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Cartilage Tympanoplasty - Anatomical and Functional Results
Sanae Mellouk*, Meryem Lahjaouj, Sara Halily, Yasser Hammouda, Sami Rouadi, Reda Allah Larbi Abada, Mohamed Roubal and Mohamed Mahtar
ENT department, 20 August hospital 1953 CHU IBN ROCHD Casablanca, Morocco
Submission: November 27, 2019; Published: December 09, 2019
*Corresponding author: Sanae Mellouk, ENT department, 20 August hospital 1953 CHU IBN ROCHD Casablanca, MoroccoPortugal
How to cite this article: Sanae M, Meryem L, Sara H, Yasser H, Sami R, et al. Cartilage Tympanoplasty - Anatomical and Functional Results. Glob J Oto, 2019; 21(2): 556059. DOI: 10.19080/GJO.2019.20.556059
Objective: To describe the anatomical and functional results of Cartilage tympanoplasty.
Material and Methods: We realized a transversal descriptive study, involving patients operated by cartilage tympanoplasty in the otolaryngology department of Casablanca University Hospital from January 2015 to December 2018.
Results: 107 patients were involved in this study. All the operations were performed under general anesthesia using the retro auricular approach in 98.1%. In 100 % of the cases, the grafting material was the cartilage. The underlay technique was applied in most of the cases. The anatomical and functional results evaluated over a mean follow-up of nine months are satisfactory. The tympanic closure was obtained in 96 % of cases. As a functional result, a hearing gain between 10 and 30 dB was obtained in 72.9%.
Conclusion: Thanks to its resistance, acoustic properties and best long-term anatomical results, cartilage is the material of choice for recurrent perforation, large perforation, uncontrolled shrink pocket, tympanic membrane atelectasis and dysfunction of the Eustachian tube.
Keywords: Tympanoplasty; Myringoplasty; Cartilage; Air-bone gap; Hearing loss
Tympanoplasty is a frequent otological surgical procedure that aims to restore the anatomical and functional integrity of the damaged eardrum. The term myringoplasty refers to type I tympanoplasty consisting of a reconstruction of the tympanic membrane without manipulation of the ossicular chain. This is one of the modalities of tympanoplasty. The main grafts used are temporal muscle fascia, conchal or tragal cartilage, and perichondrium . Cartilage is the main material used for its several advantages . The purpose of this work is to report the experience of the department of otolaryngology of Casablanca university hospital in type I tympanoplasty, and to evaluate the anatomical and functional results.
We realized a transversal descriptive study, involving patients operated by cartilage tympanoplasty in the otolaryngology department of Casablanca University Hospital from January 2015 to December 2018. We included in our study patients with tympanic perforation without ossicular involvement who underwent cartilage tympanoplasty and operated by senior surgeons. Patients with retraction pocket, ossicular chain involvement, lost to follow-up and incomplete records were
excluded from this study. The data included: Age, sex, otological history, consultation time, circumstances of discovery, otological examination, pre-operative auditory evaluation, surgical technique and postoperative anatomical and audiometric results.
The mean age in our study was 38.34 years (+/- 19.22 SD) (8 – 81 years). Most patients were female with a Male/Female ratio of 0.44. Hearing loss and otorrhea were the main complaints that motivated medical consultation. The consultation time varies from a few days to several years, but 67.3% of patients have a history that began in childhood. Tympanic perforation was more common on the left side (48.6%) and bilateral in 18.7% of patients. Subtotal perforations were the most common (41%), followed by inferior perforations (15%). The anterior edge was present in 52 patients (55.6%).
Examination of the contralateral ear showed a normal eardrum in 52% of cases, a perforation in 18.7% of cases, a retraction pocket in 16% of cases and a Myringosclerosis in 13% of cases. Audiometric evaluation showed conductive hearing loss in ninety cases (unilateral in 65 cases and bilateral in 25 cases) and mixed hearing loss in 17 cases. The average hearing loss was 47.20 dB (+/- 14.86 SD). The mean air-bone gap was 28.41 dB
Regarding treatment, myringoplasty was conducted by a
retro-auricular incision in 98.1% of cases. Per-operatively, the
tympanic cavity was dry in 83.2% of cases. The mucosa was
inflamed in 19.2% of cases. The ossicular chain was mobile and
continuous in all patients. For myringoplasty, we used cartilage
island graft with its perichondrium in an “underlay” position for
all patients. Mainly conchal cartilage (71%). We reinforced the
graft with temporal fascia in 88.8% of patients. The mean follows
up was nine months.
