ANTERIOR TUCKING VS CARTILAGE SUPPORT TYMPANOPLASTY

Transcription

1 ANTERIOR TUCKING VS CARTILAGE SUPPORT TYMPANOPLASTY K S Burse*, S. V. Kulkarni**, C. C. Bharadwaj***, S. Shaikh****, G. S. Roy***** ABSTRACT Objectives: To compare and analyze two methods of tympanoplasty in view of graft take up rate and hearing outcome. Settings: It is a descriptive study done at tertiary care centre where patients suffering from tubotympanic type of chronic suppurative Otitis media with subtotal perforation, without any complications, within age group of 10 years to 60 years, with hearing impairment of less than 50 db and without any history of previous ear surgery were selected. Method: 50 clinically diagnosed cases were randomly divided into two groups of 25 each to be operated by anterior tucking method and cartilage support method of tympanoplasty. Detailed pre operative and post operative clinical and audiometric evaluation was done. Results: Successful graft uptake was observed in 96 % of our patients in both the groups. The statistical analysis of pre and post-operative audiograms shows there is significant improvement in hearing in anterior tucking method. Conclusion: In our present study, though there is no significant difference in the graft uptake rates of either of the method. The post operative hearing improvement is significantly better in the Anterior Tucking type of tympanoplasty than the Tragal Cartilage Support method. Key Words: Anterior tucking, cartilage support, graft take up, hearing outcome, Tympanoplasty. INTRODUCTION Chronic suppurative otitis media is one of the common otological conditions In India for which patients seek advice from an otorhinolaryngologist. Poverty, illiteracy, poor hygiene and overcrowding are all factors which play an important role in causation of this disease. The perforation of tympanic membrane seen in chronic suppurative otitis media may be the only squeal remaining when the pathological process in middle ear cleft has healed. It exposes the middle ear mucosa to exogenous source of infection and also produces conductive hearing loss. Surgical reconstruction of tympanic membrane along with assessment of ossicular chain is called as type 1 tympanoplasty. It has been seen that size of perforation does affect the graft uptake post operatively. The healing of small or medium size perforation is more successful than that of subtotal perforation. 1, 2 18 *Professor and Head, **Professor, ***Lecturer ***Resident, ****Resident, Dr. Vasantrao Pawar Medical college, Hospital and Research Centre Adgaon, Natik-3, Maharastra.

2 To overcome this problem various surgical techniques of tympanoplasty have been developed and tried with varying degrees of success rate. 3 Different materials have been used to reconstruct the tympanic membrane, most accepted of which is the temporalis fascia, because of its qualities of low metabolic rate, requiring lesser blood supply and is more resistant to infection 4. In our present study, an attempt is made to study the effectiveness of two such methods used for tympanoplasty. In the first method (anterior tucking), an anterior based tympanomeatal flap is utilised along with the posterior flap to tuck in the graft. Whereas in the second method (tragal cartilage support method), the graft is supported anteriorly by a bow shaped tragal cartilage graft placed medial to the annulus ring without disturbing it and posteriorly with the posterior based flap. In both these types, temporalis fascia has been used as the primary graft material. Preoperative symptom analysis, pre and post operative clinical analysis, audiological assessment is done. Effectiveness of methods has been measured by taking into account post operative graft uptake and post operative hearing improvement. MATERIAL AND METHODS Ours was a comparative study conducted from December 2009 to November Cases suffering from Tubotympanic type of Chronic Suppurative Otitis Media with subtotal perforation (perforation involving all four quadrants of pars tensa of tympanic membrane and thin rim of tympanic membrane is surrounding it) were selected. The selected 50 cases between the age group years were further randomly divided into two groups of 25 each. Exclusion criteria: Patients who were suffering from cholesteatoma, complications of chronic otitis media, purely sensorineural hearing impairment and upper respiratory tract infection were excluded from the study. Patients with hearing impairment more than 50dB which indicate ossicular chain discontinuity were excluded from the study. Patients who had already undergone tympanoplasty (revision) or any other otologic operative intervention were excluded. The cases presented with an active disease were administered a course of antibiotic with ear toileting to obtain a dry ear. Informed consent was taken from all the patients before start of the study. All patients were subjected to detailed pre operative and post operative history taking and clinical examination which included thorough otoscopic and otomicroscopic examination. Graft uptake and complications were evaluated in each visit with the help of otoscopy and ear microscopy. Criteria for successful graft take up are intact tympanic membrane on clinical examination and movement of intact tympanic membrane on seigelization. Hearing improvements evaluated by doing pure tone audiometry at 6 th month and compared with preoperative pure tone audiometry values. In the Pure tone audiometry, frequencies of 250, 500, 1K, 2K and 4K were evaluated. The results were tabulated and paired t test were applied between the results of each group for statistical analysis All patients were subjected for required investigations for pre operative anaesthesia fitness. Patients were admitted to the hospital one day before the operation. Injection-Tetanus toxoid 0.5 ml given intramuscularly and injection- lignocaine 0.2 ml test 19

