Comparative study on usage of temporalis fascia vs. periosteum in myringoplasty.
Peforations in the tympanic membrane are commonly due to middle ear infections or trauma. Surgical management of perforation and hearing restoration by Myringoplasty is needed if the perforation fails to heal by conservative therapy. (1) Vibratory area of the tympanic membrane is restored by Myringoplasty, thus facilitating in improving hearing and providing round window protection. It also prevents exposure of the middle ear to external infections and allergens.
Biological graft materials act as a scaffold of tissue matrix when applied to seal the perforation and this subsequently revascularises, in readiness for migration of fibroblasts and epithelium. Autologous graft materials used in Myringoplasty include vein, fat, fascia lata, temporalis fascia, periosteum, perichondrium and cartilage. Materials vary regarding their ease of harvesting, preparation time, placement ease, viability, graft uptake and hearing improvement. (2)
However due to their anatomical proximity, translucency and suppleness, temporalis fascia and periosteum were the preferred grafting materials selected for this study.
Deafness in CSOM with inactive mucosal disease with central perforation has been challenging to the otologist for many years because of its morbidity, which needs early surgical intervention i.e Myringoplasty. (3, 4) Temporalis fascia is being used as a graft material for routine purposes. Even though the literature gives minimal knowledge, periosteum was selected for this study to evaluate further on it.
In adult human body, even though the periosteum is available abundantly over the bones which are superficial, the periosteum available for an ENT surgeon in the local operative and incisional area is about 120 cm that is temporal and mastoid area. Periosteum was selected for this study as 1. It is available in adequate quantity 2. Can be taken in same incision (As other grafts like vein, fat need to be taken through a separate incision and perichondrium was not chosen to avoid perichondritis) 3. Tesile strength is good. According to Mohamed Al lackany, Nadia Nassif Sarkis due to the lack of elasticity and resistance to pressure changes in the external ear canal, several authors has suggested that temporalis muscle fascia should be replaced by cartilage or strengthened by periosteium. (4)
MATERIALS AND METHODS
This prospective study has been conducted during the period of July 2012 to July 2014 on patients attending the OPD of Government ENT Hospital, Visakhapatnam, a tertiary care centre. Out of the average of 250 cases per day that attend the OPD, 60-70 were found to be suffering from CSOM.
Patients with CSOM with inactive mucosal disease i.e dry central perforation were selected. Study group of 100 patients, between the ages of 15-55 years underwent myringoplasty using temporalis fascia and periosteum.
Patients excluded from this study were those
* Below 15 years and above 55 years.
* H/o previous ear surgery/sensory neural hearing loss.
* With co-existing middle ear conditions like tympanosclerosis, ossicular discontinuity and otosclerosis.
* CSOM with granulations /polyp/ extracranial/ intracranial complications.
All 100 patients were subjected to otological examination with endoscope and microscope for any evidence of polyps, granulations, oedematous mucosa. Patients with discharging ears were given antibiotics pre-operatively to achieve dry ears. Preoperative Pure tone audiometry was recorded for all cases. General examination, routine blood investigations and X-ray of mastoids were performed. After thorough pre anaesthetic check up, patients consent was taken for Myringoplasty. Advantages and complications of the surgery were explained.
Local anaesthesia was preferred as the bleeding is minimal, hearing improvement can be assessed on-table and to avoid intubation related complications. General anaesthesia was preferred in non-co-operative patients. All the patients were operated by post aural approach.
First group of 50 patients underwent Myringoplasty with Temporalis fascia by underlay technique.
Second group of 50 patients underwent Myringoplasty with periosteum by the same underlay technique. Periosteum of size 10 mm X 20 mm was harvested from mastoid cortex below linea temporalis to tip of mastoid and kept dry.
