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ORIGINAL ARTICLE
Year : 2019  |  Volume : 25  |  Issue : 1  |  Page : 26-30

Evaluation of different graft materials (Temporalis Fascia, Tragal Perichondrium, and Vein Graft) in Type 1 tympanoplasty


Department of ENT, LLRM Medical College, Meerut, Uttar Pradesh, India

Date of Web Publication19-Jun-2019

Correspondence Address:
Dr. Nikunj Jain
House No. 19, Sector 4, Shradha Puri Phase-1, Meerut Cantt, Meerut - 250 001, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/indianjotol.INDIANJOTOL_18_19

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  Abstract 


Aims and Objective: The present study was undertaken to compare the results of various autogenous tissues temporalis fascia, tragal perichondrium, and vein as graft materials for the Type 1 tympanoplasty. Materials and Methods: A total of 120 cases with large, subtotal, and total perforation were considered in the study. Of the 120 cases, temporalis fascia graft was used in 60 cases (Group-I), tragal perichondrium graft in 40 cases (Group-II), and vein graft in 20 cases (Group-III). The results were evaluated in the form of rate of graft success, hearing gain, and mean residual air-bone gap with respect to the graft materials. Results and Observation: A nonsignificant association was observed between the groups, that is, temporalis fascia (Group-I), tragal perichondrium (Group-II), and venous graft (Group-III), and the graft uptake (P = 0.96 > 0.05) and air-bone closure (χ2 = 2.908, P = 0.059 > 0.05). Conclusion: The graft take up rate and hearing improvement are similar for the different graft materials used. Size of the perforation does not significantly influence the success rate of tympanoplasty as per our study. Normal translucent appearance of neotympanum in the postoperative period was seen only with temporalis fascia and venous graft, while in tragal perichondrial, the neotympanum was whitish, thicker, and translucent to opaque.

Keywords: Perichondrium, temporal fascia, tympanoplasty, venous graft


How to cite this article:
Singh V P, Jain N. Evaluation of different graft materials (Temporalis Fascia, Tragal Perichondrium, and Vein Graft) in Type 1 tympanoplasty. Indian J Otol 2019;25:26-30

How to cite this URL:
Singh V P, Jain N. Evaluation of different graft materials (Temporalis Fascia, Tragal Perichondrium, and Vein Graft) in Type 1 tympanoplasty. Indian J Otol [serial online] 2019 [cited 2019 Jul 16];25:26-30. Available from: http://www.indianjotol.org/text.asp?2019/25/1/26/260720




  Introduction Top


Chronic otitis media is the chronic inflammation of mucoperiosteal lining of the middle ear cleft characterized by ear discharge, a permanent perforation of the tympanic membrane and impairment in hearing. It is one of the most common ear diseases encountered in developing countries due to poor socioeconomic standards, poor nutrition, lack of health education, and unhygienic habits.[1],[2],[3] It is a major cause for deafness in India.[4]

Tympanoplasty is now an established surgery for tympanic membrane perforations being carried out routinely by otorhinolaryngologists.[5]

Autologous graft materials such as temporalis fascia, tragal perichondrium, cartilage, fat, fascia lata, and venous wall have stood the test of time in repairing tympanic membrane perforations. Such abundance of materials implies that there is no clear-cut favorite, and the choice of graft material depends on individual surgeon's preference.[6],[7]

However, due to its anatomic proximity, translucency, and suppleness, temporalis fascia is the most preferred grafting materials among the otologists, and successful closure is anticipated in approximately 90% of primary tympanoplasties. Failure rates are higher in larger perforations with temporalis fascia as a graft material.[8],[9] Graft displacement, improper placement,[10] autolysis, infection, hemorrhage, and  Eustachian tube More Details dysfunction are the known contributing factors for the failure of closure of perforation. Thus, consistent achievement of good hearing is still a challenge and one of the most difficult tasks of otology surgery. Keeping all these factors in mind and in light of good results, the present comparative study of different graft materials, that is, temporalis fascia, tragal perichondrium, and venous graft in underlay tympanoplasty was undertaken to evaluate the postoperative graft take up and hearing improvement.


