Fascia and cartilage palisade tympanoplasty. Nine years' experience.
01 Mar 1970-Archives of Otolaryngology-head & Neck Surgery (American Medical Association)-Vol. 91, Iss: 3, pp 228-241
TL;DR: While transplanted skin requires careful placement and depends largely on direct vascularization, fascia and cartilage can thrive for a long time on plasma alone 2 and can heal in any desired position, no matter how placed.
Abstract: EVEN iVEN with the best of techniques, in tympanoplasties in which several separate pieces of retroauricular skin (Wullstein, cited in Heermann and Heermann 1 ) are used as grafts, seldom does the tympanum heal without a perforation. And equally important, such transplanted skin has a marked tendency toward constant desquamation, later forcing the patients to seek repeated medical attention. Although such desquamation is not seen when only canal skin (Plester, cited in Heermann and Heermann 1 ) is used for the tympanoplasty, this leaves a defect in the epithelium of the auditory canal which in turn leads to difficult postoperative care and, at times, to obstinate stenosis. Moreover, while transplanted skin requires careful placement and depends largely on direct vascularization, fascia and cartilage can thrive for a long time on plasma alone 2 and can heal in any desired position, no matter how placed. We first used temporalis fascia in 1958 to
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TL;DR: Cartilage tympanoplasty achieves good anatomical and audiologic results when pathology and status of the ossicular chain dictate the technique utilized and significant hearing improvement was realized in each pathological group.
Abstract: Objectives/Hypothesis: The purpose of this study was to analyze the anatomical and audiologic results in more than 1,000 cartilage tympanoplasties that utilized a logical application of several techniques for the management of the difficult ear (cholesteatoma, recurrent perforation, atelectasis). Our hypothesis was that pathology and status of the ossicular chain should dictate the technique used to achieve optimal outcome. Study Design: Retrospective clinical study of patients undergoing cartilage tympanoplasty between July 1994 and July 2001. A computerized otologic database and patient charts were used to obtain the necessary data. Methods: A modification of the perichondrium/cartilage island flap was utilized for tympanic membrane reconstruction in cases of the atelectatic ear, for high-risk perforation in the presence of an intact ossicular chain, and in association with ossiculoplasty when the malleus was absent. A modification of the palisade technique was utilized for TM reconstruction in cases of cholesteatoma and in association with ossiculoplasty when the malleus was present. Hearing results were reported using a four-frequency (500, 1,000, 2,000, 3,000 Hz) pure-tone average air-bone gap (PTA-ABG). The Student t test was used for statistical comparison. Postoperative complications were recorded. Results: During the study period, cartilage was used for TM reconstruction in more than 1,000 patients, of which 712 had sufficient data available for inclusion. Of these, 636 were available for outcomes analysis. In 220 cholesteatoma cases, the average pre- and postoperative PTA-ABGs were 26.5 ± 12.6 dB and 14.6 ± 8.8 dB, respectively (P < .05). Recurrence was seen in 8 cases (3.6%), conductive HL requiring revision in 4 (1.8%), perforation in 3 (1.4%), and postand intraoperative tube insertion in 11 (5.0%) and 18 ears (8.2%), respectively. In 215 cases of high-risk perforation, the average pre- and postoperative PTA-ABGs were 21.7 ± 13.5 dB and 11.9 ± 9.3 dB, respectively (P < .05). Complications included recurrent perforation in 9 ears (4.2%), conductive HL requiring revision in 4 (1.9%), postoperative and intraoperative tube insertion in 4 (1.9%) and 6 ears (2.8%), respectively. In 98 cases of atelectasis, the average pre- and postoperative PTA-ABGs were 20.2 ± 10.9 dB and 14.2 ± 10.2 dB, respectively (P < .05). Complications included 1 perforation (1.0%), conductive loss requiring revision in 2 cases (2.0%), and post- and intraoperative tube insertion in 7 (7.1%) and 12 ears (12%), respectively. In 103 cases to improve hearing (audiologic), the average pre- and postoperative PTA-ABGs were 33.6 ± 9.6 dB and 14.6 ± 10.1 dB, respectively (P < .05). Complications included 1 perforation (1.0%), conductive loss requiring revision in 11 (11%), and post- and intraoperative tube insertion in 6 (5.8%) and 2 (1.9%), respectively. Conclusions: Cartilage tympanoplasty achieves good anatomical and audiologic results when pathology and status of the ossicular chain dictate the technique utilized. Significant hearing improvement was realized in each pathological group. In the atelectatic ear, cartilage allowed us to reconstruct the TM with good anatomic results compared to traditional reconstructions, which have shown high rates of retraction and failure. In cholesteatoma, cartilage tympanoplasty using the palisade technique resulted in precise reconstruction of the TM and helped reduce recurrence. In cases of high-risk perforation, reconstruction with cartilage yielded anatomical and functional results that compared favorably to primary tympanoplasty using traditional techniques. We believe the indications for cartilage tympanoplasty (atelectatic ear, cholesteatoma, high-risk perforation) were validated by these results.
