Comparison of cartilage graft and fascia in type 1 tympanoplasty: systematic review and meta-analysis

The novel retro-conchal approach for middle ear surgeries: Our experience in 196 patients

BACKGROUND

This study aimed to describe a new proposed retro-conchal approach for middle ear surgery and to evaluate its advantages and postoperative impact.

METHODOLOGY

A retrospective case-series study was held at a tertiary university hospital from March 2008 to April 2022. We included 196 adult patients who were candidates for middle ear surgery because of chronic otitis media. The retro-conchal approach entailed a skin incision on the medial conchal surface 1 cm anterior to the auricular sulcus. It allowed the harvesting of the required size of conchal cartilage and temporalis fascia through the same incision with access into the middle ear and complete exposure to the mastoid process. In addition, we evaluated the use of this approach in tympanoplasty, including cholesteatoma surgeries with at least one-year postoperative follow-up.

RESULT

The long-term follow-up (22.9 ± 6.37 months) revealed that most operated cases (89%) did not develop postoperative sequelae related to this approach. On the other hand, 22 patients (11%) developed adverse outcomes, with a statistically significant difference regarding adverse outcomes as the P-value <0.001.

CONCLUSION

According to our experience with a relatively large number of patients, the retro-conchal technique was practical for various middle ear surgeries. It allowed optimal access to different middle ear areas and obtaining large-sized conchal cartilage and temporalis fascia (if needed) through the same incision without needing extra surgical steps. In addition, it was a safe maneuver without significant adverse outcomes in the long-term follow-up.

Investigation of factors affecting pediatric type 1 endoscopic tympanoplasty results and success rates of surgery

OBJECTIVE

There are many factors that affect the results of tympanoplasty in children. Recurrent ear infections, hearing loss, and more serious complications due to cholesteatoma may be observed. This study examined factors affecting the success of type 1 endoscopic tympanoplasty surgery in pediatric patients and investigated recommended procedures to increase the success of the operation.

METHODS

Our study included pediatric patients who underwent type 1 endoscopic tympanoplasty operation for chronic otitis media. Patient files were analyzed retrospectively. Hearing results before and after the operations were recorded.. Patients were divided into groups according to gender, age (<12 age group, ≥12 age group), and perforation type. Hearing results and physical examination findings were compared for each group.

RESULTS

A total of 204 pediatric patients were included in our study: 114 were male and 90 were female. Patients' hearing results were compared according to the size and location of their tympanic membrane perforations. Hearing loss was found to increase as the size of the tympanic membrane perforation increased. In addition, it was observed that perforations in the posterior quadrant caused more severe hearing loss than in the other quadrants. The postoperative results of the two groups <12 years old, and ≥12 years old were evaluated according to age. Postoperative improvement was higher in the ≥12 age group compared to the <12 age group.

CONCLUSION

According to the results of this study, tympanoplasty surgeries performed on patients younger than 12 have a decreased success rate. Among the many factors that affect the success of an operation, age is one of the most important. There are many factors that affect the results of the operation, perforation size and localization is one of them. There are many factors that affect the success of surgery such as pediatric patients and adult patients. It is useful to make a personal evaluation and to plan the surgery by evaluating the obstacles such as eustachian tube maturation and difficulty in postoperative care in pediatric patients.

Comparison of temporalis muscle fascia and cartilage grafts for primary type 1 tympanoplasty: a meta-analysis of randomized controlled trials

PURPOSE

To compare the efficacy and safety of temporalis fascia (TF) with cartilage grafts for primary type 1 tympanoplasty in chronic otitis media (COM) patients.

METHODS

Computerized search was performed in MEDLINE, Embase, and CENTRAL. Eligible for inclusion were randomized controlled trials (RCTs) comparing TF and cartilage grafts in individuals with non-cholesteatoma COM and intact ossicles requiring type 1 tympanoplasty. Primary outcomes were graft success and hearing improvement, measured by the air-bone gap (ABG) closure. The secondary outcome was the occurrence of complications. Standardized mean differences (SMD) and odds ratios (OR) with 95% confidence intervals were calculated.

RESULTS

Eighteen RCTs that enrolled 1273 participants were found eligible. Data were reported at follow-up periods ranging from 6 weeks to 24 months. The pooled effect estimate revealed a higher and statistically significant graft success favoring cartilage grafts at 12 months (OR = 2.24, 95% CI 1.33-3.78) and 24 months (OR = 2.96, 95% CI 1.18-7.43). There was no significant difference between both grafts in post-operative ABG closure across all follow-up periods (6 weeks to 12 months).

CONCLUSIONS

Compared to TF, primary type 1 cartilage tympanoplasty offers better graft uptake rates and comparable postoperative hearing outcomes for COM patients.

Application of Machine Learning to Predict Hearing Outcomes of Tympanoplasty

OBJECTIVE

This retrospective study aimed to evaluate the performance of machine learning techniques in predicting air-bone gap after tympanoplasty compared with conventional scoring models and to identify the influential factors.

