Chinese Medical Journal 2010;123(3):301-304

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Original article
Perichondrium/cartilage composite graft for repairing large tympanic membrane perforations and hearing improvement
CHEN Xiao-wei, YANG Hua, GAO Ru-zhen, YU Rong and GAO Zhi-qiang Keywords: otitis media; perichondrium/cartilage; tympanoplasty; tympanomastoidectomy; hearing improvement
Background The main risk factors for postoperative failure in tympanoplasties are large perforations that are difficult to repair, annular perforations, and a tympanic membrane (TM) with extensive granular myringitis that require middle ear exploration and mastoidectomy. The aim of this study was to investigate a novel technique of perichondrium/cartilage composite graft for repairing the large TM perforation in the patient of otitis media. Methods Retrospective chart reviews were conducted for 102 patients with large tympanic membrane perforations, who had undergone tympanoplasty from August 2005 to August 2008. Tympanoplasty or tympanomastoidectomy using a perichondrium/cartilage composite graft was analyzed. The tragal or conchal perichondrium/cartilage was used to replace the tympanic membrane in patients. Results Patients aged from 13 to 67 years were followed up in average for 24 months (1036 months). Seventy-four ears (72.61%) were used the tragal perichondrium/cartilage as graft material and 27 ears (27.39%) were used the conchal perichondrium/cartilage. Graft take was successful in all patients. Postoperative complications such as wound infection, hematoma, or sensorineural hearing loss were not identified. Nine patients (8.82%) had the partial ossicular replacement prosthesis, 14 patients (13.72%) using the autologous curved incus and 79 patients (77.45%) without prosthesis. Successful closure occurred in 92% of the ears. A total of 85.8% patients achieved a postoperative hearing improvement. Conclusions The graft underlay tympanoplasty using perichondrium/cartilage composite is effective for the majority of patients with large perforation. The hearing was improved even if the mastoidectomy was required in the patients with otitis media with extensive granulation. Chin Med J 2010;123(3):301-304

he main risk factors for postoperative failure in tympanoplasties are large perforations that are difficult to repair, and a tympanic membrane (TM) with extensive granular myringitis that require middle ear exploration and mastoidectomy.1-3 The optimal repair for such defects should preserve the shape of the native tympanic membrane to best protect vibrational characteristics, prevent formation of adhesions, and resist reperforation. The durability of the grafted material is vital in a patient who is susceptible to continued Eustachian tube dysfunction and otitis media. In tympanoplasties or tympanomastoidectomies, the tragal or conchal perichondrium/cartilage grafts have many advantages because it can be used the setting of a myringosclerotic tympanic membrane so that no middle ear support is needed.2,3 We report a retrospective study of tympanoplasty and tympanomastoidectomy cases using a novel technique with a perichondrium/cartilage composite graft that follows these principles. Our results demonstrate that the perichondrium/cartilage composite graft is suitable for treating large TM perforations and can achieve satisfactory hearing improvements. METHODS Patients A chart review of patients who underwent tympanoplasty or tympanomastoidectomy using the perichondrium/

cartilage technique between August 2005 and August 2008 was performed after approval by the hospital board. Cases of failure in tympanoplasty requiring total tympanic membrane replacement were included in the study. Successful criteria graft was defined as having no perforation, graft retraction, or lateralization. Hearing results were analyzed by comparing the preoperative and postoperative pure-tone average (PTA) and air-bone gap (ABG) at 500, 1000, 2000, and 4000 Hz. Exclusion criteria included the nature of sensorineural hearing loss of the disordered ear and the contraindications of anesthesia before surgery. Informed consent forms were obtained from all the patients. All surgeries and the postoperative follow-up examinations were performed by the authors. At each visit, otological examination and pure tone audiometry were taken and status of the repaired tympanic membrane and hearing
DOI: 10.3760/cma.j.issn.0366-6999.2010.03.009 Department of Otolaryngology-Head and Neck Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China (Chen XW, Yang H, Gao RZ, Yu R and Gao ZQ) Correspondence to: Dr. CHEN Xiao-wei, Department of Otolaryngology-Head and Neck Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China (Email: chenxw_pumch@yahoo.com.cn)

