Primary cartilage tympanoplasty: our technique and results

To Study the Outcome of Cartilage Tympanoplasty Type I in Patients with Medium and Large Perforations Using 0.5 mm Sliced Conchal Cartilage Reinforced with Temporalis Fascia Grafts with 5 Years Follow-up

Aims

To study the outcome of cartilage tympanoplasty type I in patients with medium and large perforations using 0.5 mm sliced conchal cartilage reinforced with temporalis fascia grafts with 5 years follow-up.

Study Design

Retrospective clinical study.

Patients and Method

120 patients with dry tympanic membrane perforation medium and large size and intact ossicular chain, and with no history of previous ear surgery were selected. An underlay type one tympanoplasty, using 0.5 mm sliced conchal cartilage reinforced with temporalis fascia, was performed during 2018-19. A successful anatomical outcome was considered to comprise full, intact healing of the graft without perforation these patients were evaluated for at least 5 years post-operatively till 2023.

Results

In this study graft uptake rate was 95.33% for medium size and 93.66% for large perforations at 3 months and after 5 years of follow-up 92.77% medium size and large size perforations were 89.67.66% (P < 0.001). Residual perforations were there in about 7.29% in medium and 10.33% in large size perfrations.

Conclusion

Sliced conchal cartilage reinforced with temporalis fascia is a reliable technique for tympanoplasty, with improved graft uptake results in medium and large perforations in the long-term, also the residual perforations is significantly lower.

Our Experience of Comparison of Hearing Outcomes in Patients Undergoing Type-1 Tympanoplasty with Different Graft Materials

The present study was undertaken to compare the results of various autogenous tissues: temporalis fascia, sliced tragal cartilage and fascia lata as graft materials for type I tympanoplasty in terms of hearing improvement in safe type of chronic suppurative otitis media. A total of 75 cases with central perforation were considered in the study. Of the 75 cases, temporalis fascia graft was used in 25 cases (Group-A), fascia lata graft in 25 cases (Group-B), and sliced tragal cartilage graft in 25 cases (Group-C). The results were evaluated in the form of hearing improvement with respect to the graft materials. A significant association was observed between the groups, that is, temporalis fascia (Group-A), fascia lata (Group-B), and sliced tragal cartilage (Group-C) in terms of improvement in AB gap (P = 0.047). Improvement in AB gap was statistically significant between groups B and A, but not between the other groups. In the present study, fascia lata showed better graft uptake as compared to temporalis fascia and sliced tragal cartilage. The hearing assessment at post-operative 3rd month showed statistically significant hearing improvement with fascia lata when compared to temporalis fascia.

A Prospective Randomised Comparative Study Between Cartilage and Fascia Tympanoplasty in a Tertiary Care Hospital to Look for Better Alternative in High Risk Cases

Introduction

CSOM patients are most commonly managed surgically by type I tympanoplasty using either cartilage shield technique or underlay grafting technique. In our study, we have compared the graft uptake and hearing results of type I tympanoplasty using temporalis fascia and cartilage shield, and also reviewed the literature regarding the results of these two methods.

Materials and Methods

160 patients aged between 15 and 60 years were randomized into two groups of 80 patients each, with odd numbers subjected to conchal or tragal cartilage shield grafting in group I, while in group II with even numbers, the patients underwent temporalis fascia grafting by underlay technique.

Results

Three months post-surgery, the graft uptake was seen in 76 patients (95%) in the cartilage shield group as compared to 58 patients (72.5%) in the temporalis fascia group, which was statistically significant between the two groups [Fisher's exact value = 0.000]. The uptake rate was much higher in cartilage shield graft as compared to fascia graft even in complicated cases like revision tympanoplasty (TP), discharging ear, subtotal perforation and retracted/adhered TP. Also, the hearing improvement in fascia and cartilage shield group was not statistically significant comparing pre- and post-operative patients, indicating that there was not much difference in audiological outcomes between the two groups.

Conclusion

We advocate the use of cartilage shield graft as a substitute for fascia graft in all feasible cases as well as in complicated situations to improve the success rate of type I tympanoplasty, without compromising on the hearing improvement, as seen in our study.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-022-03175-1.

Endoscopic Middle Ear Cleft Surgery (EMES): Our Philosophy, Concept and Application

The functional aspect of preservation of every healthy anatomical structure, particularly the ossicles, non-diseased mastoid cortex and middle ear mucosa, and to achieve this by transacanal endoscopic dual hand approach to middle ear, aditus and mastoid antrum with minimal posterior atticotomy and proximal aditotomy. The prospective study has been conducted over a period of 12 years from 2009 to 2021 in the Jorhat Medical College, Assam Medical College and Niramoy Hospital, Jorhat, Assam. Follow up was for a minimum of 4 years. The current study was a prospective hospital based study, carried out from May 1st, 2009 to April 30th, 2021 involving 157 subjects from 18 to 65 years with mean age of 38 + 2.5. Graft uptake rate of 93.6%. Minimal atticotomy with proximal aditotomy offers a clear view of the antrum with angled scopes of 30 degree and 45 degree and if any disease is located it can be removed through the transcanal approach with angled instruments and aditus patency can be confirmed by visual inspection. Hence, decreasing the need of unnecessary bone drilling as done with cortical mastoidectomy to create a parallel view.The endoscopic ear surgeries done with "dual hand endo-holder" were uneventful and much more comfortable as compared to the single hand technique. Functional approach by minimizing bone drilling, reestablishment of ventilation pathways and preservation of ossicles with disease clearance give better postoperative results in long term follow-up.