METHODS

We reviewed the charts of 105 patients (114 ears) with chronic otitis media who underwent tympanoplasty. Two numerical scoring systems (middle ear risk index [MERI] and ossiculoplasty outcome parameter staging [OOPS]) and three algorithms (random forest [RF], support vector machine [SVM], and k nearest neighbor [kNN]) were created. Experimental variables included age, preoperative air-bone gap, soft-tissue density lesion in the tympanic cavity in CT, otorrhea, surgical history, ossicular bone problems in CT, tympanic perforation location, perforation type (central or marginal), grafting material, smoking history, endoscopy use, and the operator whose experience was 20 years or longer, or shorter. Binary classification, postoperative air-bone gap ≤15 or >15 dB, and multiclass classification, classification into seven categories by 10 dB, were performed, and the percentages of correct prediction were calculated. The importance of features in the RF model was calculated to identify influential factors.

RESULTS

The percentages of correct prediction in binary classification were 62.3%, 72.8%, 81.5%, 81.5%, and 81.5% in MERI, OOPS, RF, SVM, and kNN, respectively, and those in multiclass classification were 29.8%, 21.9%, 63.1%, 44.7%, and 50% in the same order. The RF model suggested larger preoperative air-bone gap, and older age could make the postoperative air-bone gap larger.

CONCLUSION

The machine learning techniques, especially the RF model, are promising methods for precise postoperative air-bone gap prediction.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:2371-2378, 2023.

Postoperative Outcomes of Endoscopic versus Microscopic Myringoplasty in Patients with Chronic Otitis Media-A Systematic Review

Endoscopes are increasingly being used in middle ear surgery as an adjunct to or replacement for the operative microscope. The superior visualization of hidden areas and a minimally invasive transcanal approach to the pathology are some of the endoscope's advantages. The aim of this review is to compare the surgical outcomes of a totally endoscopic transcanal approach with a conventional microscopic approach for type 1 tympanoplasty in patients with chronic otitis media (COM) in order to establish if endoscopic myringoplasty (EM) could be a better alternative to microscopic myringoplasty (MM). A literature review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis recommendations. The selected articles were identified by searching PubMed Central, PubMed, MEDLINE and Embase databases for the relevant publications. Only studies where the same surgeon in the department performed both endoscopic and microscopic myringoplasty have been included in the review. The results suggest that with an endoscopic approach, minimally invasive myringoplasty can be achieved with a similar graft success rate and postoperative air-bone gap (ABG) improvement, a shorter operative time and less postoperative complications compared to a microscopic approach.

Trans-canal tragal cartilage myringoplasty; a comparative analysis of endoscopic and microscopic approaches

BACKGROUND

The advent of Endoscopic Ear Surgery (EES) has allowed otologists an improved view of the surgical field compared with conventional Microscopic Ear Surgery (MES). EES presents different challenges for surgeons and a learning curve is necessary.

AIMS

The purpose of this study was to compare the efficacy of EES and MES for trans-canal tragal cartilage myringoplasty, an entry level EES.

METHODS

We retrospectively analysed patients who underwent push through trans-canal tragal cartilage myringoplasty in our institution over 5 years (2016-2020). Exclusion criteria were: patients with prior ear surgery, non-tragal cartilage tympanic membrane graft, additional procedure at time of surgery and patients with insufficient follow up. EES and MES groups were compared using outcomes such as graft success rate, changes in pure tone audiometry (PTA), operative time and complications.

RESULTS

Seventy-four patients met inclusion criteria (MES = 38, EES = 36). Mean age of included patients was 29.3 years with no significant demographic differences between groups. Graft success rate at 12 months was higher among the EES group versus MES (94.4% v 86.8%, p = 0.43). Mean operative time was reduced in the EES group (47.3 min v 53.8 min, p = 0.04). Hearing outcomes did not differ significantly between groups. No major operative complications occurred in either group.

CONCLUSIONS

Outcomes were marginally better in the cohort who underwent EES. This supports that EES offers an otologic choice to complement established practice for trans-canal myringoplasty and may be used to facilitate introduction to EES for trainees and otologists wishing to learn this technique.

The Wheel-Shaped Composite Cartilage Graft for Type 1 Tympanoplasty: Comparison with Palisade and Island Cartilage Graft

This study aims to compare the graft success and hearing results of the palisade and island cartilage graft, with wheel-shaped composite cartilage graft (WsCCG) for type 1 tympanoplasty. The study was designed retrospectively. Only patients with conductive hearing loss and simple pars tensa perforation of the tympanic membrane were included in the study. Pure tone average (PTA), air-bone gap gain (ABG), word recognition score (WRS), ABG closure and grafts success were compared between the graft groups. Records of 111 patients were analyzed. The graft success rate was 89.7% for palisade cartilage graft (PCG, n = 39), 86.1% for island cartilage graft (ICG, n = 36), and 97.2% for wheel-shaped composite cartilage graft (WsCCG, n = 36) (p = 0.244). Average postoperative PTA and ABG values were significantly affected by the cartilage graft type, but WRS was not affected. (p = 0.005, 0.019, 0.306, respectively, One Way-Anova test). Post-Hoc LSD test showed a statistically significant decrease in PTA and ABG averages for WsCCG group compared to the ICG group (p = 0.004; CI%95 = 15.1-2.2 dB and p = 0.023; CI%95 = 8.2-0.4 dB, respectively). Postoperative PTA and ABG averages for WsCCG and PCG groups were similar (p = 0.069 and p = 0.053, respectively). In addition, while there were 2 (5.1%) retractions in the PCG group and 1 (2.7%)in the ICG group, there was no retraction in the WsCCG group. The WsCCG provided comparable results with classical reliable graft techniques (PCG and ICG) and may recommend as a more suitable graft due to hearing results and resistance against retraction.