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Chin Med J 2010;123(3):301-304

Figure. Underlay method in both groups of tympanoplasty. A: Large perforation of right tympanic membrane. B: Placement of the cartilage graft between the malleolar manubruim and stapedial capitulum. C: Placement of the perichondrium over the cartilage graft and of the vascular strip to its original position.

were recorded. Surgical techniques All patients received operations under general anesthesia. Local anesthesia was applied with vasoconstrictor to guarantee a clean operation field and to relieve the post-operative otalgia. The decision between choosing transcanal approach or post-auricular approach was made based on the preoperative examination with a microscope. If the external ear canal was broad and straight enough to view all of the residual margins of TM perforation, transcanal approach would be chosen. If the external ear canal was narrow or curved or there was bony protuberance baffling the thorough observation of the entire TM, a post-auricular approach would be applied. If mastoid needed to be explored in surgery based on preoperative examination or CT scan, post-auricular approach would also be used. The tragal perichondrium/cartilage composite graft was harvested if transcanal approach or post-auricular approach was taken, whereas the conchae perichondrium/cartilage composite graft was obtained only when the post-auricular approach was considered. All access grafts were 2 mm larger than the perforation of TM in diameter. Tragal cartilage harvesting would not affect the cosmetic appearance if 2-mm strip of cartilage in the dome of the tragus was left. If mastoid needed to be explored, a canal-wall-up mastoidectomy would be operated first. When TM was thoroughly visualized under the surgical microscope, epithelia along the perforation margin of TM were carefully stripped and skin-TM flap was elevated to expose the tympanic cavity. A thorough exploration of the tympanic cavity was performed to make sure that there was no cholesteatoma. The integrity and mobility of the ossicular chain was tested during myringoplasty and tympanomastoidectomy. Underlay method was applied in both groups of tympanoplasty (Figure). In patients with fibrous annulus being absent, the cartilage graft was placed at the level of the tympanic

sulcus area. For patients with severe retraction of the malleus, the tensor tympani tendon was sectioned medial to the neck to lateralize the manubrium and allow medial placement of the cartilage graft. The ossicular reconstruction was performed with partial ossicular reconstruction prostheses (PORP) or an autologous curved incus if it was required. The vascular strip flap was then put back to its original position. The postauricular incision was closed in two layers with absorbable sutures. Hearing measurement Hearing was measured by testing the pure tone average PTA at 500, 1000, 2000 and 4000 Hz before the surgery and at 1st month, 3rd month and 1st year after surgery. The difference between the preoperative and post-operative PTA-ABG was compared to evaluate the hearing improvement. Statistical analysis The hearing results between the pre-operative and post-operative groups were compared by Students t test. The hearing results among the type of associated hearing reconstruction were compared using 2 test and paired t test using SPSS16.0 (USA). A P value less than 0.05 was considered statistically significant. RESULTS The results of 102 perichondrium/cartilage composite underlay grafts were retrospectively analyzed. The mean postoperative follow-up interval was 24 months (range, 1036). From August 2005 to August 2008, we treated 102 patients with large perforation of chronic otitis media with or without extensive granulartion. Patient ages ranged from 13 to 67 years, and the mean age was 37.35 years. The male to female ratio was 1:1.21. Fifteen ears in teen patients had a history of previous tympanoplasty surgery. All of the patients presented with large perforations. Fifty-six ears (54.90%) were operated through a transcanal approach and 46 ears (45.10%) were treated by postauricular tympanoplasty. In 26 cases (25.49%), the tympanomastoidectomy with intact canal

Chinese Medical Journal 2010;123(3):301-304 Table. Comparison between pre-operative and post-operative PTA-ABG according to type of associated hearing reconstruction
Perichondrium/cartilage composite graft group n Pre-operative PTA-ABG (dB) Post-operative PTA-ABG (dB) No prosthesis 79 41.6610.22 22.868.23* Partial ossicular replacement prosthesis 9 46.7710.28 23.609.33* Autologous curved incus 14 44.3010.17 25.178.80* PTA: pure-tone average. ABG: air-bone gap. * P <0.05, conmpared with pre-operative PTA-ABG..