Endoscopic Cartilage Boomerang Ossiculoplasty- as Total Ossicular Replacement Using Endoscope Holder

We report the technique of two handed transcanal endoscopic ossiculoplasty using tragal cartilage in the form of boomerang as an option for total ossicular replacement in absence of stapes superstructure. In this technique, the vertical strut is fashioned as a boomerang and measures 10 mm in length and 2 mm in breadth. A partial thickness cut is made on the vertical strut at 4-4.5 mm along the length so that it can be bent into boomerang, one end of which is placed on the stapes footplate and the other part rests in the hypotympanum. This stable assembly is placed on the footplate of the stapes (when all ossicles are absent). Tympanic membrane reconstruction is performed with or without attic reconstruction, using sliced tragal cartilage of 0.5 mm thickness. Boomerang ossiculoplasty is good option in cases of absent stapes providing a stable assembly. The use of endoscope holder during ear surgery gives additional advantages of panoramic view of middle ear spaces due to use of endoscope along with benefits of two handed technique (similar to microscopic ear surgery).

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-021-02854-9.

Feasibility of Sheep Auricular Cartilage as a Teaching Tool for Training in Slicing Techniques for Cartilage Tympanoplasty

There are temporal bone dissection workshops organised all-over the world, however, there is no dedicated teaching program to train in slicing techniques for cartilage tympanoplasty. The aim of the study is to train the otologists in slicing techniques in cartilage tympanoplasty using sheep auricular cartilage as a teaching model and to evaluate the impact of the training on the participants. A total of 98 otologists have been trained in slicing techniques using cartilage slicer during 7 workshops organised at our centre from January 2016 to January 2020 for a total of 6 days for each trainee. Each trainee performed slicing techniques in cartilage tympanoplasty using 5 sheep pinna. Evaluation of the impact of the training was done in terms of assessment of improvement in performance. The feedback forms evaluated the training technique with sheep cartilage, its feasibility and usability as a model for teaching. The impact of the training on the overall performance of the trainee was assessed in terms of confidence, ability and speed in performing tasks related to slicing and cartilage tympanoplasty. The simulation in slicing techniques using sheep auricular cartilage has a teaching potential to improve the surgical outcomes of tympanoplasty as assessed by the performance of the participants. Level of evidence: 4.

Endoscopic Cartilage Umberlla Ossiculoplasty: As Total Ossicular Replacement Using Endoscope Holder

We describe our innovative technique of endoscopic cartilage tympanoplasty using cartilage fashioned as umbrella in stapes absent condition using endoscope holder. Tragal cartilage disc of 3 × 3 mm dimensions with a circular slot of 0.8 mm to accommodate the vertical strut measuring 3 mm × 7 mm in cases with absent incus and stapes. Tympanic membrane reconstruction was done, with or without attic reconstruction, using sliced tragal cartilage of less than 0.5 mm thickness.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-021-02518-8.

Novel Drill-burr Protection Sheath with Inbuilt Suction-irrigation for Endoscopic Ear Surgery

Abstract

We have developed a novel instrument which is a drill burr protection sheath with an inbuilt suction-irrigation system for endoscopic ear surgery. It allows simultaneous suction and irrigation. It is a metallic attachment onto the mastoid drill handpiece. It provides protection for the endoscope as well as the external auditory skin during transcanal drilling procedures. It is cost effective.

Level of evidence

5.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-021-02944-8.

Paediatric Cartilage Tympanoplasty: A Two Handed Technique with Our Endoscope Holder

The aim of the study is to evaluate the functional and anatomical results of paediatric sliced cartilage type 1 tympanoplasty using our endoscope holder. It is Retrospective Non Randomized Clinical Study. A total of consecutive 81 children operated from January 2016 to December 2017 for endoscopic type I sliced cartilage tympanoplasty with endoscope holder were included in the study. The study included 44 males and 37 females. The patients ranged from 8 to 18 years. In early follow up period ranging from 24 to 48 months, the graft take up was seen in 76 follow up giving a success rate of 93.82 percent. The pre-operative air-bone gap was 32.34 ± 2.71 dB and the post-operative mean 4 tone air-bone gap at 1 and 2 years was 9.12 ± 2.37 dB and 9.42 ± 1.38 dB respectively. The study reports the good air bone closure and anatomical closure of perforation with sliced cartilage in paediatric tympanoplasty.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-021-02678-7.

Endoscopic Cartilage Butterfly Tympanoplasty: A Two-Handed Technique with Endoscope Holder

The aim of the study was to evaluate and report the short-term results of two-handed endoscopic cartilage butterfly tympanoplasty using endoscope holders. The efficacy of the operative technique was evaluated and assessed by comparing the air-bone-gap on pure tone audiometry preoperatively and on follow-up at 6 months and 1-year post operatively. Patients with uncomplicated otitis media and healthy middle ear status with no ossicular involvement underwent endoscopic transcanal cartilage butterfly tympanoplasty. Small and medium sized tympanic membrane perforations were included in the study. Pre- and postoperative air-bone gaps and presence for any residual perforation was noted. A total 69 patients consisting of 45 males and 24 females with a mean age of 24.45 years were included in the study group. Small perforations involving only one quadrant were 39 in number while the medium sized perforations involving two quadrants were 26 in number and the ones involving three quadrants were 4 in number. At the end of the follow-up period of 6 months and 1 year, successful closure occurred in 67 of 69 patients with a success rate of 97.1%. The mean preoperative Air-Bone gap was 34 ± 3.45 dB which showed a steady decline on follow-up at 6 months 13 ± 4.53 and 15.34 ± 3.39 dB at 1 year following surgery. Recurrent perforation was noted in two patients involving three quadrants of the tympanic membrane. Endoscopic two-handed butterfly cartilage tympanoplasty can be safely performed in small and medium sized perforations with no middle ear disease/ossicular involvement. The hearing outcomes and successful closure rate are similar to those of other surgical methods. Our study uses the endoscope which provides superior image quality and the use of an endoscope holder makes the technique a two handed one, thereby making the manoeuvring of the microear instruments easier. Moreover, it can be performed under local anaesthesia with low complication rates and quick recovery. Level of Evidence Level 4.

