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

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 cartilage myringoplasty: our long term results

BACKGROUND

Myringoplasty is one of the treatments used for perforated tympanic membrane.

AIM/OBJECTIVE

We aimed to evaluate the long-term anatomical and functional outcomes of patients who underwent endoscopic inlay butterfly cartilage myringoplasty.

MATERIAL AND METHODS

We retrospectively analyzed 74 patients who had undergone endoscopic butterfly cartilage myringoplasty were followed for at least five years. The evaluation included age, sex, duration of follow-up, perforation location, size, preoperative and postoperative pure tone audiometry thresholds (years 2 and 5), air-bone gap, follow-up complications, and postoperative graft and tympanic membrane status.

RESULTS

The study included 74 patients with a mean follow-up duration of 76.7 months (range: 60-125 months). The graft success rates were 89.1% at two years and 82.4% at five years postoperatively. There was a significant improvement in air conduction thresholds when comparing preoperative levels to those at two and five years postoperatively (p = 0.003). The air-bone gap showed a significant reduction from preoperative levels to those observed at two and five years postoperatively (p < 0.0001).

CONCLUSION AND SIGNIFICANCE

Our study demonstrates that endoscopic butterfly cartilage myringoplasty is safe and effective for achieving long-term anatomical and functional success. We recommend extending the follow-up period to five years with additional annual assessments thereafter.

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.

Clinical Outcomes of Endoscopic Butterfly Inlay Cartilage Myringoplasty

OBJECTIVE

To review a 3-year case series of endoscopic butterfly inlay cartilage myringoplasty performed by a single surgeon (W.S.K.) and analyze the clinical surgical outcomes.

STUDY DESIGN

Retrospective study.

SETTING

Tertiary care academic center.

PATIENTS

We enrolled 60 ears with tympanic membrane (TM) perforation, receiving endoscopic inlay butterfly myringoplasty between 2019 and 2022.

MAIN OUTCOMES AND MEASURES

We reviewed patients' demographics, size and location of TM perforation, operation time, complications, and postoperative pain evaluated by the numerical rating scale (NRS). We analyzed the graft uptake success rate in 5 weeks and the perforation closure rate in 4 months after surgery. We also compared the air-bone gap (ABG) before and after the surgery.

RESULTS

Among the 60 ears included, the mean age was 57.0 years, and 78.3% (47 of 60) had small perforations. The average operation time was 48.9 ± 11.5 minutes, and the postoperative NRS was 2.0 ± 1.6. The immediate graft uptake success rate evaluated at postoperative 5 weeks was 96.7% (58 of 60), with myringitis occurring in three ears. Except for 11 patients lost to follow-up, the perforation closure rate evaluated at postoperative 4 months was 100% (49 of 49). The mean ABG significantly improved from preoperative status (8.87 ± 5.51 dB HL) to postoperative 4 months (6.22 ± 6.03 dB HL) ( p = 0.019).

CONCLUSIONS

A single surgeon's success rate for endoscopic butterfly inlay cartilage myringoplasty was almost 100%. This surgical procedure is safe and effective, with a high graft success rate.

Comparison of the Extended Perichondrium-Cartilage Butterfly Inlay Technique and Over-Underlay Technique for Repairing Subtotal Perforation: A 2-Year Follow-up Study

OBJECTIVE

To compare graft outcomes and postoperative complications between the extended perichondrium-cartilage butterfly inlay (PCBI) technique and the perichondrium-cartilage over-underlay (PCOU) technique for repairing subtotal perforations over a 2-year follow-up period.

METHODS AND MATERIALS

Patients with subtotal perforations were prospectively randomized to either the extended PCBI (n = 52) or PCOU (n = 51) group. Evaluation metrics included operation time, graft success rate, hearing gain, and complications at 24 months postoperatively.

