ABSTRACT advantages and disadvantages. But irrespective of

 ABSTRACTBackground: Tympnaoplasty has been well accepted as the surgery ofchoice for Chronic otitis media. Since the introduction of tympanoplasty, therehas been many modifications in terms of technique, approach, and materials usedfor grafting the tympanic membrane; each with their respective advantages anddisadvantages. But irrespective of procedure done very large and subtotalperforations have always posed a problem with failure after surgery.

Thisdemands further modification of the procedure to support the graft. This studywas done to know the role of  the role ofAnterior tucking of graft in subtotal and total perforation in terms of graft take up rate and hearing outcome.Method: Asystemic retrospective analysis of case files was done. The case files ofpatient who fulfilled the inclusion criteria were selected. Detailed preoperative and post operative clinical and audiometric findings were noted down.Results: Total of 40 cases with  3 cases being bilateral, 43 ears were operatedby cortical mastoidectomy with tympanoplasty along with anterior tucking of thegraft.

Our success rate was 95.3% (n=40). 40 patients had showed theimprovement in hearing with average air bonegap gain of 12.7dbhl.

Conclusion: Underlay grafting for subtotal and total perforations isa surgically challenging and results in poor outcome. Modification to thismethod by anterior tucking of the graft is an effective surgical technique withsatisfactory outcomes and hence is advocated for the routine practice. Key words : Anterior tucking, Tympanoplasty,Total perforation,subtotal perforation                        INTRODUCTIONChronic suppurative otitis media (CSOM) is achronic inflammation of the middle ear and mastoid cavity which often resultsin long term changes in the tympanic membrane including the perforation. Tympnaoplasty is a surgical procedure whichincludes eradication of disease from middle ear and reconstruction of thehearing mechanism with or without tympanic membrane repair. It has been wellaccepted as the surgery of choice for CSOM.Among the differentmaterials used for reconstruction of tympanic membrane, temporalis fasciaremains the Gold standard. Its low metabolic rate with reduced oxygenrequirement and good functional results with resistance to infection makes itthe most popular graft 1.

Since the introduction of tympanoplasty,there has been many modifications in terms of technique, approach, andmaterials used for grafting the tympanic membrane; each with their respectiveadvantages and disadvantages. But irrespective of procedure done very large andsubtotal perforations have always posed a problem with failure after surgery 2.This demands further modification of theprocedure to support the graft. This study was done to know the role of Anterior tucking of graftin subtotal and total perforation in terms of grafttake up rate and hearing outcome.

                             METHODSPatients and methodsA systemic retrospective analysis of casefiles fromNOV-2016 to NOV-2017 was done. Patients suffering from chronicsuppurative Otitis media with subtotal perforation and total perforation,without any complications, within age group of 16 years to 60 years, withhearing impairment of less than 50 dB and without any history of previous earsurgery  who underwent cortical mastoidectomy withtympanoplasty  along with anteriortucking at our ENT Department were selected. Exclusion criteria·        Patients who were diagnosed with Squamosaltype of CSOM·        Patients diagnosed to have associatedcomplications·        Patients with Sensory Neural Hearing Loss·        Patients in whom the hearing loss >/=50dbhl (suggestive of osscicular discontinuity)·        Patients undergoing revision tympanoplasty·        Patients who have undergone any otherotological surgeries·        Patients with congenital anomaliesDemographicdata, detailed history ofcomplaints and other relevant history were recorded. Complete Otorhinolaryngology examination including earinspection, palpation , otoscopic examination and tuning fork tests for hearingassessment was noted. Pre operative Pure Tone Audiometry  (PTA) which was done for all patients were documented.SURGICAL PROCEDUREAll thecases were operated under local anaesthesia.

Patient’s head was put in positionand local infiltration with  2%lignocaine and  1 in 1,00,000 adrenalinewas given. Parts were painted and draped. Post auricular William wilde’sincision was placed and temporalis fascia graft was harvested by hydrodissection. Cortical mastoidectomy was performed.

