ABSTRACT advantages and disadvantages. But irrespective of

 

ABSTRACT

Background: Tympnaoplasty has been well accepted as the surgery of
choice for Chronic otitis media. Since the introduction of tympanoplasty, there
has been many modifications in terms of technique, approach, and materials used
for grafting the tympanic membrane; each with their respective advantages and
disadvantages. But irrespective of procedure done very large and subtotal
perforations have always posed a problem with failure after surgery. This
demands further modification of the procedure to support the graft. This study
was done to know the role of  the role of
Anterior tucking of graft in subtotal and total perforation in terms of graft take up rate and hearing outcome.

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Method: A
systemic retrospective analysis of case files was done. The case files of
patient who fulfilled the inclusion criteria were selected. Detailed pre
operative and post operative clinical and audiometric findings were noted down.

Results: Total of 40 cases with  3 cases being bilateral, 43 ears were operated
by cortical mastoidectomy with tympanoplasty along with anterior tucking of the
graft. Our success rate was 95.3% (n=40). 40 patients had showed the
improvement in hearing with average air bone
gap gain of 12.7dbhl.

Conclusion: Underlay grafting for subtotal and total perforations is
a surgically challenging and results in poor outcome. Modification to this
method by anterior tucking of the graft is an effective surgical technique with
satisfactory outcomes and hence is advocated for the routine practice.

 

Key words : Anterior tucking, Tympanoplasty,Total perforation,
subtotal perforation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INTRODUCTION

Chronic suppurative otitis media (CSOM) is a
chronic inflammation of the middle ear and mastoid cavity which often results
in long term changes in the tympanic membrane including the perforation.

Tympnaoplasty is a surgical procedure which
includes eradication of disease from middle ear and reconstruction of the
hearing mechanism with or without tympanic membrane repair. It has been well
accepted as the surgery of choice for CSOM.

Among the different
materials used for reconstruction of tympanic membrane, temporalis fascia
remains the Gold standard. Its low metabolic rate with reduced oxygen
requirement and good functional results with resistance to infection makes it
the most popular graft 1.

Since the introduction of tympanoplasty,
there has been many modifications in terms of technique, approach, and
materials used for grafting the tympanic membrane; each with their respective
advantages and disadvantages. But irrespective of procedure done very large and
subtotal perforations have always posed a problem with failure after surgery 2.

This demands further modification of the
procedure to support the graft. This study was done to know the role of Anterior tucking of graft
in subtotal and total perforation in terms of graft
take up rate and hearing outcome.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

METHODS

Patients and methods

A systemic retrospective analysis of case
files from
NOV-2016 to NOV-2017 was done. Patients suffering from chronic
suppurative Otitis media with subtotal perforation and total perforation,
without any complications, within age group of 16 years to 60 years, with
hearing impairment of less than 50 dB and without any history of previous ear
surgery  who underwent cortical mastoidectomy with
tympanoplasty  along with anterior
tucking at our ENT Department were selected.

Exclusion criteria

·        
Patients who were diagnosed with Squamosal
type of CSOM

·        
Patients diagnosed to have associated
complications

·        
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 other
otological surgeries

·        
Patients with congenital anomalies

Demographic
data, detailed history of
complaints and other relevant history were recorded. Complete Otorhinolaryngology examination including ear
inspection, palpation , otoscopic examination and tuning fork tests for hearing
assessment was noted. Pre operative Pure Tone Audiometry  (PTA) which was done for all patients were documented.

SURGICAL PROCEDURE

All the
cases were operated under local anaesthesia. Patient’s head was put in position
and local infiltration with  2%
lignocaine and  1 in 1,00,000 adrenaline
was given. Parts were painted and draped. Post auricular William wilde’s
incision was placed and temporalis fascia graft was harvested by hydro
dissection. Cortical mastoidectomy was performed. Posterior meatotomy was done
and posterior tympanomeatal flap was raised after freshening the margins of
perforation . Middle ear was examined.