3 dose given intradermally and observed for any hypersensitivity reactions for all cases. OPERATIVE PROCEDURE: Type I tympanoplasty was done in all the patients. All surgeries were done under Vario version of Ziess microscope. After infiltration of local anaesthesia with 2% lignocaine with adrenalin and painting and draping, post auricular Wilde s incision was taken. Temporalis fascia graft was harvested in all the cases. The middle ear was examined for the status of mucosa and ossicular chain continuity. Both the groups shared the same operative steps till elevation of the posterior tympanomeatal flap. Then onwards different steps were followed in two different methods as described below. 1. Anterior Tucking method: The middle ear and external auditory canal were packed with gel foam after placing the flaps in position. Wound was closed in layers and mastoid dressing was done to provide pressure. Antibiotic was given for all patients for a period of one week. Sutures were removed seven days post operatively. First post operative check up done after 15 days, second check up at 1 st month, third check up at 2 nd month, fourth check up at 3 rd month and fifth follow up at 6 th month. OBSERVATIONS AND RESULTS In two years period, 50 patients were enrolled. The patients included in this study were of age years. Most common age group involved in study was between 25 to 34 years (36%). In Tragal cartilage group 11 were males whereas 14 were females and in the anterior tucking group 10 were males and 15 were females. Incision was taken on anterior canal wall just lateral to the anterior annulus and the anterior tympanomeatal flap was elevated. The graft was placed lateral to the handle of malleus and tucked medial to the annulus anteriorly and anterior and posterior tympanomeatal flap were reposited. 2. Cartilage Support method: Here the tragal cartilage was harvested in addition to the temporalis fascia. Tragal cartilage was denuded of its perichondrium and cut into a bow or a crescentric shape. This shape helps in proper alignment of the graft in relation to the Antero-superior middle ear space. No anterior flap was elevated but the temporalis fascia graft was placed over the antero-superiorly based tragal cartilage graft. Thus the tragal cartilage graft placed medial to the annulus in the Middle ear space not only supported the temporalis fascia graft, but prevented its medialisation also. Also, Cartilage held fascia in place, preventing a residual perforation due to graft mobilisation. The Right ear was affected in 24 patients whereas the Left ear was affected in 26 numbers of patients. In all we had 14 cases of bilateral perforation amongst the study subjects. Out which 8 belonged to the tragal cartilage support group, and 6 belonged to the anterior tucking group. In the anterior tucking group, 15 patients were suffering from the symptoms for the 0 12 months, whereas 9 were suffering for13 24 months, and 1 patient had the symptoms for more than 25 months. Out of the 25 patients belonging to the tragal cartilage group, majority of patients (19 patients) were suffering from the symptoms for 0 12 months, whereas 5 were suffering for months, and 1 patient had the symptoms for more than 25 months. Failure of cases amongst the patients In all the 50 study subjects, we encountered 2 cases of failure wherein the patients developed re-perforation. 1 patient belonged to each the Cartilage and the Tucking groups. 20

