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Clinical outcome of revision cartilage tympanoplasty.

Abstract

We retrospectively reviewed 32 ears from 30 adult patients with chronic otitis media who underwent revision tympanoplasty using cartilage graft (performed by a single surgeon) from January 10, 2011, to May 10, 2016. All procedures were performed using an endaural incision for both temporalis fascia graft and tragal cartilage graft harvesting. The overall surgical success rate was 93.3%. The average preoperative hearing level was 43.1 [+ or -] 17.3 dBHL, and the average postoperative hearing level was 39.2 [+ or -] 18.2 dBHL, representing a significant improvement. The average air-bone gap was 19.4 [+ or -]7.6 dB preoperatively and 16.9 [+ or -] 9.9 dB postoperatively. Also of note, the improvement in air-bone gap reached the level of significance at 500 Hz (p = 0.023). We conclude that using cartilage graft in revision tympanoplasty is a safe and reliable technique with good surgical outcomes. Using one single endaural incision for both fascia and cartilage harvesting is simple while achieving aesthetic wound healing.

Introduction

Tympanoplasty is a commonly performed surgery for the management of chronic otitis media with the aim of preserving the tympanic membrane without infection and restoring the sound-conducting mechanism. Since it was first introduced by Wullstein in 1952 (1) and Zollner in 1955, (2) several grafting materials have been described including temporalis fascia, perichondria, periostia, vein, fat, and cartilage. (3-5)

To date, the temporalis fascia and perichondrium are still the grafting material mainstays in primary tympanoplasty, with a success rate ranging from 35 to 95%. (6,7) However, fascia and perichondrium appear to undergo atrophy and subsequently fail in the reconstruction of high-risk perforations, (8) such as total or subtotal atelectatic perforations, those with cholesteatoma, and revision cases. In these situations, cartilage tympanoplasty is being used increasingly due to its stability, resistance to negative middle ear pressure, and resistance to infections due to the lack of vascularization. (9) Compared with fascia graft, similar functional results (hearing improvement) but better morphologic results (intact eardrum) have been reported with the use of cartilage tympanoplasty. (10)

One of the possible risk factors of failed tympanoplasty is persistent negative middle ear pressure, in which fascia and perichondrium grafting might not be sufficiently robust. Therefore, in revision surgery, cartilage graft maybe preferred because of its rigidity, a property that may promote resistance to negative middle ear pressure.

The aim of this study was to analyze the anatomic and audiologic results of revision cartilage tympanoplasty.

Patients and methods

From January 10, 2011, to May 10, 2016, we analyzed 30 adult patients (32 ears) with chronic otitis media who underwent revision cartilage tympanoplasty; all surgeries were performed by a single surgeon. Patients with cholesteatoma or younger than 20 years were excluded.

By retrospective chart review, we recorded each patient's sex, age at operation, perforation size (small: perforation up to one-third of the tympanic membrane; medium: perforation between one-third and two-thirds of the tympanic membrane; large: perforation more than two-thirds of the tympanic membrane), preoperative and postoperative pure-tone audiograms (500, 1,000, 2,000, and 4,000 Hz, respectively), and surgical success.

All patients underwent revision cartilage tympanoplasty according to the following protocol. First, an endaural incision was made to facilitate temporalis fascia graft harvesting. Second, the medial part of the tragus was harvested from the same incision and cut into halves to be used as the cartilage graft. Third, after refreshing the perforation edge and elevating the tympanomeatal flap, an underlay grafting technique with a temporalis fascia graft and cartilage reinforcement was performed (figure 1). No patient underwent simultaneous ossiculoplasty.

Surgery was considered successful if no residual perforation of the eardrum was present. Postoperative pure-tone audiometry was measured 3 months after surgery. The average hearing level was defined as the mean air-conduction threshold at 500, 1,000, 2,000, and 4,000 Hz.

A paired t test was performed to determine the difference between preoperative and postoperative pure-tone average and air-bone gaps. Statistical significance was assumed forp < 0.05. Statistical analysis was performed with the Statistical Package for the Social Sciences for Windows, v. 19.0.

This study was approved by the Institutional Review Board of Taipei Veterans General Hospital.

Results

A total of 30 patients (17 men and 13 women) (32 ears) with a mean age of 52 years (range: 20 to 74) were enrolled. The mean number of previous tympanoplasties was 1.18 (range: 1 to 3); perforation size was small in 14 (43.8%) ears, medium in 13 (40.6%) ears, and large in 5 (15.6%) ears, and included 2 total perforations. The average preoperative air-bone gap was 19.4 [+ or -] 7.6 dB. The mean follow-up time was 7 months (range: 1 to 45), and the overall surgical success rate was 93.3%. An image obtained 9 months postoperatively is shown in figure 2.

Audiologic outcomes. The average hearing level was 43.1 [+ or -] 17.3 dBHL preoperatively and 39.2 [+ or -] 18.2 dBHL postoperatively. The change between preoperative and postoperative hearing level was significant (p = 0.029) (table 1). The average air-bone gap declined from 19.4 [+ or -] 7.6 dB preoperatively to 16.9 [+ or -] 9.9 dB postoperatively, a trend toward improvement that did not reach statistical significance (p = 0.196) (table 2).

