International Journal of Medical and Health Research Original Research Article

International Journal of Medical and Health Research

ISSN: 2454-9142
Received: 24-02-2019; Accepted: 27-03-2019
www.medicalsciencejournal.com
Volume 5; Issue 4; April 2019; Page No. 118-121

Assessment of anterior tucking and cartilage support tympanoplasty to Evaluate graft

uptake and hearing outcome
Dr. Chandan Kumar1*
1
Senior Resident, Department of Otorhinolaryngology (ENT), Nalanda Medical College & Hospital, Patna, Bihar, India
*
Corresponding Author: Dr. Chandan Kumar

Abstract
Advantages of the lateral graft technique include wide exposure and versatility for larger perforations and for any needed
ossicular reconstruction. Disadvantages include the requirement of a higher technical skill level, a longer operative time,
slower healing rate, and the risk of blunting and lateralization of the graft. The lateral graft technique is championed by the
some doctors as a technique more suited for total drum replacement. Based on the above literature findings the present study
was planned to evaluate the anterior tucking and cartilage support tympanoplasty with respect to graft uptake and hearing
outcome.
The present study was planned in the Department of Otorhinolaryngology (ENT), Nalanda Medical College & Hospital. Total
50 patients referred to the ENT department from March 2016 to September 2017 for chronic otitis media (COM) having tubo-
tympanic type of disease were enrolled in the present study. The cases were taken up for Anterior Tucking (AT) and Cartilage
Support (CS) Tympanoplasty for the treatment.
This study was aimed to compare the effect of the two methods on the graft uptake and hearing improvement. The study
concludes that the Anterior Tucking type of tympanoplasty shows statistically better hearing improvement as compared to that
of Tragal Cartilage Support method.

Keywords: anterior tucking, cartilage support, tympanoplasty, cortical mastoidectomy

Introduction The middle fibrous layer is composed of connective tissue

Tympanoplasty is a surgical technique to repair a defect in consisting of outer radial fibers and inner circular fibers. It
the tympanic membrane with the placement of a graft, either provides strength to the drum. A healed perforation is also
medial or lateral to the tympanic membrane annulus. The commonly deficient of this middle fibrous layer. The
goal of this surgical procedure is not only to close the epithelial and endothelial layers regenerate creating a
perforation but also to improve hearing. The success of the “dimeric” membrane. This miscalculation can be corrected
operation depends on the ability to eradicate disease from when carefully examined under binocular microscopy.
the middle ear (eg, inflamed granulation tissue and Because this middle layer is absent in the pars flaccida
cholesteatoma). Various techniques have been developed superiorly, the posterior-superior aspect of the drum can be
and refined, and a number of grafting materials are drawn inward toward the middle ear as a retraction pocket.
available. Both the lateral and medial grafting techniques The inner layer of the tympanic membrane consists of
are detailed below. Tympanoplasty is a safe and effective simple cuboidal and columnar epithelium cells. This layer is
outpatient procedure used to both eradicate disease from the identical to the mucosal lining of the rest of the middle ear
middle ear and restore hearing and middle ear function [1, 2]. mucosal tissue and is considered to be critical to ensure
A number of surgical approaches and grafting techniques healing of tympanic membrane perforations, and the
are available for use by the surgeon. Paramount to success surgeon often abrades or rasps the undersurface of the
are the preoperative assessment, good hemostasis tympanic membrane remnant to stimulate regrowth.
intraoperatively, and thoughtful surgical planning with Complications of the surgery include recurrence of the
careful placement of the graft. perforation, tympanic membrane retraction, otorrhea,
The outer epithelial layer is composed of stratified cholesteatoma development, persistence or worsening of
squamous epithelium, which is continuous with the skin of any conductive hearing loss, sensorineural hearing loss
the external auditory canal. This is significant because in- (rare), and taste disturbances. Post-auricular incisions are at
growth of this outer epithelial portion through the risk for hematoma, and a mastoid pressure dressing is
perforation can result in an epithelial cyst called an acquired recommended for the first postoperative night. Outcomes
cholesteatoma. Untreated, this cyst then releases destructive can be optimized by a proper and detailed preoperative
enzymes that can enlarge the size of the perforation and assessment and the careful construction of an effective
ultimately cause ossicular erosion. The lateral grafting surgical plan. The graft can fail because of infection, failure
technique that is discussed later in this text requires that this to pack the graft securely in place, technical error, failure to
entire epithelial layer be stripped from the drum remnant clear mastoid and middle ear disease, and because of a
prior to placement of the graft so as to avoid iatrogenic concurrent undetected cholesteatoma. Excising all
cholesteatoma formation. tympanosclerosis at the edge of the perforation so as to

