Long-Term, High-Frequency Tympanometry and Audiometry Results after Cartilage and Fascia Tympanoplasty

Abstract

Introduction The aim of tympanoplasty is to repair tympanic membranes and achieve better hearing outcomes. Various graft materials have been described in the literature, including skin graft (1), fascia lata (2), temporal fascia (3), vein graft, and cartilage (4). Temporal muscle fascia and cartilage are the most widely used graft materials. Cartilage is usually preferred in revision cases, cases with atelectatic membrane or presence of cholesteatoma, and revision tympanoplasty. However, the possibility that the thick and stiff tympanic membrane that forms in patients with cartilage tympanoplasty might reduce compliance and cause hearing loss has made the acceptance of cartilage as a routine graft material difficult (5, 6). Evaluations of graft material compliance have been conducted with standard 226 Hertz (Hz) tympanometry (7-9); however, the stiffness of new tympanic membrane might not be evaluated adequately with standard tympanometry (10, 11). In this study, we evaluated the compliance of newly obtained tympanic membranes after tympanoplasty performed with temporal muscle fascia or cartilage using high-frequency tympanometry. We compared closure of tympanic membrane rate, hearing gain, and compliance results in the newly formed membranes between the two tympanoplasty techniques. Methods The study started once ethical board approval was received. This is a retrospective study of 140 patients who underwent temporal muscle fascia or cartilage tympanoplasty in our clinic between 2009 and 2011. The long-term results were evaluated; therefore, we examined the patients at least 1 year after the operation. Thirty-eight patients who had revision surgery, bone chain reconstruction, mastoidectomy, preoperative sensorineural hearing loss, tympanosclerosis, chronic sinusitis, nasal polyposis, or nasal allergy were excluded from the study. Reperforation or chronic ear drainage was detected in 22 of the remaining 102 patients, and they were also excluded from the study. Of the remaining 80 patients, 40 underwent repair with temporal muscle fascia using an underlay technique, and 40 underwent repair with tragal cartilage. The perichondrium was protected in the patients who had cartilage tympanoplasty. An island tragal cartilage graft was used with a malleus notch. The same surgical team, including the senior assistant and physician, performed all the operations. Air volume, compliance, and pressure differences of the 80 patients were measured using highfrequency tympanometry (224 Hz, 668 Hz, 800 Hz, and 1000 Hz). Their preoperative and postoperative air and bone conductions were compared using pure tone audiograms. Informed consent was obtained from the patients. Statistical Analysis The SPSS program, version 20.0 was used in the analysis. Mean, standard deviation, median, min-max, ratio, and frequency values were used in the descriptive statistics of the data in this study. Distribution of the variables was checked with the Kolmogorov-Smirnov test. Independent sample t-test and Mann-Whitney U-test were used in the quantitative data analysis. Paired sample t-test and Wilcoxon test were used for repetitive measurements. The chi-square test was used to analyze qualitative data. P values 0.05). However, only patients who had intact postoperative tympanic membranes were included in the study. There were no significant differences in the age and sex distributions of the patients in the fascia and cartilage groups. The mean postoperative follow-up period was 10.8±2.1 (8-14) months. In the fascia group, the preoperative mean air bone gap (ABG) was 27.9±9.7 dB (7-35 dB), and the postoperative mean ABG was 19.1±7.6 dB (2-37). The postoperative mean ABG improvement was 8.8±9.9 dB; the difference was statistically significant (p=0.000, p 0.05) (Table 1, Figure 1). When the high-frequency tympanometry values were compared, there were no statistically significant differences in air volume, compliance, or pressure values at 224, 668, 800, and 1000 Hz frequencies between the two groups (p>0.05) (Table 2, Figure 2, Figure 3). Discussion When compared with cartilage, temporal muscle fascia has the advantages of an easily moldable nature, lightness, and a structure that resembles tympanic membrane (12). Although temporal muscles show high success rates in the early postoperative period after tympanoplasty, some studies have reported a decrease in graft performance in later stages (13, 14). Due to these negative results, thicker and stronger cartilage grafts are used as alternatives (13, 15, 16). With its rigid and thick structure, cartilage is resistant to resorption and atrophy (17, 18). Because it can be placed precisely into a perforation, cartilage tympanoplasty is preferred in cases with large perforations, revision surgery, tympanosclerosis, tympanic membrane atelectasis, and Eustachian tube dysfunctions (19, 20). However, there is concern that using a thick material as a graft in tympanoplasty causes worse hearing outcomes by damaging the elasticity of the tympanic membrane. In studies regarding this issue, no statistically significant differences in hearing gains were found between cartilage graft and temporal muscle fascia graft patients (21-24). Karaman et al. (22) reported that the rate of composite cartilage island graft closure of the tympanic membrane in 74 patients was 97.3% and that ABG improvement was 20.2 dB. Khan et al. (23) reported a closing rate of 98.20% and an average improvement of 7.06 dB ABG in the study that they carried out using thinned tragal cartilage grafts. Kirazli et al. (25) reported a postoperative ABG improvement of 11.9 dB in their cartilage group and 11.5 dB in their fascia group; there was no significant difference between the groups in their study. In our study, the rates of closure of the tympanic membrane were nearly similar in the cartilage and fascia groups. The difference in mean ABG improvement between the two groups was not significant. Our results indicate that there were no differences in repair rate or hearing gain between the cartilage and fascia tympanoplasty patients, similar to the results reported in the literature (24-26). Turk Arch Otolaryngol 2014; 52: 43-6 Ozdamar et al. Fascia-Cartilage Tympanoplasty 44 Table 1. Preoperative and postoperative air bone gap distribution Fascia Cartilage Mean±SD Mean±SD p Preoperative 27.9±9.6 28.2±9.3 0.888 Air Bone Gap Postoperative 19.1±7.6 17.3±10.5 0.376 ABG closure 8.8±9.9 10.1±10.3 0.348