Evaluation of inlay butterfly cartilage tympanoplasty: a randomized clinical trial

Butterfly Cartilage Inlay Technique for Repairing Medium-to-Large-Sized Tympanic Membrane Perforations

OBJECTIVE

The butterfly cartilage inlay technique was originally developed for repairing small tympanic membrane (TM) perforations but is now increasingly used for repairing large TM perforations. Although studies have evaluated the effectiveness of butterfly tympanoplasty for repairing medium-to-large-sized TM perforations, no study has compared its effectiveness with that of the conventional underlay cartilage technique. Therefore, we aimed to evaluate the effectiveness of butterfly tympanoplasty for repairing medium-to-large-sized TM perforations compared with that of the conventional underlay cartilage.

STUDY DESIGN

Retrospective chart review.

SETTING

This retrospective study analyzed patients treated for medium-to-large-sized TM perforations at a tertiary medical center between January 2017 and July 2024.

METHODS

We compared the outcomes of butterfly cartilage tympanoplasty with those of the conventional underlay technique, focusing on graft success rate, postoperative hearing outcomes, perioperative complications, and operating time. TM perforation sizes were precisely measured using the ImageJ software.

RESULTS

Among a total of 52 patients, 28 underwent butterfly tympanoplasty and 24 underwent underlay tympanoplasty. Both techniques showed comparable graft success rates (butterfly technique, 92.9%; underlay technique, 83.3%) and minimal perioperative complications. The butterfly technique had a significantly shorter operating time compared with that of underlay tympanoplasty and was performed under local anesthesia. Both groups showed a significant postoperative air-bone gap (ABG) reduction, with no significant difference in the ABG improvement.

CONCLUSION

The butterfly technique is effective for medium-to-large-sized TM perforations, offering comparable outcomes to the conventional underlay technique, with the advantages of reduced operating time and the use of only local anesthesia.

Endoscopic Butterfly Myringoplasty: Comparison of Tragal Cartilage Graft and Dermal Allograft

OBJECTIVES

Tympanic membrane perforation (TMP) is a common reason for visits to otolaryngology clinics. For decades, various surgical methods and grafts have been employed to treat TMP. This study aimed to compare the efficacy of tragal cartilage grafts (TCG) and dermal allografts (DAG) in myringoplasty for treating TMP.

METHODS

We retrospectively analyzed 80 patients who underwent endoscopic butterfly inlay myringoplasty between 2019 and 2022. The patients were divided into two groups based on the graft material used: TCG (n = 40) and DAG (n = 40). We compared preoperative and postoperative hearing results and surgical outcomes between the two groups.

RESULTS

Both the TCG and DAG groups demonstrated significant postoperative improvements in hearing. The air-bone gap decreased from 11.87 to 7.74 dB in the TCG group (p = 0.01) and from 13.6 to 8.96 dB in the DAG group (p = 0.013). Similarly, the low-tone average improved significantly: from 40.49 to 25.26 dB in the TCG group (p < 0.001) and from 38.33 to 25.15 dB in the DAG group (p < 0.001). The graft closure rates were comparable at 97.5% for TCG and 92.5% for DAG, indicating that both procedures are effective and similar in efficacy. However, the TCG group required more follow-up visits (average of 4 vs. 2.6 for DAG).

CONCLUSIONS

Both TCG and DAG techniques demonstrated comparable efficacy in terms of graft success rates and hearing improvement, with no significant differences in postoperative complications.

LEVEL OF EVIDENCE: 3

Outcomes of endoscopic modified cartilage-perichondrium tympanoplasty on different sized perforations

OBJECTIVES

To evaluate the anatomic and functional outcomes of type1 tympanoplasty with endoscopic modified butterfly cartilage-perichondrium technique.

METHODS

In our modification, perichondrium was elevated circumferentially till the attached part of the composite graft was approximately same size and shape of the perforation, cartilage was trimmed based on the perforation but 0.5 mm larger. Cartilage portion of the graft was placed medial to the edge of the perforation, then perichondrium was rolled out and draped on the circumferential raw surface of remaining tympanic membrane around.

RESULTS

At 4 months postop, the anatomic integrity rate of the tympanic membrane perforation for small & medium sized perforation and large sized perforation group were 100 % and 94 % (p > 0.05). For the small & medium perforation group, the mean pre and 4 months postop ACs were 30 ± 8 dB and 18 ± 6.4 dB (p < 0.01). The mean pre and 4 months postop ABGs were 19 ± 11 dB and 9 ± 3 dB (p < 0.01). For the large perforation group, the mean pre and 4 months postop ACs were 43 ± 12.5 dB and 21.5 ± 7 dB (p < 0.01). The mean pre and 4 months postop ABGs were 34 ± 8.5 dB and 12.5 ± 6 dB (p < 0.01). The differences of mean 4 months postop ACs and mean 4 months postop ABGs between the two groups were not significant (p > 0.05).

CONCLUSIONS

Compared to the conventional inlay butterfly cartilage tympanoplasty technique, large or marginal perforations can be sealed more securely by this modification.

Comparison of temporalis fascia and cartilage graft over-under myringoplasty for repairing large perforations

OBJECTIVE

The objective of this study was to compare the operation time, graft success, audiometric outcomes and complications of over-under technique using a temporalis fascia (TMF) and cartilage grafts for the repair of large perforations.

STUDY DESIGN

Randomized controlled trial.

MATERIALS AND METHODS

80 large perforations >2 quadrants of eardrum were prospectively randomized to undergo TMF over-under technique group (TFON, n = 40) or cartilage-perichondrium over-under technique group (CPON, n = 40). The graft success rate, audiometric outcomes, and complications were compared among two groups at 12 months.