Learning Curve of Two Handed Endoscopic Ear Surgery on Sheep Temporal Bone: A Fellow’s Perspective

The study puts forth the learning curve of two handed endoscopic middle ear dissection on a sheep temporal bone. It also highlights the usage of sheep temporal bone as an effective simulation technique for two-handed cadaveric temporal bone dissection. 6 sheep temporal bone models were dissected in a period of 15 days. Harvesting of cartilage graft, endoscopic myringotomy and grommet insertion, cartilage butterfly tympanoplasty, ossiculoplasty, stapes surgery and facial nerve decompression, using the Endohold®, were conducted on each bone. There was a remarkable decrease in the time required for subsequent temporal bone dissections, with significant improvement in efficiency, accuracy and neatness of dissection. Practice and experience resulted in upliftment in the level of confidence of the fellow. Striking similarities were noticed between sheep and human temporal bones. Availability of both the hands with a clear endoscopic view made it easier and more convenient to perform various procedures. Two handed endoscopic technique provides an excellent approach for ear surgeries. Availability of both the hands for the delicate surgery along with the spectacular endoscopic view contributes to increase in efficiency and surgery outcome. Cadaveric dissection of sheep temporal bones provides a great learning experience for a trainee to practice these delicate and skilful two-handed endoscopic middle ear surgical exercises. Its easy availability and striking similarity of the anatomy makes it a boon for the beginners. It gives ample opportunity to the trainee to explore and learn the complex anatomy, try new skills and develop an expertise in this field. The efficiency and accuracy increases significantly with each dissection, smoothening out the steep learning curve, that is, for such fine and intricate surgical skills.

Our Experience with Two Handed Endoscopic Tympanoplasty

Endoscopic tympanoplasty is a minimally invasive procedure and may be an alternative to conventional microscopic tympanoplasty with less operative time, producing similar graft uptake. Endoscopic tympanoplasty has a major disadvantage of single handedness which is overcome by a novel concept of "Two-handed technique" using Khan's Justtach (endoholder). The aim was to study the outcomes of two handed endoscopic tympanoplasty in terms of graft uptake and hearing outcome. Two handed endoscopic tympanoplasty was performed in 20 patients with chronic suppurative otitis media between April 2018-April 2019, in the Department of Otorhinolaryngology, M.G.M. Medical college and MYH hospital, Indore. Tragal cartilage graft via palisading supported with perichondrium was used. Postoperative follow up was done at 3rd month's period, graft status and hearing evaluation was done using Pure tone audiometry. Graft uptake was intact in 19 (95%) out of 20 patients and infection and failure in 1 (5%) case, average preoperative A-B gap was 15-25 dB loss (minimal) in 1 (5%) patient, 3 (15%) patients had 25-40 dB loss (mild) and 16 (80%) patients had 40-55 dB loss (moderate) hearing loss. The post-operative improvement was evaluated in which 6 (30%) patient had 15-25 dB loss (minimal), 12 (60%) patients had 25-40 dB loss (mild), and 2 (10%) patients had 40-55 dB (moderate) conductive hearing loss. We used Wilcoxon Signed Ranks Test for audiological evaluation with a 'p value' of 0.000 making the hearing improvement significant. "Two handed endoscopic tympanoplasty" is an emerging technique which can overcome almost all the major issues related with single handed technique with high degree graft uptake and good hearing outcomes. Endoscope holder is a valuable adjunct to conventional endoscopic surgery.

Exclusive Two Handed Endoscopic Cartilage Type 3 Tympanoplasty with Endoscope Holders

In present world of contemporary techniques of microscopic ear surgery and single handed endoscopic ear surgery, we propose the technique of two handed endoscopic tympanoplasty using endoscope holders. The aim of the study  is to evaluate the functional and anatomical results of our technique of endoscopic type 3 cartilage tympanoplasty using endoscope holder. It is a Retrospective Non Randomized Clinical Study. A total of 67 endoscope holder assisted exclusively two handed endoscopic type 3 cartilage tympanoplasties performed from December 2014 to March 2017 with our technique were included in the study. Patients with pars tensa retractions and perforations with absent incus were included in the study. Those with cholesteatoma were excluded from the study. Full thickness tragal cartilage disc of 3 × 3 mm dimensions with a circular slot of 1 mm to fit onto the head of the stapes was used for reconstruction. Tympanic membrane reconstruction was done along with attic reconstruction, using sliced tragal cartilage of 0.5 mm thickness. Patients were assessed at 6, 12 and 24 months for graft status. In early follow up period ranging from 24 to 52 months, the graft take up was seen in 64 ears with three perforations giving a success rate of 95.52%. The pre-operative air-bone gap was 42.6 ± 3.26 dB and the post-operative air-bone gap at 6 months, 1 and 2 years was 18.36 ± 3.46 dB, 19.42 ± 4.32 dB and 19.53 ± 4.33 dB respectively. The study reports good air-bone closure to 20 dB postoperatively following type 3 endoscopic tympanoplasty using endoscope holder. Slotted cartilage graft is definitely an excellent option for ossiculoplasty in cases of absent incus providing a stable assembly. Level of evidence: Level 4.