Posterior meatotomy was doneand posterior tympanomeatal flap was raised after freshening the margins ofperforation . Middle ear was examined. Underlaytechnique was used for placement of graft. Anterior tucking was done using a smallhorizontal incision (approximately 3 mm) placed lateral to annulus in thesuperior part of the anterior wall of the external auditory canal (EAC).Through this incision, the annulus is raised, and a small part of temporalisfascia is pulled up, to rest between the canal skin and the bone of anteriorEAC. Themiddle ear and EAC was packed with gelfoams after repositioning the flaps.Medicated wick was placed in EAC. Haemostasis achieved and wound closed.

Post operative care:Patientswere given antibiotics, analgesia (if required) and oral antihistamines for 3weeks until the pack removal. Suture removal was done after one week. Postoperative follow up was done every week for one month.Graftuptake and complications were evaluated in each visit with the help of otoscopy.Intacttympanic membrane with mobility on clinical examination was considered to be agood outcome of surgery.  Hearingassessment was done by repeating the PTA at 6th week whose findingswere recorded .The pre and post operative PTA values were analysed.

   Tympnaoplasty is a surgical procedure whichincludes eradication of disease from middle ear and reconstruction of thehearing mechanism with or without tympanic membrane repair. It has been wellaccepted as the surgery of choice for CSOM.Among the differentmaterials used for reconstruction of tympanic membrane, temporalis Fasciaremains the Gold standard. Its low metabolic rate with reduced oxygenrequirement and good functional results with resistant to infection makes itmost popular graft.Since the introduction of tympanoplasty,there has been many modifications in terms of technique, approach, andmaterials used for grafting the tympanic membrane; each with their respectiveadvantages and disadvantages. Thetwo traditional methods used are Underlay (medial) and overlay (lateral)techniques.

Among these two techniques, underlay is preferred by most of theotologists 3since its is less time consuming and easier 4,5.This method includes the placing of graft medial to both tm remnant and handleof malleus 3. While using underlay technique, inadequate bloodsupply, lack of residual TM as a source of epithelium, and poor exposure, maypose as challenge 6.Inaddition to these, decreased mesotympanic space and a lesser success rate inanterior and subtotal  perforations aresome of the disadvantages 7.

Onthe other hand, overlay technique involves elevation of epithelial layer andplacement of graft lateral to fibrous layer of TM remnant and annulus. This issuitable for subtotal and anterior perforation 8. Even though thistechnique gives high success rate, it does come at the cost of few possibledisadvantages like   graftlateralization, anterior blunting, delayed healing, stenosis of the externalcanal, epithelial pearls, iatrogenic cholesteatoma and is more technicallychallenging 9.Largely the outcome of TM grafting is  bad in case of anterior and subtotalperforations 6. So several modifications of surgery was tried. As described by Silverstein, fibrous annuluswas elevated along with tympanomeatal flap anterosuperiorly over the Eustachiantube.

Here a tunnel was made (2-4 mm) through which the graft was pulled outand between the anterior meatal skin and the bone canal 10. Whereas, Schraff et al 11  ,in his study did a modificationby  elevating the fibrous annulus frombony sulcus first and later the  canalskin over the anterosuperior quadrant in a retrograde fashion. This wasfollowed by an underlay grafting where he graft was situated between the rawbone and the anterior meatal skin. This study showed 94.5% success rate.In study by Hosmani et al 12, it was seen that  overallincidence of successful graft uptake was 96.96 per cent in group one whounderwent additional anterior tagging of graft and 81.5 per cent in group two who did not undergo any modification.

 In ourstudy the results are comparable with above mentioned studies. All 43 earswere operated by cortical mastoidectomy with tympanoplasty along with anteriortucking of the graft. Our success rate was 95.

3% (n=40). 40 patients showed theimprovement in the hearing with the average air bone gap gain of12.7dbhl.Themajor limitation of this study was it was not matched with control group, andfurther such studies are recquire to prove the efficacy of this method CONCLUSSION:Underlay grafting for subtotal and anterior perforationsis a surgical challenge because of its poor success rate. Tympanoplasty  with anterior tucking of the graft is aneffective surgical technique with satisfactory outcomes. Caution should be exercised with regard to maintainingthe integrity of the annular ring anteriorly.