Treatment given post operatively: Inj. Ceftriaxone 1 gm/i.v./twice daily for 7 days. Oral antihistaminics and decongestants for 2 weeks. Oral Analgesics and antiinflammatory were given. Mastoid bandage and sutures were removed on the 7th post-operative day. Patients were advised to avoid allergic food, entry of water into ear and take advised medication regularly. They were followed up regularly for every 2 weeks for 1 month and every 3 months for 1 year.
In this study, 54 females and 46 males were identified.
Male to female ratio is 46 : 54. Group 1-23 males and 27 females, In Group 2-23 males and 27 females
15-24 age group was most commonly (44%) effected, followed by 25-34 years (29%), 35-44 years (14%) while 45-55 years (13%) was the least.
Laterality of Symptoms
Among 100 patients, 23% were found to have bilateral disease while 77% had unilateral disease. 48% of the patients had their left ear involved while 29% had disease in the right ear.
Symptoms No. of Cases Percentage Ear discharge 80 80% Hard of hearing 100 100% Ear pain 11 11% Tinnitus 15 15%
Hard of hearing was noted to be the most common complaint with all patients, while 80% had associated ear discharge. 15% of the patients presented with tinnitus while 10% presented with ear pain
Perforation Group 1 Group 2 Total Anterior 22 28 50 Posterior 18 12 30 Subtotal 10 10 20
In the preoperative otoscopic examination, perforation in the anterior half of tympanic membrane was seen in 50% patients, while in posterior half in 30% and subtotal perforation in 20%.
Preoperative Hearing Assessment
Air Bone No. of Gap (In dBs) Cases 0-10 0 10-20 0 20-30 8 30-40 48 40-50 37 50-60 7 60-70 0
Preoperative pure tone audiogram showed 48% having air bone gap around 30-40 db, 37% around 40-50 db, 8% have 20-30 db and 7% have around 50-60 db.
Graft Total Take Residual Success Up Perf. % Temporalis fascia 50 46 4 92% Periosteum 50 48 2 96%
In this study, 4 patients had residual perforation with temporalis facia whereas 2 had residual perforation with periosteum Postoperative results after 3 months of surgery showed 92% of successful graft uptake in case of temporalis fascia where as 96% of patients with periosteum.
Hearing Improvement post post Total Success OP <15 DB OP >15 DB % Temporalis Fascia 40 10 50 80% Periosteum 38 12 50 76%
There was almost 80% improvement in hearing in patients subjected to surgery with temporalis fascia as a graft where as 76% was the hearing improvement in cases of periosteum graft.
Otitis media is a general term used to describe any inflammatory disease of the mucous membrane of the middle ear cleft. It is caused by multiple inter-related factors including infections, Eustachian tube dysfunction, allergy and barotrauma. (5) Critical problem in the surgical repair of the tympanic membrane was to find a suitable grafting material. Temporalis fascia followed by perichondrium and periosteum are being used as grafting materials but the literature available in the usage of periosteum is minimal.
Temporalis fascia and periosteum are extremely thin grafts with very low metabolic requirements and have been proved to act as excellent templates for vascularization. (6)
In this study, we have compared the results of temporalis fascia versus periosteum grafts used for the repair of tympanic membrane using underlay technique in Myringoplasty. Both the grafts are accessible near the operative site, available in adequate amount, have excellent contour, can be thinned down and possess excellent survival capacity. (7) Myringoplasty was performed on 50 cases using temporalis fascia and other 50 cases with periosteum as a graft material. It was observed that the overall uptake rate and hearing restoration with either of the grafts was almost identical. However, graft uptake was noted to be more in favour of periosteum (96%) comparative to temporalis fascia (92%) whereas the hearing restoration is in favour of temporalis fascia (80%) comparative to periosteum (76%). (8, 9) Periosteum holds advantage due to minimal shrinkage, excellent graft uptake
From the present study we conclude that both temporalis fascia and periosteum provide viable autograft material. Both materials are mesodermal in origin which excludes the risk of iatrogenic cholesteatoma. (10) Results of hearing restoration with temporalis fascia were noted to be better than that of periosteum and graft uptake was better with periosteum than that of temporalis fascia. (11, 12) Hence through this study it can be said that the periosteum can also be considered as the one of the graft material for routine Myringoplasty as it has been estimated to give equal results both in closure of the perforation and also hearing improvement.