4 Patient s hearing loss in decibels(pre-operatively) Pre-operative Pure tone audiometry amongst the groups suggested that in cartilage group 6 patients and in anterior tucking group 3 patients were having air bone gap between the 0-20 db. 17 patients with db air bone gap belonged to the Cartilage group and 19 patients were from the Tucking group. Whereas 2 patients with air bone gap of db belonged to the Cartilage group and 3 patients were from the Tucking group.(table No I) Table I. Patients Hearing loss in Decibel Patient s hearing improvement in decibels (Post- DISCUSSION The present study was conducted from December 2009 to November 2011 during which 50 cases of chronic otitis media (tubotympanic type) were included. All the 50 patients underwent myringoplasty with post aural approach. A group of 25 patients was undergone for anterior tucking method and in remaining 25 patients (second group) tympanoplasty was performed using temporalis fascia as the primary graft, along with tragal cartilage graft used for providing support to it anteriorly. These patients were followed up for a period of 6 months and were evaluated for graft uptake and hearing improvement. Graft uptake In the study of 189 cases of underlay tympanic operatively) Post-operative audiometry was performed after 6 months post-operative duration. The difference in the pre and post operative air bone gap suggested the following improvement. Majority of patients that is 15 in cartilage group and 13 patients from anterior tucking group had improvement between11-20 db. (Table No II) Table II. Patient s Hearing Improvement in Decibels membrane grafting by Michael E Glasscock (1973) 5, there were 173 case with successful graft uptakes (96%) and seven failures. Michael E Glasscock (1982) 6 in his study of post auricular undersurface tympanic membrane grafting, showed the graft take rate with fascia to be 93%. Albera R et al. (2006) 7 in their study of 212 patients, found a graft take rate of 86% (182 cases). Also, it has been seen that size of perforation does affect the graft uptake. Ikramullah Khan, et al showed healed tympanic membrane were noted in 88% cases (65 out of 74) where the perforation is medium in size. For subtotal perforation the success rate was 67% (40 out of 60). 1 B.K.Roychoudari showed that large or subtotal perforations with a very small remnant of tympanic membrane are more prone for failure % was the graft uptake rate. 2 In our study, we had selected all cases of subtotal perforation and criteria for successful graft take up are 21

5 intact tympanic membrane on clinical examination and movement of intact tympanic membrane on seigelization. Out of the 25 subjects in each groups, 24 from each group showed successful graft uptake (96 %).whereas the 2 failures (one in each group) accounted for 4% of the study subjects. Successful graft uptake was observed in 96 % of our patients in both the groups. All the above mentioned studies depict a similar result with regards to graft uptake amongst both the groups. - Cartilage support : Out of 96 patients reported by Dornhoffer et al tympanic membrane closure was achieved in about 95% of patients. There was a significant improvement in pure tone average (PTA) from 24.6 to 12.2 db, thus showing a mean improvement of 12.4 db. 10 We found that in our group of Cartilage support, the mean pre operative air conduction average was 26.2 db while the mean postoperative air conduction average was db, thus average air conduction improvement was db. So according to our study, graft uptake results with both the types of tympanoplasty we were studying were at par with the international results. HEARING IMPROVEMENT All the patients were assessed by a pre-operative audiometric evaluation. Post operative audiometry was done after a span of 6 months. The average Air bone gap was calculated and the difference noted. Mean Hearing Improvement - Anterior tucking : Caye Thomasen et al. 8 in their study of 26 cases, noted that the mean preoperative pure tone average air bone gap to be 20.1 db, the mean postoperative pure tone average of 11.5 db and thus the mean hearing gain of 8.6 db. Brown C et al. 9 in their study of 193 cases of Myringoplasty, the mean pre operative air conduction average was 35 db while the mean postoperative air conduction average was 25 db, thus average air conduction improvement was 10 db. We found that in our group of Anterior tucking, the mean pre operative air conduction average was db while the mean postoperative air conduction average was db, thus average air conduction improvement was db. Statistical analysis of hearing The average pre-operative Air bone gap in the anterior Tucking cases was found to be db with a standard deviation of +/ where as in the Cartilage support method it was found to be db with a standard deviation of+/ The paired t test applied revealed a value of p>0.05, stating that there was no significant difference between the pre operative audiometry values between the two groups. The average post operative Air bone gap in the anterior tucking cases was found to be db with a standard deviation of +/ where as in the Cartilage method it was found to be db with a standard deviation of +/ The paired t test applied revealed a value of p<0.001, stating that there is a significant difference between the post operative audiometry values between the two groups. Both of the above results showed that hearing improvement is significantly better in anterior tucking method as compared to tragal cartilage support method. SUMMARY AND CONCLUSIONS The comparative study was conducted from December 2009 to November Cases suffering 22

