 ± 7.17 dB, which at the 3rd month postoperatively was significantly improved to 36.49 ± 6.60 (P ≤ 0.00004). Preoperative mean air-bone gap was 25.45 ± 8.44 dB which was improved to 19.31 ± 8.18 dB postoperatively at the 3rd month (P = 0.0014) [Table 3].

  Discussion Top

The term tympanoplasty was first used in 1953 by Wullstein to describe surgical techniques for the reconstruction of the middle ear hearing mechanism that had been impaired or destroyed by chronic ear disease.[1] Various primary graft materials described since then are temporal fascia, cartilage, perichondrium, fascia lata, adipose tissue, skin, periosteum, vein, and dura mater. Temporal fascia is the most commonly used graft material and is a near ideal graft.[2],[3] There is a high rate of failures with the use of temporalis fascia in situations such as persistent middle ear pathology, large perforations, or retraction pockets and revision cases.[3] The postoperative dimensions of temporal fascia are unpredictable as it is composed of irregularly arranged elastic fibers and fibrous connective tissue and may shrink regardless of the surgical technique used.[2] These observations have led to the use of less compliant and more rigid grafting materials for TM reconstruction. In such cases, a more rigid grafting material such as cartilage is preferred due to its increased stability and resistance to middle ear pressure.[3]

Utech, in 1959, first introduced cartilage in middle ear surgery.[4] Reconstruction of the TM using cartilage was originally realized by Jansen and Salen.[5],[6] Although cartilage is similar to fascia in that it is mesenchymal tissue, its more rigid quality tends to resist resorption and retraction, even in the milieu of continuous  Eustachian tube More Details dysfunction. It has been shown in both experimental and clinical studies that cartilage is well tolerated by the middle ear and long-term survival is the norm.[10] Cartilage tissue is nourished by diffusion of nutrients and adapts better to focal nutritional disorders, which occurs during healing of the TM. Chondroperichondrial graft is well tolerated by the middle ear and retains their vitality for longer times.[3]

As the cartilage grafts are thick and rigid, so there has been a doubt of possibilities of hearing loss; however, Dornhoffer stated that in cases where cartilage is thinner than 0.5 mm, hearing outcomes comparable to normal TM have been achieved.[11] In an experimental study, Zahnert et al. investigated acoustic conduction properties of cartilage grafts of various thickness and their mechanical deformations when exposed to fluctuations in atmospheric pressure.[12] They also comparatively evaluated tragal and conchal cartilages but had not obtained any significant changes in outcome.[12] Tos has described cartilage grafting techniques using tragal or conchal cartilages. He classified 23 different cartilage grafting techniques into six groups. The various forms used were palisade, stripes, slices, foils, thin plates, thick plates, discs, and cartilage-perichondrium composite graft of different types.[3]

Even after so many years of the use of cartilage as a graft for tympanoplasty, there is no consensus for a particular technique. However, it is widely accepted that for reconstruction of the TM in cases of advanced middle ear pathology and eustachian tube dysfunction, especially in cases of high-risk perforations (big central, subtotal, and anterior perforation of TM), cartilage support provides excellent surgical results and minimal complications.[13],[14]

Yüksel Aslier et al. evaluated the sound energy absorbance characteristics of cartilage grafts in patients, who have undergone Type 1 cartilage tympanoplasty by wideband tympanometry and concluded that graft material, graft thickness, cartilage surface area ratio, and elapsed time after surgery affected the course of sound energy absorbance.[15]

Jeffery et al., in a systematic review and meta-analysis of palisade cartilage tympanoplasty technique, reported excellent graft take rates and good postoperative hearing outcomes for perforations of various sizes and for both primary and revision cases.[16] They suggested this technique to be predictable, long-term results with low complication rates, similar to temporalis fascia tympanoplasty.[16] Eldaebes et al. studied the effect of cartilage grafts on sound transfer function on different TM locations in temporal bones. They concluded that the placement of cartilage at the annular rim of the TM was important for the low-frequency acoustic transfer function.[17]

