Comparative study of Crescentic Cartilage and Anterior Tucking Tympanoplasty

Introduction

Ear is an important special organ of hearing. Hearing loss and discharging ear is the commonest otological disease. Hippocrates was the first to observe that painful ear with fever was ominous [1]. Primitive days when no microscope or endoscope was invented, different scientist devised ways and means to treat ear disease. In 1640 Banzer was first to attempt to repair tympanic membrane perforation. Blake in 1877 used paper patch to close the tympanic membrane perforation with improved hearing. Storr’s results of tympanoplasty were inspiring but skin grafts gave poor results which were replaced by Glasscock and Sheehy by temporalis fascia. Then various methods of onlay underlay and inlay techniques were employed to repair tympanic membrane perforations with gratifying results. In the anterior tucking method, the tympanomeatal flap was elevated with the posterior tympanic annulus, an incision was made on anterior canal wall about 5mm lateral to the anterior mesotympanum tunnel was made connecting to anterior mesotympanum. The graft was placed medical to the handle of malleus and tucked medial to the fibrous annulus anteriorly by pulling it through the tunnel. Similarly in Cresentric Cartilage Tympanoplasty, a semilunar / Cresentric cartilage is placed below the grafted material and graft was cleverly spread. This Cresentric cartilage fixed the grafted material between itself and the annulus. Cartilage harvested from patient and also used in ossicular reconstruction both helpful in anterior perforation where perforation remains if done by conventional technique.

But to achieve best results innovative techniques are devised. Hence, anterior tucking, ring cartilage tympanoplasty, boomerang cartilage tympanoplasty, cresentric cartilage tympanoplasty etc. Were used to achieve best outcome. Our study focused at the comparative outcome between cresentric cartilage tympanoplasty and anterior tucking.

Results

This study was conducted on hundred patients at Shyam Shah Medical College, Rewa, MP. The age group affected maximally was between ten to twenty years of age. The maximum number of patients were males in both the groups ie thirty five (70%) in crescentic cartilage (CCT) and thirty nine (78%) anterior tucking tympanoplasty (ATT). In CCT group the large central perforation was present in twenty six (56%)patients, subtotal in eighteen (36%) and total perforation in six(12%) patients. Similarly, in ATT group thirty four(68%) patients were having large central perforation, fourteen(28%) had subtotal perforations and two (4%) had total perforation. Forty patients(80%) were operated under local anesthesia and ten(20%) under general anesthesia in CCT group. In ATT group thirty nine (78%) were operated under local anesthesia and eleven (22%) in general anesthesia. Average air bone gap in CCT group was

38.28dB and postoperatively the A-B gap was 19.14dB with the net gain of 19.14dB.Similiarly, average A-B gap in ATT was 36.57dB and postoperatively A-B gap was 25.43dB with the net gain of 11.14dB. Infection was seen in five (10%) patients in CCT and ten (20%) patients in ATT group. Failure was seen in one (2%) patient in CCT group and five (10%) in ATT group and required surgery again. The average time of surgery in both the groups varied from forty five minutes to ninety minutes.

Discussion

Ear is a special sense organ of hearing. Its significance can be best understood by people who are deaf mute, students who can’t hear and under perform in class, girls who are to be married and hearing loss, discharging ear becomes social stigma. Job seekers in various companies especially defence are denied job if they are otologically not fit. Scientist from time to time had worked hard to devise ways and means out to close the perforation and improve hearing. The advent of microscope, endoscope and other operating instruments has helped us achieve marvellous results and reach near perfection. Microscope was first used by Cael Nylen in 1921 which was perfected by Littmann and Ziess company in 1951[2]. Han L, et al. [3] in their study found equivalent results with both endoscopic and microscopic techniques and better with endoscopes in some reference especially hidden areas. Various grafting material like temporalis fascia, tragal perichondrium, fascia lata, fat, choncal & tragal cartilage are used to reconstruct the hearing mechanism. Simple grafting, onlay, underlay and interlay etc, are various techniques used to close the tympanic membrane perforation. Fresh temporalis fascia graft shrinks after drying, rehydrating and is a major cause of failure [4], hence cartilage supplements this drawback. Similar was the findings of Ulku CH [5]. John L Dornhoffer [6] operated thousand patients and found cartilage an important grafting material especially in atelactic, chronic and in patients with large central perforations. In some cases temporalis fascia graft developed retraction in patients operated by anterior tucking technique but cartilage supported tympanoplasty prevented retraction of tympanic membrane. The use of endoscope in ear surgery has helped a lot. Scar less ear surgery, bilateral endoscopic ear surgery in single sitting and many more innovative technologies have paved way for better outcome [7]. We too used endoscope to operate all patients single handed. Stabilization of the graft material is very important so that no defect in the tympanic membrane is left postoperatively. Various techniques are used to stabilize the graft, like interlay, anterior tucking, ring cartilage, boomerang cartilage, crescentic cartilage tympanoplasty etc.

Demirci, et al. [8] conducted study in 60 patients younger than eighteen years with cartilage (n = 25) or temporalis fascia (n = 35) while our group had a larger size of hundred (ATT= 50, CTT= 50) patients making the study more relevant. Our comparison was between crescentric cartilage and anterior tucking of temporalis fascia graft whereas others compared results between crescentric and ring cartilage tympanoplasty [9]. In our study the anterior tucking took more time than crescentric cartilage placement. The ring shaped graft was difficult to insert and so it is less preferred [9].

The mean pre and postoperative air bone gap (ABG) of 28.2dB and 15.1dB in temporalis fascia group, while mean gain postoperative was 13.1dB. The mean pre- and postoperative air bone gap (ABG) was 28.9dB and 16.8dB, and the postoperative hearing gain was 12.1dB in the cartilage group [7]. In our study average hearing gain was better in crescentic cartilage group with gain of more than nineteen decibel postoperatively.

In our study the results obtained were better with the crescentic cartilage graft when compared with the anterior tucking technique contrary to temporalis fascia graft which gave better results than cartilage graft [10, 11]. Debasish, et al. [12] had more than 93.33% result with ring cartilage tympanoplasty similar to the findings of Yakup, Mustafa, et al. [13]. In Demirci’s study success rates of 82.9% was achieved with the fascia and 92.0% with the cartilage similar to our results [8]. Burse Kulkarni, et al. [14] in their study of cartilage versus anterior tucking technique found no significant difference in graft uptake but asserted that hearing was better in anterior tucking technique. Mundra, et al. [15] in their study concluded that in subtotal perforation cartilage support provided almost hundred percent results. We tried to restore the middle ear physiology as normal as possible but blunting, displacement of the cartilage graft, epithelial pearls, infections did occur in spite of all the precautions being taken. Can Ozbay et al in their study used different shapes of the cartilage {boomerang-shaped (BSG) and shield-shaped grafts (SSG)} and found similar results [10]. Ahmed Hasmat et al found no difference in their study for large central perforation and had similar results with ring cartilage composite graft and temporalis fascia tympanomeatal degloving technique [16].

Conclusion

The present study carried out on a group of hundred patients was done to compare the results of two different techniques of tympanoplasty to achieve better results. We concluded that results were better achieved with the cartilage supported grafting rather than simple grafting. Anterior tucking was also another viable option but results were inferior when compared with cartilage supported grafting and was more time consuming.