INTRODUCTION

Hearing is a sense that enables man to establish contact with his fellows via speech to
experience life more fully. Deafness in varying degrees of severity is a big impediment
to the integration of a person into the social structure.

The otologist in the past had not much to offer to hearing handicapped people with
chronic middle ear disease. With recent times the advent of the antibiotic era, the
operating microscope and modern anesthetics techniques aimed at producing a dry,
magnified operating field, have radically altered the outlook.

Permanent perforation of the tympanic membrane resulting as sequelae of chronic

suppurative otitis media is a major cause of deafness. Stalwarts from past as far back as
Hippocrates have asserted the same. Controversies range about every step of the
operation from the incision to the material used for packing. A great deal of experimental
work is being done often with contradictory results.

The first known attempt to close a perforation of tympanic membrane to improve hearing
was made by Marcus Banzer in 1640 using prosthesis made of pig’s bladder. Since then
various graft materials like pig’s bladder, Thiersch skin graft, Split-skin graft, Pedicled
graft from ear canal skin, temporalis fascia graft, Vein graft, Sclera, Corneal graft,
tympanic membrane homograft and perichondrium have been used for closure of the
perforated tympanic membrane.

Various autografts have been used for repair of the tympanic membrane perforation like
full thickness skin graft (House 1953), Pedicled skin grafts (Frenckner 1955), split skin
graft (Wullestein 1952 and Zollner 1953), vein graft (Shea 1960), Fascia grafts
(Heermann 1960) and Perichondrium (Jansen1963 and Goodhill 1967). Each of these
grafts material has its advantages and disadvantages over each other. The healing of
tympanic membrane perforation is preceded by ingrowths of connective tissue edges
over which the epithelium migrates to close the perforation, keeping this physiological
principle in consideration it follows that connective tissue grafts, that is grafts of
mesodermal origin like vein, perichondrium or fascia, prove superior to all other graft
materials. Clinical investigations and animal experiments have shown that these
connective tissues replace the missing fibrous element of the tympanic membrane and

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allow squamous epithelium and mucosal tissue to cover is medial and lateral surface
(Wolferman 1970).

Taking the above mentioned facts in consideration, this study was taken up to compare
the results of the two connective tissue graft materials. viz temporalis fascia and the
tragal perichondrium. The study includes the advantages and disadvantages of these graft
materials vis-à-vis to each other.

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 AIMS AND OBJECTIVES

This is a comparative study of tympanoplasty operation using the temporalis fascia and
tragal perichondrium as a graft material.

This study is carried out to compare the:

1. Selection of grafting materials depending on type of defects in tympanic membrane.

2. Graft uptake rate of temporalis fascia and tragal perichondrium in Myringoplasty and
Type-I Tympanoplasty.

3. Hearing improvement post operatively by using these materials.

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 REVIEW OF LITERATURE

It was Marcus Banzer in 1640 who in a treatise described a method for covering drum
perforation with a piece of pig’s bladder.

Autenrieth (1815) used the wall of fish’s air bladder impregnated with varnish as
prosthetic material to close tympanic perforation.

Yearsley (1848) replaced the prosthetic materials with a membrane of cotton soaked in
heavy oil. Toynbee (1852) used a more advanced technique with this rubber membrane
which could be applied and removed by the patients by means of a thin silver thread
attached to its centre.

Politzer (1885) published a method for closing the perforation by means of scars
obtained by cautery of the edges and growing inwards from rims. Katz (1889) used a thin
membrane of colloidin as cover. Lucae and Politzer (1908) described modification of the
method used by Toynbee.

Wullestein H1 (1952) published a method for split-skin covering of perforation of the

drum by tympanoplasty operations in cases of chronic otitis.

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Zollner F (1953) also described split-skin transplantation for covering of drum
perforation. Zollner introduced tympanoplasties intended to replace large drum defects
combined with defects of ossicles. He pointed out the importance of the split-skin graft
of German method, was changed to full thickness skin grafts.

Zollner F 3 (1953) said that he abandoned split-skin graft because of its low resistance,
preferring full thickness retro-auricular skin grafts since the skin of this site is thin and
hairless.

Frenckner P4(1955) gave a method for myringoplasties covering the perforation with
pedicle graft from the ear canal skin. Of the cases opened upon,15 were re-examined
postoperatively with only 1 failure.

Zollner F5 (1955) described 21 myringoplasties performed with split-skin graft, there

were 6 failures. Wullestein H gave a systematization of the tymapnoplasty operation
which has ever since been followed all over the world. He also gave an account of 89

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cases of myringoplasty. It was stated that 32% reached the 15 db-line while 52% more
reached the db-line. Full thickness skin graft was used.

Wright WK 6 (1956) gave the results of myringoplasties performed with different types
of skin grafts. The necessity of traumatic surgery by grafting was pointed out and the
importance of keeping infection away was emphasized. In 34 cases grafted with split-
skin from brachium there were 25 “takes” and 9 failure and 23 cases with skin “from the
mastoid area” showed 22 “take” and in 4 cases grafted with “pedicle flaps from the ear
canal”, 4 failure . Wright WK accounts for causes of failure, postoperative reinfection is
the commonest inspite of treatment with antibiotics, even locally applied but there are
cases with “no apparent cause” of perforation and late failures.

[7]
Wullestein H (1956) in a paper dealing with 400 tympanoplasties discussed the
inspection of the middle ear during operation. The following steps ought to be (1)
Control of antrum, (2) Upper control of middle ear and (3) Lower control of middle ear.
In one, it is necessary to enlarge the bony auditory meatus a little bit backward and then
open antrum thourgh a drill hole only closed behind a broad bridge which gives
protection to the whole epitympanum and the ossicles. Control of upper middle ear is
done mobilization of the drum of limbos, whereby epitympanum can be inspected, and 3
is done by detaching the drum and limbus so far backward, downward that the
hypotympanum can be inspected . There are clear and distinct statements. There were
103 myringoplastics in the series in which postoperative hearing result was given; 32%
reached the 15 db-line and 51% reached more than 30 db-lines. In all cases, full
thickness skin graft was used.

Wullestien H 8 (1957) reported a series of tympanoplasties of 1000 cases of which 23%

were myringoplasties. Postoperative hearing results were given as bone air gap, and it
was shown that in the first half of the series, 34% of the cases had a bone air gap of 0-15
db, while in second part this results was reached in 70% The number of cases in Group-2
was not given. Full thickness retro-auricular skin used as graft and supports the grafts
“the tympanic cavity was filled with reabsorbable substance”.

Beickert (1958) have shown post operative perforations may occur owing to sweat and
sebaceous glands and hair follicle in grafted skin. In happens that a Lappen-
cholesteatoma develops or microscopial perforation appear when glands and hair are
served served by grafting, or retention cysts developed from the same parts of full

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thickness grafts. Another difficulty, also emphasized, is that of effecting a complete
adaption to the vascular bed; the elastic fibres of skin cause the graft roll and curl,
thereby leaving a space between the graft and its bed, which prevents nutrition.

Guilford FR, et al9 (1959) have published results of tympanoplasties with split- thickness
skin grafts. The series contained 154 tymanoplasties of all categories which have been
divided in two different types. They carefully discussed different types of skin grafts
found thick split-skin preferable because of the structure of the vascularization of the
skin. The importance of a traumatic grafting was emphasized, so was the danger of
infection of the vascular bed and importance of fixing the graft with the lowest possible
pressure of the packing. There were 97 takes and 57 failures. Takes were observed for 3-
48 months, while the follow up of the failures covered 1- 8 months. The authors also
emphasized the necessity of a good tubal function for good results. The examination has
been carried out by polarization and calibrated valsalva test.

Urban Ortgren (1959) gave a preliminary report on a comparison between results with
fascial and a similar series of skin graft used as control in myringoplasty. Out of 5
myringoplasties performed with fascia from temporalis muscle, there were 5 takes three
months after operation, during the same period 5 failures out of 7 skin grafted
myringoplasties.