Both the change in hearing level and air-bone gap reached a level of significant improvement at 500 Hz (tables 1 and 2).

Discussion

Use of the cartilage graft was first described in middle ear surgery in 1959, (11) and it has been used in the management of high-risk perforations more recently due to its robust and rigid characteristics. In revision tympanoplasty, eustachian tube dysfunction and negative middle ear pressure are the possible causes of previous failure.

Compared with fascia and perichondrium grafts, cartilage graft proved to be a superior choice in revision surgery because of its superior resistance to negative middle ear pressure.

Although primary tympanoplasty has a high success rate, the graft-take rate decreases in revision tympanoplasty. Lesinskas and Stankeviciute reported successful closure rates of primary and revision tympanoplasty of 93.6 and 90.2%, respectively. (12) Additionally, the graft-take rates of revision tympanoplasty were 90.9% for temporal fascia, 82.4% for perichondrium, and 93.8% for perichondrium/cartilage as graft material, without a statistically significant difference between them.

Sismanis et al reported a 93.5% graft-take rate with the use of cartilage shield grafts in revision tympanoplasty, (13) and Boone et al reported a 94.7% graft-take rate with tragal cartilage-perichondrium island graft or palisaded concha cymba cartilage. (14)

In our study, the overall success rate was 93.3%, which was comparable to that obtained in previous studies. Residual perforation was found in 2 patients, 1 with a small and 1 with a large preoperative perforation. Neither size of perforation nor number of previous tympanoplasties correlated with surgical success. Possible explanations for surgical failure in these 2 cases were anterior marginal perforation in 1 patient, which was a relative surgical challenge compared with central perforation, and granulation with fibrosis in the middle ear cavity of the other patient, which may imply previous infectious status.

Several techniques for cartilage tympanoplasty have been described, such as cartilage palisade tympanoplasty, cartilage shield graft, perichondrium/cartilage island flap, cartilage butterfly inlay technique, and cartilage reinforcement tympanoplasty. (13,15-17) In the present study, we used a single endaural incision for both temporalis fascia and tragal cartilage harvesting. The advantages of this method are that only one incision was needed and there was no deformity of the tragus postoperatively. To our knowledge, this surgical technique has not been reported previously.

We showed a statistically significant improvement in the mean postoperative hearing level, from 43.1 [+ or -] 17.3 dBHL preoperatively to 39.2 [+ or -] 18.2 dBHL postoperatively, but not in the mean postoperative air-bone gap, which declined from 19.4 [+ or -] 7.6 dB preoperatively to 16.9 [+ or -] 9.9 dB postoperatively. However, changes in the hearing level and in the air-bone gap at 500 Hz both improved significantly (42.8 [+ or -] 15.5 dBHL to 32.6 [+ or -] 18.0 dBHL, and 18.6 [+ or -] 11.2 dB to 11.1 [+ or -] 14.5 dB, respectively). One possible explanation is that sound transmission was affected because of an increased mass and stiffness of the cartilage graft, especially at high frequency.

Using laser Doppler vibrotomy, Zahnert et al showed that cartilage should not exceed 0.5 mm in thickness to minimize the energy loss in sound transmission.18 Through the use of finite element analysis, Lee et al reported that the optimal thickness of cartilage graft was 0.1 to 0.2 mm for medium (55% perforation) and large perforations (85% perforation), and less than 1.0 mm for small perforations (15% perforation). (19) Sound transmission properties at different frequencies require further investigation.

The limitation of the present study was the relatively small sample size.

Conclusion

Revision cartilage tympanoplasty is a safe and reliable technique with both an excellent morphologic result and good audiologic outcome at low frequency. A novel single endaural incision approach was advantageous for both fascia and cartilage harvesting and also achieved aesthetic wound healing.

Pei-Yin Wei, MD; Chia-Hui Chu, MD, MPH; Mao-Che Wang, MD, PhD

From the Department of Otorhinolary ngology-Head and Neck Surgery, Taipei Veterans General Hospital, Taipei, Taiwan (Dr. Wei, Dr. Chu, and Dr. Wang); and the School of Medicine, National Yang-Ming University, Taipei (Dr. Chu and Dr. Wang).

Corresponding author: Mao-Che Wang, MD, No. 201, Sec. 2, Shipai Rd., Beitou District, Taipei City, Taiwan 11217, R.O.C. Email: wangmc@vghtpe.gov.tw

References

(1.) Wullstein HL. Funktionelle operationen im mittelohr mit hilfe des freien spaltlappen-transplantates. Arch Ohren-Nasen-u. Kehlkopfh 1952;161:422-35.

(2.) Zollner F. The principles of plastic surgery of the sound-conducting apparatus. J Laryngol Otol 1955;69(10):637-52.

(3.) Heermann H. Tympanoplasty with fascial tissue taken from the temporal muscle after straightening the anterior wall of the auditory meatus [in German], HNO 1961;9:136-7.

