Myringoplasty for the anterior perforation: experience with the Kerr flap

Endoscopic Double Flap Tympanoplasty

Aim

This study is aimed to compare the outcomes of the two techniques (endoscopic single flap tympanoplasty- ESFT versus endoscopic double flap tympanoplasty - EDFT) of endoscopic tympanoplasty for repairing large tympanic membrane (TM)perforations with limited anterior remnant.

Methodology

In this randomised controlled trial, forty patients with large sized TM perforations were included and randomised in the ESFT and EDFT arms with twenty patients in each group. Both the groups underwent endoscopic tympanoplasty using temporalis fascia graft. The graft uptake rates and hearing results were compared.

Results

Graft success rate was 85% (17/20 cases) in the ESFT group and 90%(18/20 cases) in the EDFT group. The ABG (air-bone gap) improvement median with interquartile range(IQR) was 5 dB (3.12 dB-10 dB) in the ESFT group and 8.75 dB (5dB-11.87 dB) in the EDFT group. The difference was not statistically significant.

Conclusions

In our study, there was no statistically significant difference in the graft success rate or hearing gain in ESFT or EDFT group. Moreover, there was longer operative time and need for an extra incision while raising the anterior flap. This lack of statistically significant results in our study may be since the study has a very small sample size. Whether the same conclusion is reproducible needs to be further explored by a larger sized randomised controlled trial.

A Comparative Study on Outcomes of Type 1 Underlay Tympanoplasty with and Without Anterior Tucking of Temporals Fascia Graft

Tympanoplasty is a surgical procedure which includes eradication of disease from the middle ear and reconstruction of the hearing mechanism with or without tympanic membrane repair. The purpose of this article was to compare the clinical and audiological outcomes of Type 1 underlay tympanoplasty with or without anterior tucking of the temporals fascia graft. This is a prospective interventional study which included 100 patients between 15 and 60 years of age, diagnosed with chronic otitis media, mucosal disease inactive stage. 100 patients were divided into two groups 50 each, who underwent type 1 underlay tympanoplasty, group A underwent anterior tucking of the temporals fascia graft and group B without anterior tucking of the temporals fascia graft. Analysis of data was made of the demographic details, graft uptake status and audiological outcomes following surgery. Among the 100 patients included in the study, majority were seen between 21 and 40 years of age group. In our study successful graft uptake was seen in 93.4% in group A temporalis fascia with anterior tucking which was better than group B which showed 84% results. However hearing outcome was almost similar in both the groups. In conclusion, graft uptake in tympanoplasty with anterior tucking was found to be better than without anterior tucking. There is significant hearing improvement following underlay technique of tympanoplasty both with and without anterior tucking. There is no significant difference in the hearing improvement with anterior tucking when compared to without anterior tucking of the temporalis fascia graft.

Myringoplasty Outcomes From a 5-Year Single Surgeon's Experience and Important Surgical Technical Aspects

BACKGROUND AND OBJECTIVES

The United Kingdom (UK) national standard for the closure rate for myringoplasty is 89.5% (90.6% and 84.2% for primary and revision surgeries, respectively). The average hearing gains for primary and revision myringoplasty are 9.14 dB and 7.86 dB, respectively. This study compared the myringoplasty outcomes for a single surgeon over 5 years.

SUBJECTS AND PURPOSE

Data for 68 cases were analyzed retrospectively. The outcome measures were achievement of the tympanic membrane closure and the average hearing gain or loss.

RESULTS

The overall and primary closure rates were 97% and 98%, respectively and significantly higher than the UK national standard (p=0.0210 and p=0.0287, respectively). The revision closure rate was 93%; however, it was not significantly higher than the national standard (p=0.1872). The average hearing gain was 5.18 dB. The gains for primary and revision surgeries were 5.15 dB and 5.25 dB, respectively.

CONCLUSIONS

We propose that these outcomes are a result of our surgical technique, including the simultaneous use of cortical mastoidectomy in ears with discharge.

The effect of anterior tab flap technique on graft success rate in large tympanic membrane perforation

PURPOSE

Questions have been raised about the effectiveness of myringoplasty techniques for the large tympanic membrane perforation. Various surgical approaches have been recommended to achieve a satisfactory graft success rate in large tympanic membrane perforations. Consequently, there is a growing body of literature that recognizes this controversial topic in otology. The aim of the present research was to investigate the graft success rate in the anterior tab flap technique in ears with large tympanic membrane perforations.

METHODS

In this retrospective study, we analyzed 157 ears (belong to 157 patients) which underwent tympanoplasty, intact canal wall mastoidectomy or canal wall down mastoidectomy with anterior tab flap method. Our primary outcome was graft success rate.

