Butterfly-cartilage tympanoplasty in children: A 28-case series and literature review

Endoscopic transcanal butterfly cartilage myringoplasty outcome; which parameters affect long-term results?

BACKGROUND

Endoscopic transcanal butterfly cartilage myringoplasty is a prominent procedure because surgeons can perform this operation without elevating the transmeatal flap.

OBJECTIVE

To evaluate factors that affect endoscopic butterfly cartilage myringoplasty regarding graft success and hearing improvement and determine long-term outcomes.

MATERIALS AND METHODS

This study included 86 patients who underwent surgery. The rates of graft success and hearing improvement were investigated, together with the effects of sex, age, operated side, and size and location of the perforation.

RESULTS

The overall graft success was 83.7%. There was a statistically significant difference between pre- and post-operation in terms of hearing improvements at 0.5, 1, and 2 kHz (p < 0.001). Sex, age, operative side, and perforation size did not significantly affect graft success or hearing improvement (p > 0.05). The perforation location was significantly associated with graft success (p < 0.05). However, the location of the perforation did not significantly affect hearing improvement (p > 0.05).

CONCLUSIONS

Endoscopic transcanal butterfly cartilage myringoplasty can be performed with a high graft success rate and improved hearing. However, surgeons should be more careful when treating patients with posterior perforations.

SIGNIFICANCE

The location of the perforation is significantly related to graft success.

Technique of Extending Cartilage Perichondrium Composite Graft into the External Auditory Canal in Type 1 Tympanoplasty and Evaluation of Graft Success

Cartilage perichondrium composite grafts (CPCG) have been used in tympanoplasty for many years. Reperforations can be seen because of various problems. The aim of our study is to describe a graft technique to minimise the complications and to evaluate the success of the graft. The ears which underwent type 1 tympanoplasty using CPCG were included in the study. Over-underlay graft technique was used in all operations. They were performed by microscopic transcanal approach and by the same surgeon. Fifty-four ear operations of 48 patients were included in the study. While the preoperative average pure tone- average (PTA) of the ears was 45 (21-75) dB, the postoperative average PTA was 28 (11-58) dB. While the preoperative air bone gap (ABG) of the ears was 23.3 (10-43.3) dB, the postoperative ABG was 11.6 (0-28.3) dB. A significant improvement was achieved in both ABG and PTA values after the operation (p < 0.001). The graft success rate was 94.4%. The cartilage graft modifications such as block cartilage, palisade, cartilage island and butterfly have been applied successfully. We aimed to reduce the risk of reperforation, maximise audiological gain and facilitate the follow-up of postoperative middle ear pathologies by thinning the cartilage island and extending the perichondrium to the external auditory canal in the modification of CPCG. The graft success rate and the audiological success rate are high enough to be compared with the literature. The described CPCG can be used safely in all types of perforations, especially in high-risk perforations.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-024-04965-5.

Tympanic Perforations in Children: When to Propose Surgical Closure?

OBJECTIVE

This study aims to analyze the impact of age and other prognostic factors on the success of myringoplasty.

STUDY DESIGN

A retrospective case series.

SETTINGS

Pediatric ENT department of a tertiary academic center.

PATIENTS

Two hundred forty-one children (318 ears) aged 3 to 17 years with tympanic perforation.

INTERVENTION

Myringoplasty performed between 2009 and 2019.

MAIN OUTCOMES MEASURES

The rate of tympanic closure, perforation recurrence, revision surgery, and audiometric gain were collected. The impact of age and anatomical and surgical factors was analyzed for each procedure.

RESULTS

With a mean follow-up time of 1 year, the tympanic closure rate was 87.7%, the perforation recurrence rate was 18.6%, and 16.7% of ears required reoperation. The mean air-bone gap decreased from 21 dB preoperatively to 12 dB postoperatively ( p < 0.0001). We did not find different anatomical and audiometric results for our three groups of patients classified according to age. Audiometric results were associated with the location of the perforation, intraoperative inflammation of the middle ear mucosa, and the surgical technique performed.

CONCLUSION

Myringoplasty in children is associated with excellent anatomical and functional results, even in the youngest patients. It can be proposed whatever the child's age if the patients are well selected before giving the indication.

Comparing Myringoplasty to Type I Tympanoplasty in Tympanic Membrane Repair: A Systematic Review and Meta-Analysis

OBJECTIVE

To compare the anatomic success rates of type I tympanoplasty (tympanoplasty) versus myringoplasty. By our definition, tympanoplasty involves entering the middle ear via elevation of a tympanomeatal flap, while myringoplasty involves surgery to the drumhead without middle ear exposure.