Heermann H10 (1960) made a through description of a method for fascial grafting used
by him for 2year.

Shea JJ11 (1960) described a method for closing central perforation of the drum by means
of a vein graft. The graft was placed on the inner side of the drum, with the intima side
inwards.

Link R 12 (1960) showed that a (corium graft) a skin graft without epithelium takes much
more easily. This was explained by the fact that skin grafts give autoimmunization
because of antigen component bound to the nuclear substance of the epithelium cell. This
might explain the allergically induced secretion observed for the Heermann and others.
Literature on plastic surgery gives support for the use connective tissue graft in shape of
fascia where great strains is expected and where nutrition is not so good during healing.

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Agazzi C (1960) presented long term result of a series of 292 tymanoplasties
performed between 1955-1958 all of these cases were re-examined at least 1 year after

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operation. The material contained 94 myringoplasties, which has not been stated, were
performed with patriotism. Healing results were provided in the groups “improved”,
“unimproved”, and “worse”.Hearing was improved in 48.8% and there were 18%
perforation; but also 32.9% moist middle ear postoperatively.

Wullstein H (1960) put a small acrylic tube through a perforation in the tympanic
membrane maintenance of ventilation.

Livingstone G, et al[14] (1961) described 26 myringoplasties with vein grafts re-examined

6 month postoperatively. There were 70% takes and 73% of the cases had reached the 30
db-line.

Stoors LA15 (1961) recorded 6 fascial grafted myringoplasties re-examined 1-5months

after treatment with 6 takes. Schlosser WD, et al16 (1961) obtained 2 takes out of 3 cases
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with the same technique. Sooy FA, et al (1961) presented a comparison between
different grafting methods, full thickness skin graft from the ear canal skin, pedicle
grafted from the ear canal skin and different types of vein graft. Skin grafts shows 12
takes out of 25 cases, pedicle grafts 11 takes out of 16 cases.

Beasles (1958), Booth TE18 (1961) and Proctor B19 (1962) have published results of
tympanoplasties performed with full thickness grafts with post operatively healing and
hearing results which agree with Agazzi’s result.

Howes EL20 (1943) observed that curling and rolling cause failures because of
insufficient adaptation to the vascular bed. The relatively limited number of cells results
in lower metabolism and thereby in stronger resistance to poor healing condition. Since,
further connective tissue surface becomes epithelialized from the edge of vascular bed
with a velocity which reduces the diameter of unepithelialized surface by 1mm/day, it is
possible for the drum surface to be epithelialized in less than 10 days both in – and out-
side.

Austin DF21 (1963) in a series of 503 tympanoplasties performed 190 myringoplasties

with vein graft.117 were re-examined 12 month later. There were 14 failures and 89% of
these the cases was air- bone gap of 0-20 db.

Jansen C22 (1963) used free tissue transplants of autogenous perichondrium of nasal
septum or homoplastic septal perichondrium septal cartilage film, which have been

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preserved and embedded in plastics materials to create new tympanic membranes the
preserved canal skin supplies favorable nutrition to the transplant. The two types of
perichondrium autogenous or preserved homoplastic heal up easily and quickly, so that a
normal looking and functioning ear drum can be formed. During a period of 3 years, over
100 operations were done with above technique. With the exception of two cases all ears
were dry within 3 weeks after the operation and required practically no postoperative
treatment. As compared to other free tissue transplants, the perichondrium is a thin
membrane and has yielded for better results with regard to mobility of new tympanic
membrane. The obtainable perichondrium flap from the nasal septum is sufficient to
cover even largest perforation.

Zollner F23 (1963) mentioned that normal function of the Eustachian tube is fundamental
condition for successful tympanoplasty and there is tendency to form adhesions in hypo-
functioning or malfunctioning Eustachian tube.

Farrior JB24 (1965) reported that tubal function impairment is one of the main causes for
failure in tympanopasty and myringoplasty. He divided the tubal obstruction into central
(nasopharyngeal) and peripheral (isthmus) obstruction.

Goodhill V25 (1967) used tragal perichondrium and cartilage for myringoplasty and
tympanoplastic reconstruction. He showed that perichondrium and cartilage obtained
from tragus provide viable autograft materials for tympanoplastic reconstruction.

Sheehy JL, et al26 (1967) noted that after tympanoplasty there will be an occasional thin
graft which will thicken greatly in healing. One of the reasons for it is Eustachian tube
dysfunction. A thick reconstructed membrane is seen more frequently in those cases,
which are left with serous otitis due to persistent tubal insufficiency.

Sengupta RP, et al27 (1974) showed the correlation between preoperative tubal function
with hearing and healing perforation1-2 years after operation. Out of 104
myringoplasties , the follow up was complete for 1-2 years in 90 cases; complete closure
of perforation was ultimately established in 73(81.2%) cases. The improvement in result
meatal skin graft was thus given in favour of tragal perichondrium.

Kacker SK (1975) used tragal perichondrium as a graft material in 650 cases. These
myringoplasties were done from September 1969 to August 1975. They were done by
permeatal technique under local anesthesia and tragal perichondrium graft was used.

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Following conclusions were reached:

1. Delayed epitheliazation of grafted tympanic membrane is seen in rainy season with

external otitis and wrong placement of graft. It is facilitated with meatal skin grafting.
2. Acute ear infection is easily controlled and the perichondrium graft offers good
resistance.
3. Epithelial pearls occur most commonly round the handle of malleus and should be
removed. Inlay graft in cases of large perfection is recommended.
4. Lateralization is often a displacement of graft rather than misplacement at surgery.
5. Thick opaque looking tympanic membrane may have fluid or cholesteatoma behind it
and tympanotomy should be done in such cases.

Kacker SK28(1976) while suggesting improvement in myringoplasty has retracted a

preoperative check up with special reference to the importance of tubal function test.

Packer P29(1982) in his comparative study of fascia and dura report a graft take rate of
88% of overlay fascia, 82% for underlay fascia and 93% for underlay dura. The average
improvement in hearing in hearing at 6month in 8db for underlay fascia and 10.2 db of
underlay dura.

Gerrit JH30(1982) in his report on tympanic membrane grafting report the graft take rate
of 92.3% in fascia,90.6% in perichondrium and 92.26% of vein.

Ahad SA31 (1986) reports a success rate of 83.3% with homologous temporalis fascia,
76.4% success rate with autologous temporalis fascia .He used onlay technique in 88.8%
of the cases.

Isiah V32 (1986) reports his result in geriatric myringoplasty using tragal perichondrium
by transcanal route. Graft uptake was seen in 94% of cases. Majority of his patients
achieved socially adequate hearing.

Kumaresean M33 (1986) claims 100% take up graft using temporalis fascia for his
myringoplasty where graft was placed under vascular strip and pars flacida. His hearing
results are means preoperative air conduction levels 28 db and postoperative air
conduction levels of 24 db.

Gordon HE34 (1986) in his review states that autologous fascia is one of the most
commonly used tympanic membrane grafting material, having a success rate of about

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95%. According to him devitalized grafts primarily provides scaffolding for the
migration of epithelium which ultimately closes the tympanic membrane effects.

Palva T35 (1987) reports a success rate of about 97% using underlay connective tissue for
repair of tympanic membrane. The average postoperative air-bone gap was gap was 4.8
db in 88cases of myringotomy.

Tos M35 (1987) finds no difference in results of myringoplasty using temporalis fascia
glued with tissue seal and myringoplasty using temporalis fascia fixed with gel-foam
balls.

Terry RM37 (1988) claims a success rate of 70% using fat graft for myringoplasties at
review at one year postoperatively.

Gross CW38 (1989) describes adipose plug myringoplasty in managing small tymapanic
membrane perforations in children reports.

Kaddour HS39(1992) in his report of graft myringotomy under local anesthesia claims
closure of 80% (8/10) of the perforations, with average improvement of 11 db.