Accurate and Specific Measuring Grid for Otorhinolaryngological Surgeries

Most of the ENT surgeries (tympanoplasty, rhinoplasty, ossiculoplasty, septoplasty) involve the reconstruction and the functional correction of the respective structures involved. Success of otorhinolaryngological surgeries depends on accurate measurements and precision in judgement. There is need to develop simple tools for measurements which are easy to procure, accurate and simple to handle. Every surgeon needs unique tools to accomplish such an outcome. In order to tackle this difficulty and to ease the learning process in ENT surgeries, we have developed an accurate specific measurement grid.

Vertical Strut Ossiculoplasty: A Versatile Alternate to Conventional Techniques-A Randomized study

INTRODUCTION

Various ossicular reconstruction materials and techniques have been described in literature using autologous ossicle, cortical bone, autologous cartilage, synthetic materials and implants like total/partial ossicular replacement prosthesis (TORP/PORP) etc., but it has always been a topic of controversy in terms of the efficacy, longevity and complications of the material or method used.

MATERIAL AND METHODS

This is a prospective, interventional, comparative, double-blind randomized control study which was done at a tertiary care center to compare outcomes of conventional and carved conchal cartilage (vertical strut) type III Tympanoplasty in terms of graft uptake and hearing gain. A total number of 52 cases were enrolled, randomized and allocated to 2 groups (26 each) i.e. group A (conventional type III) and group B (vertical strut technique).

RESULTS

Graft uptake was seen in 25 (96.16%) patients in group B while it was observed in 23 (88.5%) cases in group A. Hearing gains were also better in group B.

CONCLUSION

This study suggests that Vertical Strut technique can be studied further as it gives better gains in Air Conduction threshold and A-B Gap along with graft uptake as it provides better middle ear space and ossicular / tympanic membrane interface resulting in better hearing.

Type 1 tympanoplasty in patients with large perforations: Comparison of temporalis fascia, partial-thickness cartilage, and full-thickness cartilage

Objective

This study aimed to compare the results of different graft materials in type I tympanoplasty for patients with a large perforation of the tympanic membrane.

Methods

We performed a retrospective study on 180 patients with type I tympanoplasty. The patients were divided into three groups according to the repair materials used. Age, sex, pre- and postoperative hearing levels, mean air–bone gap, rate of graft success, hearing gain, and the postoperative graft failure rate were evaluated. We continued to follow-up the patients to 1 year after surgery.

Results

The air conduction threshold was significantly higher before the operation than after the operation in the temporalis fascia, partial-thickness cartilage, and full-thickness cartilage groups. Although the hearing gain in the temporalis fascia group and the partial-thickness cartilage group was higher than that in the full-thickness cartilage group, there was no significant difference in the graft success rate among the groups.

Conclusions

Temporalis fascia, partial-thickness cartilage, and full-thickness cartilage can be used as appropriate transplantation materials for tympanoplasty type I in patients with a large perforation. Temporalis fascia and partial-thickness cartilage may be best for improvement of hearing.

Intraoperative tragal and conchal cartilage thickness: Comparative study for cartilage tympanoplasty

INTRODUCTION

In conditions like recurrent perforations, atelectatic tympanic membrane and poor eustachian tube function, temporalis fascia graft fails to give the desired result. In such cases cartilage is used for tympanoplasty. It was demonstrated that if the thickness of cartilage is reduced to around 0.5 mm, the sound conduction is comparable to that of normal tympanic membrane with excellent mechanical stability.

AIM

To intra-operatively measure the mean thickness of tragal and conchal cartilage and compare it for age and sex variations.

MATERIAL & METHODS

A total of 114 tragal and conchal cartilage samples of 86 patients were included in the study. Thickness of cartilages was measured intra-operatively after removing the perichondrium from both sides.

RESULTS

Out of 58 tragal cartilages, 32 were from males and 26 from females. Mean thickness was 1.18 ± 0.11 mm among males and 1.12 ± 0.14 mm among females. Out of 56 conchal cartilage taken, 29 were from males and 27 females. Mean thickness among males were 1.38 ± 0.13 mm and 1.35 ± 0.08 mm in females. In 28 patients both tragal and conchal cartilage was taken. Mean thickness of both tragal (1.22 mm) and conchal cartilage (1.36 mm) increased with increase in age. Among 16 males in whom both cartilages were taken, mean thickness of tragal cartilage was 1.25 ± 0.11 mm and conchal cartilage was 1.41 ± 0.12 mm. Similarly among 12 females where both cartilages were taken, mean thickness of tragal cartilage was 1.20 ± 0.13 mm and conchal cartilage was 1.35 ± 0.07 mm.

CONCLUSION

Sliced cartilage tympanoplasty is a relatively better technique. When using cartilage splitter to get sliced cartilage, ideally thickness of every graft should be known. As it is difficult to measure the exact thickness in every case, so knowing the mean for age and sex for cartilage thickness is important to have an idea of which plates to use for a successful outcome of slicing. We concluded that thickness of tragal cartilage is significantly less than the thickness of conchal cartilage. Also there is significant age related difference between mean thickness of cartilages, both for tragal and conchal cartilage. Surprisingly the difference between thickness in male and female is not statistically different.