  Materials and Methods Top


One hundred and twenty systemically healthy patients aged between 12 and 50 years having safe or tubotympanic type of chronic otitis media with central perforation and conductive hearing loss visiting ENT Department of LLRM Medical College and SVBP Hospital.

Inclusion criteria

  • Unilateral chronic otitis media of safe or tubotympanic type having large, subtotal, or total central perforation
  • Conductive hearing loss
  • All the ears were dry for at least 6 weeks before the surgery
  • Age above 12 years and below 50 years.


Exclusion criteria

  • Patients having active ear discharge
  • Patients having any obvious ossicular dysfunction
  • Patients with sensorineural hearing loss
  • Patients having unsafe or atticoantral disease
  • Patients with complications of chronic suppurative otitis media, any external ear pathology, sinonasal pathology, nasal allergy, or any systemic disorder.


Of the 120 cases, as per the consent obtained for the use of graft materials, temporalis fascia graft was used in 60 cases (Group-I), tragal perichondrium graft in 40 cases (Group-II), and venous graft in 20 cases (Group-III).

Surgical procedure

Patients were underwent tympanoplasty under local anesthesia and if require under general anesthesia. All cases were done by postaural approach, and graft was kept by underlay technique. Temporal fascia and tragal perichondrium were taken by the conventional method. Venous graft was taken by a very small cosmetically-accepted incision from dorsal digital veins. Thereafter, all patients were called for regular follow-up once weekly for 1 month and fortnightly for 3 months, then after 6 months and 1 year. Hearing assessment with tuning fork tests and pure-tone audiometry was repeated once the tympanic membrane healed at 4–6 weeks. Thereafter, the status of the healed neotympanum was recorded, and pure-tone audiometry was done to access the auditory status after the 8th week, 3 months, 6 months, and 1 year to see if there are any changes.

Statistical analysis

The collected data were tabulated and statistical analysis was performed by estimating rates, means, and standard deviations. Statistical analysis with the Student's t-test, Chi-square test, and F-test for large sample size was used to examine these parameters with regard to graft take up and hearing improvement, and comparisons were made between the three patient groups. The criteria for statistical significance were set at P < 0.05.

In Group-I, 60 patients underwent tympanoplasty using temporalis fascia; in Group-II, 40 cases underwent tympanoplasty using tragal perichondrium; and in Group-III, 20 cases underwent tympanoplasty using venous graft.

These patients were operated in the same surgical setup, by senior staff members of the department.

The mean age of all the cases together was 28.8 years.

In our study, we have divided the perforations of the tympanic membrane into three categories depending on the size of the perforation, i.e., large, subtotal, and total central perforation involving about 50%–75%, 75%–100%, and 100% of the tympanic membrane, respectively, as shown in the [Figure 1] and [Table 1]. Small and moderate size perforations are not included in our study to avoid bias.
Figure 1: Size of the perforations of the patients included in this study

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Table 1: Distribution of size of perforation (n)

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According to our study as shown in [Table 2], the mean preoperative air-bone gap (ABG) was found to be maximum for cases with total perforations which was 24.56 ± 5.77 dB, followed by subtotal perforations of 20.44 ± 5.39 dB, and for large perforations, it was 19.5 ± 5.6 dB. The overall mean preoperative ABG was 20.38 ± 5.62 dB. Thus, hearing loss is increased with an increase in the size of perforation.
Table 2: Preoperative hearing loss in relation to perforation size

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For temporalis fascia (Group-I), 52 of the 60 cases (86.67%) showed successful graft uptake, whereas seven cases showed residual perforation while one case showed retracted graft accounting to eight failures (13.33%). For tragal perichondrium (Group-II), 35 out of 40 cases (87.50%) showed successful graft uptake, while 8 cases (12.50%) had residual perforations; and for venous graft (Group-III), 17 of the 20 cases (85%) showed successful graft uptake, while 2 cases showed residual perforation and graft was retracted in one case, accounting to three failures (15%) as shown in [Table 3]. Thus, overall, of 120 patients undergoing tympanoplasty, in 104 (86.67%) patients, grafts were accepted successfully, while 16 (13.33%) patients had residual perforations.
Table 3: Results of tympanoplasty with respect to graft material

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A nonsignificant association was observed between the groups, i.e., temporalis fascia (Group-I), tragal perichondrium (Group-II), and venous graft (Group-III), and the graft uptake (P = 0.96 > 0.05) revealing that the pattern of graft take up was same statistically in all the three groups.

