ORIGINAL ARTICLE EVALUATION OF INLAY BUTTERFLY CARTILAGE TYMPANOPLASTY

AAMJ, VOL (12), NO (3), JULY 2014 AL-AZHAR ASSIUT MEDICAL JOURNAL ORIGINAL ARTICLE ‫ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ...
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AAMJ, VOL (12), NO (3), JULY 2014

AL-AZHAR ASSIUT MEDICAL JOURNAL

ORIGINAL ARTICLE ‫ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬

EVALUATION OF INLAY BUTTERFLY CARTILAGE TYMPANOPLASTY Mohammad Fatthy, Ahmed Elsheikh and Hatem Elhabashy Departments of Otorhinolaryngology, Faculties of Medicine, Al-Azhar University ‫ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬ ABSTRACT Objective: Evaluation of graft intake success rate and audiological outcome of inlay butterfly cartilage tympanoplasty technique. Patients and methods: This was a prospective study conducted on twenty patients (9 males & 11 females) presented with dry central perforation of the tympanic membrane with ranged size from 2 to 5mm and age ranged from 14 to 50 years.The inlay butterfly cartilage tympanoplasty was performed for all patients. Results: Success rate of graft intakewas 95% with air-bone gap improved to be less than 20 dB. Conclusion: Inlay butterfly tympanoplasty is technically simple, takes less time, with good anatomical and audiological results. INTRODUCTION Since tympanoplasty was firstly proposed by Wullstein in 1950s, lotsof materials,

including

temporalis

fascia,

fascia

lata,

veins,periosteum,

perichondrium, cartilage, fatty tissue, and skin were applied (Van Rompaey et al 2013). The most commonly used graft was temporalis fascia with 93%97% success rate in tympanoplasty(Lee et al 2012).Salen from Sweden was probably the first surgeon who experimented with cartilage myringoplasty with good results. He used septal cartilage with mucosa and perichondrium on one side, He achieved a success rate in 92% of patients, along with very good hearing results (Salen 1964). During the last decade, increasingly more 247

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otologists preferred to select cartilage rather than temporalis fascia. The sufficient stiffness and strength of cartilage rendered it better than temporalis fascia to resist the negative pressure inmiddle ear resulted from dysfunction of eustachiantube. Nevertheless, some otologists considered the same properties also brought negative effect on sound transmission (Lee et al 2012).In 1998, Eavey described a novel technique for cartilage tympanoplasty. He used tragal cartilage with perichondrium on both sides with very good results. He introduced this technique as inlay cartilage tympanoplasty and termed it as the butterfly technique. PATIENTS AND METHOD The present prospective study was conducted in Al-Azhar University hospitals from January 2013 to December 2013. It included twenty patients betweenfourteen to fifty years.The majority (70%) of the patients were in the age group of 14 to 24 years. Out of the total patients, 45% were males and 55% were females( Table 1). Table(1): Ages & sex of the paients Patient age (y) Male Female Total Percentage 14-24 6 8 14 70% 25-34 1 2 3 15% >35 2 1 3 15% All patients gave history of chronic suppurative otitis media and presented with dry central tympanic membrane perforation. The size of perforation, in 8 patients (40%) it was 3mm, in 5 patients (25%) was 4 mm, in 4 patients (20%) was 5mm and in 3 patients (15%) it was as small as 2mm. (Table 2). Table(2): patients perforation size Patients number 3 8 5 4

Perforation size (mm) 2mm 3mm 4mm 5mm

Percentage 15% 40% 25% 20%

All patients underwent transcanalcartilage butterfly tympanoplasty. Patients with cholesteatoma,or sensorineural hearing loss were excluded. Any patient 248

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with large perforation (exceeding 50% of the surface area of the tympanic membrane) was also excluded. Routine preoperative preparation was done including clinical examination,

CT scan of the temporal bone, pure tone

audiometry. All patients were operated under local anesthesia. The auricle and the surrounding skin was cleaned with betadine and draped to ensure complete asepsis. The local anesthesia preparation was xylocaine 2% with 1:100000 adrenaline.It was injected all around the auricle in the pre auricular, post auricular, supra auricular and infra auricular area as well as in the tragus.After waiting for 10 minutes, to ensure that the anesthesia is working, a tragalskin incision was made 2 mm away from the lateral edge in the medial side, so any scar will be less visible(Fig 1A). Afterexposing the tragal cartilage, an incision was made on its medial side 2 mm away from its edge leaving a small strip of cartilage in place to maintain tragal contour. The cartilage was excised with intact perichondrium on both sides(Fig. 1B). The wound wasclosed with silk sutures. The diameter of the graft was larger than that of the perforation by approximately1- 2 mms.The margin of the cartilage was grooved carefully all around using surgical blade no.15 under surgical microscope (Fig.1C). Using the surgical microscope the tympanic membrane perforation was viewed in transcanal fasion. The margin of the perforation was freshened using straight neddle and the size of perforation was measured.(Fig. 2A and 2B).The cartilage graft was slipped across the perforation one edge of the cartilage at a time, so the margins of the perforation went inside the groove to about 1 to 2 mm depth. When the graft was positioned, one surface of the cartilage with its perichondrium lies inside the middle ear and the other on the lateral side(Fig. 2C). The canal was packed with gelfoam and a sterile cottonball was put in the external ear.

