TRAGAL CARTILAGE IN MIDDLE EAR RECONSTRUCTION

          TRAGAL CARTILAGE IN MIDDLE EAR RECONSTRUCTION


Desarda K. K.a Dr. Nilima. Kharade,Dr.Sheetal (ENT Residents)
• Professor and head department of ORL, KEM hospital, Pune.
• Chief residents department of ORL, KEM hospital.
This paper was read at AOI conference, Cochin, January 2000.

Email: kdesarda@gmail.com
Address:
Dr.K.K.Desarda.MS.FACS.DLO.(Lond)
Prof.Emeritus & Head Otolaryngology,
KEM Hospital, Pune

Abstract

Cartilage has become an alternative to more traditional grafting materials for the tympanic membrane reconstruction.  Vein graft was very popular for many years, but has been replaced by temporalis fascia.  Perichondrium and dura matter have also being used.  Currently temporalis fascia and perichondrium are most commonly materials used. Cartilage has shown itself to be a novel material with high success rate in more challenging cases such as retraction pockets, recurrent perforation, atelectasis, cholesteatoma and ossicular chain reconstruction

To date, temporalis fascia and perichondrium remain the most commonly employed materials for closure of tympanic membrane perforations.  The success rate in TM reconstruction with these materials approaches 90%. In certain situations, such as the atelectatic ear, cholesteatoma, and revision tympanoplasty, the results with these materials have not been as gratifying.  Fascia and perichondrium have been shown to undergo atrophy and subsequent failure in the postoperative period.  This has led to the use of cartilage, which is a less compliant, more rigid material that resists resorption and retraction.  It has also been shown by different studies that it is well tolerated by the middle ear and hearing results have been comparable with those of fascia and perichondrium

The study presents six hundred ear operations of varied middle ear pathology using tragal cartilage and perichondrium as a choice graft. The technical advantages of tragal perichondrium graft in myringoplasty, ossiculoplasty, ossiousplasty, and mastoid cavity obliteration are discussed.





KEM Hospital Pune.

The study was conducted at K.E.M. Hospital, ENT department during 1980 to 2000. we have recorded our observations and results and concluded that tragal perichondrium and cartilage is an ideal graft material for reconstructive tympanoplasty. The objective of study was to assess the efficacy of tragal perichondrium and cartilage, the functional capacity in restoring hearing acuity, it’s mechanical survival, it’s extrusion rate and it’s functional integrity in tympanomastoid reconstruction.

Keywords: Cartilage, Perichondrium, Sialastic.

Introduction




INTRODUCTION:


The technique of ‘Reconstructive Tympanoplasty’ has been improved and refined ever since the introduction of operative microscope. The methods of radical and modified radical mastoid operations have not changed for decades except for minor variations. The innumerable graft materials being used to restore the dry and functioning ear. The autologous, homologous and allograft, synthetic materials lik plastics, ceramics, hydroxyapatite and golds were used but none of these have established their universal acceptability as a proved graft except the autologous grafts (cartilage, ossicles, fascia). The functioning and survival of each graft material varies as each one has certain advantages ad disadvantages and technical problems during and after surgery.
Cartilage has become an alternative to more traditional grafting materials for the tympanic membrane reconstruction.  Vein graft was very popular for many years, but has been replaced by temporalis fascia.  Perichondrium and dura matter have also being used.  Currently temporalis fascia and perichondrium are most commonly materials used. Cartilage has shown itself to be a novel material with high success rate in more challenging cases such as retraction pockets, recurrent perforation, atelectasis, cholesteatoma and ossicular chain reconstruction.