270 citations
TL;DR: The purpose of the study was to investigate the acoustic transfer characteristics of different cartilage transplants being typically used in different reconstruction techniques of the tympanic membrane.
Abstract: Objectives/Hypothesis The use of cartilage in reconstruction of the tympanic membrane has been established especially in cases such as tubal dysfunction and adhesive processes. Cartilage offers the advantage of higher mechanical stability compared with membranous transplants but may alter the acoustic transfer characteristics of the graft. Apart from material properties, it can be assumed that, also, the microsurgical reconstruction technique might influence the sound transmission properties of the reconstructed tympanic membrane. The purpose of the study was to investigate the acoustic transfer characteristics of different cartilage transplants being typically used in different reconstruction techniques of the tympanic membrane.
Methods Cartilage plates of different thicknesses (1.0, 0.7, 0.5, and 0.3 mm), cartilage palisades, and cartilage island transplants of varying size were investigated by means of an ear canal–tympanic membrane model. In contrast to former single-point measurements, sound-induced vibrational amplitudes of the entire transplant were measured by scanning laser Doppler vibrometry (measuring points, n = 133) (PSV-200, Polytec, Waldbronn, Germany). Frequency response functions (displacement vs. sound pressure) of all measured points were determined in the frequency range of 200 Hz to 4 kHz for the different transplants.
Results Cutting thick cartilage transplants into thin plates or palisades decreased the first resonance frequency and increased its amplitude, reflecting improved sound transmission properties of the transplant. From an acoustical point of view, the 0.5-mm cartilage plate seems preferable compared with the palisade technique. Cartilage island techniques showed vibration characteristics superior to plate or palisade techniques.
Conclusions Apart from material characteristics, the sound transmission properties of the reconstructed tympanic membrane are strongly influenced by the reconstruction technique. The choice of the surgical technique should consider requirements based on mechanical stability and acoustic transfer characteristics of the transplant.
148 citations
Cites methods from "Fascia and cartilage palisade tympa..."
...Numerous modifications of these basic principles have been described, including the use of combined cartilage-perichondrium transplants.(4,10,14) –18...
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TL;DR: The perceived benefit of cartilage tympanoplasty is to prevent retraction pockets at the grafted site, even though many otologists accept that this technique may not deal with the causal factors involved in the retraction process.
Abstract: There has been renewed interest in the use of cartilage for middle-ear reconstructions. The aim of the present review is to examine the indications, techniques and surgical outcomes of cartilage tympanoplasties reported in the literature. There have been concerns regarding weakening of cartilage struts, from histological studies involving explants; as a result, cartilage struts for ossiculoplasty have not gained popularity. On the other hand, cartilage tympanoplasty is now an established procedure for tympanic membrane and attic reconstruction. The commonest techniques involve cartilage palisades and composite cartilage-perichondrial island grafts. There are many variations on the shape, size and thickness of the cartilage grafts. The perceived benefit of cartilage tympanoplasty is to prevent retraction pockets at the grafted site, even though many otologists accept that this technique may not deal with the causal factors involved in the retraction process. Concerns that the stiffness and mass of cartilage grafts may adversely affect hearing have not been substantiated in clinical reports thus far.
117 citations
TL;DR: The experience with palisade cartilage technique demonstrates that subtotal or total perforations at high risk for graft failure, can be treated efficiently and a durable and resistant reconstruction of the TM with reasonable hearing can be achieved.