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Postoperatively, Amoxicillin-clavulate 1gm. and diclofenac 50 mg were prescribed twice daily for 10 days. The patient was discharged on the same day. After one week, sutureswere removed with the cotton ball in the external ear while the gel foam was left to be absorbed.The operated ear was inspected after 4, 6, and 12 weeks. After 6 weeks,the pure tone audiometry was repeated and the averages air-bone gap was recalculated and compared with preoperative one. This statistical comparison was performed by student’s t-test. The graft intake was considered successful if the tympanic membrane get completely intact 6 weeks after the date of surgery.(Fig.2D).

Fig.(1): Tragal cartilage graft harvesting and preparation, A: tragal skin incision is 2 mm from the margin of the tragusB:excision of cartilage graft with perichondrium on both sides C: the graft after scoring of its margins

Fig. 2: The tympanic membrane perforation A: the perforation before refreshment B: refreshing the perforation margins C: the graft was positioned in the perforation D: the tympanic membrane get intact 6 weeks after surgery. RESULTS After the six postoperative week, 19 out of the 20 patients had an intact tympanic membrane with complete healing and closure of the perforation

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accounting for a 95% success rate. failure occurs in one case (male) due to infection. Preoperatively, Tenpatients had an air bone gap ranged from 11-20 dB, 5 patients ranged from 21 to 30 dB and 5 patients showed an air bone gap of greater than 30 dB, whereas no patient had an air bone gap below 10 dB prior to surgery. Postoperatively, after six weeks, 2 patients had an air bone gap below 10 dB, whereas 15 patients improved to below 20 dB, 2 patient had an air bone gap ranged fron 21-30dB and one patient remained at the same level (>30dB) (Table 3). Table(3): Comparison of pre & postoperative air bone gap on pure tone audiometry. Preoperative Postoperative Air Bone Gap(dB) (Number of patients) (Number of patients) ≤10 0 2 11-20 10 15 21-30 5 2 >30 5 1 DISCUSSION Tympanic membrane perforation is a common sequele of chronic suppurative otitis media. This will result in recurrent otorrhea and hearing loss. For repairing a tympanic membrane perforation,a commonly used graft is the temporalis fascia which may be used in an underlay or onlay technique(Onal et al 2011). In 1998 Eavey introducedcartilage,

perichondrium

tympanoplasty

to

forclosure

of

small

medium

butterfly sized

inlay

perforations.

Thistranscanal technique used composite tragal perichondriumcartilage graft, which is specially designed like a butterfly tofit in theperforation without support in middle ear orexternal auditory canal. The technique carries practicaladvantages of decreased surgical time, ease, comfort topatient, minimal

scarring,

improvedhearing and dry ear. Eavey first used tragal 251

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cartilage with perichondrium on both sides for small tympanic membrane perforation in children ranged in age from 6-19 years. His hypothesis for this technique was that since the children have repeated upper respiratory infections, the cartilage graft will resist reperforations subsequent to these infections. He also placed a split thickness skin graft on the cartilage (Eavey 1998). However, in our study we used neither skin nor any other graft over the cartilage. Cartilage tympanoplasty has many advantages in situations such as recurrent, residual, total perforations, chronic mucosal dysfunction or severely atelectatic tympanic membranes, where facia and perichondrium undergo atrophy and subsequent failure(Chen et al 2010).

In comparison to fascia and

perichondrium, cartliageis characterized by more stability and resistance to negative middle ear pressure(Yung, 2008). In a study conducted by Poe and Gadre in (1993), Cartilage was used for reconstruction of the posteriosuperior quadrant of the tympanic membrane, and it has been shown to reduce the incidence of recurrent retraction pockets because of its rigidity. Gerber, et al.(2000), studied the hearing results in patients who had cartilage tympanoplasty. The results were comparable to temporalis fascia. They advocated that a cartilage perichondrium graft is useful to prevent recurrence or progression of postoperative retraction pockets. Recent studies by Mohamad, et al.(2012), reported even better results with cartilage as compared to temporalis facia. In the present study,we applied this technique of inlay tympanoplasty for 20 patients (9 males and, 11 females)between 14-50 years. All patients were having small tomedium sized central perforation in tympanic membrane.No patient with sensory neural hearing loss or revision surgery was included in this study.