Type 1 Tympanoplasty Outcomes between Cartilage and Temporal Fascia Grafts: A Long-Term Retrospective Study

Background: To compare the functional and anatomical results of two different types of grafts in type 1 tympanoplasty (TPL I). Methods: A retrospective comparative bicentric study was conducted on patients treated with TPL I using temporal fascia or tragal cartilage. We evaluated the functional and anatomical results with intergroup and intragroup analyses. Variables predicting long-term success were also evaluated. Results: A total of 142 patients (98 fascia graft vs. 44 cartilage) were initially assessed, with a mean follow-up of 67.1 ± 3.2 months. No significant differences were observed between the two groups on the intergroup analysis of age, gender, ear side, or pre-operative hearing data (all p > 0.05). At the intragroup analysis of auditory outcomes, both groups demonstrated a significant improvement in post-operative air conduction, with greater gain for the fascia group at 6 months follow-up (p < 0.001 for both); however, at long-term follow-up, cartilage demonstrated better stability results (p < 0.001). When comparing the pre-and post-operative air-bone-gap (ABG), both groups showed a significant gain (p < 0.001); the fascia group showed that at 6 months, a greater ABG increase was found, but the difference was not statistically significant (4.9 ± 0.9 dB vs. 5.3 ± 1.2 dB; p = 0.04). On the contrary, the cartilage group at long-term follow-up at 5 years maintained greater outcomes (10 ± 1.6 dB vs. 6.4 ± 2 dB; p < 0.001). Lower age (F = 4.591; p = 0.036) and higher size of perforation (F = 4.820; p = 0.030) were predictors of long-term functional success. Conclusions: The graft material selection should consider several factors influencing the surgical outcome. At long-term follow-up, the use of a cartilage graft could result in more stable audiological outcomes, especially in younger patients or in case of wider perforations.

Comparison of cartilage and temporalis fascia grafts in type 1 tympanoplasty: A meta-analysis

OBJECTIVE

To systematically review the results of type 1 tympanoplasties with temporalis fascia (TF) vs cartilage grafts in patients with chronic otitis media.

METHODS

Eligible studies were identified from PubMed, Ovid, and EMBASE databases prior to November 2021. We analyzed the pure tone audiometry (PTA) and air-bone gap (ABG) data as continuous variables, and the success rate was analyzed as a dichotomous variable.

RESULTS

Forty-four studies, including 4582 patients, were eligible. The cartilage graft overall morphologic success rate was higher than that of the TF grafts (P < .001). In the palisade (P < .004) and island grafts (P < .001) subgroups, the analysis was significantly different. However, there was no significant difference in the inlay butterfly grafts subgroup. For hearing outcomes, the analysis revealed that TF grafts had a smaller mean post-operative ABG (P = .009). However, the subgroup analysis showed no significant difference in the mean post-operative ABG. For PTA, there was no significant difference in hearing improvement. However, the palisade cartilage graft subgroup resulted in a better hearing outcome than the TF graft subgroup in terms of the mean post-operative PTA (P = .007). There was no significant difference in the functional success rate or mean ABG gain.

CONCLUSION

Cartilage grafts have a better success rate than TF grafts in tympanoplasty. Both cartilage and TF tympanoplasty provided similar improvements in hearing outcome, while TF grafts generated a better outcome in post-operative ABG and palisade cartilage grafts in post-operative PTA. This may be related to the biological characteristics of the grafts. Further thorough studies need to be conducted.

A Comparative Study of Temporalis Fascia Graft and Full Thickness Tragal Island Cartilage Graft in Type 1 Tympanoplasty

We aim to compare the functional and anatomical outcomes of temporalis muscle fascia graft with that of full thickness composite tragal island cartilage graft in patients who are undergoing Type 1 Tympanoplasty. This is a prospective study conducted on 60 patients. Patients who underwent type 1 tympanoplasty were included in the study. Patients were divided into Group A (temporalis fascia graft) and Group B (tragal island cartilage) with 30 patients in each. Out of the 60 patients, 18 females and 12 males belonged to Group A, 20 females and 10 males belonged to Group B. The mean age group was between 31 and 40 yrs in both the groups. The mean hearing gain and ABG closure for Group A was 13.83 ± 8.11 and 13.39 ± 7.44 and in Group B it was 11.17 ± 4.06 and 11.5 ± 5. The graft uptake rate of Group A was 90% and Group B was 96.67%. The wound healing rate of Group A was 93.33% and Group B was 100%. The mean duration of surgery in Group A was 97.5 ± 17.16 and in Group B was 81.33 ± 11.14. Both the groups had significant post-operative improvement in hearing. No significant results found between both the groups in terms of hearing gain, air-bone gap closure, wound healing and graft uptake rate except lesser duration of surgery in group B. We conclude that tragal island cartilage graft is a better choice in Type 1 Tympanoplasty.

