|Year : 2016 | Volume
| Issue : 1 | Page : 31-34
Butterfly cartilage graft versus fat graft myringoplasty
Sonika Kanotra, Anil Suri, Sunil Kotwal, J Paul
Department of ENT, Government Medical College, Jammu, Jammu and Kashmir, India
|Date of Web Publication||16-Feb-2016|
Department of ENT, Government Medical College, Jammu - 180 001, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Aim: The aim of the study was to compare the graft take up rates of two minimally invasive techniques of butterfly cartilage graft (BCG) and fat graft myringoplasty (FGM).
Materials and Methods: Two groups of 30 patients each with small dry central perforations of the tympanic membrane (T.M.) were randomly subjected to either of the two techniques of myringoplasty.
Statistical Analysis Used: The results were compared using the Chi-square test. A value of <0.05 was taken as statistically significant.
Results: The graft take up rate was 93.3% with BCG and 83.3% with fat graft.
Conclusions: The BCG scores over FGM in small perforations of the T.M.
Keywords: Butterfly cartilage graft, Fat graft, Myringoplasty
|How to cite this article:|
Kanotra S, Suri A, Kotwal S, Paul J. Butterfly cartilage graft versus fat graft myringoplasty. Indian J Otol 2016;22:31-4
| Introduction|| |
Since the advent of tympanoplasty surgery, the repair of the tympanic membrane (T.M.) has been attempted with a large variety of autologous, homologous, and synthetic materials. At present, autologous temporal fascia is the most widely used material followed by perichondrium. The different techniques used include overlay, underlay, sandwich, pegging, rosette, and plugging, the former two being the most popularly used. In 1962, Ringenberg and Fornatto  used earlobe fat as a graft material for myringoplasty. In 1998, Eavey  introduced butterfly cartilage graft myringoplasty (BCGM) for selected small T.M. perforations. This transcanal technique used composite tragal perichondrium cartilage graft which is specially designed as a butterfly to fit into the perforation without support in the middle ear or external auditory canal. Both these transcanal techniques are minimally invasive and have several advantages such as decreased surgical time, ease of learning, comfort to the patient, no hair shaving, no bandage, minimum medication, no complications of the postaural wound, and no need for hospitalization. In 2005, we had reported a success rate of 85% in 120 patients with small central perforations using fat graft myringoplasty (FGM). This was comparable to the reports of the others authors. However, the reported results with BCGM have been higher.
The objective of our study was to compare the results of the two techniques of BCGM and FGM in two groups of matched patients.
| Materials and Methods|| |
This was a prospective study involving a total of 60 patients with small dry central perforations of the T.M. These were divided into two groups: Group A of 30 patients who underwent BCGM and Groups B of 30 patients who underwent FGM. The indication of surgery was the closure of the T.M. perforation to improve hearing by closing the air-bone gap and to create a dry ear where perforation was causing recurrent otorrhea. Some of the patients were those with previous failed operations and a few with a sensorineural hearing loss where the aim was to give a dry ear allowing optimum use of hearing aid.
Patients with the narrow external auditory canal, those with a history of ear discharge during the previous 4 weeks, perforation larger than 5 mm, conductive hearing loss disproportionate to the size of perforation, a perforation abutting the annulus, possibility of cholesteatoma and presence of granular myringitis.
Surgical technique of butterfly cartilage graft myringoplasty
Surgery was performed under local anesthesia in all the patients. All operations were performed permeatally using an aural speculum. A straight needle was used to circumferentially puncture the edge of the perforation, and this was followed by removal of a rim of the perforation with crocodile forceps taking care that all squamous epithelium is cleared from the edge. The size of the freshened perforation was estimated by using a right angled pick. Next, an incision was made on the medial aspect of the tragus about 2–3 mm posterior to its lateral edge. Using fine scissors, the skin was separated from the underlying perichondrium. An island of cartilage covered with perichondrium on both sides about 2 mm bigger than the freshened perforation was harvested. If required, the graft was trimmed so that it was just larger than the perforation. The graft was held vertically between the thumb and forefinger and while rotating the graft; a number 11 blade was used to make a 1 mm deep groove along the circumferential border of the cartilage disc allowing the cartilage flanges to spring open. The spreading of the two cartilage surfaces resembles the “Butterfly.”
The graft was held with a crocodile forceps and was inserted permeatally and placed over the perforation. The groove in the cartilage was engaged with the anterior rim of the perforation so that the medial flange was medial to the T.M. and the rest of the graft was manipulated into place with a needle so that the T.M. sat in the groove of the cartilage graft very much like a grommet. To confirm the proper locking of the graft onto the perforation, it was gently moved with a ball probe. In a few cases (4) the graft was small, and a new graft had to be taken from the remaining cartilage. The ear was packed with gelfoam. The tragal incision was stitched with 5/0 prolene and a cotton plug soaked in the antibiotic ointment was placed in the meatus. The stitches were removed on the 5th day and patient was called for follow-up on the 15th day and then at 3 months.
