Introduction
Myringoplasty and tympanoplasty are descriptive terms defining surgical procedures that address pathology of the tympanic membrane (TM) and middle ear. Myringoplasty is an operative procedure used in the reconstruction of a perforation of the tympanic membrane. This assumes that the middle car space, its mucosa, and the ossicular chain are free of active infection. There is no direct inspection of the middle ear during this procedure implying that the TM is not elevated from its sulcus. Tympanoplasty implies reconstruction of the tympanic membrane but also deals with pathology within the middle ear cleft, such as chronic infection, cholesteatoma, or an ossicular chain problem. To distinguish these two terms further, Rizer (1997) defines tympanoplasty to include all procedures in which "the drum is lifted from its position in the ear canal." Subsequent additional procedures such as grafting the tympanic membrane, alone, or in combination with ossiculoplasty (tympanoplasty with ossicular chain reconstruction), comprise the varying subtypes of tympanoplasty.1, 2, 3, 4, 5
Banzer (1640) described the first attempt at repair of a TM perforation with a pig's bladder. Toynbee[1853] placed a rubber disk attached to a silver wire over perforation.
Yearsley (1863) placed a cotton ball over a perforation. Blake[1877] proposed the paper patch which is still used today for preoperative evaluation. chemical cautery was performed by Roosa (1876) and Okneuff (1895). The term myringoplasty was coined by Berthold in 1878. He placed a thick skin graft. 6, 7, 8
Wullstein and Zollner[1950] are given credit for ushering in the modern era of tympanoplasty . They placed split thickness skin grafts over the de-epithelialized TM remnant, Wullstein (1956) described five types of tympanoplasty based on the relationship of the grafted TM to the middle ear structures. Storrs[1961] reported a series of patients in which temporalis fascia was used as an outer surface graft.
Past three decades temporal fascia has been the most commonly used grafting material in tympanoplasty. 9, 10
Cartilage was first used in middle ear surgery for ossicular chain reconstruction in 1958 by Jansen. In 1963, Salen and Jansen first reported the use of cartilage composite grafts for tympanic membrane reconstruction. Over the past twenty years autologous cartilage-perichondrium grafts have come into use to prevent recurrence retraction pockets and cholesteatomas in patients with Eustachian tube dysfunction. Cartilage is also reduce the rate of extrusion thought to of prostheses used for ossicular chain reconstruction. Cartilage grafts are usually used in combination with temporalis fascia grafts and are most successful when placed posterosuperiorly and in the area of the posterior pars flaccida (Poe and Gadre, 1993). Cartilage has also been used to graft the entire TM (Domhoffer, 1997]
The present study has been aimed to utilize the tragal cartilage perichondrial composite graft.
Materials and Methods
The present study was done on patients who visited the out patient department of Otorhinolaryngoloy of MBS Hospital, Kota. The study was carried out of 50 patients of different age (12-48ycars) and sex group. The cases selected for this study was carried out clinical examination including examination under microscope. The criteria for selection of these patients included dry ear for a period of I month. Intact and functioning ossicular chain, tested by paper patch test patent E. tube and absence of any other pathology like cholesteotoma and granulations.
Patients were operated upon to improve hearing and prevent recurrent infection. The method of study was carricd our under the following heading:
History of present illness
- The onset - duration
• Progress of discharge and discharge free period was specially indicated
Past history
• This was enquired in relation to ear discharge, otalgia, sorethroat, colds, allergy, infectious fevers such as measles, typhoid chickenpox etc.
Clinical examination
Was carried out with thorough car, nose and throat exam was performed
The appearance of pinna and external auditory canal was examined
The TM examined for its integrity, landmarks, contour and mobility. The size, site and appearance of edge of perforation were noted. The condition of middle ear
Mucosa through perforation was particularly looked for further the ears were subjected to thorough examination under magnification using Ziess operating microscope.
5. Preoperative hearing level was evaluated by tests using tunning forks of variable frequencies i.e. 256, 512, 1024. Conversation and whisper voice and puretone audiometry was performed in all cases.
By anterior rhinoscopy examination position of the septum, condition of nasal mucous membrane, amount of nasal airway, presence of any discharge, any polypoidal mass. The size of turbinate's were particularly looked for, the posterior choana, E-tube orifices were inspected with posterior rhinoscopy.
Paper patch test was done with all cases to see the integrity of Tympanic membrane.
Paper Patch test :- Perforation is closed with the cigarette paper pre and post operative audiogram are compared If the hearing is improved. It is known as Positive paper patch test. It indicate integrity of the ossicular chain.
Investigations
A radiological examination of both mastoids lateral- oblique views Pure tone audiometry to find out preoperative hearing levels prior to undertaking the patients for surgery.