Comparison of Inlay Cartilage Butterfly and Underlay Temporal Fascia Tympanoplasty

Objective

To systematically review the results of inlay cartilage butterfly tympanoplasty and standard underlay temporal fascia tympanoplasty for anatomic and functional end points.

Data Sources

PubMed, Embase, MEDLINE, and Virtual Health Library (VHL/Lilacs) databases were searched from inception through April 2, 2021. No restrictions on language, publication year, or publication status were applied.

Review Methods

The meta-analysis included data from articles that met inclusion criteria and were extracted by 2 authors independently. The PRISMA statement was followed. Risk of Bias 2.0 and Newcastle-Ottawa Scale were used to assess risk of bias. The primary outcome was tympanic membrane closure rate. The secondary outcome was improvement of the air-bone gap.

Results

Ten studies were included, 9 cohort studies and 1 randomized clinical trial, with 577 patients. The graft take rate was 82.8% in the butterfly cartilage inlay tympanoplasty group and 85.2% in the temporal fascia underlay tympanoplasty group (relative risk, 1.01; 95% CI, 0.93-1.11; I² = 42%, P = .08). The air-bone gap reduction ranged from 6.1 to 11.28 in the butterfly cartilage inlay group and from 5.2 to 12.66 in the temporal fascia underlay group, with a mean difference between groups of −2.08 (95% CI, −3.23 to −0.94; I² = 58%, P = .04), favoring temporal fascia underlay.

Conclusion

The 2 tympanoplasty techniques analyzed here produced similar results in terms of successful reconstruction of the tympanic membrane and reduction in the air-bone gap. Neither age nor follow-up length of time influenced outcomes.

Use of nasal mucosa graft in tympanoplasty

INTRODUCTION

Tympanoplasty techniques with different types of graft have been used to close tympanic perforations since the 19th century. Tragal cartilage and temporalis fascia are the most frequently used types of graft. They lead to similar functional and morphological results in most cases. Although little published evidence is present, nasal mucosa has also been shown to be a good alternative graft.

OBJECTIVE

Surgical and audiological outcomes at the six-month follow-up in type I tympanoplasty using nasal mucosa and temporalis fascia grafts were analyzed.

METHODS

A total of 40 candidates for type I tympanoplasty were randomly selected and divided into the nasal mucosa and temporalis fascia graft groups with 20 in each group. The assessed parameters included surgical success; the rate of complete closure of tympanic perforation and hearing results; the difference between post- and pre-operative mean quadritonal airway-bone gap, six months after surgery.

RESULTS

Complete closure of the tympanic perforation was achieved in 17 of 20 patients in both groups. The mean quadritonal airway-bone gap closures were11.9 and 11.1 dB for the nasal mucosa and temporalis fascia groups, respectively. There was no statistically significant difference between the groups.

CONCLUSION

The nasal mucosa graft can be considered similar to the temporal fascia when considering the surgical success rate of graft acceptance and ultimate audiological gain.

[Clinical study on repairing subtotal perforation of tympanic membrane with cartilage island technique combined with palisade technique under otoscope]

Objective:To investigate the healing rate of subtotal perforation of tympanic membrane repaired by cartilage island technique combined with palisade cartilage technique under otoscope. Methods:A retrospective analysis was performed on 189 patients with chronic suppurative otitis media who were admitted to the Department of Otolaryngology and Head and Neck Surgery of Hunan Provincial People's Hospital from January 2018 to January 2020. The patients were divided into twogroups, in group onethere were 100 patients treated by senior surgeon, which were divided into two subgroups, Group A （68 cases） were treated with cartilage island technique alone, and Group B （32 cases） were treated with cartilage island technique combined with palisade cartilage technique. In group two there were 89 patients treated by junior surgeons, which were divided into two subgroups. In group C, 50 cases were treated with cartilage island technique alone, and in group D, 39 cases were treated with cartilage island technique combined with palisade cartilage technique. Results:The healing rate of tympanic membrane in group 1 was 96.0% （96/100）, and in group 2 was 87.6%（78/89）.There was statistically significant in group 1 and group 2（χ²=4.504, P=0.034）.The healing rate of tympanic membrane was 94.1% （64/68） in group A, 100%（32/32）in group B, 80.0%（40/50） in group C, and 97.4% （38/39） in group D. There was no statistically significant difference between group A and group B （χ²=1.961, P=0.161）, there was statistically significant difference between group C and group D （χ²=6.149, P=0.013）, and there was statistically significant difference between group A and group C（χ²=5.492, P=0.019）There was no statistical difference between group B and group D（χ²=0.832, P=0.362）. Conclusion:For beginners of tympanoplasty, the use of cartilage island technique combined with palisade cartilage technique in otoscope can significantly improve the success rate of tympanoplasty with subtotal tympanic perforation.

Composite gelfoam/fascia graft: a novel technique in tympanoplasty surgery

BACKGROUND

Traditional tympanoplasty techniques require graft placement and then supporting material (GelFoam) as a two-step process. Both steps potentially disrupt accurate graft placement leading to failure and persistence of the perforation.