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wall was performed. The underlay technique was used with the tragal (72.61%) or conchal perichondrium/ cartilage (27.39%) as graft material. Successful closure occurred in 96.10% of the ears. Perichondrium/cartilage composite take was successful in all patients. Ossicular reconstruction partial ossicular replacement prosthesis was used in 9 patients (8.82%) and an autologous curved incus in 14 patients (13.72%). In 79 patients (77.45%), no prosthesis was required. One patient developed wound infection. No other postoperative complications such as hematomas, perichondritis, auricular deformities, or sensorineural hearing loss were identified. No patient developed recurrent cholesteatomas. The audiometric results were based on the 102 patients. The preoperative PTA-ABG was (41.6610.22) dB in the tympanoplasty group (n=76), or (46.949.26) dB in the tympanomastoidectomy (n=26), and the postoperative PTA-ABG was (26.868.92) dB or (23.6010.33) dB. An overall postoperative ABG of 20 dB or less was achieved in 57 of the 102 patients (55.88%). Hearing improvement was statistically significant in the tympanoplasty or the tympanomastoidectomy patients (P <0.05, P <0.05). There was also statistically significant hearing improvement in all patients with intact ossicular chain and those who underwent Bigel PORP reconstruction or autologous curved incus (P <0.05, P <0.05, Table). There was no significant difference among the groups in mean post-operative PTA-ABG (P >0.05). DISCUSSION The introduction of cartilage as graft for tympanoplasty almost debuted at the same era as temporalis fascia.1-4 Then different modifications of harvesting the cartilage graft led to many novel techniques for specific indications, such as the island technique, the palisade technique, the shield technique, the wheel technique.5,6 The use of cartilage as a grafting material has been advocated in cases at high risk for the tympanoplasty failure, such as subtotal or total perforations, adhesive processes, tympanosclerosis and residual defects after primary tympanoplasty.7-9 Use of cartilage material has once been criticized because of concerns regarding hearing results. Two main reasons why many otologists prefer fascia than cartilage are the compliance of operation and the postoperative hearing improvement. Thickness of the cartilage graft certainly will affect the hearing result. However, large cartilage plates with thickness no more than 0.5 mm have been suggested as an acceptable comprise and the graft take of this technique has been reported excellent. Subtotal or total perforations at high risk for graft failure could be treated efficiently and a durable and resistant reconstruction of the TM with