DATA SOURCES

PubMed, Scopus, CINAHL, Cochrane.

REVIEW METHODS

To be included, studies must have documented surgical technique, tympanic membrane (TM) perforation size (as % of TM), and success rate using tissue or alloplastic grafts. Exclusion criteria included series with more than 10% of patients with cholesteatoma or middle ear pathology. A meta-analysis of weighted summary proportions under the random effects model was performed, and proportion differences (PD) were calculated. A secondary analysis of hearing outcomes was performed.

RESULTS

Eighty-five studies met inclusion, with a tympanoplasty cohort of n = 7966 and n = 1759 for myringoplasty. For perforations, less than 50% of the TM, the success rate for tympanoplasty and myringoplasty was 90.2% and 91.4%, respectively (PD: 1.2%, p = .19). In perforations greater than 50%, tympanoplasty and myringoplasty success rates were 82.8% and 85.3%, respectively (PD: 2.5%, p = .29). For both procedures, perforations less than 50% of the TM had higher success rates than perforations greater than 50% of the TM (p < .01). Both techniques endorsed significant improvements to air-bone gap (ABG) metrics.

CONCLUSION

Our analysis suggests that the anatomic success rate is similar for tympanoplasty and myringoplasty, regardless of perforation size, and that smaller perforations experience higher success rates in both techniques. ABG outcomes were also similar between procedure techniques.

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.

Endoscopic perichondrium-cartilage button technique for repairing chronic large perforations in teenagers

OBJECTIVE

The objective of this study was to evaluate the graft outcome and complications of endoscopic perichondrium-cartilage button technique for repairing chronic large perforations in teenagers.

STUDY DESIGN

Prospective case series.

MATERIALS AND METHODS

56 patients with chronic large perforations more than 50% of the TM who underwent endoscopic perichondrium-cartilage button technique. The graft success rate, hearing outcome, and complications were evaluated at postoperative 3, 6 and 12 months.

RESULTS

Of the 56 ears, 3 (5.4%) patients lost follow-up, 53 (94.6%) patients were finally included in this study. The mean operation time was 37.2 ± 5.4 min. The retrograde tympanomeatal flap elevation was performed in 16 (30.2%) patients. The graft success rate was 96.2% (51/53) at postoperative 3 months and 94.3% (50/53) at postoperative 12 months. The mean preoperative ABG was 25.0 ± 3.7 dB, while the mean postoperative ABG postoperatively 6 months was 12.8 ± 3.1 dB; the difference between these values was significant. No graft-related complications (e.g., graft lateralization, significant blunting, and graft medialization) were encountered during the follow-up period. However, graft keratin pearl was noticed in 5.7% (3/53) patients, which occurred in the handle of malleus in 2 and antero-inferior margin in one. All the graft pearls were endoscopically removed in the outpatient setting.

CONCLUSIONS

Endoscopic perichondrium-cartilage button technique can be achieved in every teenager patient with chronic large perforation without cholesteatoma, and, is a safe and efficient procedure.

A comparison of endoscopic and microscopic inlay butterfly cartilage tympanoplasties and their educational utility

Objectives

Inlay butterfly cartilage tympanoplasty (IBCT) is a simple grafting technique. Endoscopy facilitates visualization by eliminating blind spots. We analyzed the outcomes of IBCT using both endoscopic and microscopic approaches, and assessed how trainees perceived the educational opportunities afforded.

Materials and methods

Sixty patients who underwent IBCT were allocated to Group I (n = 30; microscopic IBCT) and Group II (n = 30; endoscopic IBCT) by the dates of their visits. Anatomical success was defined as an intact, repaired tympanic membrane; functional success was defined as a significant decrease in the air–bone gap. Postoperative discomfort was analyzed using a visual analog scale (VAS). Thirteen trainees completed structured questionnaires exploring anatomical identification and the surgical steps.

Results

The surgical success rates were 96.7% in Group I and 100% in Group II. We found no between-group differences in the mean decrease in the air–bone gap or the extent of postoperative discomfort. Significant postoperative hearing improvements were evident in both groups. The mean operative time was shorter when the microscopic approach was chosen (17.7±4.53 vs. 26.13±9.94 min). The two approaches significantly differed in terms of the identification of external and middle ear anatomical features by the trainees, and their understanding of the surgical steps.

Conclusion

Both endoscopic and microscopic IBCT were associated with good success rates. The endoscopic approach facilitates visualization, and a better understanding of the middle ear anatomy and the required surgical steps and thus is of greater educational utility.

Myringoplasty without tympanomeatal flap elevation in children: A systematic review

OBJECTIVES

Systematic review of the literature on myringoplasty techniques without tympanomeatal flap elevation in children.