Pagnini P40 (1992) in his report on sandwich graft myringotomy using temporalis fascia
claims 93.1% of complete closure of perforations. An average functional recovery of
14.1 db was observed compared to preoperative gap of 21.6.In 25% of the cases, average
recovery was grater than25 db and in 5 patients a slight worsening of 3.3db was
observed. On the whole, in 41 patients residual postoperative gap 10 db was achieved.

Sitnikov VP41 (1992) reports a method of myringotomy using ultra thin allo-
cartilaginous plate (an internal layer), autofascia of temporalis muscle (as intermediate
layer) and stored amnion (external layer) in patients with extensive defects.

Hartwein J42 (1992) describe “crown-clock tympanoplasty” for complete reconstruction

of tympanic membrane, using autologuos tragal composite graft. He claims 100%
success rate.

Verbist M43(1993) reports deterioration of mean high frequency thresholds up to db

following middle ear surgeries including myringoplasties.

Ajulo SO, et al44 (1993) presented a paper in which they repaired tympanic membrane
perforation with periumbilical superficial fascia via a transtympanic route. They

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conclude that the technique was cost effective and quick, making bilateral repairs
possible under same anesthesia.

MacDonalnd RR, et al45(1994) presented a retrospective study of 26 patients who

undergone fasciaform myringoplasty surgeries. They concluded that fasciform
myringoplasty has proven to be successful procedure for closing large tympanic
membrane perforation and improving hearing acuity in the pediatric population.

Quareshi MS, et al46 (1995) presented a study of myringoplasty, in which tragal

perichondrium grafts were placed permeataly as a day case procedure in 32 patients.
They compared with a control group, matched for age and for the size of their
perforations, in which temporalis fascia was grafted via an end-aural or post-aural
incision. The success rate was 94% in the perichondrial group as compared with 84% in
the control group.

Mitchell RB, et al47 (1997) presented a review of 342 children, who underwent fat
myringoplasty. It is a safe and successful procedure, which result in a dry and safe ear in
majority of the children.

Albera R, et al48 (1998) asserted that myringoplasty can be considered a safe procedure
to be used in children and it does not appear essential to wait until they have finished
growing before performing this procedure.

Guo M, et al49 (1999) stated that the interlay method of myringoplasty is an ideal method
for healing perforation of tympani.

Supiyaphun P, et al50 (1999) described a new myringoplasty technique requiring only a

partial removal of skin on ear drum remnant followed by lateral placing of fascia and
free skin graft. The overall cure rate in their series was 97%.

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Yu L, et al (2001) studied the auricular cartilage palisade technique for repairing of
tympanic membrane. Sixty-six cases (Group1) of large tympanic membrane perforation
were treated with auricular cartilage. Results were compared with that of temporalis
fascia (Group 2) repairing in 60 ears. The closure rate is 92.4% in Group 1 and 80 % in
group 2. There was no significant improvement difference in hearing result. They
concluded that the auricular cartilage palisade technique is an ideal method for repairing
tympanic perforation.

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Jassar P, et al52 (2002) stated that flying at altitude in a pressurized environment within a
week of myringoplasty does not adversely affect early operative success.

Gierek T, al53 (2004) did a study to demonstrate the anatomical and functional results of
tymanoplasty in comparison with the material used. The studies included a selected a
group of 142 patients who were operated on because of tympanic membrane perforation.
The analyzed group consisted of 112 patients when perichondrium and cartilage were
used to reconstruct the tympanic membrane. The comparison group consists of 30
patients when temporalis fascia was used to close a defect of tympanic membrane. The
comparison of operation result showed that there was no significant difference between
the two groups.

Indorewala S54 (2005) did a retrospective analysis of tympanoplasties performed for

large perforation or granular myringitis using either a fascia lata (group I) or temporalis
fascia (group II) as material. Ears in group I had lesser rate of recurrent perforation on
long term follow-up than ears in group II. No significant difference was noted in
improvement of hearing between the two groups. He concluded that shrinkage of graft
during healing phase appears to have significant relevance in the clinical situation. Ears
having large perforation have high chances of residual perforation caused by limited
margin of remnant tympanic membrane overlapping that graft. It seems logical to use
fascia lata as graft material for large perforations because it has better dimensional
stability.

Jyothi P Dabholkar55(2007) The perforations of the tympanic membrane maybe of

traumatic origin or due to chronic suppurative otitis media. If the perforations fail to heal
conservatively, they require surgical closure. Autologous graft materials have stood the
test of time in repairing tympanic membrane perforations. In our tertiary care institution
we conducted a prospective randomized control trial on 50 subjects to evaluate the
comparative efficacy of temporalis fascia and tragal perichondrium as grafting material
in underlay tympanoplasty. In this study surgical success was evaluated in terms of intact
drum membrane during the follow up period and closure of A–B gap within 10 dB.
Temporalis fascia achieved a graft uptake of 84% and a satisfactory hearing
improvement in 76% of the patients. Tragal perichondrium achieved a success rate of
80% graft uptake and 75% hearing gain. The rates are comparable with no statistical
significance of the difference between them.

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B.J. Singh, A. Sengupta56(2009) Two hundred twenty cases of unilateral chronic
suppurative otitis media (CSOM) with dry central perforation were chosen for this study
and myringoplasty were done. Age group ranged from 13 to 48 years. Four types of
autogenous tissues were used as graft material. Grafting was done by underlay technique
when temporalis fascia,tragal perichondrium, areolar tissue were used as graft material
and when fat graft was used the ear lobule fat was placed directly into perforation
through transcanal route. Postoperative follow-up was carried out up to 6 months. In this
study, it was found that the younger age group has less impairment of hearing and better
chance of tympanic membrane perforation closure than the older age group in CSOM
with central perforation. An anterior perforation has less impairment of hearing and
better result in successful closure of tympanic membrane than posterior perforation
group. It was also observed that larger the size of perforation greater is the hearing
impairment preoperatively and postoperative hearing gain is also less compared to small
perforation. Best hearing improvement occurred using temporalis fascia. Failure
occurred may be due to postoperative infection, respiratory tract infection, neglected
post-operative advice etc.
A.Sengupta, B. Basak57 (2011) Myringoplasty is a procedure which deals on repair of the
tympanic membrane. This procedure can be done via postaural, endaural or endomeatal
route. Various grafts such as temporalis fascia, vein graft, and perichondrium are used.
The technique can be categorized as underlay, overlay, interlay or its combination
depending on the placement of the graft material. This study was done to compare
underlay, overlay and combined technique in terms of the closure of the membrane
defect, postoperative complications and overall success rates. Apart from few
complications, this study revealed overall success rate was best with combined technique
but the difference was not significant statistically when the methods are comparable
among them.
Sunita Chhapola, Inita Matta58 (2011) Temporalis fascia has long been regarded as the
ideal graft material for tympanic membrane repair. However it often does not seem to
withstand negative middle ear pressure in the post operative period. Tragal cartilage with
perichondrium would appear to be a better graft material with good hearing outcome. It
can be obtained easily with cosmetically acceptable incision. In the present study, we
have compared the graft properties of temporalis fascia verses tragal cartilage
perichondrium with respect to healing, hearing and rate of post operative retraction or
reperforation. 132 patients of chronic otitis media with pure conductive hearing loss were