E- tube function test : the E-tubal functions were evaluated in each case by valsalva's manoeuvre.
Valsalva's manoeuvre:
The external auditory canal and middle ear was cleaned of any debris and wax. Then the patients was asked to take a deep breath keeping the nose tightly SEM pinched and the lips firmly closed and then forcibly attempt to blow the nose rustling, hissing or blowing sounds if heared was noted. In cases where it was doubtful a rubber tube was connected to the patient ear under observation and the other end was put into the observer cars so that if there was any sound it was noted
Operative techniques
Graft material: In 50 cases of tragal perichondrium or cartilage with perichondrium was used as a graft material for myringoplasty.
Tragal perichondrium graft
After injecting local anaesthesia using adrenaline with xylocaine 2% in the ratio of 1 :200000.
A incision is made over tragal margine and skin flaps along with subcutaneous tissue are elevated tragal cartilage is exposed and excised out with perichondrium attached to it. The perichondrium is elevated under magnification and the cartilage is replaced back in its position and the skin sutured. The perichondrial graft so obtained is used for myringo plasty.
Onlay Technique
The operation were performed by transmeatal approach under ziess operative microscope. The meatal skin cuff was incised long the tympano mastoid suture line inferiorly. Then it was elevated and the epithelium was stripped from any anterior or inferior drum remnant and averted a continuity with the deep metal skin, when it was fully dissected, the erichondrium or cartilage with perichondrium was spread over the prepared surface of the TM. Where only a narrow rim of membrane removed the crichondrium was extended for several mm beyond the annulus on to the adjacent meatal wall. Meatal skin flaps were now replaced to overlap the 1argins of the overlap the margins of the perichondrium graft. Then it was packed with antibiotic and steroid packing and bandaged.
Inlay Technique
In "inlay" technique (Haugh, 1970) or an "underlay" echnique (shea, 1960). The rim of the perforation is removed and the subjacent mucosa is slightly secrified. Then perichondrium supported within the tympanum by gel foam is fitted under the malleus handle and any anterior drum remnant to reach the posterior meatal wall where it is covered by a previously elevated meatal skin flap. Apparently the mucosa of the TM grows around. and underneath the facia so that it becomes part of the TM. 51
After care: Antibiotic cover was provided for 7 days. The pack was removed not before 7 days. Follow up was carried at one week, two and three weeks, 1 month and 3 months. out in the following manner.
Observations
Table 1
Age wise distribution of patients
| Age in | Number of patients | Percentage of Patients |
| Years | ||
| 0-10 | 0 | 0 |
| 11-20 | 11 | 22 |
| 21-30 | 19 | 38 |
| 31-40 | 14 | 28 |
| 41-50 | 6 | 12 |
Total cases 50. Minimum age 12 year. Maximum age 50 years. Maximum number of cases were adults between 11 to 30 years.
Table 2
Sex wise distribution of patients
| Sex | Number of patients | Percentage of Patients |
| Male | 20 | 40 |
| Female | 30 | 60 |
Table 3
Distribution of patients according to Involvement of Ear
| Ear | Number of patients | Percentage of Patients |
| involved | ||
| Right | 16 | 32 |
| Left | 26 | 52 |
| Both | 8 | 16 |
Table 4
Distribution to patients according to occupation
| Nature of work | Number of patients | Percentage of Patients |
| Student | 5 | 10 |
| House wife | 21 | 42 |
| Business man | 8 | 16 |
| Service man | 12 | 24 |
| Labour | 4 | 8 |
Table 5
Distribution of patients according to duration of complaints.
| Complaints | Duration | |||||||
| 3-6 mths | % | 7-12 mths | % | 1-2 years | % | 3-5 years | % | |
| Discharge | 18 | 36 | 24 | 48 | 6 | 12 | 2 | 4 |
| Hearing loss | 16 | 32 | 22 | 44 | 8 | 16 | 4 | 8 |
| Otalgia | 4 | 8 | 2 | 4 | 0 | 0 | 0 | 0 |
| Rec. URI | 4 | 8 | 2 | 4 | 0 | 0 | 0 | 0 |
Table 6
Distribution of patients according to the area of T.M. involved
| Quardrant of T.M. Involved | Number of Percentage | Percentage of Patients |
| Antero- inferior | 3 | 6 |
| Postero- inferior | 7 | 14 |
| Sub- total | 12 | 24 |
| Centrally Situated | 28 | 56 |
Table 7
Distribution of patients according to the size of perforation
| Quadrant of T.M. | Number of Patients | Percentage of Patients |
| One Quadrant | 11 | 22 |
| Two Quadrant | 13 | 26 |
| Three Quadrant | 14 | 28 |
| Sub Total | 12 | 24 |
Table 8
No. of Patients with completed healed perforation at 1 year follow up.