Healing was faster in venous (Group-III) and took about 2–3 weeks, followed by temporalis fascia which took about 2–4 weeks. Tragal perichondrium took longer time to take up about 4–5 weeks.

In this study, we have observed that after healing, normal translucent appearance of neotympanum in the postoperative period was seen with temporalis fascia and venous graft, while with tragal perichondrial and neotympanum were whitish, thicker, and translucent to opaque, which may compromise the discovery of recurrence of disease and iatrogenic cholesteatoma formation.

As a difference in graft success with respect to the graft materials (Groups) was not significant statistically, we also studied surgical outcome for these graft materials (Groups) with respect to the size of the perforation. A nonsignificant association was observed between the graft success in groups and the size of perforation (P > 0.05) revealing that the pattern of graft take up was same statistically in all the three groups, indicating that the successful graft take up with respect to graft materials (Groups) does not depend on the size of the perforation also.

Overall, the cases of large central perforations doing well with successful graft take up in 90.2% (46/51 cases), subtotal perforations had a successful graft take up in 84.75% cases (50/59 cases), and total perforations had successful graft take up in 80% cases (8/10 cases).

The mean postoperative ABG for Group-I (temporalis fascia) was 10.5 ± 4.35 dB, for Group-II was 10.97 ± 6.63 dB, and for Group-III was 12.1 ± 4.33 dB with an overall postoperative ABG of 10.14 ± 4.74 dB.

The mean gain in hearing for Group-I (temporalis fascia) was 9.36 ± 3.63 dB, for Group-II was 10.92 ± 5.82 dB, and for Group-III was 12.10 ± 4.33 dB with an overall gain in hearing of 10.34 ± 4.68 dB as shown in [Table 4].
Table 4: Improvement in air-bone gap with different graft materials

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A nonsignificant association was observed between the graft materials (groups) and the air-bone closure (χ2 = 2.908, P = 0.059 > 0.05) revealing that the pattern of distribution of scores of different categories of air-bone closure was same in the three groups statistically. However, a highly significant difference was observed between preoperative and postoperative air-bone closures, indicating that most of the cases had air-bone closures and thus gain in hearing. Furthermore, a nonsignificant association was observed between the graft materials (groups) and the gain in hearing (P > 0.05) revealing that the pattern of distribution of scores of gain in the hearing was same in the three groups statistically indicating uniform hearing improvement for all the three graft materials (Groups).


  Result Top


A nonsignificant association was observed between the groups, that is, temporalis fascia (Group-I), tragal perichondrium (Group-II), and venous graft (Group-III) and the graft uptake. (P = 0.96 > 0.05) and air bone closure (χ2 = 2.908, P = 0.059 > 0.05).


  Discussion Top


Surgical repair of the tympanic membrane has traveled a long way after initial reports of the tympanic membrane grafting. A critical problem early in the development of tympanoplasty was finding a suitable material for tympanic membrane grafting. This evolution of the tympanic membrane grafting has been based on biological tissues of mesodermal origin which contains collagen matrix.[9]

Distribution of size of perforations

All the perforations were central perforations. In the present study, we have considered only large, subtotal, and total central perforation. Similar selection criteria regarding the size of perforation were used in the study of Indorewala[11] and Roychaudhuri[12] to have a consistency in the outcome and to avoid bias in the analysis of the results of surgery.

Preoperative hearing loss

The hearing loss is found to be increased with an increase in the size of perforation. The large perforations had a mean air conduction (AC) threshold of 32.12 dB, BC of 11.56 dB, and mean ABG of 19.89 dB. The subtotal perforations had AC of 35.38 dB, BC of 14.26 dB, and ABG of 20.83 dB. Total perforations showed an AC of 44.47 dB, bone-conduction (BC) of 23.65 dB, and mean ABG of 20.82 dB. Overall, the mean preoperative pure-tone AC threshold was 34.75 dB, BC was 13.89 dB, and ABG was 20.43 dB [Table 3].

