Desarda K. K.^a Bhisegaonkar D. A.^b Gill S.^b

• 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.

Abstract
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. 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
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.

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.

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.

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.


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 and poor follow–ups. To infection, prosthesis displacement and extrusion of 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.

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.


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

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.

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.

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. 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

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.



References

Extrusion Rate of Commonly Used Graft Material
• 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