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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 24  |  Issue : 3  |  Page : 190-193

Comparative study of clinical and audiological outcome between anterior tucking and circumferential flap methods of type I tympanoplasty in large central perforation


1 Sri Venkateswara Ent Institute, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
2 Osmania Medical College, Hyderabad, Telangana, India

Date of Web Publication11-Jan-2019

Correspondence Address:
Dr. S Mohammed Hussain
Sri Venkateswara ENT, Bangalore Medical College and Research Institute, Fort KR Road, Bengaluru - 560 002, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/indianjotol.INDIANJOTOL_60_18

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  Abstract 


Background: Tympanoplasty is a common operation performed by otolaryngologists worldwide. During the last 100 years various modifications in this surgical technique have come up because of continued efforts made by otologists all over the world to achieve the best surgical outcome. Objective: The aim of this study is to compare the surgical and audiological outcomes of anterior tucking and circumferential flap methods of type 1 tympanoplasty. Materials and Methods: This prospective randomized study included 100 patients who presented in the ENT outpatient Department of Bangalore Medical College and Research Institute with chronic otitis medialarge central perforation in an inactive stage. Patients were randomly allocated to two groups of 50 cases each. Group A contained 50 patients who underwent Type I tympanoplasty by circumferential flap method, and Group B contained 50 patients who underwent Type I tympanoplasty by anterior tucking method. Patients were followed up at the 3rd month postoperatively by otomicroscopy and pure tone audiometry (PTA), graft uptake and hearing gain were assessed. Results: There was a statistically significant mean hearing gain postoperatively compared to preoperative PTA in both techniques, among the two techniques, there was no statistically significant difference regarding hearing gain and graft uptake. Conclusion: Anterior tucking and circumferential flap methods of type 1 tympanoplasty are good regarding graft placement, graft uptake, and audiological outcome for chronic otitis media with large central perforation, especially with little or no anterior remnant of pars tensa.

Keywords: Anterior tucking tympanoplasty, chronic otitis media, circumferential flap tympanoplasty, type 1 tympanoplasty


How to cite this article:
Dhanapala N, Hussain S M, Reddy L S, Bandadka R. Comparative study of clinical and audiological outcome between anterior tucking and circumferential flap methods of type I tympanoplasty in large central perforation. Indian J Otol 2018;24:190-3

How to cite this URL:
Dhanapala N, Hussain S M, Reddy L S, Bandadka R. Comparative study of clinical and audiological outcome between anterior tucking and circumferential flap methods of type I tympanoplasty in large central perforation. Indian J Otol [serial online] 2018 [cited 2019 May 26];24:190-3. Available from: http://www.indianjotol.org/text.asp?2018/24/3/190/249876




  Introduction Top


Tympanoplasty is a common surgery performed by otolaryngologists worldwide, with various modifications. The term tympanoplasty was first used in 1953 by Wullstein to describe surgical techniques for reconstruction of the middle ear hearing mechanism that had been impaired or destroyed by chronic ear disease.[1] Wullstein classified Tympanoplasty into five different types.[2] Type 1 Tympanoplasty is repair of tympanic membrane perforation with intact ossicular chain.[3] To obtain good graft uptake and hearing gain various techniques and approaches have been described. The techniques of tympanoplasty include overlay, underlay, over underlay, and interlay methods.[4] The most common area of graft medicalisation and failure when repairing perforations is the anterosuperior area due to lack of graft support, the anterior tympanomeatal angle and less vascularity with a greater risk of re-perforation.[5] To overcome the complication of medialization of graft, tympanoplasty with anterior tucking or circumferential flap techniques are devised. This study was conducted to compare the surgical and audiological outcome of type 1 tympanoplasty done by anterior tucking and circumferential flap methods.


  Materials and Methods Top


In this randomized prospective study, 100 patients between 10 and 50 years of age with chronic otitis media with central perforation who presented to ENT outpatient Department of Bangalore Medical College and Research Institute willing to participate in the study were included. Patients with the sensorineural hearing loss, diabetes, hypertension, cardiac disease, bleeding disorders, and hemoglobin <10 g% were excluded from the study.

All patients were subjected to detailed history, thorough ENT examination, relevant laboratory investigations and preoperative pure tone audiometry (PTA).

Patients were randomly allocated to two groups of 50 cases each. Group A contained 50 patients who underwent Type I tympanoplasty by circumferential flap method, and Group B contained 50 patients who underwent Type I tympanoplasty by anterior tucking method. Both these methods involved creation of a vascular strip and grafting with temporalis fascia medial to the handle of malleus. In the circumferential flap method, the fibrous annulus was elevated with the tympanomeatal flap 360° exposing bony annulus all around, and the graft was placed over the bony annulus and supported by repositioning the tympanomeatal flap. In the anterior tucking method, the tympanomeatal flap was elevated with the posterior tympanic annulus, an incision was made on anterior canal wall about 5 mm lateral to the anterior annulus and a subcutaneous tunnel was made connecting to anterior mesotympanum. The graft was placed medial to the handle of malleus and tucked medial to the fibrous annulus anteriorly by pulling it through the tunnel.