(4.) Shea JJ Jr. Vein graft closure of eardrum perforations. J Laryngol Otol 1960;74:358-62.

(5.) Nissen AJ, Nissen RL, Yonkers AJ. A historical review of the use of bone and cartilage in otologic surgery. Ear Nose Throat J 1986;65(11):493-6.

(6.) Caylan R, Titiz A, Falcioni M, et al. Myringoplasty in children: Factors influencing surgical outcome. Otolaryngol Head Neck Surg 1998;118(5):709-13.

(7.) Vartiainen E. The results of chronic ear surgery in a training programme. Clin Otolaryngol Allied Sci 1998;23(2):177-80.

(8.) Buckingham RA. Fascia and perichondrium atrophy in tympanoplasty and recurrent middle ear atelectasis. Ann Otol Rhinol Laryngol 1992;101(9):755-8.

(9.) Beutner D, Huttenbrink KB, Stumpf R, et al. Cartilage plate tympanoplasty. Otol Neurotol 2010;31(1):105-10.

(10.) Mohamad SH, Khan I, Hussain SS. Is cartilage tympanoplasty more effective than fascia tympanoplasty? A systematic review. Otol Neurotol 2012;33(5):699-705.

(11.) Utech H. Tympanotomy in disorders of sound conduction; its diagnostic and therapeutic possibilities [in German], Z Laryngol Rhinol Otol 1959;38(4):212-21.

(12.) Lesinskas E, Stankeviciute V. Results of revision tympanoplasty for chronic non-cholesteatomatous otitis media. Auris Nasus Larynx 2011;38(2):196-202.

(13.) Sismanis A, Dodson K, Kyrodimos E. Cartilage "shield" grafts in revision tympanoplasty. Otol Neurotol 2008;29(3):330-3.

(14.) Boone RT, Gardner EK, Dornhoffer JL. Success of cartilage grafting in revision tympanoplasty without mastoidectomy. Otol Neurotol 2004;25(5):678-81.

(15.) Dornhoffer J. Cartilage tympanoplasty: Indications, techniques, and outcomes in a 1,000-patient series. Laryngoscope 2003;113(11):1844-56.

(16.) Eavey RD. Inlay tympanoplasty: Cartilage butterfly technique. Laryngoscope 1998;108(5):657-61.

(17.) Uslu C, Tek A, Tatlipinar A, et al. Cartilage reinforcement tympanoplasty: Otological and audiological results. Acta Otolaryngologica 2010;130(3):375-83.

(18.) Zahnert T, Bornitz M, Huttenbrink KB. Acoustic and mechanical properties of tympanic membrane transplants [in German]. Laryngorhinootologie 1997;76(12):717-23.

(19.) Lee CF, Chen JH, Chou YF, et al. Optimal graft thickness for different sizes of tympanic membrane perforation in cartilage myringoplasty: A finite element analysis. Laryngoscope 2007;117(4):725-30.

Caption: Figure 1. These photographs show elements of the single endaural incision approach. A: An endaural incision is made. B: Both the temporalis fascia (dashed arrow) and tragal cartilage (arrow) grafts are harvested with a single incision.

Caption: Figure 2. In this image, an intact eardrum without residual perforation can be seen on otoscopy 9 months postoperatively.
Table 1. Comparison of preoperative and postoperative hearing level

                     Hearing level (dB) [+ or -] SD        p Value

Frequency (Hz)      Preoperative        Postoperative

500              42.8 [+ or -] 15.5   32.6 [+ or -] 18.0   0.001 *
1,000            41.3 [+ or -] 16.2   37.3 [+ or -] 18.1   0.103
2,000            40.3 [+ or -] 20.0   38.4 [+ or -] 19.6   0.387
4,000            47.8 [+ or -] 25.8   48.4 [+ or -] 22.1   0.786
Average          43.1 [+ or -] 17.3   39.2 [+ or -] 18.2   0.029 *

* Statistically significant.

Key: SD = standard deviation.

Table 2. Comparison of preoperative and postoperative air-bone gap

                      Air-bone gap (dB) [+ or -] SD        p Value

Frequency (Hz)      Preoperative        Postoperative

500              18.6 [+ or -] 11.2   11.1 [+ or -] 14.5   0.023 *
1,000            19.7 [+ or -] 11.9   18.1 [+ or -] 8.6    0.537
2,000            17.7 [+ or -] 9.4    18.1 [+ or -] 8.6    0.859
4,000            21.8 [+ or -] 10.1   19.3 [+ or -] 10.4   0.320
Average          19.4 [+ or -] 7.6    16.9 [+ or -] 9.9    0.196

* Statistically significant.

Key: SD = standard deviation.
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Article Details
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Title Annotation:ORIGINAL ARTICLE
Author:Wei, Pei-Yin; Chu, Chia-Hui; Wang, Mao-Che
Publication:Ear, Nose and Throat Journal
Article Type:Report
Date:Oct 1, 2018
Words:2245
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