| Duration | Number of Patients | Percentage of Patients |
| At 3 months | 50 | 100 |
| At 6 months | 48 | 96 |
| At 1 year | 47 | 94 |
Table 9
Distribution of patients according to pre operative A-B Gap
| Degree of hearing loss | Pre operative A-B Gap | Number of patients | Percentage of patients |
| I | 20-30dB | 18 | 36 |
| II | 30-40dB | 27 | 54 |
| III | Above 40 dB | 5 | 10 |
Table 10
Surgical Technique used
| Surgical Technique | No. Patients | Percentage |
| Inlay | 50 | 100 |
| Onlay | 0 | 0 |
| Interlay | 0 | 0 |
Table 11
Distribution of patients according to mastoid cellularity (Study of X-ray Mastoid)
| Type of Skiagram | Number of Patients | % of Patients | Acceptency of Graft | |||
| Healed | % | Rejectd | % | |||
| Cellular | 20 | 40 | 20 | 100 | Nill | 0 |
| Hypo | 28 | 56 | 27 | 98 | 1 | 0 |
| Cellular | ||||||
| Sclerosed | 2 | 4 | Nill | 0 | 2 | 0 |
Table 12
Graft Material Used
| Graft Material | Number of Patients | Percentage |
| Tragal Cartilage alone | 17 | 34 |
| Cartilage with perichondrium (Composite Graft) | 33 | 66 |
Table 13
Graft material used and their result at 1 year
| Graft material | No. of Patients | % | Acceptance | % | Rejected | % |
| Tragal cartilage | 17 | 34 | 17 | 100 | 0 | 0 |
| Cartilage with perichondrium (Composite Graft) | 33 | 66 | 30 | 30 | 3 | 10 |
Table 14
Distribution of patients according to the closure of A-B gap at 1 month
| Hearing gain in dB | No. of Patients | % |
| 30 dB or above | 9 | 18 |
| 21-30 dB | 16 | 36 |
| 11-20 dB | 19 | 38 |
| 1-10 dB | 6 | 12 |
| No gain | 0 | 0 |
Table 15
Distribution of patients according to closure of A-B gap at 3 months No. of Patients 16 28
| No. of Patients | |
| 0-10 dB | 6 |
| 10-20dB | 16 |
| 30-40 dB | 28 |
Discussion
The Present study was conducted on 50 cases of CSOM with dry central perforation selected for myringoplasty in Department of E.N.T. M.B.S. Medical College Kota.
The Ist table shows that the maximum incidence in these cases were in the age group of 12-30 years (60%) followed by 31-40 years ade group (28%). Minimum age in our study was 12 years and maximum was 50 years. We have not operated any case below 12 year of age. Since it is the age of recurrent adenoiditis and upper respiratory tract infections, which can be a cause of failure in simple myringoplasties, this correspond to the studies done by Singh & Bhaskar (1972) and Gupta AK. (1972). Where the maximum number of cases were also in the age group 25-35 years.
The 2nd table shows the sex distribution of these cases in the present study with the male female ratio of 1:1.5 respectively. This explains that females were more worried about that hearing and recurrent discharge from ears. Because of Social stigma associated. Therefore they came forward for operative procedure and to improve hearing.
The 3rd table shows that the left ear was predominantly involved in the involved only in 32% both ears Present series i.c. 52 % while right car was were involved in 16% of cases.
The 4th table shows that the maximum number of cases were house wives 42% followed by service class i.e. 24 % labourer class (8%). This can be explained by the fact that ladies and educated members came forward for getting hearing improvement. Uneducated or labourer came only when there was severe hearing loss, thus we can say that education play a great role in seeking early advise regarding disease and treatment. This study in similar to Gupta J.P. (1978), in his study the maximum number of cases were house wives 63%) and students (23.4%) and minimum (13.3%) cases were in labour group
The table number 5th indicates the distribution of cases according to duration of complaints. In 48 cases (96%) the duration of discharge was more than one year and ranging up to 3-5 years. Similarly hearing loss was present in all these cases. The longer the duration more was the hearing loss. Hence the results were not as good as in the cases of short history. Four cases had also complaints of Otalgia that can be explained due to associated acute upper respiratory tract infection.
The 6th table shows the involvement of the quadrant of tympanic membrane in perforation. Most cases (56%) were of central perforation only in 2 cases (24%) sub total perforation was present. For this study small central perforation cases were good and satisfactory results were obtained. anteroinferiorly placed perforation (below the handle of malleus) were selected only for putting cartilage with perichondrium. Keeping in mind that this could not disturb the ossicular chain. Posteriorly placed perforation were not selected for putting the cartilage with perichondrium graft to avoid ossicular chain disruption. This study is similar to the Gupta J.P. (1978). In this study the large central perforation was (63,40%) and small central perforation in 36.6% cases.