Surgical technique of fat graft myringoplasty
The perforation margins were freshened in the same way as described with BCGM. The fat was harvested from the ear lobule through a small incision on the cranial aspect of the lobule. The size of the fat graft was about twice the size of the freshened perforation. Proceeding permeatally, the fat graft was introduced through the perforation and brought out thus reversing the edge of the perforation and making a dumb-bell shaped fat plug taking care that the graft did not come in contact with the medial wall of the middle ear or the ossicles. Gefloam was gently placed in the external audiyory canal and after stitching the incision on the lobule antibiotic soaked cotton was placed in the meatus. The stitches were removed on the 5th day and patient was called for follow-up on the 1 h 5th day and then after 3 months.
These are shown in [Table 1] and [Table 2].
|Table 2: Etiology of tympanic membrane perforation and graft take up rates|
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| Discussion|| |
T.M. perforations are commonly caused by infections of the middle ear and less commonly by trauma. A large number of these perforations heal spontaneously. However, recurrent infections may impair the regenerative process and result in a chronic perforation. Repair of T.M. perforations has been done with various materials using different techniques. Temporalis fascia has been a time-tested material which for harvesting needs an external incision and a possible visible scar. Use of fat graft from the ear lobule for myringoplasty is a minimally invasive technique which has given a good success rate in small perforations.,, With the introduction in 1998 by Eavey of BCG, we have found another minimally invasive method for T.M. reconstruction. Since more than 90% success rate has been reported by this method, we planned to compare these two minimally invasive techniques of BCGM and FGM in a similar set of 30 patients each.
Cartilage tympanoplasty has many advantages in situ ations such as recurrent, residual, total perforations, chronic mucosal dysfunction or atelectatic T.M, where fascia and perichondrium undergo atrophy and subsequent failure. In comparison with fascia and perichondrium, it is characterized by increased stability and resistance to negative middle ear pressure. Further, it has a low metabolic rate and is well accepted in the middle ear. The cartilage graft is easy to harvest from the tragus or the conchal bowl. However, it has been criticized due to concern regarding hearing result because of its thickness. Nevertheless, this is not the case since Aarnisalo et al. evaluated the middle ear mechanics of 0.5 and 1 mm thick tympanoplasty by computer assisted laser holography and vibrometry in cadavers and found no significant effect except above 4 kHz. Gerber et al. studied the hearing results in patients who had cartilage tympanoplasty. The results were comparable to temporal fascia.
Eavey  have described several advantages of BCGM. The cartilage graft can be used in T. Ms. with tympanoscerotic plaques and even when the malleus is exposed. According to him in these somewhat hostile settings, the stiffness of the plaques and the malleus enhance the procedure by providing a rigid interlocking surface. Also the patient is more comfortable without any tympanomeatal or postaural incision. The patients who undergo this procedure need not defer air travel. In children, who are more prone to graft failure due to recurrent upper respiratory tract infections, the authors found 100% graft take up rates. According to Ghanem et al. the instant “locking” of the graft provided by the butterfly edge diminishes concerns about graft lateralization and displacement caused by patient activities, especially in children. These authors have described their good experience with extended indications of BCG in larger perforations and in cases needing middle ear exploration and mastoidectomy. FGM shares the advantages of BCGM in being a fast, cheap and efficient method causing minimum discomfort to the patient but is limited by its contraindication for use in anterosuperior perforations where there is a possibility of eustachian tube blockage by the graft or of adhesions when the ossicle is exposed. Whenever, there is an evidence of retraction, it is better to avoid the fat graft. One theoretical disadvantage of the cartilage is that it causes an opaqueness of the repaired T.M. which could potentially hide disease recidivation.
We used butterfly cartilage and fat graft in 30 patients each aged 18–52 years. All patients had perforation smaller than 6 mm. Chronic suppurative otitis media (CSOM) was the major cause of perforations being 75% in Group A and 70% in Group B. In addition, postoperative perforations comprised 27% in Group A and 20% in Group B. Two patients in Group A and 3 (10%), patients in Group B had their perforations caused by grommet insertion.
We observed a graft take up the rate of 93.3% in Group A and 83.3% in Group B. This was statistically significant (χ2 < 0.005). An interesting aspect of our study was the comparison of the two techniques in perforations due to various causes. While 100% closure was seen in both groups in perforations caused by grommet insertion, the success rate in postoperative cases was much less (66.6%) with fat graft as compared with 80% with BCGM. In the case of CSOM, BCGM gave 100% result while it was (91%) with fat graft. Our overall results are comparable to Eavey  (100%) Kim et al. (96.3%), Anand et al. (90%), and Ranga et al.
| Conclusions|| |
BCG myringoplasty is an excellent technique in small central perforations with a success rate of 93.3% and scores over FGM, especially in revision cases. Both techniques are easy to learn, are cost-effective and good for patient comfort.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]