reasonable hearing can be achieved.10 Our data indicate that cartilage graft with perichondrium at thickness of 0.5 mm achieved TM closure in more than 96% of patients and provided satisfying hearing improvement in 85.8% of patients, suggesting cartilage/perichondrium composite graft is efficient in restoring both the integrity of TM and hearing. It is much challenging to perform tympanoplasty surgeries in children because of the anatomical features at young ages and the high prevalence of both otitis media and Eustachian tube dysfunction in this population.6-8 Promisingly, cartilage palisade tympanoplasty in children yielded good anatomic and functional results. According to report by Ozbek et al,6 children who underwent type 1 tympanoplasty with palisaded cartilage had equivalent postoperative audiometric results compared with children who underwent type 1 tympanoplasty with temporalis fascia. Furthermore, tympanoplasty with the palisade cartilage technique resulted in a significantly higher graft acceptance rate than with the fascia technique. Cartilage interleave technique also provided a minimally invasive way for tympanoplasty in children with satisfying hearing improvement comparable to other formal tympanoplasty techniques such as underlay tympanoplasty with fascia.11-13 In the atelectatic ear, cartilage also allowed reconstruction of the TM both anatomically and functionally. In patients with poor Eustachian tube function, primary insertion of a ventilation tube into the graft was not necessary if cartilage was applied.9 In our study, cartilage/perichondrium composite graft also achieved high rate of acceptance, high rate of TM closure and hearing improvement in the majority of patients. The more covert incision, shorter hospitalization and sooner recovery made cartilage/perichondrium composite grafting a relatively better choice for operations in children. Large TM perforations are relatively more difficult to treat because of the less TM margins to support the graft to survive and less tension to resist the tympanic retraction postoperatively. Subtotal to total TM perforations are at high risk of reperforation, retraction pockets and necessity of revision surgeries. According to the report by Ghanem et al,10 cartilage butterfly graft inlay tympanoplasty is effective in the majority of patients with moderate to large perforations. The closure rate exceeded 90% without graft displacement, postoperative adverse events were respectably low, and hearing results improved or remained stable despite the need for concurrent mastoidectomy in the majority of patients. The method we applied as perichondrium/cartilage composite grafting is a novel technique which has

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Chin Med J 2010;123(3):301-304 3. Dornhoffer J. Cartilage tympanoplasty: indications, techniques, and outcomes in a 1000-patient series. Laryngoscope 2003; 113: 1844-1856. Dornhoffer JL. Cartilage tympanoplasty. Otolaryngol Clin North Am 2006; 39: 1161-1176. Kazikdas KC, Onal K, Boyraz I, Karabulut E. Palisade cartilage tympanoplasty for management of subtotal perforations: a comparison with the temporalis fascia technique. Eur Arch Otorhinolaryngol 2007; 264: 985-989. Ozbek C, Ciftci O, Tuna E, Yazkan O, Ozdem C. A comparison of cartilage palisades and fascia in type 1 tympanoplasty in children: anatomic and functional results. Otol Neurotol 2008; 29: 679-683. Gaslin M, OReilly RC, Morlet T, McCormick M. Pediatric cartilage interleave tympanoplasty. Otolaryngol Head Neck Surg 2007; 137: 284-288. Elsheikh MN, Elsherief HS, Elsherief SG. Cartilage tympanoplasty for management of tympanic membrane atelectasis: is ventilatory tube necessary? Otol Neurotol 2006; 27: 859-864. Shin S, Lee W, Kim H, Lee HK. Wheel-shaped cartilage-perichondrium composite graft for the prevention of retraction pocket development. Acta Otolaryngol 2007; 127: 25-28. Ghanem MA, Monroy A, Alizadeh FS, Nicolau Y, Eavey RD. Butterfly cartilage graft inlay tympanoplasty for large perforations. Laryngoscope 2006; 116: 1813-1816. Sismanis A, Dodson K, Kyrodimos E. Cartilage shield grafts in revision tympanoplasty. Otol Neurotol 2008; 29: 330-333. Kyrodimos E, Sismanis A, Santos D. Type III cartilage shield tympanoplasty: an effective procedure for hearing improvement. Otolaryngol Head Neck Surg 2007; 136: 982-985. Doi T, Hosoda Y, Kaneko T, Munemoto Y, Kaneko A, Komeda M, et al. Hearing results for ossicular reconstruction using a cartilage-connecting hydroxyapatite prosthesis with a spearhead. Otol Neurotol 2007; 28: 1041-1044. Felek SA, Celik H, Islam A, Elhan AH, Demirci M, Samim E. Type 2 ossiculoplasty: prognostic determination of hearing results by middle ear risk index. Am J Otolaryngol 2009 Jun 9 [Epub ahead of print]. Eleftheriadou A, Chalastras T, Georgopoulos S, Yiotakis J, Manolopoulos L, Iliadis I, et al. Long-term results of plastipore prostheses in reconstruction of the middle ear ossicular chain. ORL J Otorhinolaryngol 2009; 71: 284-288. Huttenbrink KB, Luers JC, Beutner D. Titanium angular clip: a new prosthesis for reconstruction of the long process of the incus. Otol Neurotol. 2009; 30: 1186-1190. Roth JA, Pandit SR, Soma M, Kertesz TR. Ossicular chain reconstruction with a titanium prosthesis. J Laryngol Otol 2009; 123: 1082-1086. Gneri EA, Ikiz AO, Erda TK, Stay S. Cartilage tympanoplasty: indications, techniques, and results. J Otolaryngol Head Neck Surg 2009; 38: 362-368. Neudert M, Zahnert T, Lasurashvili N, Bornitz M, Lavcheva Z, Offergeld C. Partial ossicular reconstruction: comparison of three different prostheses in clinical and experimental studies. Otol Neurotol 2009; 30: 1234-1235. Yamane H, Takayama M, Sunami K, Morinaka M, Minowa Y, Yoshioka S, et al. Cartilage ossiculoplasty by lever method. Acta Otolaryngol 2008; 128: 744-749.