To date, temporalis fascia and perichondrium remain the most commonly employed materials for closure of tympanic membrane perforations.  The success rate in TM reconstruction with these materials approaches 90%. In certain situations, such as the atelectatic ear, cholesteatoma, and revision tympanoplasty, the results with these materials have not been as gratifying.  Fascia and perichondrium have been shown to undergo atrophy and subsequent failure in the postoperative period.  This has led to the use of cartilage, which is a less compliant, more rigid material that resists resorption and retraction.  It has also been shown by different studies that it is well tolerated by the middle ear and hearing results have been comparable with those of fascia and perichondrium

 We present our experince of twenty years (1980–2000) in using ‘Tragal Cartilage and Perichondrium’ in the reconstructive tympanoplasty. This study includes 600 cases of varied middle ear pathologies grouped in to four main divisions such as myringoplasty, ossiculoplasty, ossiousplasty (for defects in attic, posterosuperior quadrant, posterior canal wall and annular defects) and cavity obliterations. This study is not a comparative study to prove the superiority of any particular graft material over another.



Principles of Cartilage Tympanoplasty

This study includes 600 cases of varied middle ear pathologies of both safe and unsafe C.S.O.M. All cases were treated conservatively for prolonged time before being subjected for reconstruction. The special attention was paid to Eustachian tube function. The relevant investigations as routine otomicroscopy, mastoid X–rays, paranasal sinus X–rays, audiometries and blood biochemistry were done.


Study Design: 600 Cases


The study was designed in four groups. Group A – Myringoplasty (n=300), Group B–Ossiculoplasty (n=110), Group C – Ossiculoplasty (n=120), and Group D – Mastoid cavity obliteration (n=70) All cases were subjected for reconstruction after eradicating the middle ear pathology by various surgical approaches. The enomeatal (n=192), endaural (n=312), postaural (n=60) and transtympanic (n=36). The age group was 15 to 55 years and males were predominant. Most of these cases were done under local anaesthesia with sedation (n=480) and smaller group under general anaesthesia (n=120).

During the study it was observed that the middle ear showed different pathologies such as perforations (n=240), adhesive otitis media (n=24), tympanosclerosis (n=36) and cholesteatomas (n=120). Statistical Analysis was done in SPSS 10.0 using chi–square test.


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CLASSIFIED GROUPS:


Group A - Myringoplasty (n=300):


Out of 300 cases onlay grafting was done in 172 cases and inlay grafting was done in 128 cases. The tragal perichondrium and catilage was the choice graft used with excellent post of results. The success rate was 96% and failures 4% in this group. The hearing gain with SRT was achieved within 15 dB AB gap closure. The failure of 4% were subjected to revision surgery. The dry and healed middle ear was seen within three months time. The failure cases were attributed to infection, unhygienic conditions,prosthesis displacement, graft rejection and  poor follow–ups. In this group the follow up was 2 to 6 yrs. Audiometric thresholds revealed 15–20 dB A–B gap closure. The follow up was achieved in 50% of cases for 2 to 4 years.





Group B– Ossiculoplasty (n=110) (Fig.1–6):


In this group all cases were subjected for tympanomastoidectomy with ossicular reconstruction by tragal cartilage and perichondrium struts of various types as L–shape, Bow–shape and Boomrang strut. Various combinations of Incudo–stapedial assembly, malleo–stapes strut, malleo–footplate assemblies were done. In all cases sialistic sheet was used so also the anterior canal skin as covering the graft assembly. In this group the success rate was 84% and failure rate was 16%. The failures were due to infection, prosthesis displacements and extrusion of the graft. Audiometric thresholds revealed 15–20 dB A–B gap closure. The follow up was achieved in 50% of cases for 2 to 4 years.

The technique used for cartilage reconstruction with ossiculoplasty depends on the presence or absence of the malleus manubrium. In the malleus present situation, the palisade technique is very effective and also provides good acoustic benefit. The malleus-absent situation represents one of the most challenging situations for cartilage tympanoplasty and ossicular reconstruction. The perichondrium/cartilage island flap is used in these cases to prevent the prosthesis touching the tympanic graft and preventing extrusion. In these cases, the anterior portion of the cartilage is held securely in place while the posterior half is folded out to expose the trailing edge of the anterior piece of cartilage, which acts, in effect, as a neo-malleus. The distance between the stapes footplate or suprastructure and this trailing edge is measured and the prosthesis is cut to the appropriate length. The posterior portion is unfolded.  The nice thing about folding the prosthesis in half is that you can visualize the prosthesis and have precise placement.