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posted for tympanoplasty.Temporalis fascia graft was used in 71 patients and cartilage
perichondrium (composite graft) was used in 61 patients. Post operative healing, hearing
and rate of retraction or reperforation were compared for both the graft materials. All the
patients were followed up for 2 years. Patients where temporalis fascia graft was used,
60 (84.5%) showed a good neotympanum, 7(9.85%) had reperforation and 5(7.04%) had
retraction pockets. Patients where tragal cartilage perichondrium was used, 60(98.36%)
showed a healed tympanic membrane and only 1(1.63%) had reperforation. None of the
patients showed retraction pocket or cholestetoma. Postoperative hearing was accessed 6
months after surgery. Patients with temporalis fascia graft showed an air bone gap of less
than 10 dB in 49 (82%) patients and more than 10 dB in 11 (18%) patients. Air bone gap
closure with tragal cartilage perichondrium was less than 10 dB in 45 (78%) patients and
more than 10 dB in 13 patients (22%). Tragal cartilage perichondrium (0.5 mm) seems to
be an ideal graft material for tympanic membrane in terms of postoperative healing and
acoustic properties. It can easily withstand negative middle ear pressure which may have
contributed to the development of otitis media and significantly affect healing outcomes
in postoperative period. Tragal cartilage being composed of collagen type II is also
physiologically similar to the nature of the tympanic membrane.
P.K. Parida, S.K Nochikattil59(2012) To compare the surgical outcome of temporalis
fascia graft (TFG) and vein graft (VG) in myringoplasty. This prospective study was
carried out over 60 patients with inactive tubotympanic type of chronic suppurative otitis
media, with small to moderate size central perforation in Jawaharlal Institute of Post
Graduate Medical Education and Research, Puducherry from November 2009 to March
2011. Patients were equally randomized into two groups; TFG group and VG group
according to the graft material used for myringoplasty. After routine investigations, X-
ray mastoid and paranasal sinuses and pure tone audiometry, all cases were operated
under local anesthesia using underlay technique. Patients were followed at 2 week, 1 and
3 month postoperatively. Graft uptake, audiological improvement, degree of hearing
improvement, and complications were studied during follow up. In TFG group, graft
uptake rate was 80 % and hearing improvement was present in 66.7 % whereas in VG
group graft uptake rate was 83.3 % and hearing improvement was present in 70 %. No
patient had deterioration in hearing, sensory neural hearing loss or any other
complications postoperatively. Difference between the preoperative and postoperative air
bone (AB) gap was considered as degree of hearing improvement. Postoperative AB gap
was 10 dB in 60 % and 66.7 % of patients of TFG group and VG group respectively. The

14
difference in graft uptake rate and hearing improvement between two groups was not
statistically significant. Both TFG and VG are equally effective in terms of graft uptake
and hearing improvement in myringoplasty.

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 ANATOMY

ANATOMY OF TYMPANIC MEMBRANE

The tympanic membrane (Tony Wright and Peter Valentine)67 is a membrane partition
separating the external ear from tympanic cavity. It is a semitransparent and elliptical,
measuring 9-10 mm vertically and 8-9 mm horizontally. Its external aspect is concave,
most depressed point being the umbo, which corresponding to the tip of the manubrium
of the malleus. The manubrium itself extends from umbo to the malleal prominence,
formed by the lateral process of the malleus. From the malleal prominence, the the
anterior and posterior malleal fold extends to the edges of the tympanic notch (notch of
rivinus) and separates pars flaccida (Sharpnell’s membrane) above from pars tensa
below. The average thickness of the tympanic membrane is 0.074mm: it is thickest at
antero-superior quadrant and inferiorly near the annulus (0.09mm). It is thinnest at
posterosuperior quadrant (0.055mm).

The pars tensa of the tympanic membrane is composed for three layers. The outer
epitelial layer is continuous with the skin lining the external auditory meatus. Medial to
this is a fibrous layer, or lamina propria. More medial is the mucous layer continuous
with the tympanic cavity. The connective tissue fibers originate from the handle of
malleus and inserts on the annular ring. Circular fibers originate from the short process
of malleus more medially. Transverse and parabolic fibers intertwine between these two
layers.

Epithelial migration of the tympanic membrane has been demonstrated by the Litton
(1963) who showed centrifugally from the umbo at about 0.05mm per day.

The blood supply is provided by vessels from the epidermal mucosal surface that
communicate within the lamina propria. The arterial supply laterally is from the
tympanic branch of the deep auricular artery and medially from the anterior tympanic
branch of the internal maxillary artery, the stylomastoid branch of the internal maxillary
artery, and the stylomastoid branch of the posterior auricular artery.These three arteries
join to form a peripheral vascular ring.(Rete arterisom marginlae).The venous drainage is
to maxiallary + external juglar vein and pterygoid venous plexus. Innervation is via the
auricular branch of the vagus, the tympanic branch of glosso-pharyngeus (of Jacobson),
and auriculotemporal branch of the mandibular nerve.

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17
ANATOMY OF TEMPORALIS FASCIA

Ortegren described the use of temporalis in the repair of the tympanic membrane in
1959.

Temporalis fascia (anatomy of temporails fascia by Wormald P.J68. is having two distinct
layers: Superficial and deep temporal fascia. Superficial temporal fascia is thin highly
vascular layer of moderately dense connective tissue, which is attached loosely to
overlying subdermal tissues, above zygomatic arch. This layer has its own rich blood
supply. Its arterial supply comes from superficial temporal artery.

Deep temporal fascia closely covers the temporalis muscle and its aponeurosis follows
the muscle’s anatomical boundaries. Blood supply of this is from middle temporal artery,
which arises from superficial temporal artery.

The total area of fascia on each side of the head is 260sq.cm. Importance of this is
emphasized because temporal fascia (superficial or deep) should always be available for
myringoplasties and tympanoplasties even in repeat operations. Access to the fascia is
easily obtained by extending a post- auricular incision.

The advantage of temporalis fascia graft.

a) It is easy to harvest.
b) It can be used as onlay,intermediate,or underlay graft.
c) No size limitation.
d) Low BMR-requires less nutrition- high survival.
e) It can be used in more than one piece,each piece overlapping other,
f) The only suitable autologous membrane for recostruction of tympanic cavity and ear
canal.
g) It can be used as sandwich technique as one of the double grafts with ear canal skin
on the fascia.

18
AREA FOR HARVESTING TEMPORALIS FASCIA GRAFT

19
ANATOMY OF TRAGAL PERICHONDRIUM

GoodHill V 25 in 1967, advocate the use of tragal perichondrium for myringoplasties and
tympanoplasties surgeries.

Based on the recipient area provide the most physiologically desirable autografts.

The advantages to the tragal perichondrium are:

1. Easy accessibility in the operative field.

2. Availability in the adequate amount.
3. It is a mesodermal graft,
4. Excellent contour.
5. Excellent survival capacity, better dimensional stability.

SURGICAL PRINCIPLE

The perforations of tympanic membrane that tend to heal spontaneously rend to exclude
the connective tissue layer (monomeric membrane). The tympanic membranes that do
not heal tend to have ingrowth of outer squmous epithelium covering the edges of the
perforation. The aim of the grafting is truly anatomic reconstruction (Marcos VG,
1989).69

The collagen layer placed as a graft reinstates the middle layer allows epithelial cells to
migrate, re- establishes continuity, and membrane to recover its vibratory characterizes.

TYMPANOPLASTY

Tympanoplasty is final step in the surgical conquest of the conductive hearing loss is the
culmination of cover 100 years of development of surgical procedures on the middle ear
to improve the hearing.

Tympanoplasty is a procedure to eradicate dieses in the middle ear and to reconstruct the
hearing mechanism. Tympanoplasty implies reconstruction of the membrane but also
deals with pathology within the middle ear cleft such as chronic infection,
cholesteatoma, or problems with the ossicular chain.

Zollner and Wullstein provided a classification of tympanoplasty that focuses on the type
of ossicular chain reconstruction needed. This classification is of historical interest

20
because reconstruction of the ossicular chain was not undertaken at that time. It does
provide a standardized method for analyzing pathology of the ossicular chain and for
reporting outcomes of middle ear reconstruction. The five types of tympanoplasty that
these authors described define the status of the ossicular chain as a result of pathologic
changes from eustachain tube dysfunction and middle ear disease. Progression from type
I to type V describes the status of the remaining ossicular chain.

Type I have all ossicles intact and require reconstruction of only the tympanic
membrane.

Type V consists of no ossicles and connection to the inner ear through a fenestrated
horizontal semicircular canal or the vestibule at the oval window.

WULLSTEIN & ZOLLNER’S CLASSIFICATION OF TYMPANOPLASTY

(1952).

It is based on the type of damage caused and the method of reconstruction used.