RESULTS

We achieved a graft success rate of 89.8% (141 ears from a total of 157 ears) by the usage of anterior tab flap method.

CONCLUSION

We suggest anterior tab flap as a safe and effective surgical technique for large tympanic membrane perforations.

Endoscopic cartilage myringoplasty with the removal of a small rim of the external auditory canal to repair marginal perforations

Objective

To evaluate the graft success rate and postoperative hearing gain for marginal perforations using endoscopic cartilage myringoplasty with the removal of a small rim of the external auditory canal (EAC).

Study design

Prospective case series.

Materials and methods

We performed a prospective study in 41 patients with marginal perforations who underwent endoscopic cartilage myringoplasty with the removal of a small rim of EAC. Patients were followed up for 6 months.

Results

Of the 41 patients with unilateral marginal perforation included in this study, the graft success rate was 100% (41/41). The mean ABG improved from 11.31 ± 9.71 dB preoperatively to 7.31 ± 2.32 dB postoperatively for small-and medium-sized perforations (P = 0.13); the mean ABG improved from 21.46 ± 8.39 dB preoperatively to 9.84 ± 2.41 dB postoperatively for large perforations (P < 0.05); the mean ABG improved from 28.79 ± 6.74 dB preoperatively to 10.13 ± 3.56 dB postoperatively for subtotal and total perforations (P < 0.05). There were no cases of graft lateralization or significant blunting or atelectasis or graft adhesions. Three patients developed postoperative otorrhoea and five patients had mild myringitis.

Conclusions

Endoscopic cartilage myringoplasty with the removal of a small rim of the EAC is simple and feasible, showing a high graft success rate and minimal complications for repairing marginal perforations.

Comparison between clinical and audiological results of tympanoplasty with double layer graft (modified sandwich fascia) technique and single layer graft (underlay fascia and underlay cartilage) technique

INTRODUCTION

Surgical repair of the tympanic membrane, termed a type one tympanoplasty is a tried and tested treatment modality. Overlay or underlay technique of tympanoplasty is common. Sandwich Tympanoplasty is the combined overlay and underlay grafting of tympanic membrane.

OBJECTIVE

To describe and evaluate the modified sandwich graft (mediolateral double layer graft) tympanoplasty using temporalis fascia and areolar fascia. To compare the clinical and audiological outcome of modified sandwich tympanoplasty with underlay tympanoplasty.

METHODS

A total of 88 patients of chronic otitis media were studied. 48 patients (Group A) underwent type one tympanoplasty with modified sandwich graft. Temporalis fascia was underlaid and the areolar fascia was overlaid. 48 patients (Group B) underwent type one tympanoplasty with underlay fascia technique. 48 patients (Group C) underwent type one tympanoplasty with underlay cartilage technique. We assessed the healing and hearing results.

RESULTS

Successful graft take up was accomplished in 47 patients (97.9%) in Group A, in 40 patients (83.3%) Group B, and in 46 (95.8%) patients in Group C. The average Air-Bone gap closure achieved in Group A was 24.4±1.7dB, in Group B, it was 22.5±3.5dB and in group C, it was 19.8±2.6dB. Statistically significant difference was found in graft healing rate. Difference in hearing improvement was not statistically significant.

CONCLUSION

Double layered graft with drum-malleus as a 'meat' of sandwich maintains a perfect balance between sufficient stability and adequate acoustic sensitivity.

Comparison between clinical and audiological results of tympanoplasty with modified sandwich technique and underlay technique

INTRODUCTION

Surgical repair of the tympanic membrane, termed a type one tympanoplasty is a tried and tested treatment modality. Overlay or underlay technique of tympanoplasty is common. Sandwich tympanoplasty is the combined overlay and underlay grafting of tympanic membrane.

OBJECTIVE

To describe and evaluate the modified sandwich graft (mediolateral graft) tympanoplasty using temporalis fascia and areolar fascia. To compare the clinical and audiological outcome of modified sandwich tympanoplasty with underlay tympanoplasty.

METHODS

A total of 88 patients of chronic otitis media were studied. 48 patients (Group A) underwent type one tympanoplasty with modified sandwich graft. Temporalis fascia was underlaid and the areolar fascia was overlaid. 48 patients (Group B) underwent type one tympanoplasty with underlay technique. We assessed the healing and hearing results.

RESULTS

Successful graft take up was accomplished in 47 patients (97.9%) in Group A and in 40 patients (83.3%) Group B. The average Air-Bone gap closure achieved in Group A was 24.4±1.7dB while in Group B; it was 22.5±3.5dB. Statistically significant difference was found in graft healing rate. Difference in hearing improvement was not statistically significant.