RESULTS

The mean operation time was 56.8 ± 4.2 (range:52-71) min in the TFON group and 37.9 ± 2.8 (range: 31-47) min in the CPON group (P < 0.001). The lost follow-up rate was 3 (7.5 %) patients in the TFON group and 2 (5.0 %) patient in the CPON group (P = 0.644). Finally, 37 patients in the TFON group and 38 patients in the CPON group were included in this study. The graft infection rate was 2 (5.4 %) patients in the TFON group and 2 (5.3 %) patient in the CPON group (P = 0.626), all the graft infection resulted in the residual perforation. The remaining residual perforation was 2 (5.4 %) patients in the TFON group and 1 (2.6 %) patient in the CPON group; the re-perforation was 3 (8.1 %) patients in the TFON group and 0 (0.0 %) patient in the CPON group. The graft success rate was 81.1 % (30/37) patients in the TFON group and 92.1 % (35/38) patient in the CPON group. The mean preoperative and 12-month postoperative ABGs were significantly different in any group (P < 0.01). However, there were no significant difference among two groups regardless of pre-or post-ABGs or ABG closure. No lateralization of the graft or blunting was noted in any group. Four (10.8 %)patients developed atelectasis and one (2.7 %) developed the EAC scarring in the TFON group. Graft cholesteatomas was found in 2 (5.4 %) patients in the TFON group and in 5 (13.2 %) patients in the CPON group (P = 0.449). Three (8.1 %) patients had temporary hypogeusia in the TFON group.

CONCLUSION

Although temporalis fascia graft over-under technique obtained similar graft success rates and hearing outcomes for large chronic perforations to the cartilage-perichondrium over-under technique, temporalis fascia graft technique prolonged the operation time and increased the re-perforation and graft atelectasis. Nevertheless, the graft cholesteatomas were comparable among two techniques.

Comparison between endoscopic and microscopic butterfly cartilage graft inlay tympanoplasty: a systematic review and meta-analysis

PURPOSE

The purpose of this study was to compare the effectiveness of endoscopic and microscopic approaches for butterfly cartilage graft inlay tympanoplasty regarding anatomical and hearing outcomes through a systematic review and meta-analysis.

METHODS

A search of PubMed, Embase, MEDLINE, and Virtual Health Library was performed from inception to July 3rd, 2021, using keywords, such as tympanoplasty, cartilage graft, and inlay technique. Data from articles that met inclusion criteria were extracted by two authors independently. The PRISMA statement was followed. RoB-2 and ROBINS-I tools 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

Five studies were included, one randomized clinical trial and four retrospective cohorts, in which a total of 318 patients were included. Graft take rate was 91.3% in the endoscopic group and 93.6% in the microscopic group (RR 0.98; 95% CI 0.93-1.03; I² 0%; P = 0.68). Four studies provided data about the secondary outcome, all showing significant reductions in air-bone gap, ranging from 5.7 to 11.0 in the endoscope group and from 5.8 to 11.6 in the microscope group, with a mean difference between groups of 0.85 (95% CI - 0.79 to 2.48).

CONCLUSION

Although the overall evidence of the included studies was low, endoscopic and microscopic butterfly cartilage graft inlay tympanoplasties have similar results on anatomical and hearing outcomes, making the selection between such approaches an individual choice for the surgeon.

Task force Guideline of Brazilian Society of Otology - hearing loss in children - Part II - Treatment

OBJECTIVES

To provide an overview of the main evidence-based recommendations for the diagnosis of hearing loss in children and adolescents aged 0-18 years.

METHODS

Task force members were educated on knowledge synthesis methods, including electronic database search, review and selection of relevant citations, and critical appraisal of selected studies. Articles written in English or Portuguese on childhood hearing loss were eligible for inclusion. The American College of Physicians' guideline grading system and the American Thyroid Association's guideline criteria were used for critical appraisal of evidence and recommendations for therapeutic interventions.

RESULTS

The topics were divided into 2 parts: (1) treatment of sensorineural hearing loss: individual hearing aids, bilateral cochlear implants, cochlear implants in young children, unilateral hearing loss, and auditory neuropathy spectrum disorder; and (2) treatment of conductive/mixed hearing loss: external/middle ear malformations, ventilation tube insertion, and tympanoplasty in children.

CONCLUSIONS

In children with hearing loss, in addition to speech therapy, Hearing AIDS (HAs) or implantable systems may be indicated. Even in children with profound hearing loss, both the use of HAs and behavioral assessments while using the device are important.

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.

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.

Interlay Cartilage Rim Augmented Fascia Tympanoplasty: An Effective Graft Model in Mucosal Chronic Otitis Media

To study the efficacy of interlay cartilage rim augmented fascia tympanoplasty in mucosal chronic otitis media. A retrospective, observational study was conducted in a tertiary care hospital including charts of patients spanning a duration of one year, where 15 patients diagnosed with chronic otitis media-mucosal disease with large and subtotal perforations (with or without ossicular erosion), and had undergone interlay cartilage rim augmented fascia tympanoplasty, were analysed for morphological and functional improvement following surgery. Pre- and post-operative otomicroscopic examination and pure tone audiometry findings were the parameters considered. 86.6% had a well-healed, non-retracted, undisplaced mobile neotympanum, 6.7% who underwent a type III (minor columella) tympanoplasty had a medialised neotympanum and 1 subject (6.7%) who underwent a type I tympanoplasty had a residual pinpoint perforation which healed with conservative management. The overall morphological success rate was 93.3%. The mean hearing gain following surgery was 20.84 dB with a minimum gain of 10 dB and a maximum gain of 30 dB. The mean air-bone gap closure gain achieved was 19.2 dB with a minimum gain of 6.4 dB and a maximum gain of 30 dB. The interlay cartilage-fascia rim augmentation tympanoplasty is a novel, effective graft model suggested for large and sub-total central perforations. Future randomized studies with a larger sample size could be performed with longer follow-up to assess the outcome of this technique.