The 7th table shows that the distribution of patients according to the size of perforation is maximum in three quadrant (28%6) of TM. involved. Two quadrant of T.M. involved in (26%) cases. And One quadrant of T.M. involved in (22%). Sub total perforation occurs in (24 %) cases.
The 8th table shows that (100 %) of cases at 3 month duration as completely healed. (96%) of cases healed at 6 months duration. (94%6) cases healed at 1 year duration.
In 9 table shows that the maximum number of cases had hearing loss of 30-40 dB i.e. 27 cases (54%) followed by 20-30 dB hearing loss in (36%) cases, while more that 40 dB hearing loss was present only in five (5) cases. This hearing loss can be explained by the size of perforation patients with ossicular discontinuity were excluded from the study.
The 10th table shows that inlay technique was used in all cases i.e. 100 The result of inlay technique were excellent in the present series with only three failure, so we can that inlay technique stands superior to onlay and interlay techniques.
The 11th table revealed the radiological features of middle ear cleft. In (40%) cases mastoids were cellular, (56%) mastoids were hypo cellular while only in (4%) cases had sclerosed mastoid. This indicates that disease was limited only upto the middle ear not extending to antrum aditus and epitympanum. This study is similar to Gupta J.P (1978). In his study (4076) mastoids were cellular while (60%) were hypo cellular.
The 12th table shows that in most of the cases tragal cartilage with perichondurim (composite graft) was used as a graft material from the patients himself (66%), followed by cartilage alone i.e. (34%) cases.
The 13th table shows that out of 17 cases done using tragal cartilage as a graft, in all 17 cases graft material remained healthy till complete healing Out of 33 cases where cartilage with perichondrium was used ended with satisfactory graft take up and bearing, while in 3 cases the graft was not accepted due to infection.
The 14th table shows the postoperative hearing gain in dB. The maximum SEM hearing gain was 11-20 dB or above which was in 19 cases i.e. (36%) while 21- 30 dB hearing gain was seen in 16 case (32%) and 10 dB gain found in 6 cases ie. (12%). No hearing improvement seen in 3 cases which included the failure Cases. These findings are quite similar to those mentioned by Kacker et al (1974), Ghosh and Mehra (1975) and kicker (1976) where good hearing was obtained in 71% cases and satisfactory in 17 % cases with no improvement in 12% cases. Good hearing gain was observed in the cases where cartilage was taken as a graft material while satisfactory hearing gain was observed in the cases where cartilage with perichondrium were used as a graft material. We can explain the less hearing gain with cartilage with perichondrium, graft as compared to cartilage which restricts the mobility of tympanic membrane.
The 15th table shows that 28 cases shows closure of A-B gap of 30-40 dB. At 3 months duration. 16 cases shows closure of A-B gap 10-20 dB. 6 cases shows closure of A-B gap of 10 dB.
The 16th table shows that 25 cases shows hearing improvement at 1 year of 30-40 dB. 19 cases shows hearing improvement of 10-20 dB. 3 cases shows hearing gain of only 10 dB. While 3 cases no hearing improvement occurs at 1 years duration.
The 17th table shows that the residual hearing loss of 10-20 dB. In 6 cases and 10 dB residual hearing loss in 2 cases in1yearduration.
Conclusion
50 cases of dry central perforation in which myringoplasty was performed using tragal cartilage alone or tragal cartilage with perichondrium were studied. The main point of interest are summarised as follow:
That most of the cases were young adults between 21-30 years of age. The male to female ratio being about 1: 15 most of which were middle class house wives.
The chief complaints found in all the cases were diminished hearing and discharge from car off and on. 56% of the cases had central perforation and the cars were dry for over a period of I to 3 months.
On radiological examination 40% of the cases had cellular mastoid, 56% had hypocellular mastoid and 4 % sclerosed. All the cases had normal patent E. tube.
All cases inlay graft technique (100% was used
We found that the successful results i.e. taking up of the graft and good hearing achieved in cellular mastoid were 100% while in hypocellular the results achieved were 98%.
Out of 50 cases in which myringoplasty was performed (94%) healed completely while in (6%) there was graft failure. When compared with graft material used the success rate was (100%) with tragal cartilage alone and 90% with cartilage with perichondrium. (composite graft) which was used in large central or sub total perforation. In none of the cases we came across any perichondritis therefore we conclude from our study that tubal function and cellularity of mastoid play a vital role in achieving good results in myringoplasty. Tragal cartilage and cartilage with perichondrium (composite graft) used as graft material gave good results in the present series.