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Graft intake was seen in 95% of patients (with one failuredue to infection). Hearingimprovement was estimated by comparing air bone gap pre and postoperative and a significant improvement is observed. This procedure offers many advantages. Surgery takes 30minutes or less, thetechnique is easy to perform, and can be done as a daycare surgery. Cartilage perichondrium graft used appears to be stiff, thick, more resistant to initialperiod of bad nutritionand allows good sound conduction and. CONCLUSION Transcanal butterfly inlay tympanoplasty is a simple technique forrepair of small to medium sized perforation with good hearing improvement and highly intake rate up to 95%. It takesless operative time,

hasminimal donor site

scarring and can be accepted as a routine procedure inday-to-day practice.

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REFERENCES Chen XW, Yang H, Gao RZ, Yu R, Gao ZQ (2010): Perichondrium/cartilage composite graft for repairing large membrane perforations and hearing improvement. Chin Med J (Engl);123(3):301-304. Eavey R.D.(1998): Inlay tympanoplasty: cartilage butterfly technique. Laryngoscope. May;108(5):657-661. Gerber MJ, Mason JC, Lambert PR. (2000): Hearing results after primary cartilage tympanoplasty. Laryngoscope. 110(12):1994-1999. Lee JC, Lee SR, Nam JK, Lee TH, KownJk. (2012): Comparison of different grafting techniques in type I tympanoplasty in casas of significant middle ear granulation, OtoNeurotol. 33: 586- 590 Mohamad SH, Khan I, Hussain SS.(2012): Is cartilage tympanoplasty more effective than fascia tympanoplasty? A systematic review. OtolNeurotol. ;33(5):699-705. Onal K, Arslanoglu S, Songu M, Demiray U, Demirpehlivan IA.(2012): Functional results of temporalis fascia versus cartilage tympanoplasty in patients with bilateral chronic otitis media. J Laryngol Otol. 126(1):22-5. Poe DS, Gadre AK. (1993):Cartilagetympanoplasty for management of retraction pockets and cholesteatomas. Laryngoscope. 103(6):614-8. Salen B.(1964):Myringoplasty using septal cartilage. ActaOtolaryngol Suppl. 1964;188:SUPPL 188:82+. Van Rompaey V, Farr MR, Hamans E, Mudry A, Van de HeyningPH (2013): Allograft Tympanoplasty: a historical perspective. OtolNeurotol. 34: 180188 Yung M. (2008):Cartilage tympanoplasty: literature review. J Laryngol Otol. 22(7):663-72.

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‫الملخص العربى‬ ‫تقيين جراحة إصالح طبلة األذنباستخدام الغضروف بتقنية الفراشة‬ ‫انٓذف يٍ ْزِ انذساست كاٌ حمييى َخائج جشاحت إصالح رمب غشاء طبهت األرٌ باسخخذاو سلعت يٍ‬ ‫غضشٔف األرٌ بعذ إعذادِ بعًم شك حٕل يحيطّ بحيذ يكٌٕ نّ شفخاٌ إحذاًْا حكٌٕ داخم األرٌ‬ ‫انٕسطٗ ٔاألخشٖ خاسجٓا (حمُيت انفشاشت)‪.‬‬ ‫أجشيج ْزِ انذساست عهٗ عششيٍ يشيضا (حسعت ركٕس ٔ احذٖ عششة إَاد) فٗ انفخشة يٍ يُايش ‪2014‬‬ ‫إنٗ يُايش ‪ 2015‬بًسخشفياث جايعت األصْش ٔحشأحج أعًاس انًشضٗ بيٍ‬

‫‪ 14‬إنٗ ‪ 50‬عايا يًٍ‬

‫يعإٌَ يٍ رمب جاف صغيش أٔ يخٕسظ انحجى بطبهت اإلرٌ ٔأجشيج نٓى جًيعا انجشاحت سابمت‬ ‫انزكشٔكاَج َسبت انُجاح فٗ ْؤالء انًشضٗ‬

‫‪ %95‬يع ححسٍ فٗ انسًع يخٕسطّ‬

‫‪20‬ديسيبم فٗ‬

‫إخخباساث لياس انسًع بعذ انعًهيّ‪.‬‬ ‫أربخج ْزِ انذساست أٌ ْزِ انخمُيت أكزش سٕٓنت ٔحسخغشق ٔلخا ألم يٍ غيشْا ٔحعطٗ َخائج جيذةيٍ‬ ‫انُاحيت انخششيحيت ٔانسًعيت‪.‬‬

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