achieved very high rate of closure and AB gap reduction in patients. Both anatomic rebuilding and functional restoring regained in patients with total TM perforation using the perichondrium/cartilage composite graft. We intentionally preserved a strip of the most lateral tragal cartilage of at least 2 mm in width, so that no cosmetic consequences occurred after harvesting the tragal cartilage. If the Eustachian tube dysfunction existed, we prefer to use the cartilage which could support the TM with more tension and be much more resistant to tympanic retraction.11 The natural arch structure of the tragal cartilage and the concave contour of concha cartilage make it easier to rebuild the shape of the normal tympanic membrane.4 The other potential mechanism is because that the intact perichondrium made the cartilage more viable. Conchal cartilage could also be shaped to reconstruct the ossicular chain in patients with the incus being absent and a diminished space between the stapes superstructure and malleolar manubrium.12 Cartilage material can not only be used for myringoplasty but can also be applied in assistance of ossicular chain reconstruction. In intact canal wall tympanomastoidectomy, using a wheel-shaped cartilage-perichondrium composite graft with the insertion of an ossicular prosthesis in one stage can decrease the formation of retraction pockets as well as improving hearing function.9,14-16 The cartilage connecting the prosthesis with a spearhead is reported to be an effective ossicular implant and offers an attractive alternative for ossicular reconstruction with relatively low extrusion rate, particularly for total ossicular reconstructions.13,17-20 Cartilage could also be tailored to function as a lever in ossiculoplasty to elevate postoperative hearing gain in the case of canal wall down tympanoplasty.14 In our cases, cartilage was also used as assistance in ossiculoplasty besides myringoplasty. In patients without functional malleus or incus, tailored cartilage was positioned to connect the residual ossicles with or without a PORP. Excellent postoperative hearing improvement was succeeded with no displacement or extrusion of PORP. In cases with atticotomy or call-wall-up tympanoplasty, cartilages were applied to rebuild the wall of attic which reduced the potential of postoperative retraction pocket and reperforation. In conclusion, perichondrium/cartilage composite graft is an easy-taking graft for tympanoplasty and tympanomastoidectomy with high efficiency and reliability. Perichondrium/cartilage composite graft underlay tympanoplasty is effective in the majority of patients with large perforations. Hearing is improved even if a mastoiddectomy is required for the patients.
REFERENCES 1. 2. Heermann J, Herman H, Kopstein E. Fascia and cartilage palisade tympanoplasty. Arch Otolaryngol 1970; 91: 228-241. Dornhoffer JL. Hearing results with cartilage tympanoplasty. Laryngoscope 1997; 107: 1094-1099.

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(Received May 7, 2009) Edited by GUO Li-shao