Butterfly Cartilage Tympanoplasty as an Alternative to Conventional Surgery for Tympanic Membrane Perforations: A Systematic Review and Meta-Analysis

OBJECTIVE

To compare the effectiveness of butterfly cartilage tympanoplasty (BCT) with that of conventional surgical approaches in the treatment of tympanic membrane perforations.

METHODS

A systematic search was performed by screening the PubMed, Embase, and Cochrane Library databases up to October 31, 2020. Two coauthors independently identified studies in accordance with the selection criteria. Data were pooled and analyzed via Review Manager version 5.3 and Stata version 12.0 software. The postoperative outcomes were measured and expressed as odds ratios (ORs) and standardized mean differences (SMDs). Additionally, heterogeneity was assessed through the I² statistic.

RESULTS

A total of 15 articles were eligible for final inclusion. The OR values for the graft uptake rate, compared to conventional tympanoplasty, were 1.12 (95%CI: 0.56-2.22, I² = 52%, P = .75) and 1.22 (95%CI: 0.58-2.59, I² = 0%, P = .60), and the OR compared to fat plug myringoplasty was 3.02 (95%CI: 1.04-8.77, I² = 0%, P = .04). The qualitative analysis of the hearing results reflected significant postoperative auditory gains with no significant differences between the BCT and control groups, indicating satisfactory and similar postoperative hearing improvement. Moreover, the operation time was shortened (SMD = -2.19, 95%CI: -2.79 to -1.59, I² = 82%, P < .05), and the postoperative pain was less with the BCT approach.

CONCLUSION

Butterfly cartilage tympanoplasty has satisfactory efficacy in terms of anatomical and functional results in small to medium perforations. It reduces operation time and postoperative pain. However, the effectiveness on large perforation requires further assessment by well-designed studies.

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.

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.

High-Frequency Conductive Hearing following Total Drum Replacement Tympanoplasty

OBJECTIVES

Conventional reporting of posttympanoplasty hearing outcomes use a pure-tone averaged air-bone gap (ABG) largely representing a low-frequency sound conduction. Few studies report high-frequency conductive hearing outcomes. Herein, we evaluate high-frequency ABG in patients following temporalis fascia total drum replacement.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary care center.

SUBJECTS AND METHODS

All patients who underwent type 1 tympanoplasty using a lateral graft total drum replacement technique between August 2016 and February 2019 were identified. Patients with pre- and postoperative audiograms were included. Low-frequency ABG was calculated as the mean ABG at 250, 500, and 1000 Hz. High-frequency ABG was calculated at 4 KHz. Pre- and postoperative ABGs were compared.

RESULTS

Twenty-three patients were included, and the mean age at surgery was 44 years (range, 9-68 years). Perforation etiology was from trauma (n = 14) or chronic otitis media (n = 9). Preoperative mean low-frequency ABG was 27.8 ± 12.6 dB and mean high-frequency ABG was 21.5 ± 15.1 dB (P = .044). Postoperatively, the mean low-frequency ABG was significantly reduced by 15.5 ± 13.3 dB (P < .001) while the mean high-frequency ABG insignificantly changed (reduced by 2.6 ± 16.2 dB, P = .450).

CONCLUSION

In a series of patients undergoing temporalis fascia total drum replacement, low-frequency ABG improved; however, high-frequency conductive hearing loss persists. Conventional methods of reporting ABG may not identify persistent high-frequency ABG. These results merit further study across a range of tympanoplasty graft materials and surgical techniques.

Success rates for various graft materials in tympanoplasty - A review

Objectives

The aim of this paper is to review how successful each type of grafts is in tympanoplasty.

Methods

Pubmed, Google and the Proquest Central Database at Kırıkkale University were queried using the keywords “graft”, “success” “tympanoplasty”, “success rate” with the search limited to the period 1955 to 2017.

Results

Various types of graft materials including temporalis fascia, cartilage, perichondrium, periosteum, vein, fat or skin have been used in the reconstruction of tympanic membrane (TM) perforation. Although temporalis fascia ensures good hearing is restored, there are significant concerns that its dimensional stability characteristics may lead to residual perforation, especially where large TM perforations are involved. The “palisade cartilage” and “cartilage island” techniques have been stated to increase the strength and stability of a tympanic graft, but they may result in a less functional outcome in terms of restoring hearing. Smoking habits, the size and site of a perforation, the expertise level of the operating surgeon, age, gender, the status of the middle ear mucosa and the presence of myringosclerosis or tympanosclerosis are all important in determining how successful a graft is.

Conclusion

Although temporal fascia is the most commonly used graft material for tympanoplasty, poor graft stability may cause failure. This failure is due to the inclusion of connective fibrous tissue containing irregular elastic fibers present in the grafted fascia. Cartilage grafts offer better ability to resist infection, pressure, and cope with insufficient vascular supply. This means that cartilage grafts are suitable for use in revision cases.

Audiological function in a group of adults following myringoplasty: an exploratory study in South Africa

Introduction

Chronic suppurative otitis media is a global middle ear disease with quality of life as economic implications, which are worse felt in low and middle income (LAMI) countries; thus the need for myringoplasty. This study aimed to explore audiological function in a group of adults following myringoplasty in South Africa, with an exploration of the possible influence of factors such as HIV/AIDS and type of surgical technique on hearing outcomes.

Methods

Within a retrospective chart review research design, 41 participant files for a six-year period from two academic hospitals in Johannesburg, South Africa, were reviewed. Data were analysed using both descriptive and inferential statistics.

Results

Participant files comprised of 16 males and 25 females between 18-63 years. Findings revealed that clinically, overall hearing improved post-operatively, as indicated by improved tympanometry findings, pure tone air-conduction and speech reception thresholds. Descriptively, the predictors of improved hearing outcomes post-operatively appeared to be HIV negative status and butterfly cartilage inlay surgery as a surgical technique adopted. Although clinically, hearing outcomes improved post-operatively at all air-conduction frequencies tested; these clinical improvements were only statistically significant at specific frequencies.

