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Year : 2017  |  Volume : 23  |  Issue : 1  |  Page : 32-35

Interlay Type I tympanoplasty in large central perforations: Analysis of 500 cases

1 Department of ENT and Head and Neck Surgery, Jain ENT Hospital, Jaipur, Rajasthan, India
2 Department of Otorhinolaryngology - Head and Neck Surgery, King George Medical University, Lucknow, Uttar Pradesh, India
3 Department of Otorhinolaryngology - Head and Neck Surgery, SMGS Hospital, Government Medical College, Jammu, Jammu and Kashmir, India

Date of Web Publication6-Feb-2017

Correspondence Address:
Dr. Rohan Gupta
Department of Otorhinolaryngology - Head and Neck Surgery, SMGS Hospital, Government Medical College, Shalamar Road, Jammu - 180 001, Jammu and Kashmir
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0971-7749.199503

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Aims and Objectives: To study the outcomes of interlay tympanoplasty (Type I) in patients with large central perforations (inactive mucosal chronic otitis media [COM]) in terms of graft uptake and hearing improvement. Materials and Methods: The present study is an analysis of database of 500 patients of inactive mucosal COM with large central perforation, who had undergone Type I interlay tympanoplasty at Jain ENT Hospital, Jaipur, during the past 5 years. Results: The graft uptake rate in the present study was found to be 96.6%, and 95.4% of the patients reported an improvement in terms of hearing with the mean air-bone gap improving from 26.08 to 10.12 dB. Conclusion: Tympanoplasty done by interlay technique has excellent results both in terms of graft uptake and hearing improvement, with minimal complications.

Keywords: Graft uptake, inactive mucosal chronic otitis media, interlay, tympanoplasty

How to cite this article:
Jain S, Gupta N, Gupta R, Roy A. Interlay Type I tympanoplasty in large central perforations: Analysis of 500 cases. Indian J Otol 2017;23:32-5

How to cite this URL:
Jain S, Gupta N, Gupta R, Roy A. Interlay Type I tympanoplasty in large central perforations: Analysis of 500 cases. Indian J Otol [serial online] 2017 [cited 2021 Apr 15];23:32-5. Available from: https://www.indianjotol.org/text.asp?2017/23/1/32/199503

  Introduction Top

Damage to the tympanic membrane is most commonly the result of chronic ear disease; however, it can also result from various forms of trauma, which includes iatrogenic and direct physical injuries, burns, scalds, and pressure effects.[1] Most of these perforations heal spontaneously,[2] whereas the remaining long-standing perforations that lead to recurrent ear discharge need tympanoplasty.

Type I tympanoplasty, being the most common otological procedure after myringotomy,[3] is a surgical technique that involves the repair of the tympanic membrane, in cases where the only existing lesion is a tympanic membrane perforation. It was introduced by Berthold [4] and was further popularized and developed by Wullstein [5] and Zollner.[6] It has been reported in the literature that the final results of tympanoplasty in terms of uptake rate [7] of the graft varies between 74% and 97%, depending on surgical skill, technique used, and site and size of the perforation. Therefore, to achieve excellence and perfection, the otologists have refined various yielding techniques of tympanoplasties and these include the underlay technique,[8] overlay technique,[9] interlay technique, “gelfilm sandwich” technique,[10] “swinging door” technique,[11] tipple “C” technique,[12] double breasting technique,[13] fascial pegging technique,[14] anterosuperior anchoring technique,[15] and “spot welding” technique assisted by laser.[16] Out of all these, the three most universally accepted techniques for graft positioning are “underlay,” “interlay,” and “overlay,”[17] with each one of these having its own advantages as well as disadvantages.

Interlay technique (graft supported by the mucosal layer medially and the fibrosquamous layer laterally) is considered better than both overlay as well as the underlay techniques as getting an interlay plane is easier and faster; there is no reduction in the middle ear space, the bed size for the graft is not limited, and there is the presence of faster healing time. The chances of graft medialization or lateralization, blunting of the anterior meatal recess, and fear of residual epithelium are also reduced.[18] The interlay approach has also shown promising results with success rates higher than 90%.[19],[20],[21],[22]

The aim of the present study is to analyze the results of interlay Type I tympanoplasty, in terms of graft uptake and hearing improvement.