METHODS

We demonstrate a novel technique for graft preparation and placement using composite gelfoam/fascia in which the gelfoam and fascia are compressed into a common layer and applied to the perforation and drum remnant in a single step. Placement is ergonomically efficient and effective.

CONCLUSION

This novel modification of traditional graft preparation and placement is simple and ergonomically efficient.

The new "cubism" graft technique in tympanoplasty: A randomized controlled trial

OBJECTIVES

The aim of this prospective, randomized-controlled study is to analyze the outcomes of a new graft technique in tympanoplasty and compare its outcomes with cartilage island graft plus extra perichondrium.

METHODS

A total of 44 patients with noncomplicated chronic otitis media were included in this prospective randomized-controlled clinical trial. Patients were randomly divided into 2 double-layer graft groups: The cartilage island graft + cubism graft (study group) and the cartilage island graft + extra perichondrium (control group). The main outcome measures of the study were the air-bone gap (ABG), ABG gain, and graft status.

RESULTS

Graft success rate was 100% and 95.5% in the study group and the control group, respectively. There were statistically significant differences in the postoperative first month ABG and ABG gain between study and control groups (P < .05). ABG and ABG gain showed no significant differences in the postoperative sixth month between groups (P > .05).

CONCLUSION

This study revealed that both graft techniques have satisfactory functional and morphological results compared to preoperative findings. The use of cubism graft with cartilage island graft has significantly better auditory outcomes in short-term and similar results in long-term compared to double-layered cartilage island graft with extra perichondrium. Cubism graft is a highly promising graft technique with its many advantages.

LEVEL OF EVIDENCE

1b.

Totally endoscopic tympanic membrane repair

BACKGROUND

Transcanal totally endoscopic ear surgery (TEES) has become increasingly popular internationally; however, for surgeons trained with a two-handed microscope-guided approach, the potential challenges of adopting TEES can appear off-putting.

OBJECTIVES

This article outlines the pros and cons of TEES for tympanic membrane repair and describes aspects of surgical technique relevant to those who might adopt this approach.

MATERIALS AND METHODS

Data are provided from the author's experience along with a review of relevant literature, including several meta-analyses of tympanoplasty outcome.

RESULTS

Meta-analyses show that TEES tympanoplasty is as effective at closing tympanic membrane perforations and improving hearing as microscope-guided surgery. Yet patients benefit from avoidance of a skin incision and faster recovery.

CONCLUSION

Repair of the tympanic membrane with TEES is feasible and effective. This minimally invasive approach is very appealing to patients.

Central versus marginal tympanic membrane perforations: does it matter? An analysis of 792 patients

BACKGROUND

There is a lack of studies concerning chronic otitis media without cholesteatoma.

OBJECTIVES

To perform an analysis of tympanic membrane perforations (TMP), compare the parameters of central and marginal TMP, combining both the traditional and more recent technologies available.

MATERIAL AND METHODS

792 consecutive patients. The TMP subgroups were divided by central and marginal locations and compared based on signs suggestive of previous tympanic retraction, namely, medialized malleus, tympanic remnants over the promontory, tympanic remnants over the ossicular chain, and incus/stapes erosion. Analysis of the status of the contralateral ear (CLE).

RESULTS

Central TMP was diagnosed in 79.8%. Compared with the central group, the marginal group had more reported hearing loss (95.6%), greater conductive hearing loss (pure tone average for air-conduction 43.3 dB and average air-bone gap of 28.7 dB), a larger perforated area (46.45%), more posteroinferior quadrant involvement, a greater number retraction signs prior to the TMP, and more changes in the CLE (71%).

CONCLUSION

The differences between TMP subgroups are highlighted when we use all technologies available to compare them. Marginal TMPs have more altered parameters than central TMPs.

SIGNIFICANCE

There is a great possibility to enhance the knowledge of TMPs and to improve the pathogenesis-based treatment.

Endoscopic full-thickness cartilage-perichondrium double graft myringoplasty in adhesive perforation: retrospective case series

BACKGROUND

The adhesive perforation could be the sequela of adhesive otitis media, that partial tympanic membrane remnant is bound completely to the medial wall of the middle ear by fibrous adhesions. However, few studies have reported on the repairing of adhesive perforation.

OBJECTIVES

To evaluate the long-term outcome of endoscopic full-thickness cartilage-perichondrium double graft myringoplasty for adhesive perforation.

MATERIALS AND METHODS

In total, 26 patients with unilateral adhesive perforation associated with chronic otitis media who underwent full-thickness cartilage-perichondrium double graft myringoplasty were included. Outcomes were evaluated in terms of the hearing gain and graft success rate at 12 and 24 months.

RESULTS

The graft success rate was 96.15% (25/26) at 12 months and 88.46% (23/26) at 24 months. The neovascularization and epithelium covering the lateral surface of the cartilage graft were seen at preoperative 4 weeks, the superficial cartilage graft got complete epithelialization within 4-6 months. CT revealed the well-pneumatized middle ear and mastoid cells at postoperative 24th months in all the patients, no middle ear cholesteatoma formation and keratin pearls were found during the period of follow up.