CONCLUSION

Double layered graft with drum-malleus as a 'meat' of sandwich maintains a perfect balance between sufficient stability and adequate acoustic sensitivity.

How I do it: Anterior pull-through tympanoplasty for anterior eardrum perforations

Conclusions This technique is offered as a convenient and reliable method for cases with anterior TM perforation and inadequate anterior remnant. Objectives Chronic otitis media surgery is one of the most common procedures in otology. Anterior tympanic membrane (TM) perforation with inadequate anterior remnant is associated with higher rates of graft failure. It was the goal of this series to evaluate the anatomical and functional outcomes of a modified underlay myringoplasty technique-the anterior pull-through method. Materials and methods In a retrospective clinical study, 13 patients with anterior TM perforations with inadequate anterior remnants underwent tympanoplasty with anterior pull-through technique. The anterior tip of the temporalis fascia was pulled through and secured in a short incision lateral to the anterior part of the annulus. Data on graft take rate, pre-operative, and post-operative hearing status were analyzed. Results A graft success rate of 84.6% (11 out of 13) was achieved, without lateralization, blunting, atelectasia, or epithelial pearls. The air-bone gap was 21.5 ± 6.8 dB before intervention and 11.75 ± 5.7 dB after surgery (p = 0.003).

Early healing and hearing improvement following type one tympanoplasty using the 'drum sandwich' technique

BACKGROUND

The results of a number of tympanic membrane perforation closure techniques have been reported. However, relatively little has been published on the 'drum sandwich' technique.

METHOD

Retrospective chart review of 123 patients undergoing type one tympanoplasty, performed by one surgeon using the drum sandwich technique.

RESULTS

Ninety-two per cent of perforations were successfully closed, and 87 per cent of patients had healed ears and were free from aural discharge 6 weeks following surgery. Post-operative hearing data were only available for 81 ears. Of these, 58 per cent had closure of the air-bone gap to within 10 dB. The mean hearing gain for the group was 10.6 dB.

CONCLUSION

The drum sandwich technique produces rapid healing of the ear with acceptable hearing outcomes. Drum closure rates are comparable with those reported for other techniques.

Factors affecting hearing improvement following successful repair of the tympanic membrane

BACKGROUND

The main aim of tympanic membrane repair is the elimination of chronic or intermittent aural discharge. Hearing improvement may or may not occur following a technically successful operation.

METHOD

This study entailed a retrospective analysis of prospectively collected data from 203 operations that resulted in an intact tympanic membrane 6 months after surgery.

RESULTS

Complete hearing data were available for 169 operations on 160 patients. Of these, 53 per cent resulted in closure of the air-bone gap to within 10 dB, and 54 per cent of cases had post-operative hearing thresholds of at least 30 dB. The mean hearing change after surgery was +8.3 dB. Multiple regression analysis indicated that hearing improvement was more likely in large compared with small perforations. Smaller hearing gains occurred in ears with erosion of the stapes arch and/or fixation of the stapes, as well as in those with active discharge at the time of surgery and in revision cases.

CONCLUSION

Greater hearing improvement can be expected following successful repair of perforations involving more than 50 per cent of the drum area. Poorer results are likely to occur in ears with additional middle-ear pathology and in revision cases.

Surgical and hearing results of the circumferential subannular grafting technique in tympanoplasty: a randomized clinical study

PURPOSE

Circumferential elevation of the anullus away from its bony seat and extension of the graft onto the anterior bony canal increase the bed of the graft anteriorly but may be associated with anterior blunting, and so, a significant conductive hearing loss may result. The purpose of this study was to compare the surgical and audiologic success rates of circumferential subannular grafting with the conventional underlay tympanoplasty.

MATERIALS AND METHODS

A randomized clinical study was conducted from September 2007 to December 2010 at a tertiary referral center. Thirty-eight patients underwent circumferential subannular grafting (group A), and 25 patients underwent conventional underlay tympanoplasty with extension of the anterior edge of the graft forward against the lateral wall of the Eustachian tube, and therefore, the anterior sharp tympanomeatal angle remained unbroken (group B). All patients underwent preoperative and postoperative audiogram. Blunting and lateralization of the graft were evaluated 6 months after the surgery.

RESULTS

The surgical success rate was 97% in group A and 100% in group B patients. Improvement of the air conduction thresholds in all frequencies and closure of the mean air-bone gap were significant and similar among the 2 groups. There were no cases of significant blunting and tympanic membrane lateralization in the 2 groups.