Goodhill described the circumferential cartilage grafting, especially in patients with a shallow middle ear cavity. The technique avoids prolapse of the perichondrium into the promontorium.[18] Debasish et al. used a composite graft comprising perichondrium and peripheral ring of tragal cartilage for TM reconstruction in high-risk cases.[13] They emphasized that the ring cartilage graft does not fold and helps in smooth growth of epithelium over it. They concluded that graft supported by cartilage ring achieves good anatomical and audiological results.[13]

The boomerang-shaped chondroperichondrial graft technique used in the present study is a modification to Goodhill technique.[18] Özbay et al. compared boomerang- and shield-shaped chondroperichondrial cartilage grafts for Type 1 tympanoplasty in children and concluded that boomerang-shaped chondroperichondrial graft procedure is a reliable and safe method of performing pediatric tympanoplasty.[19] The principal is to strengthen the anteriorly placed graft near the opening of eustachian tube and to prevent retraction and lateralization of neotympanum. In the present study, graft was successfully taken up after 3 months in all patients. Sözen et al. in a series of 246 patients compared conchal cartilage, tragal cartilage, and temporalis muscle fascia and found corresponding graft success rates of 100%, 88.5%, and 80.5%, respectively.[20] In a study of Dündar et al., most perforations involved over 50% of the TM and the success rate with a boomerang-shaped chondroperichondrial graft was 95% (99 cases).[8] Debasish et al. reported overall graft take-up rate of 93.33% with composite graft comprising perichondrium and peripheral ring of tragal cartilage.[13]

In the present study, postoperatively after 3 months, mean air conduction was improved from 43.21 ± 7.17 to 36.49 ± 6.60 dB (P = 0.00004). The preoperative mean air-bone gap was 25.45 ± 8.44 dB which was improved to 19.31 ± 8.18 dB at the 3rd postoperative month (P = 0.0014). Boone et al. used cartilage for revision tympanoplasty in patients who have experienced at least one failed attempt at repair of the TM and were, therefore, at higher risk for subsequent repair failure.[21] They reported average postoperative pure-tone air-bone gap of 12.2 ± 7.3 dB compared with 24.6 ± 13.8 dB preoperatively.[21]

In a study of Dündar et al. during the as first year after the tympanoplasty surgery using boomerang-shaped cartilage, graft lateralization was not detected in any patient. Retractions were Grade 1 according to the Sade classification and were localized to the posterosuperior quadrant of the TM.[8] They emphasized that the technique reduces the chances of residual perforation at the anterior quadrant and avoids graft lateralization. The part of the graft which plays an important role in the auditory function which also comes in contact with the manubrium demonstrates acoustic properties comparable to temporalis muscle fascia due to the thinness of perichondrium.[8] Similarly, we noted that the boomerang-shaped chondroperichondrial graft helped in maintaining the anteroinferior angle of TM with canal wall by preventing lateralization of graft. None of the patients was presented with the retraction of neotympanum.

  Conclusions Top

We noted that “boomerang-shaped chondroperichondrial graft” technique gives good anatomical and audiological results in Type I tympanoplasty. Anteriorly circumferentially placed chondroperichondrial graft helps in proper positioning of neo-TM and prevents retraction of TM at the anterior quadrant and avoids graft lateralization.