  Materials and Methods Top

The present study is an analysis of records of 500 cases who underwent ear surgery (Type I tympanoplasty with interlay technique) in Jain ENT Hospital, Jaipur, during a period of 5 years from 2010 to 2015.

Inclusion criteria

Patients with large central perforation, dry for at least 6 weeks (inactive mucosal chronic otitis media [COM]).

Exclusion criteria

Patients with active mucosal COM, active or inactive squamosal COM, ossicular discontinuity/necrosis, tympanosclerosis, revision surgeries, sensorineural/mixed hearing loss, presence of focus of infection in nose, sinuses, or throat, and failure to follow-up for at least 3 months.

All these cases had undergone detailed workup which included history of the disease, thorough clinical examination of ear, nose, and throat along with routine laboratory investigations. Ear examination included examination with otoendoscope and microscope, tuning fork tests, pure tone audiometry, and radiological tests (X-ray mastoid, Towne's view). Informed consent was obtained from all the patients.

All the cases were performed under local anesthesia with sedation, through postauricular approach, using fresh true temporalis fascia graft with bed-to-bed grafting.

In all these cases, after meatotomy and freshening of margins, tympanomeatal flap was elevated circumferentially (up to the level of the fibrous annulus), except superiorly, in the region of head of malleus. Canaloplasty was done wherever required. After taking the fibrous annulus out of the bony sulcus all around, using a curved blunt hook, the fibrosquamous layer was lifted off the tympanic membrane remnants along with the annulus, leaving behind the mucosal layer (remnant). After inspecting the middle ear, the  Eustachian tube More Details opening, and checking the ossicular mobility, the tip of malleus was nibbled wherever required (cases of medialization of handle). The patency of the aditus was checked. Fresh temporalis fascia was then harvested, and it was then grafted in such a fashion that it rested on the remnant mucosal layer, under the malleus handle, and on the bony canal walls all around. The tympanomeatal flap was then reposited.

The graft was covered with blood-soaked gelfoam, and a medicated ointment pack was kept in the external auditory canal for 1 week. The patient was followed up on a regular basis, i.e., 2nd week, 4th week, 8th week, and 12th week. At 12th week, a postoperative pure tone audiogram was done to assess and compare the hearing levels.

  Results Top

The 500 cases included in the present study comprised 359 (71.8%) male and 141 (28.2%) female patients. The age of the patients ranged from 12 to 54 years, with the mean age being 31.23 ± 10.54 years and maximum number of patients being in the age group of 21–30 years [Table 1].
Table 1: Age-wise distribution of the patients

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Left ear was operated in 253 (50.6%) patients while right ear was operated in the remaining 247 (49.4%) cases.

The preoperative air-bone gap (ABG) was between 11 and 20 dB in 125 (25%) patients, 21–30 dB in 247 (49.4%) patients, 31–40 dB in 99 (19.8%) patients, and >40 dB in 29 (5.8%) patients, with the mean ABG being 26.08 ± 8.32 dB [Table 2].
Table 2: Preoperative air-bone gap of the patients

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The graft uptake rate was 96.6% implying thereby that successful uptake was observed in 483 out of the 500 patients, with graft uptake failure being present in 17 (3.4%) patients [Table 3].
Table 3: Graft uptake and failure rate

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The hearing improved in 477 (95.4%) patients with the postoperative mean ABG reducing to 10.12 ± 5.84 dB and the postoperative ABG changing to < than 10 dB in 289 (57.8%) patients and between 11 and 20 dB in 188 (37.6%) patients. There was no improvement in hearing in 20 (4%) patients, while deterioration in hearing was seen in 3 (0.6%) patients [Table 4].
Table 4: Postoperative air-bone gap of the patients

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  Discussion Top

CSOM, one of the most common causes of preventable hearing loss, particularly in developing countries like India (which according to WHO reports is among the nations with the highest burden), needs tympanoplasty for its correction.[23] Tympanoplasty has come a long way after it was first introduced by Wullstein and Zollner in the early 1950s [24] as there was a constant desire to improve the technique as well as outcomes. In the past few years, interlay technique of tympanoplasty has gained a lot of popularity and has emerged as the preferred approach because of its low incidence of complications and promising results.