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allow vascularized perimeters to incorporate the graft is The middle ear was examined for the status of mucosa and
critical. ossicular chain continuity.
When planning tympanoplasty, the surgeon must consider Both the groups shared the same operative steps till
the location of the perforation (marginal versus central), and elevation of the posterior tympanomeatal flap. Then
size (total versus subtotal). Areas of myringosclerosis and onwards different steps were followed in two different
tympanosclerosis should be noted. Important comorbidities methods as described below.
worth noting include craniofacial disorders and underlying
environmental allergies or chronic allergic rhinitis. Critical 1. Anterior Tucking (AT) method: Incision was taken on
factors that make tympanoplasty less successful include anterior canal wall just lateral to the anterior annulus and the
adhesive otitis media, severe eustachian tube dysfunction anterior tympanomeatal flap was elevated. The graft was
with either perforation of the contralateral ear or ongoing placed lateral to the handle of malleus and tucked medial to
intermittent otorrhea, cholesteatoma, and previous surgical the annulus anteriorly and anterior and posterior
repair [3-4]. Various techniques and grafting materials can be tympanomeatal flap were reposited.
used, and these are covered later. Which approach is used
depends on the size and location of the perforation, the 2. Cartilage Support (CS) method: Here the tragal
presence or absence of cholesteatoma or granulation tissue, cartilage was harvested in addition to the temporalis fascia.
the status of the ossicles and mastoid, other anatomical Tragal cartilage was denuded of its perichondrium and cut
considerations (eg, narrow external auditory canals), as well into a bow or a crescentric shape. This shape helps in proper
as the surgeon’s preference and expertise [5-6]. Examining alignment of the graft in relation to the Antero-superior
the middle ear and ossicles and removing any elements of middle ear space. No anterior flap was elevated but the
adhesions or cholesteatoma is critical. The chosen approach temporalis fascia graft was placed over the antero-superiorly
should provide optimal visualization of the perforation and based tragal cartilage graft. Thus the tragal cartilage graft
tympanic membrane. One should be careful not to disrupt an placed medial to the annulus in the Middle ear space not
intact and mobile ossicular chain if the hearing loss is only only supported the temporalis fascia graft, but prevented its
low-frequency conductive, as is often the case with hearing medialisation also. Also, Cartilage held fascia in place,
loss secondary to a perforation [7]. preventing a residual perforation due to graft mobilisation.
Although variations exist, 2 primary grafting techniques All the patients were informed consents. The aim and the
exist: medial grafting (or underlay) and lateral grafting (or objective of the present study were conveyed to them.
overlay). These terms refer to the position of the graft in Approval of the institutional ethical committee was taken
relation to the fibrous annulus, not to the malleus or prior to conduct of this study.
tympanic remnant. The medial grafting technique is Following was the inclusion and exclusion criteria for the
performed as described previously. The primary advantage present study.
of the medial graft technique is that it is quicker and easier
to perform than lateral grafting. It also carries a high success Inclusion criteria: Inclusion criteria were cases of
rate (approximately 90% in experienced hands). The biggest tubotympanic type COM with subtotal perforation, where
disadvantage is its limited exposure and poor utility for discharging ears were also included; patients with age group
larger perforations and its difficulty with repair of near-total – 15 to 60 yrs.
perforations.
Advantages of the lateral graft technique include wide Exclusion criteria: Patients with or who had following
exposure and versatility for larger perforations and for any conditions were excluded cholesteatoma with atticoantral
needed ossicular reconstruction. Disadvantages include the disease; hearing impairment more than 50 dB which
requirement of a higher technical skill level, a longer indicate ossicular chain discontinuity; already undergone
operative time, slower healing rate, and the risk of blunting tympanoplasty or any other otologic surgery; sensorineural
and lateralization of the graft. The lateral graft technique is hearing loss.
championed by the some doctors as a technique more suited
for total drum replacement. Based on the above literature Results & Discussion
findings the present study was planned to evaluate the A group of 25 patients was undergone for anterior tucking
anterior tucking and cartilage support tympanoplasty with method and in remaining 25 patients (second group)
respect to graft uptake and hearing outcome. tympanoplasty was performed using temporalis fascia as the
primary graft, along with tragal cartilage graft used for
Methodology providing support to it anteriorly. These patients were
The present study was planned in the Department of followed up for a period of 6 months and were evaluated for
Otorhinolaryngology (ENT), Nalanda Medical College & graft uptake and hearing improvement.
Hospital. Total 50 patients referred to the ENT department In the past, many techniques of grafting have been used.
from March 2016 to September 2017 for chronic otitis There have been many modifications and variations of the
media (COM) having tubo-tympanic type of disease were technique of tympanoplasty. Primrose and Kerr [8] described
enrolled in the present study. The cases were taken up for their techniques of closing the anterior marginal perforation,
Anterior Tucking (AT) and Cartilage Support (CS) wherein a small tag was fashioned anteriorly and later
Tympanoplasty for the treatment. pulled through a small tunnel under the anterior-superior
Type I tympanoplasty was done in all the patients. All annulus.
surgeries were done under microscope. After infiltration of Palva described the surgical treatment of chronic
local anaesthesia with 2% lignocaine with adrenalin and suppurative otitis media (CSOM) using myringoplasty and
painting and draping, post auricular Wilde’s incision was tympanoplasty. His underlay “swinging door” technique
taken. Temporalis fascia graft was harvested in all the cases. was successful in 97% of the ears. Palva's “swinging door”

