Portuguese Version

Year:  2002  Vol. 68   Ed. 1 - (9º)

Artigo Original

Pages: 54 to 56

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Tragal pericondrium and cartilage timpanoplasty

Author(s): José Ricardo Gurgel Testa 1,
Miriam Scapin Teixeira 2,
Katia M. X. Ribeiro 2,
Gilberto Ulson Pizarro 3,
Ieda Millas 3

Keywords: cartilage, tympanoplasty.

Abstract:
Introduction: the cartilage tympanoplasty began to be use by Jansen in 1963 and has advocated for advanced middle ear problems. The cartilage had excellent survival capacity and tolerate retractions pockets. In 1998 Eavey describe the use of the cartilage butterfly technique with a inlay method. Study design: clinical prospective randomized. Material and method: There were 100 patients with chronic otites media and ear drum perforations with margins and submitted a ear plug tympanoplasty. The perforations ranged in size and approximately 40% of the surface area of the tympanic membrane. The average preoperative conductive hearing loss was 28.3 dB and 9.8 dB postoperative. Results: Total closure of the tympanum occurred in 95,0%. Conclusion: Finally, studying the results it is important to emphasize that the method is easy, with low complications, good audiological results and better anatomical results. It is a good option for the otologist to solve the chronic otites sequelae.

1 Professor, Discipline of Pediatric ORL,-UNIFESP - EPM
2 Post-graduate studies under course, Discipline of Pediatric ORL,- UNIFESP- EPM
3 Resident of Hospital Paulista de ORL

Discipline of Pediatric ORL, UNIFESP - EPM / Hospital Paulista de ORL

Address correspondence to: Rua dos Otonis, 684 - São Paulo - SP - Tel.: (55 11) 5576-4395

Article submitted on October 17, 2001. Article accepted on December 13, 2001.

INTRODUCTION

The first surgeries that aimed at closing the perforation of the tympanic membrane seemed to have been performed by Toynbee in 1853, by Kessel in 1878, and by Stacke in 18938,9. The lack of surgical microscope and antibiotics determined the early abandonment of the surgeries. They were restarted thanks to the studies conducted by Schulhof and Valdez in 1944 and Zollner and Wullstein in 19526,8,9, which used skin graft from the retroauricular region. As time went by, this type of graft failed and Hemann started to use fascia from the temporal muscle, which is well accepted up to today. Next, Tabb and Shea started to use the forearm vein. In 1960, Garcia-Ibanez proposed the use of tragus perichondrium 9.

Cartilage graft started to be used by Jansen9, especially in cases of advanced middle ear affections, because it was a more rigid graft that resisted better to reabsorption.

Altenau and Sheehy in 1978 used tragus grafts to tympanoplasties 1.

The use of graft with double perichondrium was proposed in 1967 by Harris and Goodhill8. Eviatar6 in 1978 made an extensive review of the use of tragus cartilage with perichondrium in otological surgery. Brockman in 1995 described the successful use of cartilage in type III myringoplasty 4. Eavey in 1998 described the tympanoplasty with the use of tragus cartilage and bilateral perichondrium (cartilage plug) and placement of the graft without incisions in the external acoustic canal5. In 2000, Luibianca-Neto published his first results with this type of technique, presenting good results12. Sperling and Kay used cartilage grafts to correct lateralized tympanic membranes15. Gerger et al. reported excellent auditory results with the use of cartilage in primary tympanoplasty. Danner and Dornhoffer in 2001 referred to the use of this type of graft with some variations of primary tympanoplasty 4.

Most recent studies showed that cartilage graft, when compared to other types of grafts, do not produce statistically significant difference concerning hearing, including gender and/or age. In addition, it has also shown 100% success in closing the tympanic cavity2, 5, 11, 13.

OBJECTIVE

In the present study, the tympanoplasty technique with tragus cartilage and perichondrium and its outcomes are discussed based on the prospective analysis of 100 patients surgically treated and followed up with clinical and audiometric assessment.

MATERIAL and Method

We studied 100 patients who had chronic otitis sequelae, with tympanic membrane perforation with margins, being 44 (44%) on the left ear and 56 (56%) on the right ear. The distribution was 65 (65%) male and 34 (34%) female patients, mean age of 23.6 years, ranging from 5 to 56 years. All ears were relatively healthy. Preoperative conditions of the ears, previous surgeries, other associated surgeries, pre and postoperative conductive hearing loss, closing index and complications were analyzed. All surgeries were performed by the same surgical team in the period between 1999 and February 2001. Mean pure tone audiometry was calculated based on values of 500 Hz, 1 KHz, 2 KHz and 4 KHz of air and bone curves.

technique

Under general or local anesthesia, with microscopic visualization, we observed the perforation. With a straight knife we removed the margins of the perforation and with a curved knife we cut the mucosa aspect of the tympanic membrane. Dimensions and formats of the perforation were measured with a hook knife, drew on a piece of sterile paper (package of the nylon thread that was going to be used later to close the tragus incision - donor area). We cut the paper and checked the real dimensions with the prepared model.

The tragus received a small incision of approximately 1cm long using a scalpel No. 15, transfixing it. Using delicate scissors, we dissected inferiorly the tragus cartilage, preserving the perichondrium on both sides of the anterior and posterior tissue and removed a fragment of slightly larger dimensions than the previously prepared model. We sutured the incision with nylon thread 5.0.