Pinna stay suture in two handed endoscopic ear surgery: Our experience

Transcanal endoscopic ear surgery provides a minimally invasive approach to the middle ear. We operate exclusively by the two handed technique of endoscopic ear surgery with Endoscope holders. We have incorporated the technique of stay suture for retraction of external ear canal into our practice of transcanal two handed endoscopic ear surgery after observing this technique by Prof Muaaz Tarabichi at the First International Congress on Endoscopic ear surgery Dubai, April 2015 for the single handed endoscopic ear surgery.

AIM

To report our experience of the stay suture in transcanal two handed endoscopic ear surgery and highlight its advantages.

DESIGN

Prospective non randomized clinical study.

METHODS AND MATERIALS

A total of 354 two handed transcanal endoscopic ear surgeries (202 endoscopic cartilage tympanoplasties and 152 endoscopic attic cholesteatoma surgeries) with endoscope holders operated from May 2015 to September 2017 with the stay suture were included in the study.

RESULTS

The ear canal and the tympanic membrane visualisation, instrument manipulation were better with the stay suture technique of pinna retraction.

CONCLUSION

The study reports the successful application and use of the pinna stay suture. It is a good option during two handed technique in Endoscopic Ear Surgery for pinna retraction.

LEVEL OF EVIDENCE

Level 4.

Modified Endoscope Holder for Two Handed Endoscopic Ear Surgery

We have been doing Endoscopic ear surgeries since 2013. Inorder to overcome the disadvantage of the single handed endoscopic ear surgery technique, we have developed the endoscope holders, Justtach^® and EndoHold^®. Due to its certain limitations, we modified the pre-existing, endoscope holder-Justtach, to add more features as well as to increase the comfort and ease of the technique. The aim of this paper is to describe the design of our modified endoscope holder and to report our preliminary experience of two handed endoscopic ear surgery with it. Descriptive study. A total number of 68 two handed endoscopic tympanoplasties have been operated with the modified endoscope holder from January 2017 to May 2018 with a minimum follow up period of 10 months. Our study reports the successful application of the modified endoscope holder for two handed endoscopic ear surgery, highlighting its advantages. Our modified endoscope holder, is a good option for two handed endoscopic tympanoplasties and mastoidectomies. Level of Evidence Level 4.

Minimal Invasive Endoscopic Ear Surgery: A Two Handed Technique

To evaluate the surgical outcome of two handed technique of endoscopic ear surgery with endoscope holder. Retrospective Non Randomized Clinical Study. A total of 547 endoscope holder (Justtach) assisted ear surgeries (331 cartilage tympanoplasties and 216 cholesteatoma surgeries) were operated with Justtach from July 2013 to April 2016 with a follow up period ranging from 12 to 45 months to evaluate its feasibility and results with the technique. The design of the endoscope holder, Justtach is described along with its functioning and maneuvering techniques. In the endoscopic tympanoplasty group, at 1 year follow up, the graft uptake was seen in 323 ears with three residual perforation and 5 recurrent perforations giving a success rate of 97.58%. At the 2 years follow up, the graft uptake was in 322 ears with 6 recurrent perforations and 3 residual perforations with a success rate of 97.28%. Whereas in case of endoscopic cholesteatoma surgery, there was residual cholesteatoma in 5 and recurrent in 6 out of 216 cases. The study reports the successful application and use of endoscope holder in two handed technique of endoscopic ear surgery. Level of Evidence Level 4.

A Comparative Study of Type-I Underlay Tympanoplasty with Temporalis Fascia Graft Alone and with Conchal Cartilage

Tympanoplasty which is the repair of the tympanic membrane using temporalis fascia, has been done worldwide and has stood the test of time. However in cases of reperforation or large/subtotal perforations, we are often left in need of some sturdy material for grafting. To compare the graft uptake and hearing improvement in patients undergoing type I tympanoplasty using temporalis fascia alone and temporalis fascia along with conchal cartilage. The current research is a prospective study of 60 patients with chronic suppurative otitis media (Tubo tympanic type), undergoing type I tympanoplasty, using temporalis fascia alone and temporalis fascia along with conchal cartilage. The graft uptake and hearing improvement was much better using temporalis fascia along with conchal cartilage graft as compared to cartilage alone. The use of temporalis fascia along with conchal cartilage graft is beneficial for patients with chronic suppurative otitis media (tubotympanic type) undergoing type I tympanoplasty than using temporalis fascia alone.

Rates of success in hearing and grafting in the perichondrium-preserved palisade island graft technique

INTRODUCTION

Various graft materials have been used in the tympanoplasty technique. Cartilage grafts are being used increasingly in recent years.

OBJECTIVE

The aim of this study was to present the comparative outcomes of the perichondrium-preserved palisade island graft technique previously defined by ourselves.

METHODS

We retrospectively compared the hearing and graft success rates in 108 patients with chronic otitis media, who had undergone cartilage tympanoplasty, where both island and perichondrium-preserved palisade graft techniques were used.

RESULTS

The success rates among the study and the control groups with regard to graft take were 97% and 93%, respectively. No significant difference was observed between the groups with regard to the postoperative mean pure tone values, improvement in air-bone gaps and reduction in air-bone gaps to under 20dB. However, better results were observed in the study group.

CONCLUSION

The perichondrium-preserved palisade island graft technique is an easy method with high graft success rates and hearing outcomes.