CONCLUSIONS

Endoscopic full-thickness cartilage-perichondrium double graft myringoplasty without the tympanomeatal flap elevation is a feasible method for repairing adhesive perforations, with a higher graft success rate and satisfactory hearing results.

Endoscopic myringoplasty in pediatric patients: a comparison of cartilage graft push-through and underlay fascia graft techniques

BACKGROUND

Although myringoplasty is performed in pediatric patients, there is still no consensus on the graft material and surgerical procedure.

OBJECTIVE

To compare the short-and long- term graft take rates of the cartilage push-through and fascia graft techniques employed during pediatric myringoplasty.

MATERIALS AND METHODS

93 pediatric patients with perforation who underwent myringoplasty were randomized into the cartilage push-through and underlay fascia graft group. The outcomes evaluated were hearing gains, and graft success rates at 12 and 24 months.

RESULTS

The graft success rate was similar between two groups (95.7% vs 91.3%, p = .653) at postoperative 12th months, however, the graft success rate was significantly higher 91.5% for the cartilage graft group compared with 73.9% for the fascia group at postoperative 24th months. No significant between-group differences were observed pre- (p = .694) or post- (p = .812) operative ABG values or mean ABG gain (p = .745).The re-perforation rate in fascia group was significantly higher than that in push through group (19.05 vs. 4.44%). No middle ear cholesteatoma formation was found in either group.

CONCLUSION

Endoscopic cartilage push-through and underlay fascia graft myringoplasty afforded comparable hearing results in pediatric patients; however, the push-through technique without the elevation of a tympanomeatal flap exhibited better long-term graft success rate compared to underlay fascia graft.

Over-under cartilage tympanoplasty: technique, results and a call for improved reporting

OBJECTIVE

This study aimed to describe the microscopic over-under cartilage tympanoplasty technique, provide hearing results and detail clinically significant complications.

METHOD

This was a retrospective case series chart review study of over-under cartilage tympanoplasty procedures performed by the senior author between January 2015 and January 2019 at three tertiary care centres. Cases were excluded for previous or intra-operative cholesteatoma, if a mastoidectomy was performed during the procedure or if ossiculoplasty was performed. Hearing results and complications were obtained.

RESULTS

Sixty-eight tympanoplasty procedures met the inclusion criteria. The median age was 13 years (range, 3-71 years). The mean improvement in pure tone average was 6 dB (95 per cent confidence interval 4-9 dB; p < 0.0001). The overall perforation closure rate was 97 per cent (n = 66). Revision surgery was recommended for a total of 6 cases (9 per cent) including 2 post-operative perforations, 1 case of middle-ear cholesteatoma and 3 cases of external auditory canal scarring.

CONCLUSION

Over-under cartilage tympanoplasty is effective at improving clinically meaningful hearing with a low rate of post-operative complications.

Type I Tympanoplasty: surgical success and prognostic factors

OBJECTIVES

To evaluate success rate of type I tympanoplasty in adults and to investigate the importance of selected prognostic factors on graft uptake.

MATERIAL AND METHODS

Retrospective medical chart review of 155 patients who underwent Type I Tympanoplasty, in our department, from January 2013 to December 2017. Graft uptake rate was evaluated and the effects of prognostic factors on surgical outcome such as sex, smoking and otological surgery history, status of the contralateral ear, size and location of the perforation, middle ear mucosa status, surgical approach and graft material. Preoperative and postoperative audiometric data were collected, and the functional success was determined.

RESULTS

The overall surgical anatomical success rate was 75%. Analysis of the selected variables, identified as independent prognostic factors of anatomical unsuccess (95% CI): smoking (OR=3.29, p<.01), middle ear tympanosclerosis (OR=2.96; p=.04). Perforations above 50% of the tympanic membrane area had a borderline effect on graft uptake (p=.05). There was a significative improvement in the average air conduction thresholds of 7.44dB and an ABG closure rate at 10dB and 20dB was achieved in 47% and 84.5%, respectively. Patients who received temporalis fascia graft had similar hearing gain compared to patients who underwent cartilage tympanoplasty (7.7 vs. 7.3dB, p=.79).

CONCLUSION

Type I tympanoplasty is an effective and safe procedure with a high anatomical success rate in the treatment of mucosal COM. Poorer outcomes were found in patients with smoking habits, in those with tympanosclerosis of middle ear mucosa and in larger perforations. These prognostic factors should be considered in surgical planning and patients should be advised to quit smoking. Tympanoplasty with cartilage graft had a hearing outcome comparable to temporalis fascia graft and should be considered in high-risk patients.

Comparison of temporal muscle fascia and tragal cartilage perichondrium in endoscopic type 1 tympanoplasty with limited elevation of tympanomeatal flap

INTRODUCTION

Elevation of tympanomeatal flap is one of the basic steps of tympanoplasty. A satisfactory level of anatomic and functional success can be achieved by using different grafts with limited tympanomeatal flap elevation.

OBJECTIVES

We aimed to compare the anatomic and functional success of tragal cartilage perichondrium and temporal muscle fascia in cases of endoscopic type 1 tympanoplasty performed with limited tympanomeatal flap elevation.