In the present study, we have recorded the graft uptake rate to be 96.6%, and this is in accordance with the success rate (96%) reported by Guo et al.[20] on 53 patients and Patil et al.[18] on 100 patients. Our results were slightly better than those reported by Komune et al.[19] and Kawatra et al.,[1] who in their respective studies reported the success rate to be 94.2% and 93.3%. Hay and Blanshard [22] reported a 91% success rate with interlay myringoplasty, lower as compared to the present study.

In the present study, the preoperative ABG was between 11 and 20 dB in 125 (25%) patients, 21–30 dB in 247 (49.4%) patients, 31–40 dB in 99 (19.8%) patients, and >40 dB in 29 (5.8%) patients, with the mean ABG being 26.08 ± 8.32 dB dB. In a study on 100 cases done by Patil et al.,[18] 34 patients (34%) had preoperative ABG within the range of 31–40 dB, 32 cases (32%) had it above 40 dB, 26 cases (26%) and 8 cases (8%) had ABG in the range of 21–30 dB and 11–20 dB, respectively, with the mean preoperative ABG of 36.42 ± 12.01 dB, while in the study done by Kawatra et al.,[1] the mean preoperative ABG was 27.50 dB.

The hearing improved in 477 (95.4%) patients with the mean postoperative ABG reducing to 10.12 ± 5.84 dB and the postoperative ABG changing to < than 10 dB in 289 patients and between 11 and 20 dB in 188 patients in the present study. In the study done by Patil et al.,[18] in the 3rd month, 76 (76%) cases had ABG within 10 dB, 4 (4%) cases had ABG in the range of 21–30 dB, 2 (2%) cases had ABG between 31 and 40 dB, while none of the cases (0%) had ABG >40 dB, all of which were statistically significant. Eighteen (18%) cases had ABG in the range of 11–20 dB, which was statistically not significant (P = 0.1403). The four cases with postoperative ABG of 21–30 dB and two cases with 31–40 dB had preoperative ABG of more than 40 dB and tympanosclerotic plaques in remnant tympanic membrane, so these cases also had a hearing improvement postoperatively, though not satisfactory. The mean postoperative ABG at the end of 3rd month was 9.7 ± 6.71 dB (P = 0.0000), which was statistically highly significant. In the study by Kawatra et al.,[1] ABG changed from 27.50 dB preoperatively to 13.67 dB postoperatively after 16 weeks.

Only 17 (3.4%) patients had graft failure in our study. There was no improvement in hearing in 20 (4%) patients while deterioration in hearing was seen in 3 (0.6%) patients. In the study by Patil et al.,[18] complications took place in 6 (6%) patients. Out of 6 cases, 4 (4%) had a residual perforation and 2 (2%) cases developed a partial thrombomodulin flap necrosis.

Since in the interlay technique, the graft is supported medially by the mucosal layer and laterally by the fibrosquamous layer, the fibrous annulus is placed back close to the bony sulcus; therefore, none of the cases in the present study had blunting, lateralization, epithelial cyst formation, and medialization. This finding was consistent with the study done by Patil et al.[18]