Conclusion

Current findings provide useful initial evidence on the benefits of myringoplasty from the South African context; particularly because of the HIV/AIDS prevalence and its potential influence on middle ear disease and its management. Prospective efficacy studies with bigger sample sizes are recommended, with early identification strategies for middle ear disease to reduce the need for myringoplasty seriously considered bearing in mind the resource constraints.

Comparison of Temporalis Fascia and Transcanal Composite Chondroperichondrial Tympanoplasty Techniques

The purpose of this study was to compare the success rates and hearing outcomes of transcanal composite chondroperichondrial cartilage graft with that of underlay temporal muscle fascia (TMF) graft for myringoplasty. In this retrospective study, the medical records of patients who underwent type 1 myringoplasty between September 2015 and February 2018 at Otorhinolaryngology Department of Erzurum Ataturk University were reviewed. Demographic properties, preoperative otological findings, preoperative pure ton audiogram findings, postoperative pure ton audiogram findings, and duration of surgeries were reviewed from medical records. The patients with lack of one or more of these information at medical records or lost to at least 3 months of follow-up were excluded from the study. According to the graft material used in the operation, the patients were divided into 2 groups. The patients operated with cartilage graft by transcanal composite chondropericondrial cartilage graft myringoplasty (TCM) technique was regarded as first group, while patients operated with temporal fascia was regarded as the second group (TMF). Both groups were compared according to preoperative and postoperative air-bone gap (ABG), graft acceptance rate, and duration of operation using SPSS version 20.0 software. A total of 113 patients whose medical records met the inclusion criteria were included in the study. Of these, 59 underwent TCM and 54 underwent TMF myringoplasty. Tympanic membrane perforation closure success rate was higher in the cartilage group (94.9%) than in the fascia group (83.3%; P = .046). In the former, preoperative and postoperative ABG was 19.5 ± 5 and 10.8 ± 4.8 dB, respectively. In the latter, the corresponding values were 20.7 ± 5.4 and 11.5 ± 5.4 dB, respectively (P < .05). Duration of surgery was 29.5 ± 3.4 minutes in the TCM group and 61.5 ± 6.0 minutes in the TMF group (P < .05). Transcanal cartilage myringoplasty could be considered as an appropriate surgical option because of its simplicity, shorter operation time, and rapid patient recovery, with no significant difference in terms of hearing outcomes compared to temporal fascia.

Surgical outcomes of tympanoplasty using a sterile acellular dermal allograft: a prospective randomised controlled study

Acellular human dermal allografts have been shown to be effective for soft-tissue implantation. We compared treatment outcomes of tympanoplasty using tragal perichondrium and acellular human dermal allograft (MegaDerm^®). In a prospective randomised controlled study, 60 patients scheduled to undergo tympanoplasty were randomly assigned to the autologous tragal perichondrium group (n = 33) or acellular human dermal allograft group (n = 27). Postoperative hearing gain, graft success rate at 1 and 6 months and operation times were compared between groups. Graft success rate, defined as the complete closure of tympanic membrane perforation, did not show any significant intergroup difference (75.8% vs 85.2%, p = 0.519). Air conduction thresholds and air-bone gaps showed significant improvements in both groups; from 38.7 ± 15.9 dB to 30.2 ± 15.6 dB (p < 0.001) and from 17.8 ± 7.3 dB to 11.5 ± 7.0 (p = 0.001) in the autologous tragal perichondrium group, and from 30.4 ± 12.2 dB to 24.5 ± 13.0 dB (p = 0.006) and from 14.3 ± 5.1 dB to 7.6 ± 4.6 dB (p < 0.001) in the acellular human dermal allograft group. The amount of hearing gain (p = 0.31) and closure of air-bone gap (p = 0.863) were not meaningfully different between groups. The mean operation time was significantly lower in the acellular human dermal allograft group (35.2 min vs 27.4 min, p = 0.039). In this prospective randomised controlled study, acellular human dermal allograft was shown to be an effective alternative to tragal perichondrium, with similar graft success rates and postoperative hearing results, but with reduced operation times.

Comparison of anterior and posterior tympanomeatal flap elevations in endoscopic transcanal tympanoplasty

Background: There is not an ideal tympanomeatal flap incision type for transcanal procedures. Aims/Objectives: Comparing the outcomes and feasibility of posteriorly and anteriorly based tympanomeatal flap incisions for anterior perforations in endoscopic transcanal cartilage tympanoplasty. Material and methods: Twenty-six patients who had anterior TM perforation were included. Patients were divided into two groups with randomization. All of the data were prospectively collected. These included demographic data, date of the surgery, mean surgery time, preoperative and postoperative sixth-month pure-tone audiometry (PTA), type of tympanomeatal flap incision and graft healing success. Results: Mean follow up time was 20.69 ± 5.03 months. Graft healing rate was 100% in both groups. There was no major complication in both of groups. Mean air bone gap level improvement of (dB HL) at all frequencies was 7.69 ± 2.83 dB HL in group 1 and 7.98 ± 3.08 dB HL in group 2 respectively. Regarding pre-and postoperative mean air bone gap levels and mean surgery times, there was no significant difference between groups (p>.05). Conclusions and significance: For non-complicated anterior perforations that are less than 50% of TM, endoscopic transcanal cartilage tympanoplasty using anterior tympanomeatal flap elevation procedure was seemed minimally invasive and feasible to perform with successful audiologic and postoperative outcomes.