Type I- Perforated tympanic membrane with normal ossicles. The procedure includes
inspection of the middle ear cleft with closure of the perforation.

Type II- Membrane perforation with erosion of malleus. Graft placed against malleus
remnant or incus.

The subtypes are as follows:

Type IIa: Classical myringoincudopexy.
Type IIb: Malleus – Stapes assembly.
Type IIc: Resconstruction independent of malleus.
Type III- Membrane perforation with erosion of malleus and incus with presence of
intact and mobile stapes .Graft placed over the stapes superstructure (Columella
tympanoplasty or myringostapediopexy).
Type IV- Membrane perforation with erosin of malleus,incus and stapes superstructure
with presence of intact and mobile stapes footplate. Stapes footplate left exposed and
graft is kept coveringEustachian tube orifice and the round window with an air pocket
(cavum minor) providing sound protection to the round window (baffle effect).Skin graft
placed over stapes footplate.

21
TypeV- Membrane perforation with erosion of malleus, incus and stapes suprastrutcure
with presence of intact but fixed stapes footplate. Fenestration made over lateral semi
circular canal. Graft placed over the fenestration and the middle ear space for sound
protection of round window.
Type VI- Membrane perforation with erosion of malleus, incus and stapes suprastructure
with presence of intact and mobile stapes footplate.Round window left exposed and graft
placed over the stapes footplate.(SONO INVERSION – Garcia – Ibanez)

22
HISTOPATHOLOGY OF HEALING AFTER MYRINGOPLASTY

Various grafts can be used in closure of perforation. According to MARQUET(1968),

the graft interested during myringoplasty acts as a temporary scaffolding over which the
external epithelium and the internal endothelium grow to completely seal the perforation.
This scaffolding gets absorbed soon and is replaced by the newly formed fibrocytes of
the host by the 10th day (PLESTER AND STEINBACH, 1977). The growth of
epithelium occurs from the periphery to the centre of the graft necroses before the
perforation gets sealed. This leaves a residual perforation.

Placing the graft on the medial surface of the tympanic membrane does not interfere with
the healing since the endothelial mucosa lateral to the graft undergoes atrophy. At the
junction of the graft and the endothelium, a layer of flattened endothelium slowly
advances to cover the medial surface of graft. On the external surface, keratinized
epithelium migrates over the lateral surface of the graft. Within 6-8 weeks, the graft is
covered on both sides (PLESTER AND STEINBACH, 1977).

Most important of all the successful myringoplasty is an understanding of the manner in

which the free skin graft becomes vascularized and survives. PADGETT (1942) and
CONWAY (1951) studied the histopathology of survival of skin grafts and concluded
that for the first 48 to 72 hours, the graft is nourished by a “Plasmic circulation”, with a
continuity of blood vessels between the graft and its bed not taking over until 65 to 72
hours. This vascularization proceeds from the annulus and the mucosa.

Wright (1956) points out that in the case of large or medium sized tympanic membrane
perforation where a space of several millimeters or most must be bridged by the graft it
could hardly be expected to survive for three days by means of “Plasmic circulation”
alone. McLAUGHIN (1954) believes that tiny blood vessels of free skin grafts come in
contact with open blood vessel of the bed, establishing a vascular circulation within first
day or two.

WRIGHT confirmed this conclusion by removing free split thickness grafts 4 hours and
24 hours they had been placed on their bed. At 4 hours microscopic section show an
intense spasm of the graft’s of blood vessels which had squeezed out all erythrocytes .At
24 hours of blood vessels of the grafts were relaxed and filled with erythrocytes,
indicating that capillary continuity with the bed had been established.

If, as seems probable this is mechanism of survival of free grafts bridging a perforation,
the need is evident for a graft of sufficient thickness to include a capillary network, and
for a good vascular bed on which place it. Moreover undue pressure on the grafts that
might interface with capillary circulation must be avoided, while the drafts itself must be
handled with a minimum of trauma. At least 3mm of vascular bed on all sides of the
perforation should be provided.

23
 MATERIALS AND METHODS
This prospective study was carried out from July 2010 to September 2012 on the patients

attending the ENT Outpatient Department of our institution.

All patients with the complaint of discharging ear and decreased hearing were screened.

Those patients, in whom tubotympanic type of chronic suppurative Otitis Media was

found, were taken for this prospective study with randomization.

The necessary permission and approval from ethics committee and authority, prior to

starting the study was taken. Informed written consents were obtained from the patients

involved in the study according to the protocol approved by the Ethics Committee of our

institution.

This study comprises of patient who were subjected to tymapnoplasty for the treatment

of chronic suppurative otits media. Each patient was subjected to a detail examination of

nose, paranasal sinuses and throat to rule out any focus of infection, which could

influence the result of tympanoplasty. Patients were subjected to tympanoplasty with

temporalis fascia while the remaining underwent with tragal perichondrium.

24
CRITERIA FOR SELECTION

INCLUSION CRITERIA

1. Cases of safe type of chronic suppurative otitis media.

2. The ear should be dry minimum for 1 month with intact ossicular chain.

3. Patent Eustachian Tube.

EXCLUSION CRITERIA

1. Unsafe CSOM

2. Safe CSOM with sensorineural hearing loss.

3. Patient <15years >50years.

25
METHOD OF COLLECTION OF DATA

Cases selected for the study were subjected a detailed history taking and clinical

examination of ear, nose and throat and special reference to the ear.

The method of study was carried out under the following heading.

History taking.
1. Clinical examination
2. Investigation
3. Operative procedures
4. Follow Up

HISTORY

A details history was taken in following parts:

A. Complaints:
 Ear discharge
 hearing loss
 vertigo
 pain
 if any other

B. History of present illness :

 Onset, duration, progress
 Blood stained discharge
 Aggravating and relieving factor noted
 Dry ear since
 Recurrent URTI

C. Personal history:
Any relevant points in relation to occupation and habits were noted.

D. Past history:
This was enquired in relation to discharge, otalgia, sore throat, cold throat, colds allergy,
infectious disease like measles, chickenpox etc.

26
CLINICAL EXAMINATION

GENERAL EXAMINATION

EXAMINATION OF EAR:

1. Examination of pre-auricular area

2. Examination of post-auricular area
3. Examination of pinna
4. Examination of EAC
5. Examination of Tympanic membrane
6. Examination of under microscope

Assessment of hearing

1. Tuning Fork testing with 256,512 and 1024 Hz.

2. Pure Tone audiometry.

EXAMINATION OF NOSE

EXAMINATION OF THROAT

LABORATORY INVESTIGATION
1. Routine investigation
TLC
Hb%
DLC
2. Blood Sugar (Fasting and PP if indicated)
3. Urine investigation
4. X-ray chest
5. X-ray mastoid
6. X-ray PNS(if indicated)
7. PTA (Pure Tone Audiometry)

27
OPERTAIVE TEQHNIQUE
ANAESTHESIA
Tympanoplasty for reconstruction of the tympanic membrane and correction of
conductive hearing loss was typically performed through a postauricular approach,
especially in patients with large or anterior perforations and revision operations.
However, intravenous sedation with local anesthesia is prefer and typically well tolerated
by the patients.
Majority of patients underwent surgery under Local anaethesia with sedation after a
xylociane sensitivity test.
Local anesthesia was achieved by using 2% xylocaine with 1:2 00,000 adrenaline in the
subcutaneous tissues of post-auricular region and external auditory canal.

SURGICAL APROACH
POSITIONING AND PREPARATION
The patient was positioned supine on the operating table. The head was turned toward
the side away from the operated ear. While taking care to ensure that the contralateral
auricle is not being compressed.
A small amount of hair in the post–auricular region was shaved to keep the operating
field free of hair. The patient’s remaining hair was then secured with tape to keep it out
of field.
The post-auricular crease was cleaned with betadine and inject with lidocaine with
epinehrine. The patient was secured to the table with straps because rotating the bed was
sometimes necessary during the procedure.
The operative field was then prepared with povidone-iodine (Betadine) and the ear canal
was flooded with preparative solution. Suction and irrigation tubing was set up, the
instrument table and operating microscope are brought into position. Before the start of
the procedure, the surgeon should ensure that the microscope was properly balanced and
that the correct lens (usually 200 or 250mm) was attached.
The external auditory canal (EAC) and tympanic membrane (TM) are examined under
the operating microscope. Cerumen o debris in the EAC was removed while taking care
to not cause bleeding.