The hearing threshold increases with increase in the size of perforation total >subtotal >large; our results were comparable to the studies conducted by Dornhoffer[13] and Singh et al.[14]

When success rate of the tympanic membrane closure with different graft materials was compared, successful graft take up rate of 86.67% was achieved for temporalis fascia (Group-I), 87.5% for tragal perichondrium (Group-II), and 85% for venous graft (Group-III) with overall successful graft take up rate of 86.67%. However, this difference in graft success was not significant statistically. Thus, our results suggest that type of graft material does not influence the successful graft take up.

Our results are comparable with a study of Strahan et al.,[15] in which take up rate of 87.5% was achieved using temporalis fascia and 86% by tragal perichondrium. Eviatar[16] noted that graft take rate with tragal perichondrium by underlay technique was 88% at the end of 1-year follow-up.

Dornhoffer[13] achieved graft uptake success rate of 85% using tragal perichondrium by underlay technique. Rizer[17] achieved a success rate of 88.8% using temporalis fascia by underlay technique. Dabholkar et al.[7] compared temporalis fascia with tragal perichondrium in underlay tympanoplasty and achieved a graft success rate of 84% for temporalis fascia and 80% for tragal perichondrium. Our results were comparable with the above studies.

Our result is comparable in terms of graft uptake rate for venous graft King (86%),[18] Dr. Devnath (85%),[19] Parida et al. (83.3%),[20] and Lebo.[21]

Graft uptake rate

We also studied results for graft materials with respect to the size of the perforation. Among the temporalis fascia (Group-I) patients, graft take up rate for large central perforations was 85.19%, subtotal perforations were 88.89%, and total perforations were 83.33%. Among the tragal perichondrium (Group-II) patients, graft take up rate for large central perforations was 95%, subtotal perforations were 83%, and total perforations were 67%. Among the venous graft (Group-III) patients, graft take up rate for large central perforations was 100%, subtotal perforations was 78.5%, and total perforations was 100% (1/1 case). However, there was no significant statistical difference between these graft materials in relation to the size of the perforation.

Our results were comparable with the studies conducted by Indorewala[11] and Al Lackany and Sarkis,[22] for large and subtotal perforations.

Improvement in air-bone gap

In our study, mean gain in ABG was not significantly different between the different graft materials used. The mean gain for temporalis fascia was 9.36 dB, tragal perichondrium was 10.92 dB, and venous graft was 12.10 dB [Table 2]. Similar findings were noted by Dornhoffer[13] and Singh et al.[14]

In our study with temporalis fascia graft, good hearing results, that is, closure rate of ABG within 10 dB was found in 57.7% cases which is comparable to Singh et al.,[14] Herman and Tang,[10] and Dabholkar et al. (76%)[7] but is less than studies conducted by Strahan et al. (82%)[15] and Gupta and Mishra.[23] With tragal perichondrial graft, closure of ABG within 10 dB was found in 54.3% cases which is comparable to Singh et al.[14] With venous graft, the closure of ABG within 10 dB was found to be 70.6% which is comparable to Gupta and Mishra.[23]

It was also observed that tragal perichondrium is thicker and stiffer than temporalis fascia and venous graft and need not be dried and can be placed as wet graft and is easier to manipulate in the middle ear.

In this study, we have observed that after healing, normal translucent appearance of neotympanum in the postoperative period is achieved only in temporalis fascia, while in tragal perichondrial and venous grafts, the neotympanum was whitish and translucent to opaque which may compromise the discovery of recurrence of disease and iatrogenic cholesteatoma formation.


  Conclusion Top


From the present study, we may conclude that:

  • Temporalis fascia, tragal perichondrium, and venous graft-free grafts provide viable autograft material for tympanoplasty
  • These materials are mesodermal in origin which excludes the risk of iatrogenic cholesteatoma
  • They achieve comparable and excellent graft takes of 86.7%
  • They achieve comparable and good hearing restoration
  • The very fact that P value is nonsignificant in the graft take up rate and the hearing improvement for the different graft materials shows that the graft take up rate and hearing improvement are similar for the different graft materials used
  • Size of the perforation does not significantly influence the success rate of tympanoplasty
  • Tragal perichondrium is thicker and stiffer than temporalis fascia and venous graft. They are easier to manipulate in the middle ear as they do not get folded on itself and thus have ideal handling qualities
  • However, graft preparation time for tragal perichondrium was longer
  • Normal translucent appearance of neotympanum in the postoperative period was seen only with temporalis fascia, while in tragal perichondrial and fascia lata grafts, the neotympanum was whitish, thicker, and translucent to opaque
  • Thus, with all the things being equal, the graft material does not influence the success rate of tympanoplasty in terms of graft take up and hearing improvement.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
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2.
Saha AK, Munsi DM, Ghosh SN. Evaluation of improvement of hearing in type I tympanoplasty and its influencing factors. Indian J Otolaryngol Head Neck Surg 2006;58:253-7.  Back to cited text no. 2
    
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Chandra KS. Combined effect of eustachian tube function and middle ear mucosa on tympanoplasty. Indian J Otol 2006;12:267.  Back to cited text no. 3
    
4.
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6.
Gibb AG, Chang SK. Myringoplasty (A review of 365 operations). J Laryngol Otol 1982;96:915-30.  Back to cited text no. 6
    
7.
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. 7
    
8.
Booth JB. Myringoplasty. The lessons of failure. J Laryngol Otol 1974;88:1223-36.  Back to cited text no. 8
    
9.
Booth JB. Myringoplasty – Factors affecting results. Final report. J Laryngol Otol 1973;87:1039-84.  Back to cited text no. 9
    
10.
Herman MK. Tang: The perforated eardrum: To repair or not? Hong Kong J Online 1989;11:1245.  Back to cited text no. 10
    
11.
Indorewala S. Dimensional stability of free fascia grafts: Clinical application. Laryngoscope 2005;115:278-82.  Back to cited text no. 11
    
12.
Roychaudhuri BK. 3-flap tympanoplasty – A simple and sure success technique. Indian J Otolaryngol Head Neck Surg 2004;56:196-200.  Back to cited text no. 12
    
13.
Dornhoffer JL. Hearing results with cartilage tympanoplasty. Laryngoscope 1997;107:1094-9.  Back to cited text no. 13
    
14.
Singh BJ, Sengupta A, Das SK, Ghosh D, Basak B. A comparative study of different graft materials used in myringoplasty. Indian J Otolaryngol Head Neck Surg 2009;61:131-4.  Back to cited text no. 14
    
15.
Strahan RW, Acquarelli M, Ward PH, Jafek B. Tympanic membrane grafting. Analysis of materials and techniques. Ann Otol Rhinol Laryngol 1971;80:854-60.  Back to cited text no. 15
    
16.
Eviatar A. Tragal perichondrium and cartilage in reconstructive ear surgery. Laryngoscope 1978;88 Suppl 11:1-23.  Back to cited text no. 16
    
17.
Rizer FM. Overlay versus underlay tympanoplasty. Part II: The study. Laryngoscope 1997;107:26-36.  Back to cited text no. 17
    
18.
King PF. The use of vein homografts in tympanoplasty. Ann R Coll Surg Engl 1965;37:65-92.  Back to cited text no. 18
    
19.
Devnath B. Vein graft myringoplasty in small and medium sized perforations. Int J Sci Res Publ 2017;7:567-74.  Back to cited text no. 19
    
20.
Parida PK, Nochikattil SK, Surianarayanan G, Saxena SK, Ganesan S. A comparative study of temporalis fascia graft and vein graft in myringoplasty. Indian J Otolaryngol Head Neck Surg 2013;65:569-74.  Back to cited text no. 20
    
21.
Lebo CP. Graft selection for tympanoplasty. Ann Otol Rhinol Laryngol 1963;72:40-9.  Back to cited text no. 21
    
22.
Al Lackany M, Sarkis NN. Functional results after myringoplasty and type 1 tympanoplasty with the use of different graft materials. J Med Res Inst 2005;26:36974.  Back to cited text no. 22
    
23.
Gupta N, Mishra RK. Tympanoplasty in children. Indian J Otolaryngol Head Neck Surg 2002;54:2713.  Back to cited text no. 23
    


    Figures

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    Tables

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



 

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