CONCLUSION

This study showed underlay tympanoplasty with elevation of the annulus away from the sulcus tympanicus in the anterior sharp tympanomeatal angle and placement of the graft between it and anterior bony canal is not associated with increased risk of blunting and lateralization of the graft, if that sharp angle is adequately restored.

Comparative study of efficacy of graft placement with and without anterior tagging in type one tympanoplasty for mucosal-type chronic otitis media

OBJECTIVES

To assess the efficacy of anterior tagging of graft material with respect to graft uptake and hearing results, in type I tympanoplasty.

STUDY DESIGN

Prospective, randomised, cohort study.

METHODS

Sixty patients with chronic otitis media of the mucosal type, with pars tensa perforations, were included in the study. Patients were randomly allocated to two groups: group one underwent type one tympanoplasty with anterior tagging, while group two underwent type one tympanoplasty without anterior tagging. Follow up included evaluation of graft uptake and hearing improvement.

RESULTS

There were 33 patients in group one and 27 patients in group two. The overall incidence of successful graft uptake was 96.96 per cent in group one and 81.5 per cent in group two. Closure of central and posterior perforations was successful in 100 per cent of both groups. Closure of anterior and subtotal perforations was successful in 95.45 per cent of group one and 54.54 per cent of group two.

CONCLUSION

Type one tympanoplasty with anterior tagging of graft material is a suitable technique for anterior and subtotal perforations.

???Window Shade??? Tympanoplasty for Anterior Marginal Perforations

OBJECTIVES/HYPOTHESIS

Anterior marginal perforations of the tympanic membrane often present a reconstructive challenge to the otolaryngologist. Poor surgical outcomes are often due to inadequate exposure, a lack of residual tympanic membrane, impaired vascular supply, and delayed healing. This study reports on the success of the "window shade" technique, combining aspects of both the traditional underlay and overlay tympanoplasty techniques, for the management of anterior marginal tympanic membrane perforations.

STUDY DESIGN

Retrospective review of patients undergoing window shade tympanoplasty from July 1, 1994, to July 1, 2003, at a tertiary care referral center.

METHODS

Only patients found to have anterior tympanic membrane perforations and who underwent a window shade tympanoplasty were included in the study. Tympanoplasty success rate was studied by examining postoperative complications of recurrent perforation, tympanic membrane lateralization, or anterior blunting.

RESULTS

The authors identified 164 patients who underwent window shade tympanoplasty during the study period. The overall success rate for tympanic membrane repair was 94.5%. There were no cases of tympanic membrane lateralization or significant blunting. The average healing time was 4 weeks. The surgical technique is described in detail.

CONCLUSION

The window shade tympanoplasty is an excellent surgical option for repair of anterior marginal perforations of the tympanic membrane.

Dimensional Stability of Free Fascia Grafts: Clinical Application

OBJECTIVES/HYPOTHESIS

Animal experiments and human studies show that autologous fascia lata and temporal fascia change their dimensions during first 5 days of healing. Poor dimensional stability of the temporal fascia grafts may be responsible for the residual perforation sometimes seen in clinical practice.

STUDY DESIGN

Retrospective.

METHODS

Tympanoplasties performed for large perforations or granular myringitis using either fascia lata or temporal fascia as graft material are included. The ears are divided into two groups. Group I includes ears with fascia lata, and group II includes ears with temporal fascia as graft material. Ears with minimum 1-year follow-up are included in the study.

RESULTS

The results are studied in terms of 1) rate of primary closure of perforation, 2) rate of recurrent perforation, and 3) hearing improvement. It is noted that the ears with very large or subtotal perforations fared better (alpha = 0.05) in group I than similar ears in group II with respect to rate of primary closure of perforations. Similarly, ears in group I also have a lesser rate of recurrent perforation on long-term follow-up than ears in group II. No significant difference is noted in hearing improvement between the two groups.

CONCLUSION

Shrinkage of graft during healing phase appears to have significant relevance in the clinical situation. Ears having large perforations have high chances of residual perforations caused by limited margin of remnant tympanic membrane overlapping the graft. It seems logical to use fascia lata as graft material for large perforations because it has better dimensional stability.

Dimensional stability of the free fascia grafts: a human study

OBJECTIVES/HYPOTHESIS

In animals it has been shown that autologous free fascia grafts (fascia lata and temporal fascia) change dimensions during the vital first 5 days of healing. Poor dimensional stability of these grafts can be an important reason for failure of complete closure of tympanic membrane perforations in tympanoplasty operations, particularly in large perforations. Dimensional stability of these fascias has been studied in humans.

STUDY DESIGN

Prospectively, 11 patients were studied.