Study of steroid effects on graft and inner ear outcomes in tympanoplasty: Randomized controlled trial

More studies are needed to investigate the side effects of steroids in tympanoplasty, owing to the paucity of such studies in the literature. This randomized, controlled clinical trial included 59 patients with chronic otitis media who underwent tympanoplasty and were randomized after surgery to a systemic steroid or no steroid treatment. Patients were randomized into two groups. Perforation size, graft outcome, and complications such as tinnitus and hearing loss were compared between the two groups. Postsurgical steroid injection had no effect on graft outcome (p = 0.927) or tinnitus (p = 0.478). Tympanic membrane perforation (p = 0.92), plaque size (p = 0.94), bleeding amount (p = 0.38), and mucosal status (p = 0.96) during surgery had no effect on graft outcome after the tympanoplasty. In conclusion, administration of steroids after tympanoplasty failed to improve outcome and may put the patient at risk of side effects.

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.

Cartilage rim augmented fascia tympanoplasty: a more effective composite graft model than temporalis fascia tympanoplasty

OBJECTIVE

To validate a newly introduced cartilage rim augmented temporalis fascia tympanoplasty technique by statistically comparing it with the morphological and audiological outcomes of traditional temporalis fascia tympanoplasty.

METHODS

A retrospective comparative study was conducted on 115 patients who underwent tympanoplasty during 2013 and 2015. Fifty-eight patients underwent temporalis fascia tympanoplasty and 57 underwent cartilage rim augmented fascia tympanoplasty.

RESULTS

In the cartilage fascia group, graft healing was achieved in 94.7 per cent of cases; in the temporalis fascia group, the graft take-up rate was 70 per cent. In those with a normal ossicular chain, the post-operative air-bone gap was within 20 dB in 92.6 per cent of cartilage fascia group cases and in 69.7 per cent of the temporalis fascia group cases, which was a statistically significant difference. Among the defective ossicular chain cases, the post-operative air-bone gap was within 20 dB in 76.9 per cent in the cartilage fascia group, as against 57.1 per cent in the temporalis fascia group.

CONCLUSION

Cartilage rim augmented temporalis fascia tympanoplasty has a definite advantage over the temporalis fascia technique in terms of superior graft take up and statistically significant hearing gain in those with normal ossicular mobility.

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.

Comparative Analysis of Fascia Lata and Cartilage Graft in Revision Type 1 Tympanoplasty

To evaluate graft epithelialization and hearing outcome in type 1 revision tympanoplasty using fascia lata and cartilage as graft material. In this study 33 revision cases of dry central perforations were divided into two groups, group 1 (n = 21) in which cartilage was used as a graft and group 2 (n = 12) in which fascia lata was used. Group 1 patients were divided according to the technique used as group 1a (n = 16) cartilage perichondrium composite island graft and group 1b (n = 5) cartilage butterfly inlay graft. Patients were followed up for at least 12 months postoperatively, mean 15.63 (± 4.21) months. Outcome among the two groups were measured and compared in terms of graft epithelization and hearing improvement measured as the difference between pre and post operative mean air bone gap (ABG) at 1 year. The graft epithelialization of group 1 was 85.72% (87.5% group 1a/80% group 1b) and of group 2, 83.34%. Statistically no significant difference was found in the success rate between the two groups (p = 0.6). No significant difference was found in the hearing outcome as well (p = 0.44). The overall hearing improvement was significant in both groups (p = < 0.001) including the sub groups 1a and 1b separately. 21 out of 33 patients (63.63%) operated had a mean postoperative ABG of 20 db or less. The results of cartilage and fascia lata as graft are comparable in terms of graft epithelialization and hearing outcome in revision tympanoplasty.

Type I Tympanoplasty Meta-Analysis: A Single Variable Analysis

OBJECTIVE

To determine which independent variables influence the efficacy of type I tympanoplasty in adult and pediatric populations.

DATA SOURCES

A search of the PubMed database and Cochrane Database of Systematic Reviews using the key words "tympanoplasty OR myringoplasty" from January 1966 to July 2014 was performed.

STUDY SELECTION

Studies reporting outcomes of myringoplasty or Type I tympanoplasty in primary non-cholesteatomatous chronic tympanic membrane (TM) perforation were included.

DATA EXTRACTION

Of 4,698 abstracts reviewed, 214 studies involving 26,097 patients met our inclusion criteria and contributed to meta-analysis.

DATA SYNTHESIS

The primary outcome of success was defined as closure rate at 12 months. The independent variables analyzed were age, follow-up period, approach, graft material, perforation cause, size, location, ear dryness, and surgical technique. Only those studies providing data on a given parameter of interest could be included when comparing each variable.

CONCLUSION

The weighted average success rate of tympanic closure was 86.6%. Based on this meta-analysis, pediatric surgery has a 5.8% higher failure rate than adults and there is no correlation between follow-up period and success. Other variables associated with improved closure rates include perforation with a size less than 50% of total area (improved by 6.1%) and the use of cartilage as a graft (improved by 2.8% compared with fascia), while ears that were operated on while still discharging, those in different locations of the pars tensa, or using different surgical approaches or techniques did not have significantly different outcomes.

Inlay Butterfly Cartilage Tympanoplasty: Anatomic and Functional Results

To evaluate anatomic/functional results of inlay butterfly cartilage tympanoplasty and compare those with the results of over-underlay perichondrium-cartilage island or temporalis fascia tympanoplasties. Patients who operated for primary type 1 tympanoplasty (n = 78) with inlay butterfly cartilage (n = 25), over-underlay perichondrium-cartilage island (n = 36) or over-underlay temporalis fascia (n = 17) graft from January 2005 to January 2015 were included in the study. Age, gender, pre-/postoperative otoscopy findings/audiograms, and follow-up time were obtained from the patient's file. Anatomic integrity rates of the tympanic membrane, the mean gains of air bone gap on pure tone audiogram at four frequencies (0.5, 1, 2, 4 kHz) and complications were reviewed parameters. Functional evaluation was made in patients with intact tympanic membrane. Anatomic integrity rates of the tympanic membrane was 92.00% for inlay butterfly cartilage tympanoplasty, 91.67% over-underlay perichondrium cartilage island tympanoplasty and 88.2% over-underlay fascia tympanoplasty. The mean gains of air bone gap on pure tone audiogram for the inlay butterfly cartilage, over-underlay perichondrium cartilage island and over-underlay fascia graft group were 11.28, 12.84 and 12.66 dB respectively. Inlay butterfly cartilage tympanoplasty is a reliable and simple technique with satisfactory outcomes in selected cases. The anatomic and functional results after inlay butterfly cartilage tympanoplasty are parallel to the results of over-underlay perichondrium-cartilage island or temporalis fascia tympanoplasties.