MATERIAL AND METHODS

A systematic review following PRISMA guidelines reported papers on patients under 18years of age undergoing myringoplasty for chronic tympanic perforation on a transcanal approach without tympanomeatal flap elevation. Tympanic closure rates and audiometric results were analyzed.

RESULTS

Twenty studies were included. Nine reported the butterfly technique, using a microscope or endoscope, with closure rate of 82.3% (246/299), for perforations of various sizes. Ten reported the fat-plug technique, with closure rate of 86.8% (869/1001), mostly for perforations of less than one-third of the tympanum. Both techniques improved audiometric results. Morbidity was very low. The absence of chronic otitis or co-morbidities (contralateral otitis media with effusion, craniofacial malformations, Down's syndrome) implies that patient selection technique may be necessary to obtain the best results.

CONCLUSION

Fat-plug myringoplasty, for small perforations, and butterfly cartilage myringoplasty seem to be reliable procedures in selected patients, with low morbidity in children.

Evaluating butterfly inlay tympanoplasty

OBJECTIVE

To compare closure rate, reduction in air-bone-gap, and operative time of butterfly tympanoplasty (BT) to underlay tympanoplasty (UT).

METHODS

Retrospective cohort study of children (age <18y) undergoing Type I tympanoplasty between 2009 and 2017. Patients were excluded if they had <6 months of follow up, mastoidectomy, fat graft or cholesteatoma.

RESULTS

Twenty-one patients (mean age 13.4) underwent BT while forty-one patients (mean age 13.5) underwent UT. The mean size of perforation in 30.6% in BT patients and 43.6% in UT patients (p = 0.01). Preoperative audiogram showed a similar air-bone-gap between the two groups of 31.7, 22.7, and 17.9 dB in BT vs 29.6, 24.8, and 17.6 dB in UT at 500, 1000, and 2000 Hz, respectively (p = 0.65, 0.63, and 0.94). Operative time was reduced in BT as compared to UT (94.0 min vs. 150.9, p = 0.01). Closure rate was similar at 85.7% in BT vs 75.6% in UT patients (p = 0.40). Average reductions in air-bone gap were similar with 19.2, 11.7, and 13.2 dB for BT vs 16.6, 12.1, and 10.3 dB for UT at 500, 1000, and 2000 hz, respectively (p = 0.66, 0.93, 0.40).

CONCLUSION

BT has become a reliable tool for the pediatric otolaryngologist. This retrospective study shows that pediatric BT results in similar outcomes with reduced operative time.

Endoscopic inlay butterfly cartilage tympanoplasty in pediatric patients

OBJECTIVE

To present and to compare the results of microscopic and endoscopic inlay butterfly cartilage tympanoplasties (MIBCT and EIBCT) in pediatric patients with COM using tragal cartilage as a grafting material and to discuss the advantages and superiorities of endoscope use and IBCT in pediatric patients.

MATERIAL AND METHODS

This retrospective study was carried out to evaluate the outcomes of 79 pediatric patients up to 16 years old who underwent either EIBCT (58 children) or MIBCT (21 children) between July 2013 and August 2017 at a tertiary referral hospital. Audiometric data including air-bone gap (ABG), air-bone gap gain, and air-conduction (AC) and bone-conduction (BC) thresholds, otologic examination findings involving size, side, and site of tympanic membrane perforations, the average lengths of surgery time, hospital stay, and follow-up period, technical success (TS), and functional success (FS) were all assessed by screening hospital records. The preoperative and postoperative averages of 0.5, 1, 2, and 3 kHz of pure-tone thresholds were used for the mean AC and BC thresholds according to the guidelines of the Committee on Hearing and Equilibrium.

RESULTS

TSs of EIBCT and MIBCT were achieved in 91.4 % (53/58) and 85.7% (18/21), respectively. The overall mean of ABG of EIBCT and MIBCT improved from 21.97±7.06 dB vs 20.90±4.78 dB preoperatively to 9.84±4.31 dB vs 9.33±3.54 dB postoperatively (p<0.05) thus the ABG gain was 12.00±7.32 dB and 11.57±5.49 dB, respectively. The mean lengths of surgery time were 28.03±4.79 minutes and 40.76±3.98 minutes, the mean lengths of hospital stay were 9.24±1.4 hours and 9.42±1.32hours, the lengths of follow-up period were 21.40±9.15 months and 23.19±9.40 months, in the order given.