  Different ossicular defects and their correction by cartilage struts.























Group C– Osseusplasty (attic, PSQ, PCW, annular defects) (n=70):





 



Attic,marginal,post.superior quadrants defects(cholesteatoma)


Cholesteatoma represents one of the most controversial but important pathologic conditions in which cartilage is used. The primary purpose of cholesteatoma surgery is to eradicate disease and provide a safe, hearing ear. The magnitude of the controversy regarding optimal surgical care is beyond the scope of this presentation, but cartilage should arguably be involved in each technique. The palisade technique has been very useful in the cholesteatoma setting as it gives the opportunity, if needed, to perform an ossiculoplasty in a precise way. Also, some authors prefer to leave the anterior portion of the TM without cartilage for surveillance and possible tube placement, if necessary, in the postoperative period. However, cartilage placement in the posterior aspect of the TM can certainly delay a recurrence. but, in most series, cholesteatoma will recur in the anterior portion of the TM and it can be suspected in the setting of a recurrence in conductive hearing loss. After my review of literature, I found that the recurrence rate for cholesteatoma after cartilage tympanoplasty is less than 10%.  And if we compare this rate with cholesteatoma recurrence rate overall in children, we can appreciate that is much lower than rates previously reported in the literature which ranges from 10-46%

In this group the various defects of attic, posterosuperior quaderants, posterior canal wall and annular defects were closed by tragal perichondrium and cartilage grafts. The composite graft proved to be the best than nonbiological grafts in takeup and restoring dry ears. The cholesteatoma from the defect was removed and the defect was closed with the grafts. The posterior canal wall defect was reconstructed with the tragal cartilage graft and lined by perichondrum and anterior canal wall skin. This group achieved 75% success rate and 25% were failures which needed revision surgery.



Group D– Mastoid obliterations (n=120):




Mastoid obliterations

All mastoid cavities were preoperatively treated by suction clearance, dry mopping with antifungal and antibiotic drops for about 4–6 weeks. The cavities were fashioned by smooth drilling and removing all debris, pockets of cholesteatomas etc. the tragal cartilage was arranged in the palisade manner with the perichondrium coverage and the pedicled temporalis muscle was swinged to obliterate the mastoid cavities for good healing. Periodical follow up and aural toilet were done. The cavities re–epithelised well and achieved 70% success rate. 30% failures was because of infection and poor post op. follow ups. The modified radical mastoidectomy cavities were transformed into radical cavities to achieve good healing. The problems of mastoid cavities are still unresolved despite the treatment of various modified techniques being weak.

Table I – Age group in the study:
Age group (years) No. of cases Percent
15–25 168 28
25–35 264 44
35–45 120 20
45–55 48 08
Total 600 100

Table II: Sex distribution:
Age group (years) Male (no.) Female (no.) Total
15–25 108 60 168
25–35 120 144 264
35–45 72 42 120
45–55 24 24 48
Total 324 276 600
Percent 54 46 100


Table III – Surgical approaches:
Approaches No. of cases Percent
Endaural 312 52
Endomeatal 192 32
Postaural 60 10
Transtympanic 36 06
Total 600 100

Table IV – Anaesthesia:
Anaesthesia No. of cases Percent
General 120 20
Local + Sedation 480 80
Total 600 100


Table V – Pathological defects:
Type of Pathology No. of Cases %
Performation 240 40
Adhesive Otitis media 24 04
Tympanosclerosis 36 06
Retration pocket 180 30
Cholesteatoma 120 20
Total 600 100


Discussion:

Cartilage has become an alternative to more traditional grafting materials for the tympanic membrane reconstruction.  Vein graft was very popular for many years, but has been replaced by temporalis fascia.  Perichondrium and dura matter have also being used.  Currently temporalis fascia and perichondrium are most commonly materials used. Cartilage has shown itself to be a novel material with high success rate in more challenging cases such as retraction pockets, recurrent perforation, atelectasis, cholesteatoma and ossicular chain reconstruction




Pathological-Defects

For many years the so called conservative methods of radical mastoid operations (Barany, Bondy, Citelli, Heerman, Stacke) were done in the clearance of disease but none of these proved better. At later dates Farrior, House, Lempert, Morrison added some minor variations in the technique of reconstructive tympanoplasty but still could not achieve the good results because the recurrence of the disease was very high. To modify these Victor Goodhill, Heerman and Heerman demonstrated their new techniques which prevented the recurrence of the cholesteatoma and gained the high success rates.


Distinct Advantages of Tragal Cartilage Graft

In this study 600 ear operations were performed with tragal perichondrium and cartilage as a composite graft in various types of middle ear reconstructions such as myringoplasty, ossiculoplsty, osseous reconstructions and mastoid obliterations. This study was done at K.E.M. Hospital E.N.T. department, Pune during 1980–2000. We have presented our observations of this reconstructive study of 20 years and found that the tragal cartilage is an ideal graft for the reconstructive middle ear surgery.

In the simple myringoplasty group the tragal perichondrium and cartilage achieved 96% success rate, the small, large and subtotal central perforations healed well in six weeks time. The inlay and onlay methods were used in the neotympanic reconstruction. In the total perforations and missing annulus the perichondrium angle was appropriate fit in forming the new annulus the perichondrium angle was appropriate fit in forming the new annulus. By this technique the blunting and lateralisation of the graft was prevented from the various cartilage assemblies in ossicular reconstruction achieved excellent stability and contact to bridge the gap in transformer mechanism. The incudostapedial gap was restored by cartilage sturt and maintained assembly. The malleostapedial, malleofootplate assembly proved good in restoring hearing.
 I

Ideal Graft

In TORP. & PORP ossicular graft the interposed tragal cartilage and drum have increased the ossicular stability and improved hearing to 75% (Victor Goodhill). Chronic endotympanic depression is a pathological entity which leads to atelectasis, retraction pockets and cholestestoma formation. The tragal cartilage and perichondrium composite graft intervention has prevented the recurrence of the cholesteatoma pocket adhesions and tympanosclerosis. The postop results were dryhealed middle ears with good hearing.



Results of Cartilage Tympanoplasty

During the study it was observed that middle ear patology of 40% perforaytions of safe and unsafe types, 4% adhesive otitis media, 6% tympaosclerosis, 30% retraction pockets and 20% cholesteatoma sacs. All these pathologies were corrected by radical removal and tragal cartilage reconstruction.

In mastoid obliteration the palisade cartilageplasty proved in gaining dry cavities in 70% of the cases. The Eustachian tubal obstruction was relieved by tunnelplasty and improved the good middle ear aeration. The cartilage bridge over promontory and hypotympanum assures the proper contact with stapes and in the combined approach tymparoplasty procedure the recurrence of cholesteatoma in the sinus tympani and facial recess could be prevented by incorporating the composite tragal cartilage and perichondrium. In open cavities the tympanocartige stapedopexy improved the hearing. It was our observation that biological material like tragal cartilage, perichondrium, facia or ossicles etc. are much better than nonbiological materials in reconstructive surgery.



Poor Results in Cartilageplasty


The survival rate of tgragal graft material is much better than nonbiological materials.

The extrusion rate of cartilage is very minimal as compared to the other graft materials. The review of literature revealed the different extrusion rates of different materials, such as autologous, 1.19%, isografts 3.06% the synthetics 5.04%, human dentine 7.14%, gold prosthesis 8.7%. Overall the tragal cartilage and perichondrium proved to be the best graft materials in reconstructive tympanoplasty which is universally accepted.