28
PLANNING THE POSTAURICULAR INCISION
The microscope is moved aside and a post-auricular incision is made with a no. 15 blade.
The incision extends from just superior and posterior to the root of the helix down to the
mastoid tip. The incision was placed 5 millimeters behind the post-auricular sulcus.

In young children without a well-developed mastoid tip, the inferior aspect of the
incision is more posterior and is not carried down as far to avoid injuring the facial
nerve. The incision is carried down to the level of the loose areolar tissue overlying the
temporalis fascia. Identification of this plane is facilitated by pulling laterally on the
auricle as the incision is made. Once the correct plane has been entered, the knife blade
is turned flat and dissection is carried anteriorly toward the posterior EAC while taking
care to not enter the EAC at this point.

Temporalis fascia was now harvested. The inferior-most aspect of the fascia harvest site
should be placed at least one centimeter above the linea temporalis. Preserving the fascia
at the linea temporalis allowed more solid closure of the superior periosteal incision.

GRAFT MATERIAL

In 25 cases temporalis fascia and 25 cases tragal perichondrium were used as a graft
materials for tympanoplasty.

a. Tragal Perichondrium

After injecting local anesthesia, an incision is made over tragal margin and skin flap
along with subcutaneous tissue are elevated. Tragal cartilage is exposed and excised out
with perichondrium attached to it. The perichondrium is separated from the cartilage
using a flag knife. The perichondrium graft so obtained was used.

b. Temporalis fascia

After injecting local anesthesia, a post-aural incision is made to expose the temporalis
muscle alone with its fascia. Fascia was taken out from the surface of the temporalis
muscle.

It was spread on a hard surface such as a graft plate and any fat or connective tissue was
scrapped away with a sharp knife edge.

29
Majority of patients were operated by the post-aural route. Patients were operated by
underlay technique. Integrity of ossicular chain was confirmed in all cases of
tympanoplasty.

STEPS OF SURGERY

After harvesting the appropriate graft following steps were followed-

1. Elevation of the periosteal flap

2. Meatotomy in cases of post- auricular approach.
3. Freshening of the edges of the perforation.
4. Elevation the tympanomeatal flap.
5. Assessing the ossicular continuity and freedom from the disease.

30
6. Placing the graft by underlay technique.
7. Reposing the tympanomeatal flap.
8. Packing the EAC with antibiotic soaked gel foam.
9. Suturing of periosteal flap and postauricular skin.
Standard mastoid dressing was given in cases operated by post-aural route.

Postoperative stay in wards was usually one week. In this period all patients were on the
following medications:

1. Antibiotic as indicated.
2. Analgesia and anti-inflammatory.

Patients were discharged with instruction to continue antibiotics and antihistaminic.

Sutures were removed on 7th day. Steroid-antibiotic ear drops for local instillation were
started after 7th day.

Thereafter, patients were followed up in the OPD for:

1. Cleaning the ear

2. Otoscopy.
Visit:
 1st follow up
(15 POD)
 2nd follow up
(21 OPD)
 3rd follow up
(After 45 days)
 Then monthly follow up.
 PTA done after 6 month of operation.

Result evaluation by appropriate statistical test was done subsequently.

Pure tone audiometry was repeated once the tympanic membrane healed usually after 6
months.

Ear finding and audiometry reports were recorded. Any complication was treated as and
when it arose.

31
Data Analysis – Observations were tabulated on a spread sheet by using Microsoft
excel. Statistical analysis of the patients was carried out with Student‘t’ test and “Z” test.
A ‘P value’<0.05 was considered statistically significant.

32
OBSERVATIONS AND RESULTS

33
 Total number of patients in this study 50

 Mean age of patients 30.36 years

 Range 16 to50 years

 Male 22

 Female 28

 Sex ratio 1:1.27

 Type of graft material used:

a) Temporalis fascia 25
b) Tragal perichondrium 25

 Route of surgery:
a) Post –auricular 45
b) Endaural 05

 Age distribution:
a) Mean age 30.36years

 Duration of illness / symptoms prior to surgery:

a) Mean duration 15.78 months

TABLES

34
TABLE-1 : SEX DISTRIBUTION.

Sex No. of Patients Percentage

Male 22 44%

Female 28 56%

Total 50 100%

The above table indicates that there were 22 (44%) males and 28 (56%)
females. The male to female ratio is 1:1.27.

35
 sex distribution

56% female
44% male

TABLE-2 : AGE DISTRIBUTION.

Age in years No of Patients Percentage

< 20 09 18%

21 - 30 17 34%

31- 40 16 32%

>40 08 16%

Total 50 100%

The above table indicates that maximum number of patients belonged

between the age group of 21-40 years.

36
 CHART SHOWING AGE WISE DISTRIBUTION
18 17
16
16
14
12
No of Patients

10 9
8
8
no of patients
6
4
2
0
< 20 21 - 30 31 - 40 > 40
Age in Years

37
TABLE-3 : PREOPERATIVE HEARING LEVELS.
Preoperative No.of Patients Percentage
Air- Bone Temporalis Tragal Total
Gap
Fascia Perichondrium
0-5 0 0 0 0
5-10 0 0 0 0
10-15 6 7 13 26%
15-20 4 6 10 20%
20-25 1 2 3 06%
25-30 5 3 8 16%
30-35 3 3 6 12%
35-40 4 3 7 14%
40-45 2 0 2 04%
45-50 0 1 1 02%

Majority of the patients shows mild to moderate hearing loss.

46% of being in 0-20 db air- bone gap range.

38% of being in 20-40 db air- bone gap range.

Only 6% of them had air- bone gap range above 40 db.

38
 8
7
7
6 6
6
5
5
no of patients

4
4
temporalis fascia
3
3 tragal perichondrium
2
2
1
1
0 0 0 0
0
0-5 5 - 10 10 - 15 15 - 20 20 - 25 25 - 30
hearing loss in db

39
TABLE-4 : POSTOPERATIVE HEARING LEVELS.

Postoperative No.of Patients Percentage

Air- Bone Temporalis Tragal Total
Gap
Fascia Perichondrium
0-5 10 14 24 40%
5-10 9 7 16 32%
10-15 3 1 4 08%
15-20 0 1 1 02%
20-25 0 0 0 00%
25-30 2 1 3 06%
30-35 0 0 0 00%
35-40 0 1 1 02%
40-45 1 0 1 02%
45-50 0 0 0 00%

In the postoperative hearing analysis,

80% of the patients showed air- bone gap in the range of 8-10db

10% of the patients showed air- bone gap in the range of 11-20db

74% of the patients operated with temporalis fascia showed air bone gap in
the range of 0-10db.

84% of the patients operated with tragal perichondrium showed air-bone

gap up to 10db.

40
 Bar diagram showing post operative hearing
levels

16
14
14

12
10
10
no of patients

8 7
temporalis fascia
6
tragal perichondrium
4 3
2
2 1 1 1 1 1
0 00 00 0 0 00
0
0 - 5 5 - 10 10 - 15 - 20 - 25 - 30 - 35 - 40 - 45 -
15 20 25 30 35 40 45 50
hearing loss in db

41
TABLE-5 :
POSTOPERATIVE HEARING LEVELS WITH
RESPECTIVE TO SEX.
Postoperative No. of Patients Percentage
Air- Bone Male Female Total
Gap

0-5 12 12 24 48%
5-10 6 10 16 32%
10-15 1 2 3 06%
15-20 0 2 2 04%
20-25 0 0 0 00%
25-30 2 1 3 06%
30-35 0 0 0 00%
35-40 0 1 1 02%
40-45 1 0 1 02%
45-50 0 0 0 00%

In the postoperative hearing analysis,

81.81% male showed air bone gap in the range of 0-10db

78.57% female patients showed 0-10db air-bone gap.