Temporalis fascia is good as a graft material in routine Myringoplasty, particularly in professionals with hearing importance. Periosteum also can be chosen as a graft material in routine myringoplasty and particularly in Revision Myringoplasty due to two reasons 1. Previous surgeon already used temporalis facia. 2. The graft uptake is better with periosteum in this observation.
(1.) Jaisinghani VJ, Paperella MM, Schachern PA. Lect tympanic membrane correlates in chronic otitis media. Laryngoscope 1999;109(5):712-6.
(2.) Fisch U. Myringoplasty in Fisch u, may j eds. Tympanoplasty, mastoidectomy and stapes surgery. sttugart; George theime verlag, 1994;9-41.
(3.) Storrs LA. Myringoplasty with use of fascia graft. JAMA otolarygal 1961;74(1):45-9.
(4.) Mohamed Al lackany, Nadia Nassif Sarkis. Functional results after myringoplasty and type 1 tympanoplasty with the use of different graft materials. Journal of the Medical Research Institute 2005;26(4):369-74.
(5.) Hentzer E. Ultra structure of human tympanic memebrane. Acta oto laryngological 1969;68(1-6):376-90.
(6.) Albert PW. Epithelial migration over tympanic membrane and external auditory canal. Journal of laryngology and otology 1964;78:808-30.
(7.) Merchant SN, Mckenna MJ, Rosowski JJ. Current status and futre challenges of tympanoplasty. European archives of otorhinolaryngology 1998;255(5):221-8.
(8.) Black JH, Wormold PJ. Myringoloplasty effects on hearing and contributing factors. South African medical journal 1995;85(1):41-3.
(9.) Meyer AG, Albers FW. Validation of hearing results in tympanoplasty. In: Huettenbrink ed. Middle ear mechanics in researches and otosurgery, 1997;147-50.
(10.) Palva T, Ramsay H. Myringoplasty and tympanoplastyresults related to training and experience. Clinical otolaryngology and allied sciences 1998;23:177-80.
(11.) Salmaz MA, Yucel EA, Ozdemir M, et al. Comparison of hearing levels and tympanic membrane healing obtained bycartilage palisade and temporal fascia in tympanoplasty technique: preliminary results. Kulak Burun Bogaz Ihtis Derg 2002;9(4):271-4.
(12.) Gierek T, Slaska KA, Majzel K, et al. Results of myringoplasty and type 1 tympanoplasty with the use of fascia, cartilage and perichondrium grafts. Otolaryngol Pol 2004;58(3):529-33.
S. Surya Prakasa Rao , T. V. S. S. N. Leela Prasad , N. Veeraswamy , Swathi Vadlamani 
 Professor, Department of ENT, Andhra Medical College, Visakhapatnam.
 Assistant Professor, Department of ENT, Andhra Medical College, Visakhapatnam.
 Assistant Professor, Department of ENT, Andhra Medical College, Visakhapatnam.
 Post Graduate, Department of ENT, Andhra Medical College, Visakhapatnam.
Financial or Other, Competing Interest: None.
Submission 06-02-2016, Peer Review 08-04-2016, Acceptance 13-04-2016, Published 02-05-2016.
Corresponding Author: Dr. S. Surya Prakasa Rao, 50-27-15/1, Seethammadara, North East, Visakhapatnam-530013.
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|Title Annotation:||Original Article|
|Author:||Rao, S. Surya Prakasa; Prasad, T.V.S.S.N. Leela; Veeraswamy, N.; Vadlamani, Swathi|
|Publication:||Journal of Evolution of Medical and Dental Sciences|
|Article Type:||Clinical report|
|Date:||May 2, 2016|
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