METHODS

Patients who were subjected to open mastoid cavity surgery were included in the study. The mastoid cavity was exteriorized, and the fascia graft was used to seal the perforation and cover a part of the bare mastoid bone in the routine way. At this stage, equally cut pieces of temporal fascia and fascia lata were laid on the remaining part of the bare mastoid bone. The mastoid cavity was then packed with Gelfoam and wound sutured. The pieces of graft material under study were removed after 5 days, leaving the graft used to seal the tympanic membrane perforation undisturbed. The harvested grafts were measured for their dimensional variations, if any.

RESULTS

It was observed that free autologous temporal fascia grafts exhibited poor dimensional stability as compared with free autologous fascia lata grafts.

CONCLUSION

Poor dimensional stability of free temporal fascia grafts as seen in animals was confirmed in the present human study. This poor dimensional stability of temporal fascia grafts might be contributing to failure of closure of tympanic membrane perforations in tympanoplasty.

Adipose graft: an original option in myringoplasty

OBJECTIVE

To describe the fat graft as a reconstructive material in myringoplasty.

METHOD

In a review of 45 patients conducted between 1993 and 1999, the authors analyzed their patients' outcomes after having myringoplasties with fat graft. Median follow-up was 2.5 years (range, 6 mo-6 yr).

RESULTS

We achieved a success rate of 91.1%. Different features of the patient and the tympanic perforation were studied to demonstrate their role in the quality of the surgical closing. A review of the literature was done to compare our results with the results of other series using this type of graft as well as with studies of the temporalis fascia as a graft material.

CONCLUSION

The high reliability of the fat graft and the technical simplicity of this procedure in anterior perforations, especially with the use of intraoperative endoscopy, make it an attractive technique.

Dimensional stability of the free fascia grafts: an animal experiment

OBJECTIVES/HYPOTHESIS

It appears that autologous free fascia grafts (fascia lata and temporal fascia) change their dimensions during the vital first 5 days of healing. Poor dimensional stability of these grafts can be an important reason for failure of complete closure of tympanic membrane perforations in tympanoplasty operations. There has been no study regarding this dimensional instability.

STUDY DESIGN

Prospectively dimensional instability of the free fascia grafts studied in 14 mongrel dogs.

METHODS

Fourteen healthy Mongrel dogs were operated on twice. During the first surgery, fascia lata and temporal fascia grafts of measured dimensions (length, breadth, and thickness) were implanted in the subcutaneous pockets on the thoraco-abdominal wall of the same dog (autograft). Five dogs were operated on again after 2 days, and 7 dogs were operated on again after 5 days to harvest the implanted grafts. The dimensions of the harvested grafts were noted. Changes with respect to their implant dimensions after 2 days and after 5 days were calculated.

RESULTS

It was found that free fascia lata exhibits significantly superior dimensional stability when compared with free temporal fascia during the early healing phase, before graft integration has occurred. Shrinking and thickening of temporal fascia are greater and are also most unpredictable.

CONCLUSIONS

Poor dimensional stability of temporal fascia may compromise a well-sealed perforation at the time of surgery, and it may reopen by the 5th day. This must be one of the causes of failure of tympanoplasty, which needs to be studied further.

Myringoplasty with temporalis fascia : Analysis of 200 cases

Two hundred cases of chronic suppurative otitis media with dry ear were taken up for myringoplasty operation by underlay technique through transcanal route. Autologous temporalis fascia was used as the graft material in all cases. Surgery was done during the period from April 1987 to November 1992. The patients were reviewed 5 years after the surgery [1997] and analysed.

The Anterior Hitch Method of Tympanic Membrane Repair

Anterior perforations of the tympanic membrane have been previously shown to have a higher failure rate than others following tympanoplasty procedures. A technique has been previously described utilizing an anterior hitch graft stabilization with avoidance of anterior blunting of the tympanic membrane. Follow-up cases in which this technique has been utilized show greatly improved results in terms of perforation closure.

Myringoplasty and tympanoplasty--results related to training and experience

The results of surgery in a series of 452 ears having either myringoplasty (281 ears) or tympanoplasty (171 ears) were studied in relation to the experience of the surgeons. The trainees received an annual course in temporal bone dissection and were given daily surgical instruction in the operating theatre. The 142 ears operated by them showed less disease than those operated upon by the programme chairman (114 ears) and by the faculty (196 ears). The performance of the trainees was safe, and as to healed tympanic membrane and hearing results all studied parameters were statistically equal to those of the faculty. Repair of anterior perforations proved to be the most difficult and the overall results of both the faculty and trainees left place for improvement. On-line recording of surgical data and annual evaluation of an individual surgeon's results is suggested as a necessary means for continuous post-graduate training.