42
 Bar diagram showing post operative hearing
loss with respect to sex

14
1212
12
10
10
no of patients

8
6 male
6
female
4
2 2 2
2 1 1 1 1
0 00 00 0 0 00
0
0 - 5 5 - 10 10 - 15 15 - 20 20 - 25 25 - 30 30 - 35 35 - 40 40 - 45 45 - 50
hearing loss in db

43
 TABLE 6: POST OPERATIVE IN HEARING

Mean No of patients Percentage

change in Temporalis Tragal Total
hearing fascia perichondrium
levels
No change 3 3 6 12%
or worsen
0–5 1 0 1 2%
5 – 10 4 4 5 10 %
10 – 15 6 8 14 28 %
15 – 20 3 2 6 12 %
20 – 25 2 4 7 14 %
25 – 30 3 2 7 14 %
30 – 35 3 2 4 8%

Hearing at 3months

 44 of 50 patients showed improvement in hearing between 0 to 35 db

(88%).
 Out of these patients, 22 were operated using temporalis fascia i.e. 22 out of
25 patients (88%).
 22 out of 25 using tragal perichondrium showed improvement in hearing i.e.
(88%).
 There is no statistical significant difference in hearing improvement, using
temporalis fascia or perichondrium for tympanoplasty.

44
 Bar diagram showing post operative
improvement in hearing
9
8
8
7
6
no of patients

6
5
4 4 4
4 temporalis fascia
3 3 3 3 3
3 tragal perichondrium
2 2 2 2
2
1
1
0
0
<0 0–5 5 – 10 10 – 15 15 – 20 20 – 25 25 – 30 30 – 35
hearing loss in db

TABLE 7: MEAN HEARING LEVEL IN TYMPANOPLASTY USING FASCIA

AND PERICHONDRIUM

Mean levels of hearing

Preoperative Post Post
Type of graft hearing operative operative
levels hearing change in
levels hearing
Temporalis 640/25 = 242.5/25 397.5/25 =
fascia 25.6 = 9.7 15.9

Tragal 580/25 = 193.75/25 383.75/25

perichondrium 23.2 = 7.75 = 15.35

Total 1220/50 = 436.25/50 781.25/50

24.4 = 8.725 = 15.625

45
 Mean improvement in hearing temporalis fascia is 15.90 db.
 Mean improvement in hearing using tragal perichondrium is 15.35 db.
 On applying Student‘t’ test, t= 0.19, P>0.05, we found that there was no
statistically difference in mean improvement in hearing using either
temporalis fascia or tragal perichondrium.

Bar diagram showing mean hearing level in

tympanoplasty using fascia and
perichondrium
30
25.6
25 23.2

20
mean value

15.9 pre operative hearing levels

15.35
15
9.7 post operative hearing levels
10 7.75
post operative change in
5
hearing
0
temporalis fascia tragal perichondrium
Type of graft

TABLE NO 8: GRAFT UPTAKE RATE

Type of graft Graft uptake Percentage

Temporalis fascia 21/25 84 %
Tragal perichondrium 20/25 80%
Overall 41/50 82 %

The above table indicates that 21 (84%) out of 25 ears operated using
temporalis fascia graft healed completely at the end of 6months with well
taken graft.20 (80%) out of 25 ears operated using tragal perichondrium

46
were dry with graft in place at the end of 6 months. No statistical significant
association was found in graft uptake with respect to type of graft (P>0.05).

Most revision patients were not included in the study as these patients were
subjected to more extensive surgery including atticotomy and
mastoidectomy to detect and treat hidden pathologies.

Z=0.36, P>0.05

47
GRAFT TAKE RATE ACCORDING TO SITE AND SIZE OF
PERFORATION

SUBTOTAL 10/12

POSTERO-SUPERIOR 2/4

ANTERO-SUPERIOR 1/2

POSTERIOR 5/6

ANTERIOR 3/3

POSTERO-INFERIOR 9/10
ANTERO-INFERIOR 7/9

INFERIOR 4/4

TABLE NO 9: TYPE OF PERFORATIONWISE GRAFT UPTAKE IN

STUDY GROUP

S. NO TYPES OF GRAFT UPTAKE TOTAL

PERFORATION + -
1 Subtotal 10 2 12
2 Anterior 3 0 3
3 Inferior 4 0 4
4 Posterior 5 1 6
5 Posterosuperior 2 2 4
6 Posteroinferior 9 1 10
7 Anteroinferior 7 2 9
8 Anterosuperior 1 1 2
TOTAL 41 9 50

48
 10 out of 12 subtotal perforations were successful
 5 out of 6 perforations in posterior half of ear drum were successful.
 4 out of 4 perforations in inferior part of drum were successful.
 3 out of 3 perforations in anterior half of drum were successful.
 2 out of 4 perforations in posterosuperior quadrant of drum were successful.
 9 out of 10 perforations in posteroinferior quadrant of drum were successful.
 7out of 9 perforations in anteroinferior quadrant were successful.
 1 out of 2 perforations in anterosuperior quadrant were successful.

Most of the smaller perforations here were taken for tympanoplasty when they failed to
respond to medical treatment of weekly trichloro – acetic acid cautery or when patient
cannot come for repeated sittings.

49
FACTORS AFFECTING GRAFT TAKE RATE

Age and sex of the patients were also compared with graft take rate:

TABLE 10: GRAFT UPTAKE RATE WITH RESPECT TO AGE OF

THE PATIENTS (n = 50).

Age in years No of patients Percentage %

≤ 20 7/9 77.77
21 – 30 14/17 82.35
31 – 40 12/16 75
>40 6/8 75

From the above table it is seen that maximum graft uptake rate observed in
the age group 21-30 years (82.35%).

TABLE 11: GRAFT UPTAKE RATE WITH RESPECT TO SEX (n = 50).

Sex Graft uptake Percentage %

Male 17/22 77.27

Female 24/28 85.71

The above table shows that graft uptake rate was 77.27 %( 17 out of 22
ears) in males and 85.71 %( 24 out of 28 ears) in female.

Z=0.77, P>0.005

There is no statistical significant difference seen in graft uptake rate in sex.

50
 DISCUSSION
This is the prospective study of 50 Tympanoplasties on patients between the age of 16 to
50 years, who were admitted in the Department Of E.N.T and Head and Neck Surgery at
Dr D.Y Patil medical college, Pimpri, between July 2010 to September 2012. This entire
study group of patient suffered from Chronic Suppurative Otits Media. Patients in this
study were from all socioeconomic groups, including patients referred from other
practitioners also.

Conservative measures were first tried in all cases, particularly for small to
moderately sized perforations. These included systemic antibiotics, trichloro-acetic acid
cautery, repeated aural toilet in ears with active infections. Cases with bilateral ear
diseases with suspected central septic focus were operated with tonsillectomy,
adenoidectomy, septoplasty, etc. as needed. 25 patients were subjected to tympanoplasty
with temporalis fascia remaining 25 with tragal perichondrium. Follow up of
postoperative cases was for 6months.

TECHNICAL ASPECTS

Tympanoplasty is technically more difficult in patients having a narrow

canal, undergoing revision surgery, by transcanal approach and in anterior perforations.
Only a few difficult cases were operated by seniors E.N.T surgeons. All other cases were
operated by resident. Perhaps hearing result and graft uptake would have been better if
more experienced surgeon would have taken over. Sade (1982) has expressed similar
opinion.

51
 Post-auricular approach is commonly used in our institution; end-aural route was
used in some of the cases with wide external auditory canals and tragal perichondrium
cases.

It was technically easier in endaural cases to harvest the tragal perichondrium graft from
same incision.

The contour of tragus was found to be satisfactory in postoperative period without any
cosmetic deformity.