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

CONCLUSIONS

Tympanoplasty using cartilage grafts has a better graft take rate than that using temporalis fascia grafts. There are no significant differences between cartilage grafts and temporalis fascia grafts for hearing outcomes. Contrary to the sliced cartilage sub-group, full-thickness cartilage grafts generate better hearing outcomes than temporalis fascia grafts.

OBJECTIVE

Tympanic membrane perforation can cause middle ear relapsing infection and lead to hearing damage. Various techniques have been applied in order to reconstruct the tympanic membrane. Recently, cartilage grafts and temporalis fascia grafts have been widely used for tympanic membrane closure. A systemic review and meta-analysis was carried out based on published retrospective trials that investigated the efficacy of cartilage grafts and temporalis fascia grafts in type 1 tympanoplasty. Both graft take rates and mean AIR-BONE-GAP gains were analyzed.

METHODS

Cochrane Library, PubMed, and Embase were systematically searched. After a scientific investigation, we extracted the relevant data following our selection criteria. Odds ratio (OR) of graft take rates and mean difference (MD) of AIR-BONE-GAP gains were calculated within 95% confidence intervals.

RESULTS

Eight eligible articles with 915 patients were reviewed. The pooled OR for graft take rate was 3.11 (95% CI =1.94-5.00; p = 0.43) and the difference between the two groups was significant, which means that the cartilage grafts group got a better graft take rate than the temporalis fascia grafts group. The pooled MD for mean AIR-BONE-GAP gain was 1.92 (95% CI = -0.12-3.95; p < 0.000 01) and the difference was not significant. However, in the full thickness cartilage grafts sub-group, the pooled MD for mean AIR-BONE-GAP gains was 2.56 (95% CI =1.02-4.10; p = 0.14) and the difference was significant, which means that the full thickness cartilage grafts sub-group got a better hearing outcome than the temporalis fascia grafts group. On the contrary, the pooled MD of sliced cartilage grafts sub-group was 0.12 (95% CI = -0.44-0.69; p = 0.61) and there was no significant difference between the sliced cartilage grafts and temporalis fascia group.

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

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

Butterfly myringoplasty for total, subtotal, and annular perforations

OBJECTIVES/HYPOTHESIS

The inlay "butterfly" cartilage tympanoplasty was first described as a treatment for small, central ear drum perforations. This technique can also be applied in large, marginal perforations, whereas the cartilage graft is anchored on the bony annulus. The aim of this study was to present the technique, to evaluate the results of butterfly tympanoplasty in marginal perforations, and to compare with the results of butterfly tympanoplasty in patients with nonmarginal perforations.

STUDY DESIGN

Retrospective case series.

METHODS

The files of patients who underwent inlay butterfly cartilage tympanoplasty for subtotal and total perforations from May 2011 to May 2013 were reviewed. Patients were followed with otoscopy and audiometry, and their results were compared with those of patients who underwent butterfly tympanoplasty for nonmarginal perforations.

RESULTS

Forty-eight patients underwent butterfly tympanoplasty for subtotal and total perforations during the study period. Exclusion criteria included: active inflammation during the 3 months prior to surgery, cholesteatoma, lack of follow-up, incomplete data, ossicular chain anomaly/discontinuity, and significant sensorineural hearing loss (average bone-conduction threshold at 500,1000 and 2,000 Hz poorer than 20 dB). Thirty-three patients were included. The mean age at surgery was 34 years (range, 19-76 years); 17 patients (51%) were male. Four patients were treated previously by tympanoplasty (revision surgery), whereas the other 29 had primary surgery. None of the patients had intraoperative or immediate postoperative complications such as sensorineural hearing loss on the operated ear or facial nerve palsy. One month after surgery, two patients had a residual perforation (94% success rate), and the mean speech recognition threshold (SRT) improved from 38 dB to 24 dB. The pure tone audiogram improved from 37.7 dB to 10.6 dB, and the word recognition score improved from 97.7 to 99.75. These results are comparable with our results in nonmarginal perforations, whereas a 92% success rate and a postoperative SRT of 26 dB were achieved in a cohort of 42 patients.

CONCLUSIONS

Inlay butterfly cartilage tympanoplasty is safe and effective in patients with total or subtotal perforations, and the results are comparable to those seen in nonmarginal perforations.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:2565-2568, 2016.

The effect of inlay butterfly cartilage tympanoplasty technique on compliance

CONCLUSION

IBCT technique should be preferred owing to its high graft survival rate and ABG gain. While no significant difference was found in middle ear pressures between ears that underwent IBCT and normal ears, compliance values were found to be decreased in patients undergoing IBCT. However, the lack of correlation between ABG gain and compliance values indicated that compliance increase had no effect on post-operative ABG results.

OBJECTIVE

The aim of the present study was to compare tympanometric and audiological parameters in patients undergoing inlay butterfly cartilage tympanoplasty (IBCT) with their normal ears and to determine their difference with normal ear tympanometric parameters.