RESULTS

The study included 103 patients with 103 ears. Follow-up loss occurred in 11 of 52 patients (21.2%) in the PCBI group and 13 of 51 patients (25.5%) in the PCOU group (P = .773). The final analysis included 41 of 52 patients (78.9%) in the PCBI group and 38 of 51 patients (74.5%) in the PCOU group. The average operation time was significantly shorter in the PCBI group (31.2 ± 1.9 min) compared to the PCOU group (52.8 ± 6.3 min, P < .001). At 24 months postoperatively, the graft success rate was 82.9% (34 patients) in the PCBI group and 92.1% (35 patients) in the PCOU group (P = .374). No significant group difference was noted in mean air-bone gap (ABG) gain (P = .759). High-resolution computed tomography (HRCT) demonstrated well-pneumatized mastoids and middle ears in both groups. Altered taste was reported in no PCBI group patients and 23.7% (9 patients) of the PCOU group patients (P < .05). Graft cholesteatoma was found in 4.9% (two patients) in the PCBI group and 7.9% (three patients) in the PCOU group (P = .930).

CONCLUSION

The endoscopic extended PCBI technique is safe and effective for repairing subtotal perforation. It avoids raising a tympanomeatal flap and demonstrates high long-term graft success with minimal complications.

Local Anesthesia-Based Modified Cartilage "Inlay" Graft Myringoplasty for Repairing Large Perforation

OBJECTIVE

The objective of this study was to evaluate the graft success rate and hearing outcome of modified cartilage inlay graft technique for repairing large perforations under local anesthesia.

STUDY DESIGN

Prospective case series.

METHODS AND MATERIALS

We performed a prospective study in 31 patients with large perforations who underwent endoscopic local anesthesia-based modified cartilage inlay graft technique with no raising of the squamous epithelium and no rimming of the perforation margins. The graft outcomes and complications were evaluated at 6 and 24 months postoperatively.

RESULTS

Thirty-one patients (31 ears) were included in this study. The mean operation time was 42.3 ± 2.6 (ranged 36-51) minutes. The visual analog scale pain scores at intraoperative and 2 and 48 hours postoperatively were, respectively, 2.6 ± 0.6, 1.4 ± 0.2, and 0.6 ± 0.1. The graft success rate was 100.0% (31/31) at 6 months after surgery. However, only 25 (80.6%, 25/31) patients completed a 2-year follow-up and performed a temporal bone CT examination; re-perforation was seen in 2 patients, the graft success rate was 92.0% (23/25). CT revealed the well-developed pneumatization of the mastoids and middle ear in all the patients. Nevertheless, 1 (1/25, 8.0%) patient developed a graft epithelial inclusion cyst, which was removed by endoscope in the outpatient setting. The mean preoperative air bone gap (ABG) was 23.1 ± 4.3 dB, while the mean postoperative ABG after 6 months was 14.9 ± 2.6 dB; the difference between these values was significant (P < .05; Wilcoxon's signed-rank test), and the functional success rate was 93.5% (29/31).

CONCLUSION

Endoscopic modified cartilage "inlay" graft technique with no raising the squamous epithelium and no rimming the perforation is a minimally invasive technique with a short operative time and satisfying success rate for closure of large perforations under local anesthesia.

The possible mechanism of Hippophae fructus oil applied in tympanic membrane repair identified based on network pharmacology and molecular docking

OBJECTIVE

This study aimed to explore the mechanisms of Hippophae fructus oil (HFO) in the treatment of tympanic membrane (TM) perforation through network pharmacology-based identification.

METHODS

The compounds and related targets of HFO were extracted from the TCMSP database, and disease information was obtained from the OMIM, GeneCards, PharmGkb, TTD, and DrugBank databases. A Venn diagram was generated to show the common targets of HFO and TM, and GO and KEGG analyses were performed to explore the potential biological processes and signaling pathways. The PPI network and core gene subnetwork were constructed using the STRING database and Cytoscape software. A molecular docking analysis was also conducted to simulate the combination of compounds and gene proteins.

RESULTS

A total of 33 compounds and their related targets were obtained from the TCMSP database. After screening the 393 TM-related targets, 21 compounds and 22 gene proteins were selected to establish the network diagram. GO and KEGG enrichment analyses revealed that HFO may promote TM healing by influencing cellular oxidative stress and related signaling pathways. A critical subnetwork was obtained by analyzing the PPI network with nine core genes: CASP3, MMP2, IL1B, TP53, EGFR, CXCL8, ESR1, PTGS2, and IL6. In addition, a molecular docking analysis revealed that quercetin strongly binds the core proteins.

CONCLUSION

According to the analysis, HFO can be utilized to repair perforations by influencing cellular oxidative stress. Quercetin is one of the active compounds that potentially plays an important role in TM regeneration by influencing 17 gene proteins.