Sutureless Tragal Cartilage Island Tympanoplasty: Our Experience

To evaluate graft take up and hearing improvement using the technique of tragal cartilage island in COM-mucosal type. Prospective study. A total of 258 type 1 tympanoplasty surgeries were done using tragal cartilage island graft from December 2013, to December 2015; in Jubilee Mission Medical College and Research Institute with a follow up of 1 year. Inclusion criteria-all the patients undergoing type 1 tympanoplasty for chronic otitis media (mucosal type, inactive) with an intact ossicular chain by the senior author. The youngest patient was 6 years old and the oldest was 64 years. This pattern was selected for getting a uniform pattern even though cartilage tympanoplasty can be done in other forms of COM also. Graft take up in our study was found to be 96.12% in 1 year of follow up. Closure of tympanic membrane was achieved in 248 of 258 cases. None of the patients showed retraction pockets or cholesteatoma during follow up. The average pre-op AB gap was 21.62 dB which was lowered to 4.22 dB post op. The mean gain in hearing was 17.37 dB. It is worthwhile to consider tragal cartilage island graft as an alternative to temporalis fascia.

Endoscopic Management of Tympanic Membrane Retraction Pockets: A Two Handed Technique with Endoscope Holder

The tympanic membrane retraction pocket is a pathological invagination of tympanic membrane into the middle ear space. The most common sites for formation of retraction pocket are pars flaccida and postero-superior parts. Decision about the procedure and the timing of the treatment of retraction pockets is debatable and depends on the functional and anatomic condition of the ear. To evaluate the results of the technique of two handed endoscopic management of retraction pockets with sliced tragal cartilage. Prospective Non Randomized Clinical Study. The study included 41 ears operated with the technique of two handed endoscopic cartilage tympanoplasty for retraction pockets with endoscope holders from November 2013 to May 2016 with a follow up period ranging from 22 to 53 months. Cases of cholesteatoma and tympanic membrane perforation were excluded from the study. Pre and postoperative symptoms and air-bone gaps were recorded. The average preoperative air-bone gap in the study group was 24.53 ± 4.326 dB. 28 ears were of pars tensa retractions (stage II-4, stage III-15, and stage IV-9) and 13 were pars flaccida retractions (stage III-8 and stage IV-5). 24 ears had ossicular erosion. The follow up revealed that, the results of two handed endoscopic sliced cartilage tympanoplasty for retraction pockets were stable and there was no recurrence of the retraction and the post-operative air-bone-gap closure was achieved to 13.62 ± 4.78, 14.13 ± 5.91 dB, 14.32 ± 3.46 and 14.57 ± 3.88 dB at 6 months, 1 year, 2 years, 3 years respectively. Though, indications for surgery are based mostly on anatomic status and observation of behaviour of retraction pocket over time, we recommend early management of retraction pockets by the technique of endoscopic sliced tragal cartilage tympanoplasty with tragal cartilage of 0.5 mm thickness using endoscope holder. Level of Evidence: Level 4.

Transplantation of autologous perichondrium with amniotic membrane for progressive scleral necrosis

PURPOSE

Scleral necrosis with severe ischemia is refractory to conventional treatment because of avascular progressive necrosis. We assessed the therapeutic efficacy and safety of autologous perichondrium transplantation in patients with progressive scleral necrosis (PSN) and analyzed the clinical effects.

METHODS

This study was a prospective, interventional, and noncomparative case series. Reconstructive surgery using autologous perichondrium and amniotic membrane (AM) was performed in patients with PSN who showed progressive ischemic scleral melting with impending perforation state and/or broad avascular area larger than 10 mm in diameter. The primary outcome was restoration of scleral integrity with healthy vascularized epithelium over the graft at six months after surgery. The secondary outcome was complication rate associated with autologous perichondrium graft use.

RESULTS

Eighteen eyes of 14 patients underwent reconstructive surgery using autologous perichondrium patch and AM grafts. Observations indicated the graft provided the eyeball with successful structural integrity in 17 out of the 18 cases (94.4%) at six months after surgery. One eye showed a small scleral defect due to wound dehiscence at four month after the surgery. Additional surgery using perichondrium and AM stabilized the eye. The scleral necrosis healed completely after perichondrium and AM transplantation, even in cases with full-thickness scleral defect. The scleral integrity was maintained until the last follow-up session. There were no serious complications of endophthalmitis or graft infection.

CONCLUSIONS

Reconstructive surgery using autologous perichondrium and AM is an effective method for restoration of scleral integrity and vascularization of the episclera and conjunctiva in eyes with PSN. Therefore, autologous perichondrium can be considered as an appropriate new biologic tissue for PSN.

New Cartilage Slicer for Slicing Techniques in Tympanoplasty: Design and Applications

ABSTRACT

Cartilage-perichondrium composite graft is used in middle ear surgery for tympanic membrane, ossicular and for soft wall reconstruction. The thickness of the cartilage is thought to interfere with the sound conduction. In our otology practice for tympanic membrane reconstruction, we prefer the sliced cartilage graft to achieve acoustic benefit. At times in the process of slicing, the cartilage gets wasted if not sliced with a precision slicing instrument. We have designed and developed a multi-purpose cartilage slicer for precise reduction of the thickness of the cartilage. To describe the design of our cartilage slicer and to report our preliminary experience with the cartilage slicer. Descriptive study. The technique of slicing with our new cartilage slicer and its usage has been described in detail. A total number of 689 cartilages in tympanoplasty and mastoidectomy have been sliced with it from 2013 to 2017. Our study reports the technique of slicing the tragal cartilage for tympanoplasty, highlighting its advantages and precision of the cartilages slices obtained. Our cartilage slicer is a good option for cartilage slicing in tympanoplasty.