GRAFT TAKE RATE

The graft take rate after 6 months was 82%. Long term studies were not possible due
to patient’s noncompliance. Similar reports was given by Palva T et al (1995)60 with
graft take rate was 97%.

In our study, graft uptake rate for temporalis fascia was 84% as compared to tragal
perichondrium (80%). Graft take-rate was slightly better for temporalis fascia than for
tragal perichondrium (not significant p>>0.005).

These result compare well with Jyoti P Dabholkar (2007)55 whose postoperative graft
uptake rate with temporalis fascia 84% and tragal perichondrium showed 80%.

Tragal perichondrium was used in revision tympanoplasty where temporalis fascia was
initially used. There was good graft-take in these cases. These reports compare well with
Jain CM (1968) 61 who reports 83.33% success rate with temporalis fascia, Ahad SA
(1986)31, with 83.30% success with homologous temporalis fascia, Blanshard JD
(1990)62, 78% take-rate with tempoarlis fascia in pediatric tympanoplasty.

Tragal perichondrium graft take rate was 90.91% in cases of subtotal perforation which
was significantly better than that of temporlis fascia. Wiegand (1978)63 also found good
for closing large defects with satisfactory sound transmission.

Most of graft failures seen in the follow-up period were due to infection probably
transmitted either along Eustachian tube or along external auditory canal.

HEARING RESULT

52
88% of cases showed improvement in hearing, while 12% of them showed either
deterioration or no improvement, at 6 month follow-up period. About 88% cases
operated with temporalis fascia showed hearing improvement, while same percentage
(88%) of cases who were operated using tragal perichondrium showed improvement in
hearing (statistically not significant p>> 0.05) as shown in the Table-6.

Mean improvement in hearing using temporalis fascia was 15.9 db and that with tragal
perichondrium it is 15.35 db (statistically not significant p>>0.05) as shown in Table -7
These result compare well with Strauss et al(1975) who found that improvement in air
bone gap was 15 db. These result also compare well with Ophir D (1987)64, Terry RM
(1988)37, result with fat myringoplasty.

Hartwein (1992)42 claims reduction of air bone gap of around 15 db with tragal
perichondrium graft.

This study compare well with Sunita Chhapola,Inita Matta (2011)58 whose postoperative
hearing accessed after 6 months of surgery, with temporalis fascia graft showed air bone
gap of less than 10dB in 82% of patients and more than 10dB in 18% patients. Air bone
gap closure with tragal perichondrium was less than 10 dB in 78% patients more than
10dB in 22% of patients.

The patient population attending our hospital was also from low socioeconomic status,
many had poor personal hygiene and poor nutritional status. These were probably some
of the factors which contribute to higher rate of graft rejection.

FACTORS AFFECTING GRAFT TAKE-RATE

Majority of perforations operated in our study were subtotal (24%) followed by

posteroinferior (20%) and anteroinferior perforations (18%) Least number of
perforations was seen in anterosuperior quadrant (4%).

Take-Rate was maximum for perforation in inferior half of the drum where all 4
perforations have healed well, take rate was least for perforation involving superior half
of tympanic membrane anterior quadrant or posterior quadrant. But the ears operated
with perforation in these sites were small in number to be significant. Finally, then take-
rate is not influenced by size or site of perforation.

53
 Similar opinion is expressed by Blanshard JD (1990)62 who opines that age at
operation, size of perforation and prior adenoidectomy had no significant influence on
the success rate or audiological outcomes.

Factor such as duration of illness, age and sex of patients used, did not significantly
affect graft uptake rate in our study. Vartiainen E (1993)65 also states that the
preoperative factor like dryness or discharging ear, site of perforation of technique
(onlay/underlay) do not affect the take rate.

Berger G, et al (1997)66, stated that results of myringoplasty were independent of

patient’s age, location and size of perforation and the seniority were not decisive factors
in the result of myringoplasty.

As the number of patients for tympanoplasty after 6 months were too less, hence
were not taken into consideration.

54
 SUMMARY
 50 tympanoplasties were performed on indoor basis.

 Age range from 16-50 years with mean age of patients 30.36 years.

 22 (44%) males and 28 (56%) females with male to female ratio 1:1.27.

 Mean duration of illness was 15.78 months.

 Majority of the patients preoperatively showed mild to moderate hearing

loss.70% patients showed upto 30 db air bone gap range, 24% patients being
in 30-40db air-bone gap and only 6% patients is above 40db.

 Surgeries were performed by post-aural or end-aural approach.

 In all surgeries grafts were placed as underlay technique.

 25(50%) patients were operated using temporalis fascia and 25(50%)

patients using tragal perichondrium.

 Graft take rate was overall 82%.

 Take-rate was 84% with temporalis fascia and 80% with tragal
perichondrium. This might be because tragal perichondrium was used in
large central perforation and revision tympanoplasties.

 In postoperative hearing analysis, 80% patients showed air-bone gap

around10db.

 Overall mean improvement in hearing was 15.625 db.

 Mean improvement in hearing for temporalis fascia was 15.90 db and for
tragal perichondrium was 15.35 db.

 Take rate of graft was not influenced by the size of perforation.

55
 Improvement in hearing was also not significantly influenced by the type of
graft used.

56
 CONCLUSIONS

 Tympanoplasty is the most effective method for control of the disease and
hearing improvement.

 Both temporalis fascia and tragal perichondrium are excellent graft

materials for closure of perforation of tympanic membrane and hearing
improvement.

 Graft uptake rate is good for both with slightly better take rates for
temporalis fascia, than tragal perichondrium.

 Hearing improvement does not depend on type of graft (No statistically

significant difference – p>>0.5).

 In our study, take –rate of graft was neither influenced by the (p>>0.5) site
or size of the perforation.

 Improvement in hearing is not significantly influenced by duration of

disease, age or sex of patients.

57
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62
 APPENDIX ‘A’ – ABBREVATION

db - desi-bel

EAC - External Auditory Canal

U.R.T.I - Upper Respiratory Tract Infection

PNS - Para- Nasal Sinus

DLC - Differential Leukocyte Count

TLC - Total Leukocyte Count

Hb - Haemoglobin

TF - Temporalis Fascia

TP - Tragal Perichondrium

PTA - Pure Tone Audiometry

63
 APPENDIX ‘B’ PROFORMA

Serial Number :

Reg No. :

Name of patient :

Age / Sex :

Occupation :

Indoor Number :

Address :

DOA :

DOO :

DOD :

64
 PRESENTING COMPLAINTS WITH DURATION
1. Ear discharge (Duration, Side, Character, Smell ,Amount ,Associated with cold or not,
Bleeding, Responding to medicines
2. Decreased Hearing(Uni/bilateral, Rate of progression, Fluctuating or not)
3. Tinnitus
4. Vertigo
5. Otalgia
6. Recurrent URTI
7. Headache, vomiting, facial weakness
8. Nose complaints
9. Throat complaints

PAST HISTORY
1. H/o similar complaints int the past
2. H/o any significant medical illness
3. H/o trauma

PERSONAL HISTORY

FAMILY HISTORY

65
 EXAMINATION
Examination of Ear:
1. Examination of pre- auricular area
2. Examination of post auricular area
3. Examination of pinna
4. Examination of EAC
5. Examination of tympanic membrane

Rt.Ear Lt.Ear

Assesement of hearing Acuity

1. Qualitative
 Tuning fork testing with 256,512 and 1024Hz
 Pure Tone Audiometry
2. Symptomatic

Examination of Nose:

Examination of Throat:

66
 LABORATORY INVESTIGATION:

1) Routine investigation-
 TLC
 DLC
 Hb%

2) Urine investigation

3) X-ray chest

4) X-ray mastoid ( Schuller’s view)

5) X- ray PNS (if indicated)

OPERATIVE DETAILS

1. Date of operation.
2. Graft used
3. Approach
4. Intraoperative complication

POST OPERATIVE CHECK –UP

1. Graft takes up
2. Assessment of Hearing Acuity : (after 6 months)

Qualitative

67
68