Using the same No. 15 scalpel, we followed the whole perimeter of the graft, making micro sulcus of approximately 1mm deep. Next, we adapted the graft into the perforation with perfect fixation. We applied a thin layer of gelfoam with antibiotic ointment and a cotton ball into the external acoustic canal.

One week after the surgery, we removed the incision stitches and aspirated the fragments of gelfoam, allowing the visualization of the graft and the assessment of its feasibility.

RESULTS

We observed a number of elements in 100 patients submitted to tympanoplasty with the use of tragus cartilage and perichondrium.

Dimensions of the perforation of the operated membranes ranged from a minimum of 10% to a maximum of 90% of the area (mean of 40%).

From the auditory assessment, we observed initial minimum air-bone gap of 5dB, up to a maximum of 50dB (mean of 28.3 dB) and final postoperative assessment at least 3 months after with minimum gap of 0dB up to a maximum of 30dB (mean of 9.8 dB). We noticed improvement of threshold averages in all cases.

We observed postoperative complications in five patients (5%), four subjects had local infections and another one had local infection and late facial paresis (6th post-op day). In both cases, there was improvement of signs and symptoms with clinical measures. There were no problems with the incision on the tragus.

We performed surgeries in patients with perforation of tympanic membrane with margins, and 12 subjects (37.5%) were cases of re-operation, whereas 20 subjects (62.5%) had their first surgery. Associated surgeries were performed in 13 subjects (40.6%), normally mastoidectomies in order to de-obstruct the antrum and the attic.

We observed closure of perforation in 95 cases (95%).

DISCUSSION

The use of cartilage grafts in reconstruction of tympanic membrane and middle ear is becoming very frequent3, 4, 5, 6.

Initially, the use of cartilage with perichondrium was indicated in subjects with large perforations, without posterior borders or attic retraction pockets1, 2, 8, 9, 10, 11, 14.

Procedures performed without incisions in the external acoustic canal provide great facilitation to the total surgical process, not requiring the removal of large plaques of tympanosclerosis, reducing the surgical time and dispensing acoustic canal packing. The graft format enables excellent fixation without requiring middle ear support or external acoustic canal support3, 4, 5.

Auditory outcomes, despite graft volume and mass, are very good and result in significant decrease of conductive hearing loss3.

The procedures presented good results both in primary cases and in re-operations3, 5.

Complications were not frequent in the studied references1, 2, 3, 4, 5, 12.

The success rate of perforation closure is very good and similar to other materials that are frequently used.5,11,12

CONCLUSION

Upon the analysis of the results, we concluded that:

1. tympanoplasty with tragus cartilage and perichondrium is easy to be performed;
2. complications are not frequent;
3. auditory results are very good and similar to other most frequently used techniques;
4. results concerning perforation closure are excellent.

REFERENCES

1. ALTENAU, M.M. & SHEEHY, J.L. - Tympanoplasty: cartilage prostheses - a report of 564 cases. Laryngoscope. 88(6):895-904, 1978.
2. AMEDEE, R.G.; MANN, W.J. & RIECHELMANN, H. - Cartilage palisade tympanoplasty. Am. J. Otol. 10(6):447-50, 1989.
3. DORNHOFFER, J.L. - Hearing results with cartilage tympanoplasty. Laryngoscope. 107(8):1094-9, 1997.
4. DANNER, C.J. & DORNHOFFER, J.L. - Primary intubation of cartilage tympanoplasties. Laryngoscope. 111:177-80, 2001.
5. EAVEY, R.D. - Inlay tympanoplasty: Cartilage butterfly technique. Laryngoscope. 108(5):657-61, 1998.
6. EVIATAR, A. - Tragal perichondrium and cartilage in reconstructive ear surgery. Laryngoscope. 88(11):1-23, 1978.
7. GERBER, M.J.; MASON, J.C. & LAMBERT, P.R. - Hearing results after primary cartilage tympanoplasty. Laryngoscope. 110:1994-99, 2000.
8. GOODHILL, V. - Tragal perichondrium and cartilage in tympanoplasty. Arch.Otolaryng. 85:480-91, 1967.
9. JANSEN, C. - Cartilage - tympanoplasty. Laryngoscope. 73:1288-1301, 1963.
10. KERR, A.G.; BYRNE, J.E.T. & SMYTH, G.D.L. - Cartilage homografts in the middle ear: a long term histological study. Laryngol. Otol., 87:1193-9, 1973.
11. LEVINSON, R.M. - Cartilage-perichondrial composite graft tympanoplasty in the treatment of posterior marginal and attic retraction pockets. Laryngoscope. 97:1069-74, 1987.
12. LUBIANCA-NETO, J.F. - Inlay butterfly cartilage tympanoplasty modified for adults. Otolaryngol Head Neck Surg. 123:495-4, 2000.
13. PAPPAS, D.G. & SIMPSON, L.C. - Annular wedge tympanoplasty. Laryngoscope, 102:1192-7, 1992.
14. POE, D.S. & GADRE, A.K. - Cartilage tympanoplasty for management of retraction pockets and cholesteatomas. Laryngoscope. 103:614-8, 1993.
15. SPERLING, N.M & KAY, D. - Diagnosis and management of the lateralized tympanic membrane. Laryngoscope. 110:1987-93, 2000.

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