6 from Tubotympanic type of Chronic Suppurative Otitis Media with subtotal perforation were selected. The selected 50 cases between the age group years were further randomly divided into two groups of 25 each. This study was aimed to compare the effect of the two methods on the graft uptake and hearing improvement. The significant features of this study are as follows: - In this study there were 21 males and 29 females. The age group ranged from 15 years to 60 years and most of them were in the age group of years. - Graft take up was successful in 48(96%) of the patients. Only 2(4%) patients (one from each group) had a re-perforation. So there is no significant difference in the graft uptake rates of either of the method (96%). - Statistically the post operative hearing improvement is significantly different in two methods (p<0.001). Thus the study concludes that the Anterior Tucking type of tympanoplasty shows statistically better hearing improvement as compared to that of Tragal Cartilage Support method. REFERENCES 3. 89: 1980; James L, Sheehy, Robert G, Andrerson. Phone no: / Myringoplasty-A review of 472 cases Ann otol 4 Singh BJ, Sengupta A, Sudipkumar Das, Ghosh D, Basak B. A comparative study of different graft materials used in myringoplasty. Indian J Otolaryngol Head Neck Surg(April-June2009); 61: Glasscock ME. Tympanic membrane grafting with fascia: overlay Vs. undersurface technique. Laryngoscope 1973 Jan; Glasscock ME, Jackson CG, Nissen AJ, Schwaber MK. Post-auricular undersurface tympanic membrane grafting: A follow-up report. Laryngoscope 1982 Jul;92(7): Albera R, Ferrero V, Lacilla M, Canale A. Tympanic reperforation in myringoplasty: evaluation of prognostic factors. Annals of Otology Rhinology Laryngology 2006 Dec; 115(12): Thomas CP, Nielsen RT, Tos M. Bilateral myringoplasty in chronic otitis media.laryngoscope 2007 May; 117: Brown C, Yi Q, McCarty DJ. The success rate following myringoplasty at the Royal Victorian Eye and Ear Hospital. Australian Journal of Otolaryngology; 2002 Apr. 10. Dornhoffer JL. Cartilage tympanoplasty. Otolaryngology Clin Norht Am 2006; 39: Ikramulla Khan, Amir M Jan, Farrukh Shahzad. Address for correspondence: Middle ear reconstruction: a review of150 cases..the journal of Laryngology and otology. June 2002; Vol.116. pp Dr. K. S. Burse Head Of Department of ENT 2. Roy choudri BK. 3- Flap tympanoplasty-a simple and sure success technique. Indian journal of otolaryngology and Head and Neck surgery: 2004; 56: Dr. Vasantrao Pawar Medical college, Hospital and Research Centre Medical college, Adgaon, Nashik-3, Maharashtra E mail address: drksburse@gmail.com Issue-II, July-Dec

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