CONCLUSION

EIBCT is a comfortable, attractive, and safer approach in pediatric patients with COM for both otologists and patients for many reasons including children's narrower external ear canal, endoscopes' wide field of view when compared with microscopes, instead of endaural, postauricular or transcanal circumferential insicions need for just a tragal incision for graft harvesting, and literature reports of satisfactory technical and functional results.

Butterfly cartilage tympanoplasty outcomes: A single-institution experience and literature review

PURPOSE

In 1998, Dr. Eavey described the trans-canal inlay butterfly cartilage tympanoplasty technique, also known as cartilage button tympanoplasty. Many retrospective studies have since demonstrated its efficacy and decreased operative time when compared to underlay and overlay tympanoplasty techniques. The butterfly cartilage tympanoplasty approach uses only a cartilage graft to repair tympanic membrane perforations. The aim of this study was to review the literature for studies that examined butterfly cartilage tympanoplasty success rates and outcomes and compare them to outcomes from our cohort.

MATERIALS AND METHODS

Butterfly cartilage tympanoplasties were performed in 23 pediatric patients and 7 adult patients. We evaluated the tympanic membrane perforation closure rate and hearing results measured by closure of the air-bone gap.

RESULTS

The reviewed studies evaluating butterfly cartilage tympanoplasties demonstrated perforation closure rates between 71%-100%. The hearing outcomes in the reviewed literature varied, although the majority reported improved hearing. In our cohort, 21 of the 32 repaired tympanic membrane perforations demonstrated complete perforation closure. The mean follow-up length was 13.4 months. The mean air-bone gap decreased from 13.4 dB to 6.9 dB.

CONCLUSIONS

The butterfly cartilage/cartilage button technique is effective in closing tympanic membrane perforations and decreasing the air-bone gap in both adults and children.

Surgical Success of Tympanoplasty Using Composite Tragal Cartilage in Chronic Otitis Media

This study aims to investigate the preoperative, postoperative airway hearing threshold levels, and perforation closure rates in patients who underwent primary tragal cartilage tympanoplasty. One hundred seventy-one patients who had chronic otitis media without cholesteatoma underwent primary tragal cartilage tympanoplasty with endaural approach by using underlay technique. Preoperative and postoperative airway hearing threshold levels at 500, 1000, 2000, 4000 Hz frequencies in 8 to 99 months' follow-up were found and compared with each other. Postoperative perforation closure rates were also investigated. At 500 Hz in 112 patients, at 1000 Hz in 106 patients, at 2000 Hz in 96 patients, and at 4000 Hz in 80 patients, more than 9.5 dB airway hearing gain was determined. The authors found their postoperative perforation closure rate as 84.8%. In conclusion, tragal cartilage tympanoplasty may be chosen as the primary operation technique in primary chronic otitis media patients and by this technique perforation closure rates are also acceptable in addition to satisfactory hearing gain.

Butterfly Cartilage Tympanoplasty Long-term Results: Excellent Treatment Method in Small and Medium Sized Perforations

OBJECTIVES

The aim of this study was to evaluate and report the long-term results of the butterfly cartilage tympanoplasty. Short-term and long-term hearing outcomes were compared according to age and perforation location as well.

METHODS

Ninety-three patients who were diagnosed with noncomplicated chronic otitis media and underwent microscopic transcanal butterfly cartilage tympanoplasty due to anterior, posterior, and central tympanic membrane perforation were included. Age, gender, follow-up time, pre- and postoperative pure tone audiometry thresholds (both air and bone conduction), pre- and postoperative air-bone gaps (ABGs), if any residual perforation was noted.

RESULTS

At the end of the follow-up period, successful closure occurred in 88 of 93 patients and success rate is 94.6%. In all patients, including those with residual perforations, the mean preoperative bone conduction threshold was 15.9 dB (range, 5 to 50 dB) among all groups whereas mean air conduction threshold was 36.4±15.1 dB (range, 10 to 90 dB) preoperatively and 28.8±14.3 dB in 6th month follow-up and 24.9±14.1 dB 24th month follow-up. Preoperative mean ABG was 22.1±7.1 dB (range, 5 to 40 dB) whereas 13.3±5.9 dB 6 months after surgery and 11.9±5.5 dB 24 months after surgery. There was a significant difference between pre- and postoperative ABG in both 6th and 24th month follow-up (P6 mo-24 mo<0.05). Furthermore, preoperative mean air conduction differed significantly from postoperative 6th and 24th month follow-up mean air conduction thresholds (P<0.05).

CONCLUSION

We suggested that butterfly cartilage tympanoplasty can be safely performed in small, moderate, and even large perforations, as the hearing outcomes and successful closure rate are similar to those of other surgical methods. Moreover, it can be performed under local anaesthesia and it has low complication rates.