Underlay
technique was used for placement of graft. Anterior tucking was done using a small
horizontal incision (approximately 3 mm) placed lateral to annulus in the
superior part of the anterior wall of the external auditory canal (EAC).
Through this incision, the annulus is raised, and a small part of temporalis
fascia is pulled up, to rest between the canal skin and the bone of anterior
EAC.

The
middle 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:

Patients
were given antibiotics, analgesia (if required) and oral antihistamines for 3
weeks until the pack removal. Suture removal was done after one week. Post
operative follow up was done every week for one month.

Graft
uptake and complications were evaluated in each visit with the help of otoscopy
.

Intact
tympanic membrane with mobility on clinical examination was considered to be a
good outcome of surgery.  Hearing
assessment was done by repeating the PTA at 6th week whose findings
were recorded .The pre and post operative PTA values were analysed.

 

 

 Tympnaoplasty is a surgical procedure which
includes eradication of disease from middle ear and reconstruction of the
hearing mechanism with or without tympanic membrane repair. It has been well
accepted as the surgery of choice for CSOM.

Among the different
materials used for reconstruction of tympanic membrane, temporalis Fascia
remains the Gold standard. Its low metabolic rate with reduced oxygen
requirement and good functional results with resistant to infection makes it
most popular graft.

Since the introduction of tympanoplasty,
there has been many modifications in terms of technique, approach, and
materials used for grafting the tympanic membrane; each with their respective
advantages and disadvantages.

The
two traditional methods used are Underlay (medial) and overlay (lateral)
techniques. Among these two techniques, underlay is preferred by most of the
otologists 3since its is less time consuming and easier 4,5.
This method includes the placing of graft medial to both tm remnant and handle
of malleus 3. While using underlay technique, inadequate blood
supply, lack of residual TM as a source of epithelium, and poor exposure, may
pose as challenge 6.

In
addition to these, decreased mesotympanic space and a lesser success rate in
anterior and subtotal  perforations are
some of the disadvantages 7.

On
the other hand, overlay technique involves elevation of epithelial layer and
placement of graft lateral to fibrous layer of TM remnant and annulus. This is
suitable for subtotal and anterior perforation 8. Even though this
technique gives high success rate, it does come at the cost of few possible
disadvantages like   graft
lateralization, anterior blunting, delayed healing, stenosis of the external
canal, epithelial pearls, iatrogenic cholesteatoma and is more technically
challenging 9.Largely the outcome of TM grafting is  bad in case of anterior and subtotal
perforations 6. So several modifications of surgery was tried.

 

As described by Silverstein, fibrous annulus
was elevated along with tympanomeatal flap anterosuperiorly over the Eustachian
tube. Here a tunnel was made (2-4 mm) through which the graft was pulled out
and between the anterior meatal skin and the bone canal 10.

Whereas, Schraff et al 11  ,in his study did a modification
by  elevating the fibrous annulus from
bony sulcus first and later the  canal
skin over the anterosuperior quadrant in a retrograde fashion. This was
followed by an underlay grafting where he graft was situated between the raw
bone and the anterior meatal skin. This study showed 94.5% success rate.

In study by Hosmani et al 12, it was seen that  overall
incidence of successful graft uptake was 96.96 per cent in group one who
underwent additional anterior tagging of graft 
and 81.5 per cent in group two who did not undergo any modification.

 In our
study the results are comparable with above mentioned studies. All 43 ears
were operated by cortical mastoidectomy with tympanoplasty along with anterior
tucking of the graft. Our success rate was 95.3% (n=40). 40 patients showed the
improvement in the hearing with the average air bone gap gain of
12.7dbhl.

The
major limitation of this study was it was not matched with control group, and
further such studies are recquire to prove the efficacy of this method

 

CONCLUSSION:

Underlay grafting for subtotal and anterior perforations
is a surgical challenge because of its poor success rate. Tympanoplasty  with anterior tucking of the graft is an
effective surgical technique with satisfactory outcomes. Caution should be exercised with regard to maintaining
the integrity of the annular ring anteriorly.