METHODS

Overall, 25 patients that underwent an operation between August 2010-May 2014 were included in the present study. In 13 of these patients, the ear that did not undergo operation was normal. 0.5, 1, 2, 4 kHz pure sound average values, tympanometric measurements and compliance values of normal and operated ears were compared.

RESULTS

The graft survival rate in patients was found to be 92%. Mean pre-operative air-bone gap (ABG) was 16.4 ± 5.4 in patients, while mean post-operative ABG was 10.9 ± 5.8, with a statistically significant difference (p = 0.001) While there was no significant difference between operated and normal ears of patients in terms of middle ear pressure (0.441), compliance values were significantly higher in normal ears than those in operated ears (0.032). When post-operative ABG gain was compared with compliance values, no significant correlation was found between ABG gain and compliance measurements (r = -0.025 and p = 0.936).

Comparison of Short- and Long-term Hearing Outcomes of Successful Inlay Cartilage Tympanoplasty Between Small and Large Eardrum Perforations

OBJECTIVES

To compare the short- and long-term hearing outcomes after successful inlay cartilage tympanoplasty between patients with small (≤25%) and large (≥50%) eardrums perforations.

METHODS

This is a retrospective case series study conducted in a tertiary referral center. Twenty-five patients who underwent 27 procedures were enrolled. Their mean age was 60.26 years (range, 42 to 76 years). The mean follow-up time was 18.86 months (range, 12.30 to 35.83 months). The preoperative, initial postoperative, and long-term hearing results in patients with total repair of the eardrum were analyzed.

RESULTS

In the small size group, the average (±standard deviation) air-bone gap (ABG) closure was 1.08±7.53 dB in the short-term and 2.33±11.56 dB in the long-term hearing examinations. There was no difference between short- and long-term ABG closure (P=0.689). In the large size group, the average ABG closure was 9.77±9.40 dB in the short-term and 16.25±6.01 dB in the long-term hearing examinations. There was a significant difference between short- and long-term ABG closure (P=0.029).

CONCLUSION

Patients with large perforations have continuous hearing improvement and ABG closure for more than one year. In contrast, the short- and long-term postoperative ABGs are almost the same in patients with small perforations. More long-term postoperative follow-up of hearing results is necessary for large perforations.

A randomized prospective trial of a novel device for measuring perforation size during inlay 'butterfly' myringoplasty

AIM

This study introduces a new device to facilitate perforation size measurement during "butterfly" myringoplasty. The purpose of this study is to evaluate the use of 'otological compass' on short-term results of inlay cartilaginous 'butterfly' tympanoplasty technique in adult patients.

STUDY DESIGN

Prospective, randomized, controlled, blinded.

PATIENTS AND METHODS

This study included 25 patients who underwent inlay cartilage myringoplasty. All operations were performed under general anesthesia by the same surgeon with a microscope-assisted approach. The patients were divided randomly and consecutively into two groups: Group 1 (n=12) had perforation dimensions and shape measured using the Otologic Compass (OC) and the control group (n=13) had perforation measured by means of a Fisch elevator. The duration of surgery, number of trials for correct placement of the cartilage graft, results and complications of the surgery were evaluated and compared.

RESULTS

The mean follow-up duration was 6 months. Groups were similar in terms of age and perforation diameters (p>0.05). Average number of cartilage shaping before satisfactory graft fitting was significantly fewer in the OC group: 1.1 ± 0.3 and 2.2 ± 0.6 trials for OC and control groups, respectively (p<0.001). Mean duration of preparation and satisfactory graft fitting was 9.6 ± 4.2 minutes in the OC group whereas it was 18.1 ± 5.2 minutes for the control group. Operative duration was significantly shorter in the OC group (p<0.001). At the end of the follow-up period, successful closure occurred 91.7% and 84.6% patients in the OC and control groups, respectively (p>0.05). The mean preoperative to postoperative three-tone air-bone gap improved 7.9 dB and 9.0 dB in OC and control groups, respectively (p>0.05).

CONCLUSION

This study shows that OC presents as a useful tool that expedites and refines butterfly myringoplasty procedure. The number of cartilage shaping prior to satisfactory graft fitting revealed significantly better results: almost all surgeries in the OC group were complete after a single cartilage shaping attempt.

Inlay butterfly cartilage tympanoplasty in the treatment of dry central perforated chronic otitis media as an effective and time-saving procedure

The aim of this study is to compare the inlay butterfly transcanal cartilage tympanoplasty with the conventional underlay tympanoplasty. Operation time, pre- and postoperative hearing levels, successful closure rate of tympanic membrane (take rate) and long-term re-perforation in dry perforated chronic otitis media were evaluated. The study design consists of case series with a chart review. The study settings are tertiary referral center. Of the 72 patients (age range 14-57 years) with dry perforated chronic otitis media, 29 patients underwent inlay butterfly transcanal cartilage tympanoplasty (group 1) and 43 patients underwent conventional underlay tympanoplasty without mastoidectomy (group 2) between January 2010 and June 2012. The outcome measures were the duration of surgery, "take rate" at the 30th postoperative day and the audiometric results at the 45th postoperative day. Long-term re-perforation was evaluated at least postoperative 1 year. The graft take rate was 96.5 % in group 1 and 90.7 % in group 2 at the 30th postoperative day (p > 0.05). Mean air-bone gap was improved from 18.8 ± 8.09 to 11.9 ± 7.12 dB in group 1 and from 21.9 ± 7.32 to 11.6 ± 8.43 dB in group 2. The improvement of air-bone gap in both groups was statistically significant (p < 0.05) but the improvement between the groups was not statistically significant (p > 0.05). The average duration of the surgery was 29.9 ± 5.38 min for inlay tympanoplasty group and 58.9 ± 12.1 min for underlay tympanoplasty group (p < 0.05). Two patients in group 2 had re-perforations after an initial take of the graft in 1-year follow-up period. Inlay butterfly transcanal cartilage tympanoplasty is a good choice in selected cases. Although this technique has the similar take rate and audiological results with conventional underlay tympanoplasty, it is a time-saving procedure.