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  References Top

Wullstein H. Theory and practice of tympanoplasty. Laryngoscope 1956;66:1076-93.  Back to cited text no. 1
Indorewala S, Pagare R, Aboojiwala S, Barpande S. Dimensional stability of the free fascia grafts: A human study. Laryngoscope 2004;114:543-7.  Back to cited text no. 2
Tos M. Cartilage tympanoplasty methods: Proposal of a classification. Otolaryngol Head Neck Surg 2008;139:747-58.  Back to cited text no. 3
Utech H. Tympanotomy in disorders of sound conduction; its diagnostic and therapeutic possibilities. Z Laryngol Rhinol Otol 1959;38:212-21.  Back to cited text no. 4
Jansen C. Cartilage – Tympanoplasty. Laryngoscope 1963;73:1288-301.  Back to cited text no. 5
Salen B. Myringoplasty using septum cartilage. Acta Otolaryngol Suppl 1964;188 Suppl 188:82.  Back to cited text no. 6
Kazikdas KC, Onal K, Boyraz I, Karabulut E. Palisade cartilage tympanoplasty for management of subtotal perforations: A comparison with the temporalis fascia technique. Eur Arch Otorhinolaryngol 2007;264:985-9.  Back to cited text no. 7
Dündar R, Soy FK, Kulduk E, Muluk NB, Cingi C. A new grafting technique for tympanoplasty: Tympanoplasty with a boomerang-shaped chondroperichondrial graft (TwBSCPG). Eur Arch Otorhinolaryngol 2014;271:2687-94.  Back to cited text no. 8
Dean AG, Sullivan KM, Soe MM. OpenEpi: Open Source Epidemiologic Statistics for Public Health, Version. Available from: http://www. OpenEpi.com. [Last accessed on 2017 Aug 10; Last updated on 2013 Apr 06;].  Back to cited text no. 9
Yung M. Cartilage tympanoplasty: Literature review. J Laryngol Otol 2008;122:663-72.  Back to cited text no. 10
Dornhoffer JL. Hearing results with cartilage tympanoplasty. Laryngoscope 1997;107:1094-9.  Back to cited text no. 11
Zahnert T, Hüttenbrink KB, Mürbe D, Bornitz M. Experimental investigations of the use of cartilage in tympanic membrane reconstruction. Am J Otol 2000;21:322-8.  Back to cited text no. 12
Debasish G, Arindam D, Sayan H, Arunabha S. Maximising graft take-up in type 1 tympanoplasty using peripheral cartilage ring and perichondrium. Indian J Otolaryngol Head Neck Surg 2018;70:290-4.  Back to cited text no. 13
Heo KW. Outcomes of type I tympanoplasty using a cartilage shield graft in patients with poor prognostic factors. Auris Nasus Laryn×2017;44:517-21.  Back to cited text no. 14
Yüksel Aslıer NG, Gürkan S, Aslıer M, Kirkim G, Güneri EA, Ikiz AÖ. Sound energy absorbance characteristics of cartilage grafts used in type 1 tympanoplasty. Auris Nasus Laryn×2018;45:985-93.  Back to cited text no. 15
Jeffery CC, Shillington C, Andrews C, Ho A. The palisade cartilage tympanoplasty technique: A systematic review and meta-analysis. J Otolaryngol Head Neck Surg 2017;46:48.  Back to cited text no. 16
Eldaebes MM, Landry TG, Bance ML. Effects of cartilage overlay on the tympanic membrane: Lessons from a temporal bone study for cartilage tympanoplasty. Otol Neurotol 2018;39:995-1004.  Back to cited text no. 17
Goodhill V. Tragal perichondrium and cartilage in tympanoplasty. Arch Otolaryngol 1967;85:480-91.  Back to cited text no. 18
Özbay C, Soy FK, Kulduk E, Dundar R, Yükkaldiran A, Güler OK, et al. Boomerang-shaped vs. shield-shaped chondroperichondrial cartilage grafts for type 1 tympanoplasty in children: A study of 121 patients. Ear Nose Throat J 2017;96:419-32.  Back to cited text no. 19
Sözen E, Orhan Uçal Y, Tansuker HD, Uslu Coşkun B, Yasemin Korkut A, Dadaş B, et al. Is the tragal cartilage necessary for type 1 tympanoplasties? J Craniofac Surg 2012;23:e280-3.  Back to cited text no. 20
Boone RT, Gardner EK, Dornhoffer JL. Success of cartilage grafting in revision tympanoplasty without mastoidectomy. Otol Neurotol 2004;25:678-81.  Back to cited text no. 21


  [Table 1], [Table 2], [Table 3]


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