  Conclusion Top

The interlay technique of doing Type I tympanoplasty has high success both in terms of graft uptake as well as ABG closure. The complications associated with this are less as compared to other techniques. Therefore, in view of the advantages it offers, it should be preferred over the other conventional approaches in patients with large central perforations.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Kawatra R, Maheshwari P, Kumar G. A comparative study of the techniques of myringoplasty – Overlay, underlay & interlay. IOSR J Dent Med Sci 2014;13:12-6.  Back to cited text no. 1
Gladstone HB, Jackler RK, Varav K. Tympanic membrane wound healing. An overview. Otolaryngol Clin North Am 1995;28:913-32.  Back to cited text no. 2
Castro O, Pérez-Carro AM, Ibarra I, Hamdan M, Meléndez JM, Araujo A, et al. Myringoplasties in children: Our results. Acta Otorrinolaringol Esp 2013;64:87-91.  Back to cited text no. 3
Berthold E. Overlay myringoplasty. Wier Med Bull 1878;1:627.  Back to cited text no. 4
Wullstein H. Theory and practice of tympanoplasty. Laryngoscope 1956;66:1076-93.  Back to cited text no. 5
Zollner F. The principles of plastic surgery of the sound-conducting apparatus. J Laryngol Otol 1955;69:637-52.  Back to cited text no. 6
Palva T, Ramsay H. Myringoplasty and tympanoplasty – Results related to training and experience. Clin Otolaryngol Allied Sci 1995;20:329-35.  Back to cited text no. 7
Shea JJ Jr. Vein graft closure of eardrum perforations. J Laryngol Otol 1960;74:358-62.  Back to cited text no. 8
House WF. Myringoplasty. AMA Arch Otolaryngol 1960;71:399-404.  Back to cited text no. 9
Karlan MS. Gelatin film sandwich in tympanoplasty. Otolaryngol Head Neck Surg 1979;87:84-6.  Back to cited text no. 10
Schwaber MK. Postauricular undersurface tympanic membrane grafting: Some modifications of the “swinging door” technique. Otolaryngol Head Neck Surg 1986;95:182-7.  Back to cited text no. 11
Fernandes SV. Composite chondroperichondrial clip tympanoplasty: The triple “C” technique. Otolaryngol Head Neck Surg 2003;128:267-72.  Back to cited text no. 12
Juvekar MR, Jurekar RV. The double breasting technique of tympanoplasty: A study of 200 cases. Indian J Otol 1999;5:145-8.  Back to cited text no. 13
Goodman WS, Wallace IR. Tympanoplasty – 25 years later. J Otolaryngol 1980;9:155-64.  Back to cited text no. 14
Hung T, Knight JR, Sankar V. Anterosuperior anchoring myringoplasty technique for anterior and subtotal perforations. Clin Otolaryngol Allied Sci 2004;29:210-4.  Back to cited text no. 15
Escudero LH, Castro AO, Drumond M, Porto SP, Bozinis DG, Penna AF, et al. Argon laser in human tympanoplasty. Arch Otolaryngol 1979;105:252-3.  Back to cited text no. 16
Gersdorff M, Gérard JM, Thill MP. Overlay versus underlay tympanoplasty. Comparative study of 122 cases. Rev Laryngol Otol Rhinol (Bord) 2003;124:15-22.  Back to cited text no. 17
Patil BC, Misale PR, Mane RS, Mohite AA. Outcome of interlay grafting in type 1 tympanoplasty for large central perforation. Indian J Otolaryngol Head Neck Surg 2014;66:418-24.  Back to cited text no. 18
Komune S, Wakizono S, Hisashi K, Uemura T. Interlay method for myringoplasty. Auris Nasus Larynx1992;19:17-22.  Back to cited text no. 19
Guo M, Huang Y, Wang J. Report of myringoplasty with interlay method in 53 ears perforation of tympani. Lin Chuang Er Bi Yan Hou Ke Za Zhi 1999;13:147-9.  Back to cited text no. 20
Vishal US. A One-year Prospective Study to Evaluate the Results of Superiorly Based Tympanomeatal Flap in Endoscopic Myringoplasty Conducted in District Hospital, Belgaum and KLES and MRC, Belgaum during July 2003 to July 2004, Dissertation, MS (ENT), 2006, RGUHS, Karnataka; 2006.  Back to cited text no. 21
Hay A, Blanshard J. The anterior interlay myringoplasty: Outcome and hearing results in anterior and subtotal tympanic membrane perforations. Otol Neurotol 2014;35:1569-76.  Back to cited text no. 22
World Health Organization. Chronic suppurative otitis media, burden of illness and management options. Geneva: WHO Child and Adolescent Health Department, Prevention of Blindness and Deafness; 2004.  Back to cited text no. 23
Primrose WJ, Kerr AG. The anterior marginal perforation. Clin Otolaryngol Allied Sci 1986;11:175-6.  Back to cited text no. 24


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

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