Factors Affecting Success and Results of Cartilage-Perichondrium Island Graft in Revision Tympanoplasty

Abstract

OBJECTIVE:The chance of complete postoperative healing of the tympanic membrane is relatively low due to poor blood supply of the graft in patients who undergo revision tympanoplasty. The aim of this study is to assess postoperative healing and the factors affecting closure of the tympanic membrane and hearing gain after revision tympanoplasty with cartilage-perichondrium island graft. MATERIALS and METHODS:This study was conducted as a retrospective review of charts of patients who underwent revision tympanoplasty with composite cartilage-perichondrium island graft at our clinic. Patients who underwent radical or modified radical mastoidectomy for the treatment of cholesteatoma and who had stapes fixation were excluded. All grafts were placed using over-under technique. Ossiculoplasty and mastoidectomy were performed as needed. Closure of the tympanic membrane and hearing thresholds were evaluated at the end of postoperative year 1. RESULTS:Thirty-three cases, 14 females and 19 males with mean age 37.5±12.7, were included in the study. Ossiculoplasty was performed in 8 cases, and mastoidectomy was added to tympanoplasty in 12 cases. Tympanic membrane was intact in 29 cases (87.4%) in the 12th postoperative month. Large perforation, adhesive tympanic membrane, and especially hypertrophic middle ear mucosa were found to have negative impact on success of graft (p<0.01). The success of graft in patients with mastoidectomy was lower than without mastoidectomy (p<0.001). Age (p=0.491), gender (p=0.567), surgical approach (p=0.378), and the number of operations (p=0.283) did not contribute to the success of the graft. Average improvement of postoperative air conduction hearing threshold was 13.2±5.5 dB, and average decrease in air bone gap was 11.7±5.5 dB. CONCLUSION:Postoperative closure rate of the tympanic membrane was high and audiologic improvement was satisfactory with cartilage-perichondrium island graft in revision tympanoplasty. Cartilage-perichondrium island graft may be preferred for reconstruction of the tympanic membrane because of its resistance to inflammation and poor feeding in revision tympanoplasty.

Success rates for various graft materials in tympanoplasty – A review

“…The success rate in tympanoplasty reported in the literature varies from 75 to 98% ( Sheehy and Anderson, 1980 ; Westerberg et al., 2011 ; Callioglu et al., 2013 ; Mohamad et al., 2012 ). Age of the patient, the size and site of perforation, eustachian tube functionality, the status of the middle ear mucosa, the type of graft and surgical experience have all been cited as factors which may influence the surgical outcome ( Westerberg et al., 2011 ; Mohamad et al., 2012 ; Lin et al., 2011 ; Şahan et al., 2014 ).…”

“…Furthermore, the technique entails certain risks, such as tympanomeatal blunting and cholesteatoma formation. Revision tympanoplasty, involving reconstruction of a TM perforation, is highly challenging, whichever technique is employed, because the tissues have a reduced nutritional supply ( Şahan et al., 2014 ).…”

“…Cartilage grafts offer better protection against infection, and can cope with high pressures, and vascular supply insufficiency. This means cartilage grafting is suitable for revision cases ( Mohamad et al., 2012 ; Şahan et al., 2014 ; Dornhoffer, 2003 ; Boone et al., 2004 ; Indorewala, 2004 ; Altuna et al., 2012 ; Ozbek et al., 2008 ).…”

“… Lesinkas and Stankeviciute (2011) detected tympanosclerosis and ossicular changes in 29.5% of patients during primary tympanoplasty, whilst these pathologies were present in 63.4% of revision cases. Furthermore, mucosal hypertrophy or discharge may indicate active inflammation or eustachian tube dysfunction ( Noh and Lee, 2012 ; Webb and Chang, 2008 ), which significantly reduces the rate of successful grafting in revision tympanoplasty ( Şahan et al., 2014 ). The presence of tympanosclerosis or adhesive otitis media decreases the chance of graft survival ( Callioglu et al., 2013 ; Dornhoffer, 2003 ; Lesinkas and Stankeviciute, 2011 ; Bhat and De, 2000 ).…”

Tympanoplasty Type-I using tragal perichondrium graft: Our experience

“…On the other hand the demerits of cartilage graft are that it mechanically reduces the vibratory pattern of TM, participating in impairment of functional results specifically of high tones and producing an opaque tympanic membrane that may hide underlying residual cholesteatoma 5. The common factors responsible for failure of tympanoplasty are atelactasis, eustachian tube dysfunction, tympanosclerosis, active suppuration, large perforation, unfavorable middle ear mucosa and revision myringoplasty 9. The mechanism of TM healing is described as such that there is prior ingrowths of connective tissue edges over which epithelium migrates till gap of perforation is closed.…”