Abstract: The use of cartilage as a grafting material has been advocated in cases at high risk for failure, such as subtotal perforations, adhesive processes, tympanosclerosis and residual defects after primary tympanoplasties. The cartilage palisade technique, in which the TM is fully reconstructed with palisade-shaped cartilage pieces, was first described by Heermann. Cartilage material has been critized because of concerns regarding hearing results, however, large cartilage plates with thicknesses ≤0.5 mm have been suggested as an acceptable comprise and the graft take of this technique has been reported to be excellent. The purpose of this study was to compare the graft take rates and hearing results of primary type I cartilage tympanoplasty operations with palisade technique with those of primary tympanoplasty using temporalis fascia in a homogenous group of patients. Study design: retrospective chart review. Setting: tertiary medical center. The study population included 51 patients who were operated between January 2000 and 2006 at the Department of Otorhinolaryngology of Ataturk Training and Research Hospital, Izmir, Turkey. Primary tympanoplasty cases with pure subtotal perforations (perforation >50% of the whole TM area), intact ossicular chain, at least more than 1 month dry period and normal middle ear mucosa were included in the study. Palisade cartilage tympanoplasty group included 23 cases, whereas 28 patients were were in the fascia group. Intervention: therapeutic. Graft take rates were noted in 51 patients and pre- and post operative audiograms were compared using the chi-square test with Yates’ continuity correction, Fisher’s exact test, t test and repeated measures ANOVA. Graft take was achieved in 22 patients (95.7%) in palisade cartilage group and in 21 patients (75%) in temporalis fascia group (P = 0.059). Mean speech reception treshold, air–bone gap and pure-tone average scores comparing the gain between both techniques showed no significant changes in the threshold (P > 0.05). However the functional success was achieved with the palisade cartilage technique postoperatively, regarding to mean air–bone gap and speech reception threshold changes. Our experience with palisade cartilage technique demonstrates that subtotal or total perforations at high risk for graft failure, can be treated efficiently and a durable and resistant reconstruction of the TM with reasonable hearing can be achieved.
105 citations
TL;DR: The 23 known cartilage tympanoplasty methods to reconstruct the eardrum are classified in six main groups, and each method is briefly defined, described, and illustrated.
Abstract: The 23 known cartilage tympanoplasty methods to reconstruct the eardrum are classified in six main groups. Each method is briefly defined, described, and illustrated: Group A: Cartilage tympanoplasty with palisades, stripes, and slices. The eardrum is reconstructed by several, various, full-thickness pieces of cartilage with attached perichondrium on the ear canal side. In this group six different methods are described. Group B: Cartilage tympanoplasty with foils, thin plates, and thick plates, not covered with the perichondrium. In this group four methods are included. Group C: Tympanoplasty with cartilage-perichondrium composite island grafts. The perichondrium flap suspends or fixates the cartilage. In this group four methods are included. Group D: Tympanoplasty with special total pars tensa cartilage-perichondrium composite grafts. All three methods are used to close a total perforation, but differ from each. Three special methods are included in this group. Group E: Cartilage-perichondrium composite island grafts tympanoplasty for anterior, inferior, and subtotal perforations. Two on-lay and two underlay methods are included. Group F: Special cartilage tympanoplasty methods: The cartilage disc is placed under the perforation, the perichondrium onto the denuded eardrum remnant.
90 citations
References
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Book•
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25 Jul 1990
TL;DR: This book discusses surgery of the Ear, diagnosis of Ear Disease, and surgical Anatomy of the Temporal Bone Through Dissection.
Abstract: Part 1 Introduction to Surgery of the Ear: Development Anatomy of the Ear: Surgical Anatomy of the Temporal Bone: Diagnosis of Ear Disease: Conventional Radiologic Examination of the Temporal Bone: Neuroradiologic Examination: Principles of Temporal Bone Surgery. Part 2 Surgery of Infections of the Ear: Pathology and Clinical Course of Inflammatory Disease of the Middle Ear: Operations of the Auricle, External Meatus and Tympanic Membrane: The Simple Mastoid Operation: the Open Cavity Mastoid Operations: Intracranial Complications of Otitis Media: Aural Complications of Otitis Media: Mechanics of Hearing: Surgical Correction of Congenital Malfformations of the Sound-Conducting Mechanism: Closure of Tympanic Meembrane Perforations: Tymparoplasty: Diagnosis, Indications for Saurgery and Medical Therapy of Otospongiosis (Otosclerosis): Stapes Operations for Otospongiosis (Otosclerosis). Part 3 Surgery of the Facial Nerve, Endolymphatic Hydrops and Tumours of the Ear: Facial Nerve Surgery: Surgical Treatment of Peripheral Vestibular Disorders: Skull Base Surgery: Acoustic Neuroma and Tumours of the Cerbellopontine Angle: Implantable Hearing Devices: Surgical Anatomy of the Temporal Bone Through Dissection.
473 citations
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