LEVEL OF EVIDENCE

Level 4.

Indian Perspectives on Graft Materials Used for Repair of Tympanic Membrane

INTRODUCTION

Repair of Tympanic Membrane (TM) is one of the most common surgeries performed by the otologists. Literature reveals that Indian surgeons have contributed substantially in the research on techniques and graft materials used for the repair of tympanic membrane, though no review has been written so far highlighting their contributions.

AIM

To summarize and analyse the contributions of Indian authors who have used different graft materials for repair of TM and their studies listed in Medline search.

MATERIALS AND METHODS

A literature review was conducted using a Medline search using keywords of 'myringoplasty' and 'tympanoplasty' with 'India' on 30th June 2016. A total of 243 articles were found listed onwards from year 1998. Out of these 50 articles in which type 1 tympanoplasty or myringoplasty was performed using different graft materials were selected. The content of each abstract was studied in order to identify studies related to topic.

RESULTS

Authors have experimented with a variety of tissues as graft materials. Temporalis Fascia (TF) has been most widely used in 58.6% studies as graft material. The next popular graft is tragal perichondrium. The graft take up rates varied from 68.5% to 100%, while method of reporting of hearing gain in most studies was inconsistent amongst studies, though most studies have reported achievement of serviceable hearing of < 25 dB in most patients.

CONCLUSION

TF was the most prefered material due to anatomic proximity, light material and strength. It was followed in popularity by tragal perichondrium and tragal cartilage. All graft materials have given satisfactory hearing results.

The audiological and take results of perichondrium attached cartilage island graft in tympanoplasty: PACIT

Cartilage is one of the most preferable grafts for tympanoplasty (TPL). The anatomical and audiological results and take rates of perichondrium attached cartilage island graft in tympanoplasty (PACIT) are presented herein. One hundred ninety four ears of 191 patients (108 male, 83 female) were evaluated retrospectively in terms of the type of surgery, graft take rate and hearing results. Type I, II, and III TPL were performed in 127 (65.46%), 45 (23.20%), and 22 (11.34%) ears, respectively. The overall mean preoperative pure tone average-air bone gaps (PTA-ABGs) for TPL types were 33.74 ± 9.60, 52.58 ± 9.07, and 56.58 ± 10.27 dB HL, respectively; postoperative mean values for TPL groups were 18.55 ± 9.25, 31.21 ± 4.36, and 44.84 ± 12.45 dB HL. Postoperative hearing results showed an improvement (≥ 10 dB) in 76.81% of ears with a mean gain of 20 dB HL (range 10-40 dB). However, 19.07% of ears showed no change (< 10, ≥ 0 dB) in hearing, and hearing worsened in 4.12% of ears (< 0 dB) postoperatively. Overall, graft take was 91.24% at least 13 months (mean 68.64) after surgery with a graft failure rate of 8.76%. Graft take was successful in TPL groups. Postoperative PTA-ABG results demonstrated significant improvement. The long-term eligibility of perichondrium attached cartilage island graft in TPL is emphasised with this study.

Boomerang-Shaped Chondro-Perichondral Graft Versus Temporalis Muscle Fascia Graft: Which One is to be Trusted?

The aim of this study was to compare anatomical and audiological results of boomerang-shaped chondroperichondrial graft (BSCPG) with temporal muscle fascia in type 1 tympanoplasties. Sixty-eight patients in BSCPG group and 54 patients in fascia group were evaluated. Otomicroscopic examination was done periodically till 24 months as for graft perforation, lateralization and retraction and mean air conduction threshold and airbone gap values were measured. At long term controls, in BSCPG group, rates of neomembrane, perforation, retraction and lateralization were 91.17 % (n = 62), 8.82 % (n = 6), 4.41 % (n = 3) and 0 % (n = 0), respectively. In fascia group, the corresponding rates were 79.62 % (n = 43), 20.37 % (n = 11), 12.96 % (n = 7) and 3.7 % (n = 2), respectively. In both groups, mean postoperative PTA and ABG values were significantly better while postoperative same values were significantly different between groups (p = 0.044 and 0.032, respectively). Compared to fascia, BSCPG is an ideal grafting technique in the repair of tympanic membrane perforations.

Comparison of Modified Cartilage Shield Tympanoplasty with Tympanoplasty Using Temporalis Fascia Only: Retrospective Analysis of 142 Cases

The current study compares outcomes of modified cartilage shield tympanoplasty (CST) with temporalis fascia tympanoplasty in type I procedures in Indian patients. Graft uptake rates are better with the CST technique and hearing results are almost equivalent with both techniques except at 8000 Hz where improvement in hearing was found better with the use of temporalis fascia alone. The CST technique used in the study is unique.