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tympanoplasty was modified and reported by several have concluded that tympanoplasty using cartilage with or
surgeons including Glasscock, Fisch, Smyth, and without perichondrium has better morphological outcome
Pennington. The basic technique involves the elevation of than tympanoplasty using temporalis fascia. However, there
superiorly based and inferiorly based canal skin flaps, or was no statistically significant difference in hearing
“swinging doors.” outcomes between the 2 grafts. Khan and Parab [13] have
A retrospective study of 200 cases was conducted by Moras shown good anatomical and functional results using sliced
et al. [9]. data were sourced from 200 patients who cartilage for tympanoplasty technique. Chhapola and Matta
underwent tympanoplasty for CSOM, tubotympanic disease [14]
have mentioned that cartilage thickness of <0.5 mm is
by 360° technique. The study showed an overall success rate seen to have similar acoustic properties as the tympanic
of 96% for graft uptake. Eight patients (4%) were found to membrane.
have a residual perforation. This study was designed to evaluate results of
In a study conducted by Burse et al. 2009 [10]. 50 clinically tympanoplasty and to see if there is significant difference in
diagnosed cases were randomly divided into two groups of hearing when cartilage shield tympanoplasty is used for
25 each to be operated by anterior tucking method and reconstruction of tympanic membrane and also to note the
cartilage support method of tympanoplasty. Successful graft graft uptake rates. Many patients of chronic otitis media in
uptake was observed in 96% of patients in both the groups India have unhealthy middle ear mucosa and large, subtotal,
but it was not statistically significant. or total perforations of the ear drum. This requires
additional support for the graft material to increase chances
Table 1: Age & Sex of Study Groups of graft uptake. The current study was done in cases of
Groups Group I Group II mucosal disease to objectively evaluate results of
Method C.S. method A.T method tympanoplasty and to study if there is any difference in
Total Cases 25 25 hearing improvement as cartilage is a thicker grafting
Age material.
20 – 30 years 4 3
31 – 40 years 12 15 Conclusion
41 – 50 years 7 5 This study was aimed to compare the effect of the two
51 – 60 years 2 2 methods on the graft uptake and hearing improvement. The
Gender study concludes that the Anterior Tucking type of
Male 15 20 tympanoplasty shows statistically better hearing
Female 10 5
improvement as compared to that of Tragal Cartilage
Total 25 25
Support method.
Table 2: Graft uptake
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