METHODS

In total, 81 cases (33 females, 48 males, mean age 22.1 ± 10.1 years, interval 18-49 years) which underwent transcanal endoscopic type 1 tympanoplasty with limited elevation of tympanomeatal flap were included the present study. All cases were divided into two groups as tragal cartilage perichondrium (group A) and temporal muscle fascia (group B). The comparison of the groups were made considering the pre- and postoperative air-bone gap and the tympanic membrane status.

RESULTS

There was no statistically significant difference between Group A and Group B in preoperative and in postoperative air-bone gap values (p = 0.608 and 0.529, respectively). In Group A and B, postoperative air-bone gap values demonstrated significant decrease compared to the preoperative values (p = 0.0001). Group A and group B did not demonstrate significant differences between postoperative improvements of air-bone gap values (p = 0.687). Graft retention success was 92.6% in group A while it was 90.0% in group B. There was no statistically significant difference between the groups in terms of graft retention success (p = 0.166).

CONCLUSION

In accordance with the results of this study, we believe that both tragal cartilage perichondrium and temporal muscle fascia, and also in limited tympanomeatal flap elevation in endoscopic tympanoplasty are all eligible for result in safe and successful surgery.

Endoscopic myringoplasty: comparison of double layer cartilage-perichondrium graft and single fascia grafting

Objective

To compare surgical results of endoscopic myringoplasty using double layer cartilage-perichondrium grafts versus single fascia grafts.

Study design

Prospective, randomized, controlled.

Setting

University-affiliated teaching hospital.

Subjects and methods

In total,134 patients who underwent endoscopic myringoplasty were included in this study. Patients in group A received a double layer tragal cartilage-perichondrium graft and those in group B received a temporal muscle fascia graft. The groups were compared with respect to the pre- and postoperative air-bone gap (ABG) and the graft success rate.

Results

The graft success rate was 98.5% (66/67) in the Group A and 94.0% (63/67) in the Group B at 6 months, the difference wasn’t statistically significant (p = 0.362). However, the graft success rate was 97.0% (65/67) in the Group A and 85.1% (57/67) in the Group B at 12 months, the difference was statistically significant (p = 0.034).

In addition, only one patient (1.49%) had small keratin pearls in the Group A, no patients developed cholesteatoma of middle ear in either group.

Conclusions

The endoscopic double layer perichondrium-cartilage graft technique is feasible for repairing medium or larger perforations, it has a better long-term graft success rate and less operative time compared with the single layer fascia graft technique. However, long-term hearing outcomes were the same for the single and double layer closure techniques.

The Effect of Auricular Graft Donor Site on Morbidity and Cosmetic Appearance in Cartilage Tympanoplasties

OBJECTIVES

The aim of the present study was to compare the postoperative morbidity and cosmetic results between the use of the scapha and the use of the tragus as the auricular cartilage graft donor site in patients who had undergone cartilage tympanoplasty. The fascia graft was used as the control.

MATERIALS AND METHODS

The patient's visual symmetry, cosmetic satisfaction, and anthropometric measurements were studied to objectively evaluate the cosmetic condition. The formation of skin scar changes, pigmentation changes, and sensory changes as clinical criteria were compared.

RESULTS

A total of 234 patients and their 257 operated ears were included in the study. Forty prospectively operated ears with preoperative findings were also included. All patients (100%) felt that their results were good, as indicated by the visual analog scale, and the anthropometric ear measurements used to reinforce the data showed no significant differences between the groups. A significant difference with respect to clinical sensory changes was found between the groups only in patients undergoing unilateral surgery via the retro auricular approach (p<0.05). There was no difference between the scapha and tragus groups with respect to scar formation or skin pigmentation change.

CONCLUSION

Neither scapha nor tragus use for graft retrieval led to dissatisfaction or cosmetic problems in the postoperative period. Sensory changes in the skin on clinical evaluation were less common in patients in whom the scapha donor site was preferred than in cases in which the tragus was used.

Tympanoplasty: factors associated with anatomical and audiometric results

INTRODUCTION

Tympanoplasty is a frequent surgery in otolaryngology. Its main indication is tympanic perforation, followed by adhesive otopathy. Its main and (or) anatomic objective is to restore the tympanic membrane's integrity, preventing infections, and its secondary or audiometric objective is to preserve or improve hearing.

MATERIAL AND METHOD

Retrospective study of all patients submitted to tympanoplasty at our hospital. Biodemographic, ear pathology and surgery characteristics were registered, and anatomic and audiometric success rates were analyzed.

RESULTS

A total of 182 patients were included, most female (57.1%), with average age of 36.1 years. The main surgical indication was tympanic perforation (89.0%), followed by adhesive otopathy (7.1%). Most tympanoplasties were primary surgeries (84.1%), type I (62.6%), performed by endoaural approach (83.5%) using medial or Austin technique (90.1%). Compound cartilage-perichondrium grafts were most frequently used (87.9%). The anatomic success rate was 84.6%, and the audiometric success rate was 66.8%. Patients who underwent myringoplasty (without raising of tympanomeatal flap) presented a better audiometric result (p=.003). No factors associated with better anatomical results were identified.