The mean post-operative air-bone gap was 15.79 (+/-7.25) dB
and the average hearing loss was 32.16 (+/-7.25) Db. A significant
improvement in hearing thresholds and air-bone gap was noted
after tympanoplasty (p <0.001) (Table 1). An improvement in
hearing (> 10 dB) was noted in 75.7% of patients (Table 2).
The main purpose of myringoplasty is reconstruction of the
perforated tympanic membrane and improvement of hearing.
The most commonly used graft materials are the temporal fascia,
perichondrium and cartilage. The latter has demonstrated its
advantages in many studies because of its anatomical stability,
ease of sampling, and resistance to shrinkage and necrosis.
Cartilage is available in enough quantity, slightly antigenic, and
better tolerated by the middle ear than other grafts . However,
there is concern that the thickness and rigidity of the cartilage
may affect functional performance . Studies showed that this
risk is eliminated by the refinement of the cartilage during graft
preparation . The ideal cartilage thickness in several studies is
0.4 mm .
Cartilage is increasingly used for recurrent middle ear
infections, retraction pockets, adhesive otitis, tympanosclerotic
perforations, anterior perforations, tubal insufficiency, bilateral
perforations and in the pediatric population [1,6,7]. In our series, we chose cartilage for all patient for its resistance, and because
perforation was often associated with Myringosclerosis. The
cartilaginous graft can be harvested from two preferential sites:
concha and tragus. However, we obtain a larger graft when using
The latter can be used as first line or second line if the tragal
cartilage has already been removed. Tragal cartilage is used
because of its flat surface, its thinness and its size adapted to
small perforations . The choice of cartilage type depends on
the size and location of the perforation, as well as the surgeon’s
experience. In our series, we used conchal cartilage in 76 patients
for large perforations and tragal cartilage in 31 patients for
anterior and small perforations.
The perichondrium (tragal or conchal) is nowadays
increasingly used as it has the advantage of being more resistant
while being thin. It behaves from an impedancemetric point of
view like a fascia . The temporal fascia is very often chosen as
a graft material in myringoplasty. Its physical qualities make it
easy to use especially after spreading and drying, but its relative
flexibility increases the risk of deformation in case of chronic tubal
dysfunction . The temporal fascia reinforced by cartilage has
become a widespread technique because of the better anatomical
and functional results compared to the use of the fascia alone.
In our study, 95 patients underwent myringoplasty using
temporal fascia reinforced by cartilage and achieved a tympanic
closure in all cases. On the other hand, the 12 patients in whom
cartilage alone was used, a tympanic closure was observed in 8
cases and 4 cases retained residual perforation. Evaluation of
the quality of closure of the tympanic membrane using cartilage
has been studied by many authors and compared to other
techniques such as fascia or perichondrium. We obtained closure
of the eardrum in 96.26% of cases which is close to the literature
data (Table 3) [12-15]. These authors also demonstrated better
auditory results in favor of cartilage tympanoplasty when
compared to other grafts. The average residual air-bone gap in
our study was 15.79 dB, slightly higher compared to other studies
(Table 4) [6,16,17].
Several parameters can influence anatomical and functional
results of cartilage tympanoplasty. The age, perforation size and
localization, middle ear inflammation, status of the contralateral
ear, tympanosclerosis and tubal dysfunction. The impact of each
factor remains difficult to determine. It is rather the combination of
these factors that influence the results of cartilage tympanoplasty
[18,19]. Thanks to its resistance, acoustic properties and better
long-term anatomical results, cartilage is the material of choice
in case of recurrent perforation, large perforation, uncontrolled
retraction pocket, atelectasis of the tympanic membrane and
eustachian tube dysfunction.
Lou Z, Lou Z H (2017) Full-thickness cartilage myringoplasty on the patulous Eustachian tube. Eur Arch Oto-RhinoLaryngol Off J Eur Fed Oto-Rhino-Laryngol Soc EUFOS Affil Ger Soc Oto-Rhino-Laryngol - Head Neck Surg 274(11): 4051-4053.