Novel Concept of Attaching Endoscope Holder to Microscope for Two Handed Endoscopic Tympanoplasty

The well established techniques in tympanoplasty are routinely performed with operating microscopes for many decades now. Endoscopic ear surgeries provide minimally invasive approach to the middle ear and evolving new science in the field of otology. The disadvantage of endoscopic ear surgeries is that it is one-handed surgical technique as the non-dominant left hand of the surgeon is utilized for holding and manipulating the endoscope. This necessitated the need for development of the endoscope holder which would allow both hands of surgeon to be free for surgical manipulation and also allow alternate use of microscope during tympanoplasty. To report the preliminary utility of our designed and developed endoscope holder attachment gripping to microscope for two handed technique of endoscopic tympanoplasty. Prospective Non Randomized Clinical Study. Our endoscope holder attachment for microscope was designed and developed to aid in endoscopic ear surgery and to overcome the disadvantage of single handed endoscopic surgery. It was tested for endoscopic Tympanoplasty. The design of the endoscope holder attachment is described in detail along with its manipulation and manoeuvreing. A total of 78 endoholder assisted type 1 endoscopic cartilage tympanoplasties were operated to evaluate its feasibility for the two handed technique and to evaluate the results of endoscopic type 1 cartilage tympanoplasty. In early follow up period ranging from 6 to 20 months, the graft uptake was seen in 76 ears with one residual perforation and 1 recurrent perforations giving a success rate of 97.435 %. Our endocsope holder attachment for gripping microscope is a good option for two handed technique in endoscopic type 1 cartilage tympanoplasty. The study reports the successful application and use of our endoscope holder attachment for gripping microscope in two handed technique of endoscopic type 1 cartilage tympanoplasty and comparable results with microscopic techniques.

LEVEL OF EVIDENCE

IV.

Average thickness of tragal cartilage for slicing techniques in tympanoplasty

BACKGROUND

Cartilage-perichondrial grafts are often used for tympanic membrane and middle-ear reconstructions. Tragal and conchal cartilages are most frequently used for this purpose. Studies have shown that slicing the cartilage to less than 0.5 mm thickness improves acoustic benefit. However, the thickness of the cartilage in a given population may not be uniform.

OBJECTIVE

This descriptive cross-sectional study aimed to determine the average thickness of tragal cartilage (in terms of age and sex) in an Indian population.

METHOD

A prospective study of 61 tragal cartilages harvested during serial tympanoplasty and modified radical mastoidectomy were analysed according to thickness.

RESULTS

The total average thickness of tragal cartilage was 1.228 ± 0.204 mm in males and 1.090 ± 0.162 mm in females. The overall thickness was 1.018 ± 0.139 mm in those aged less than 15 years, 1.139 ± 0.238 mm in those aged 15-30, and 1.189 ± 0.155 mm in those aged over 30 years.

CONCLUSION

The findings help us to determine age-related cartilage thickness for slicing techniques in tympanoplasty.

Comparative study of sliced tragal cartilage and temporalis fascia in type I tympanoplasty

OBJECTIVE

To compare anatomical and audiological results using sliced tragal cartilage and temporalis fascia in type I tympanoplasty.

METHOD

A retrospective review was undertaken of primary tympanoplasties using sliced tragal cartilage and temporalis fascia from May 2005 to January 2008. In total, 223 ears were operated on using sliced tragal cartilage graft and 167 using temporalis fascia. Statistical analysis of the outcome data was performed.

RESULTS

At the two-year and four-year follow ups, successful closure of the tympanic membrane was achieved in 98.20 per cent and 97.75 per cent, respectively, of the cartilage group compared with 87.42 per cent and 82.63 per cent, respectively, of the temporalis fascia group. At the four-year follow up, the average air-bone gap was 7.10 ± 3.01 dB in the cartilage group and 8.05 ± 3.22 dB in the temporalis fascia group.

CONCLUSION

The overall success rate for primary cartilage tympanoplasty is higher when using sliced cartilage than with temporalis fascia grafting.

Preparation and placement of cartilage island graft in tympanoplasty

INTRODUCTION

Cartilage graft tympanoplasty has a better success rate in the treatment of chronic otitis media if regularly prepared and placed.

OBJECTIVE

To prepare cartilage island material and evaluate its effect on the success rate of tympanoplasty.

METHODS

The medical records of 87 patients (48 males and 39 females; mean age, 27.3±11.2 years; range, 14-43 years) with chronic otitis media without cholesteatoma who underwent intact canal-wall-up tympanoplasty and revision surgery between December of 2007 and October of 2011 were retrospectively evaluated. Surgery was performed under general anesthesia via a retroauricular approach.

RESULTS

The overall success rate of this technique was 93% in terms of perforation closure. No graft lateralization or displacement into the middle ear occurred. The overall average preoperative air bone gap was 37.27±12.35 dB, and the postoperative air bone gap was 27.58±9.84 dB. The mean postoperative follow-up period was 15.3 months (range: 7-21 months).

CONCLUSION

If cartilage graft is properly prepared and placed, cartilage graft tympanoplasty appears to provide better success rates and hearing results.

Tympanoplasty with island cartilage or temporalis fascia: a comparative study

PURPOSE

To compare clinical and audiological outcomes of the type 1 tympanoplasties where conchal cartilage (island graft) and temporalis fascia were used as the graft material.

PROCEDURES

In this retrospective study, the results of type 1 tympanoplasty operations (n = 50) in which cartilage and temporalis fascia were used for graft material were compared.

RESULTS

Pre- and postoperative otoscopic findings of both groups were similar (p > 0.05). Preoperatively, the pure tone averages (PTAs) and hearing thresholds of the fascia and cartilage groups were similar (p > 0.05). However, postoperatively, the PTAs and air-bone gap closure were better with temporalis fascia compared to cartilage grafting (p < 0.05). On frequency-specific comparisons, the pure tone thresholds at the frequencies of 0.5, 1 and 2 kHz recovered better with temporalis fascia compared to cartilage (p < 0.05). Although the pure tone recovery was better at 4 kHz with temporalis fascia, the difference between the groups were not significantly different (p > 0.05).

CONCLUSION AND MESSAGE

In conclusion, in contrast to many reports in the literature, temporalis fascia grafting seems better in our study than grafting with conchal cartilage.