CONCLUSIONS

Our anatomic and audiometric results are comparable to those previously published. Further prospective studies are required to define factors associated with improved anatomic and audiometric results.

The Elevation of Tympanomeatal Skin Flap Could Not be Necessary for Endoscopic Cartilage Myringoplasty

Endoscope provide the excellent view and observe the entire perforation edges, endoscopic cartilage myringoplasty doesn't require the lateral circumferential incision and the elevation of tympanomeatal skin flap in most cases. The cartilage graft may be pushed through the perforation and place medial to the remnant tympanic membrane and annulus.

Cartilage reinforcement graft versus fascia graft in tympanoplasty

Background/aim: The purpose of this study was to compare cartilage reinforcement graft results with temporalis fascia graft alone in terms of hearing and anatomical outcomes in tympanoplasty. Materials and methods: Patients who underwent tympanoplasty with/without ossiculoplasty and/or mastoidectomy at a university hospital from 2006 through 2013 were reviewed retrospectively. The patients were divided into those grafted with temporalis muscle fascia alone and with fascia reinforced with cartilage. The postoperative air bone gap, gain in hearing thresholds, and graft status were evaluated for each group. Results: The study subjects included 179 patients. There were 82 patients in the fascia group and 97 patients in the cartilage group. Successful hearing results were elicited in 79.2% of the fascia group and 85.5% of the cartilage group. There was no significant difference in overall graft success. The graft was intact in 82.9% of the fascia group and 86.5% of the cartilage group. Conclusion: In this comparative study the use of cartilage to reinforce the temporalis muscle fascia was analyzed, showing better hearing and anatomical results than sole use of fascia in tympanoplasty both for primary and revision cases. Thus, in the light of our results, when performing tympanoplasty we recommend the use of cartilage reinforcement grafting whenever needed and indicated.

The palisade cartilage tympanoplasty technique: a systematic review and meta-analysis

Background

Tympanoplasty is a common procedure performed by Otolaryngologists. Many types of autologous grafts have been used with variations of techniques with varying results. This is the first systematic review of the literature and meta-analysis with the aim to evaluate the effectiveness of one of the techniques which is gaining popularity, the palisade cartilage tympanoplasty. PubMed, EMBASE, and Cochrane databases were searched for "palisade", “cartilage”, “tympanoplasty”, "perforation" and their synonyms.

Main body of abstract

In total, 199 articles reporting results of palisade cartilage tympanoplasty were identified. Five articles satisfied the following inclusion criteria: adult patients, minimum 6 months follow-up, hearing and surgical outcomes reported. Studies with patients undergoing combined mastoidectomy, ossicular chain reconstruction, and/or other middle ear surgery were excluded. Perforation closure, rate of complications, and post-operative pure-tone average change were extracted for pooled analysis. Study failure and complication proportions that were used to generate odds ratios were pooled. Fixed effects and random effects weightings were generated. The resulting pooled odds ratios are reported. Palisade cartilage tympanoplasty has an overall take rate of 96% at beyond 6 months and has similar odds of complications compared to temporalis fascia (OR 0.89, 95% CI 0.62, 1.30). The air-bone gap closure is statistically similar to reported results from temporalis fascia tympanoplasty.

Conclusions

Cartilage palisade tympanoplasty offers excellent graft take rates and good postoperative hearing outcomes for perforations of various sizes and for both primary and revision cases. This technique has predictable, long-term results with low complication rates, similar to temporalis fascia tympanoplasty.

Comparison of cartilage with temporalis fascia tympanoplasty: A meta-analysis of comparative studies

OBJECTIVE

To systematically review the results of type 1 tympanoplasty with temporalis fascia (TF) versus cartilage in patients with chronic otitis media (COM) for graft integration and hearing improvement.

DATA SOURCES

The English language literature (until June 1, 2016) was searched, using Medline (via PubMed), Scopus, ProQuest, Ovid, Cochrane database, and Google Scholar.

REVIEW METHODS

A comprehensive review of the literature was performed. Prospective and retrospective studies enrolling patients with COM were included. Relevance and validity of selected articles were evaluated. Heterogeneity was assessed using I² statistics. For dichotomous variables, absolute rate differences, and number needed to treat (NNT) were calculated. For continuous variables, standard mean differences were calculated.

RESULTS

A total of 11 prospective and 26 retrospective studies involving 3,606 patients were included. In general, the overall graft integration rates of cartilage and fascia tympanoplasty were 92% and 82%, respectively (NNT = 11.1, P < 0.001). Although there was no significant difference in the air-bone gap (ABG) closure of < 10 dB between the two groups, the subanalysis of prospective studies showed that patients in the TF group had less mean postoperative ABG (P = 0.02). Subgroup analysis of palisade grafts compared with that of TF graft revealed a significant difference in the graft integration rate favoring cartilage tympanoplasty (P = 0.01).

CONCLUSION

Cartilage grafting seemed to show a higher graft integration rate compared with TF grafting. Both cartilage and fascia tympanoplasty provided similar improvements in the hearing outcome postoperatively. Large prospective trials are necessary to collect high-quality data.

LEVEL OF EVIDENCE

NA. Laryngoscope, 127:2139-2148, 2017.