Patients were followed up at the 3rd month postoperatively. The success of graft uptake was assessed by otoendoscopic examination. Postoperative improvement in hearing was assessed by PTA. The success of surgery was defined as complete closure of tympanic membrane perforation and postoperative improvement in hearing.

Statistical methods

Student t-test was used for the mean hearing improvement and to compare the mean of hearing gain between the two groups.

Chi-square/Fisher exact test was used to find the significance of study parameters on categorical scale between groups.


  Results Top


In anterior tucking group, 24 were female and 26 were male and in the circumferential flap group, 19 were female and 31 were male. Most common age group involved in the study were between 31 and 40 years (45%) [Figure 1]. The right ear was affected in 55 patients and left ear was affected in 45 patients [Table 1].
Figure 1: Age distribution

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Table 1: Tympanic membrane perforation distribution in two groups of patients

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Preoperative PTA among the groups suggested that, in anterior tucking group 10 patients and in circumferential flap group 9 patients had air-bone gap <30 dB. 40 patients with 30–40 dB air-bone gap belonged to the anterior tucking group and 41 patients were from the circumferential flap group [Figure 2].
Figure 2: Pure tone audiometry distribution

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One patient in anterior tucking group and two patients in circumferential flap group had <4 dB hearing gain postoperatively whereas 31 patients in anterior tucking group and 41 patients in circumferential flap group had hearing gain between 4 and 8 dB and >8 dB hearing gain was seen in 18 patients in anterior tucking group and 7 patients in circumferential flap group [Table 2].
Table 2: Hearing gain in two groups of patients

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With regard to graft uptake 98% of patients showed graft uptake in anterior tucking group with one case of residual perforation, and in circumferential flap method, the graft uptake was 94% with three cases of residual perforation and in two cases there was medialization of the graft [Table 3] and [Figure 3]. There was no intraoperative (bleeding, facial nerve palsy, chorda tympani nerve injury, and wound hematoma) or postoperative complications (infections, bleeding, wound gaping, facial paralysis perichondritis, epithelial pearl formation, granulation tissue formation at the tympanomeatal flap, or sensorineural hearing loss) noted in both the groups. There was no statistically significant difference in graft uptake between the two groups.
Table 3: Tympanic membrane distribution in two groups of patients

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Figure 3: Graft uptake

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In anterior tucking group, the mean hearing gain was 7.95 dB and 7.59 dB in circumferential flap group. This was statistically significant (P < 0.05), but P value between groups was not statistically significant (P = 0.36).


  Discussion Top


Graft uptake

In the past, many techniques of grafting have been used. There have been many modifications and variations of the technique of tympanoplasty. Primrose and Kerr[6] described their techniques of closing the anterior marginal perforation, wherein a small tag was fashioned anteriorly and later pulled through a small tunnel under the anterior-superior annulus.

Palva described the surgical treatment of chronic suppurative otitis media (CSOM) using myringoplasty and tympanoplasty. His underlay “swinging door” technique was successful in 97% of the ears. Palva's “swinging door” tympanoplasty was modified and reported by several surgeons including Glasscock, Fisch, Smyth, and Pennington. The basic technique involves the elevation of superiorly based and inferiorly based canal skin flaps, or “swinging doors.”

A retrospective study of 200 cases was conducted by Moras et al.,[7] data were sourced from 200 patients who underwent tympanoplasty for CSOM, tubotympanic disease by 360° technique. The study showed an overall success rate of 96% for graft uptake. Eight patients (4%) were found to have a residual perforation.

In a study conducted by Burse et al., 2009[8] 50 clinically diagnosed cases were randomly divided into two groups of 25 each to be operated by anterior tucking method and cartilage support method of tympanoplasty. Successful graft uptake was observed in 96% of patients in both the groups but it was not statistically significant.

In a prospective study conducted by Murugendrappa et al.,[9] 50 patients with subtotal perforation who underwent the two different techniques of myringoplasty-circumferential subannular grafting technique and conventional underlay technique in cases of chronic otitis media with inactive mucosal disease the success rate of graft take-up by circumferential subannular grafting technique was 96% and by conventional underlay technique 76%. The study concluded that circumferential grafting technique is superior in graft success rate.

In a retrospective clinical study conducted by Harris et al.,[10] patients with anterior TM perforations with inadequate anterior remnants underwent tympanoplasty with anterior pull-through technique. A graft success rate of 84.6% (11 out of 13) was achieved, without lateralization, blunting, atelectasia, or epithelial pearls.