Table VIII :Extrusion rates of commonly used graft materials:
Graft material Extrusion rate (%)
Autograft 1.19
Isograft 3.06
Synthetic 5.04
Human Dentine 7.14
Gold prosthesis 8.70

Table IX :Results of cartilage tympanoplasty: P=0.0001 by chi square:
Group Success (%) Failure (%)
Myringoplasty 96 04
Ossiculoplasty 84 16
Osseusplasty 75 25
Mastoid obliteration 70 30

Table X – Poor results in cartilageplasty:
Causes No. of cases
Displacement 12
Fibrosis 10
Absorption 06
Infection 08
Total 36

TABLE V – Pathological Defects:
Type of Pathology No. of Cases Percet
Performation 240 40
Adhesive Otitis media 24 04
Tympanosclerosis 36 06
Retration pocket 180 30
Cholesteatoma 120 20
Total 600 100


Table VI – Ossiculoplasty:
Lesion No. of cases Percent
Attic 55 50
Posterosuperior quadrant 33 30
Posterior canal wall 11 10
Eustachian tube 11 10
Total 110 100

Table VII – Ossicular Status (300 cases): –P=0.0001 by Chi square:
Structure Normal Eroded Destroyed
Maleus 120 72 108
Incus 000 96 204
Stapes 108 00 192










 Conclusion

 The use of cartilage is experiencing a renaissance in ear surgery because it appears to offer an extremely reliable method for reconstruction of the tympanic membrane in cases of advanced middle ear pathology and Eustachian tube dysfunction.
Cartilage is particularly useful for the atelectatic ear, cholesteatoma, high risk perforation and for reinforcement of the tympanic membrane in conjunction with ossiculoplasty.
Hearing improvement can be experienced with the use of cartilage regarding the underlying pathology. Excellent clinical and experimental evidence exists to justify the use of cartilage as a grafting material in pediatric tympanoplasty. Cartilage tympanoplasty provides a tympanic membrane repair with greater structural stability and strength than traditional graft materials in many patients with challenging middle ear environments
In view of the above study we strongly recommend the tragal perichondrium and cartilage composite graft in various tympanoplasty reconstructions. The main reason being the cartilage is easily available at the site of operation, nontoxic, less, extrusion, minimum shrinkage, and lateralisation above all it is very cost effective to our patients. The hearing improvement within 15db of bone conduction has become almost a standard criterion for the analysis of surgical success.







Extrusion Rate of Commonly Used Graft Material


References:

• Aeaham Evitor and Bronx NY: Tragal perichondrium and cartilage in reconstructive ear surgery, Laryngoscopy, 88 (Suppl.): 1–23,1978.
• Heerman and Heerman tympanoplasty and mastoidoplasty, Laryngorhinootology, 46:370–382, May 1968.
• Plester D.: Myringoplasty methods, Archieves otolaryngology, 78:310–316, Sept.1963.
• House H. P.: Surgical repair of the perforated drum, Annales otorhinolaryngology, 62 : 1072–1093, 1956.
• Goodhill Victor, Harris I., and Brockman S. J.: Tympanoplsty with perichondrium graft, Archieves otolaryngology, 79, 131, 1963.
• Claus Jansen : Cartilage tympanoplasty, Laryngoscope, 73: 1288, 1963.
• Heerman and Heerman: Fascia and cartilage palisade tympanoplasty, Archieves otology, 91 : 228–241, 1970.
• Victor Goodhill: Tragal perichondrium and cartilage in tympanoplasty, Archieves otology, 85:480–491,1963.
• Jansen C.: Use of perichondrium for tympanoplasty, Archives ohren, 182:610–614, 1963.
• Shea J. J.: Vein graft in tympanic reconstruction, Journal of laryngootology, 74:358–362, 1960.
Contributed by Dr. K. K. Desarda