Are bovine pericardium underlay xenograft and butterfly inlay autograft efficient for transcanal tympanoplasty?

To evaluate the success rate and the surgical procedure of two different transcanal myringoplasty techniques using the Tutopatch(®) (Tutogen Medical, Inc., Alachua, FL, USA), a xenograft produced from bovine pericardium or the butterfly, an inlay tragal cartilage autograft. This is a retrospective study. We studied all cases of transcanal myringoplasty with Tutopatch and butterfly, performed by the same surgeon between April 2005 and May 2013. Perforations were secondary to chronic otitis media without cholesteatoma, perforation post ventilation tube or trauma. They were not exceeding one-third of the tympanic membrane surface for the Tutopatch and one quarter for the butterfly. We evaluated the anatomical success rate, complications and postoperative hearing results in both techniques. A total of 106 myringoplasties were performed: 66 with Tutopatch and 40 with butterfly with a mean follow-up of 16.5 and 5.2 months, respectively. Successful closure rates of Tutopatch and butterfly were 75.8% (P < 0.0001) and 85.0% (P < 0.0001), respectively. Myringitis controlled with topical antibiotics treatment occurred in 8 (12.1%) and 5 (12.5%) cases. Eighty percent of patients with Tutopatch had a mean residual air-bone gap within 10 dB, compared to 85.0% in patients with butterfly. When anatomically feasible, a transcanal approach myringoplasty with a Tutopatch(®) graft or butterfly appears to provide good anatomical and functional results. We show that both techniques provide good anatomical and functional results. The butterfly has the advantage to use an autograft, which is surgically easier because it does not require tympanomeatal flap elevation. We recommend the butterfly technique for non-marginal perforation not exceeding one quarter of the tympanic membrane after excision of the perforation edge and Tutopatch for bigger perforation or when standard autografts are not available. Myringitis is the only described complication without specific incidence.

Is cartilage better than temporalis muscle fascia in type I tympanoplasty? Implications for current surgical practice

The aim of this study was to compare the hearing results and graft integration rates in patients undergoing myringoplasty for the reconstruction of the tympanic membrane, with the use of either cartilage or temporalis muscle fascia (TMF). A systematic literature review in Medline and other database sources up to February 2012 was carried out, and the pooled data were meta-analyzed. Twelve studies were systematically analyzed. One represented level I, one level II and ten level III evidence. The total number of treated patients was 1,286. Cartilage reconstruction was used in 536, TMF in 750 cases. Two level III studies showed a significant difference between the pre- and postoperative air-bone gap closure, in favor of cartilage grafting. The mean graft integration rate was 92.4 % in the cartilage group and 84.3 % in the TMF group (p < 0.05). The rates of re-perforations were 7.6 and 15.5 %, respectively (p < 0.05). Among the other complications of type I tympanoplasty, retraction pockets, otitis media with effusion, anterior blunting, and graft lateralization were usually surgically managed, whereas most of the rest were minor and could be dealt with conservatively. The graft integration rate in myringoplasty is higher after using cartilage, in comparison with fascia reconstructions (grade C strength of recommendation), and the rate of re-perforation is significantly lower. Although cartilage is primarily used as grafting material in cases of Eustachian tube dysfunction, adhesive otitis media, and subtotal perforation in everyday surgical practice, a wider utilization for the reconstruction of the tympanic membrane in myringoplasties can be recommended.

Inlay "butterfly" cartilage tympanoplasty

OBJECTIVES

The aim of this study was to analyze the outcome of inlay "butterfly" cartilage tympanoplasty.

METHODS

The files of 42 patients (24 were male, 18 were female) who underwent primary or revision inlay butterfly cartilage tympanoplasty in 2005 to 2011 at a tertiary medical center were reviewed. Patients were regularly observed by otoscopy and audiometry.

RESULTS

The mean patient age was 27 years (range, 14-75 years), and the mean duration of follow-up was 24 months (range, 3-36 months). The postoperative period was uneventful. The technical (anatomical) success rate was 92% at 1 year. There was a significant decrease in the mean air-bone gap in 32 patients (preoperatively, 49.6 dB; postoperatively, 26.2 dB; P = .006). Results were suboptimal in 3 patients with persistent small perforations of the operated ear.

CONCLUSION

Inlay butterfly cartilage tympanoplasty appears to be effective in terms of defect closure and improved hearing, comparable with temporalis fascia graft tympanoplasty. Follow-up is necessary for at least 1 year when some perforation may reappear.

Randomized study comparing fascia and cartilage grafts in myringoplasty

OBJECTIVES

The study compares the medium-term outcomes of myringoplasty procedures using fascia and cartilage grafts.

METHODS

Patients with chronic otitis media with perforations larger than 50% of the size of the tympanic membrane were included in a randomized, controlled, prospective clinical trial. The perforations were repaired with either temporalis fascia (20 ears) or cartilage (18 ears) grafts selected randomly. A search of the literature was performed to look for other randomized studies comparing fascia and cartilage.

RESULTS

The graft take rates of fascia and cartilage grafts at 24 months were 84.2% and 80%, respectively. The postoperative air-bone gaps and hearing gains at 24 months were 16.97 dB and 13.63 dB, respectively, in the fascia group and 20.63 dB and 12.60 dB, respectively, in the cartilage group. There was no significant difference in the graft take rates or postoperative hearing between the two groups. The literature search identified one other randomized study comparing fascia and cartilage grafts in the repair of large perforations. The pooled data from the two studies did not show a difference in the graft take rates or hearing gains between cartilage and fascia.

CONCLUSIONS

There was no statistical difference in the outcomes of fascia and cartilage grafts in the repair of large perforations.