In our study graft uptake was 98% in anterior tucking and 94% by circumferential flap method, as 1 (2%) patient had a residual perforation in anterior tucking and 3 (3%) patients in circumferential flap method, and two patients had a medialization of graft. None of the grafted ears exhibited anterior marginal blunting, graft lateralization, or epithelial pearls.

Hearing improvement

In a prospective study conducted by Murugendrappa et al.[9] in circumferential subannular grafting technique, the preoperative mean PTA was 36.92 dB, and the postoperative mean PTA after 3 months was 25.87 dB with a mean difference in PTA (dB) of 11.05 with t = 7.74. In case of conventional underlay technique, the preoperative mean PTA was 38.24 dB, and the postoperative mean PTA after 3 months was 30.28 dB with a mean difference in PTA (dB) of 7.96 with t = 14.39. The study concluded that circumferential grafting technique is superior in postoperative hearing improvement when compared to conventional underlay technique.

In our study, in anterior tucking group preoperative PTA was 33.16 (±4.01) and postoperative PTA was 25.21 (±3.72) the mean hearing gain was 7.95, and in circumferential flap group the preoperative PTA was 33.59 (±3.87) and postoperative PTA was 26.87 (±3.87) the mean hearing gain was 7.59, which was statistically significant (P < 0.05). P value between anterior tucking group and circumferential flap group was not statistically significant (P = 0.36) in terms of hearing gain.

In a study conducted by Burse et al., 2009[8] the average postoperative air bone gap in anterior tucking cases was found to be 10.12 dB with a standard deviation of ±6.82 where as in the Cartilage method it was found to be 14.48 dB with a standard deviation of ±6.45. The above results showed that hearing improvement was significantly better in anterior tucking method as compared to tragal cartilage support method, whereas in our study, in anterior tucking group the mean hearing gain was 7.95 and 7.59 in circumferential flap group which was statistically significant (P < 0.05).


  Conclusion Top


Anterior tucking and circumferential flap techniques of tympanoplasty are good regarding ease of graft placement, graft uptake rate, and audiological outcome. Both techniques are good for CSOM with large central perforation, especially with little or no anterior remnant of pars tensa.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Wullstein H. Die tympanoplastikalsgehorverbessernde Operation bei Otitis Media chronica und ihrResultate. In: Proceedings of the Fifth International Congress on Otorhinolaryngology; 1953.  Back to cited text no. 1
    
2.
Wullstein H. Theory and practice of tympanoplasty. Laryngoscope 1956;66:1076-93.  Back to cited text no. 2
    
3.
Aristidis Athanasiadis Sismanis. Tympanoplasty: Tympanic membrane repair. Glasscock-Shambaugh's Surgery of the Ear. 6th ed., Ch. 28. Athens University, Director, ORL Clinic Ippokration Hospital Athens: Greece; 2010. p. 466.  Back to cited text no. 3
    
4.
Sarkar S. A review on the history of tympanoplasty. Indian J Otolaryngol Head Neck Surg 2013;65:455-60.  Back to cited text no. 4
    
5.
Sismanis AA. Tympanoplasty: Tympanic membrane repair. In: Glasscock ME, Gulya AJ, editors. Glasscock-Shambaugh Surgery of the Ear. 6th ed. New Delhi: Reed Elsevier India Pvt. Ltd.; 2010. p. 465-86.  Back to cited text no. 5
    
6.
Primrose WJ, Kerr AG. The anterior marginal perforation. Clin Otolaryngol Allied Sci 1986;11:175-6.  Back to cited text no. 6
    
7.
Moras K, Lasarado S, Shivaraj R, Aramani A, Pinto G. 360 degree subannular tympanoplasty a retrospective study of 200 cases. J Evol Med Dent Sci 2015;4:5455.  Back to cited text no. 7
    
8.
Burse KS, Kulkarni SV, Bharadwaj CC, Shaikh S, Roy GS. Anterior tucking vs. cartilage support tympanoplasty. Odisha J Otorhinolaryngol HNS 2014;8:20.  Back to cited text no. 8
    
9.
Murugendrappa MA, Siddappa PN, Shambulingegowda A, Basavaraj GP. Comparative study of two different myringoplasty techniques in mucosal type of chronic otitis media. J Clin Diagn Res 2016;10:MC01-3.  Back to cited text no. 9
    
10.
Harris JP, Wong YT, Yang TH, Miller M. How I do it: Anterior pull-through tympanoplasty for anterior eardrum perforations. Acta Otolaryngol 2016;136:414-9.  Back to cited text no. 10
    


    Figures

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

  [Table 1], [Table 2], [Table 3]



 

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