Temporal Fascia Versus Tragal Perichondrial Graft in Myringoplasty and Tympanoplasty

The objective of this study is to compare the results of tympanoplastywith underlay technique with respect to graft uptake, hearing improvement and complications. Thestudy was conducted between January 2006 & January 2018 at Haider clinic, Kulsum international Hospital Islamabad, MaroofInternational Hospital, Social security Hospital Islamabad and PAF hospital Islamabad. Sampling was done by non-probability convenient sampling type by random selection. Total of 1677 patients were selected had Tympanoplasty type 1. All had dry central perforations of different sizes for more than 3 months and conductive hearing loss of less than 40dB with patent Eustachian tube. Informed consent was taken from patients andethical committee. Patients with sensorineural hearing loss and with severe nasal pathology were excluded. Patients were divided into 2 groups, A and B, were subjected totympanoplasty by underlay technique by the same group of surgeons. In group A, temporalis fascia graft and in group B tragalperichondrial graft was used. Postoperative audiometry was done after 3 months in each case to calculate air bone gap. In our study there were 62% males and 38% females, mean age was 32.5. In Group A, 689 patients hadtympanoplasty with temporalis fascia and in group B 988 patients with chondro-perichondrial graft. Medialization was seen in 30(4.3%) patients in Group A and in 10(1%) in group B. Persistent Perforations happened in 32(4.6%) patients in group A and in 8(0.8%) patients group B. Graft uptake success rate using temporalis fascia was 85.9% and was 97.4% with Chondro-perichondrial graft. Hearing improvement was seen in 627(91%) patients in group A and 970(98%) patients in group B. Statistical analysis of the data was done using SPSS 16. Temporalis fascia and tragal perichondrium both are excellent material to repair tympanic membrane. Graft uptake rate and hearing improvement are better in perichondrial graft.


Introduction
Permanent perforation oftympanic membrane may be the sequelae of chronic suppurative otitis media, trauma and acute suppurative otitis media [1]. Dry ear with hearing loss is the indication of myringoplasty and tympanoplasty [1]. Myringoplasty can be used for small perforations. Tympanoplasty is repairing of tympanic membrane after having a look in the middle ear [2]. The first known attempt to close aperforation to improve hearing was made by Marcus Benzer in 1640. The fundamental principles of surgical procedure were first described by Wullstein [2]. Size and location of perforation, tympanosclerosis, allergies, Eustachian tube dysfunction and active infection in ear must be considered to evaluate surgical outcome [3]. Various grafting materials can be used to reconstruct tympanic membrane. Among theautologous grafts temporalis fascia, perichondrium, cartilage, fat, fascia lata and skin have been used [1,4]. Several allografts are mentioned in literature include duramatter, temporalis fascia, pericardium, amniotic membrane, skin, peritoneum, cornea and vein [4]. Alloplastic graft materials like paper, absorbable gelatin sponge andacellular dermal matrix have also been used. Each of these grafts material has its ownadvantages and disadvantages over each other. Healing of tympanic membrane perforation is due to ingrowth of connective tissue edges over which fresh edges of epithelium of membrane migrate over graft material. This fact proves that the graft of mesodermal origin (fascia, perichondrium, cartilage) is the best [5,6]. As proved by literature ideal graft is one that is easy to take with less invasive procedures, with shorter hospitalization, less morbidity to donor area, less risk ofinfection, with no transfer of infectious disease as can be with allografts and costslessas synthetic grafts cost high [7]. The temporalis fascia is the most common graft tobeused because it is abundant and easy to harvest, can be taken via same post auricular incision and can also be used in revision surgery [3,8,9]. Cartilage and perichondrium can be harvested either from the tragus or concha. Perichondrium can be used alone or with cartilage [9]. This graft is easy to take, no preparation of surgical area (shaving) is required, size is usually appropriate and incision carries a little morbidity [9].
This study was performed while considering all these facts to compare the results oftympanoplasty with two mesodermal tissue graft materials, temporalis fascia and perichondrium. The aim of this study is to compare the results of tympanoplasty withunderlay technique in respect with graft uptake, hearing improvement and complications.

Material and Methods
A total of 1677 patients were selected for this study that had my ringoplasty and Tympanoplasty type 1 done between January 2006 & January 2018 at Haider clinic Islamabad, Kulsum international Hospital Islamabad, Maro of International hospital Islamabad, Social Security hospital and PAF hospital Islamabad. Sampling technique used was nonprobability convenient sampling. Random selection of patients presented with chronic suppurativeotitis media with tubotympanic disease was done. Informed consent was taken frompatients and written permission was taken from ethical committee. Hearing screening was done in all patients. Only those patients were included with safe tubotympanic disease and ear remained dry for at least 3 months, non-healed dry traumatic perforation, patients with drycentral perforation and conductive hearing loss of less than 40dB and patent Eustachian tube (checked subjectively by Valsalva and taste of ear drops felt in throat), only adults with age 15-50 years were included in the study.
Patients with unsafe ear, tubotympanic disease with active mucosal disease, tubotympanic disease with sensorineural hearing loss, patients having severe allergyand obvious nasal pathology like marked DNS, nasal polyps or recurrent sinusitis, patients less than 15 years of age, with only hearing ear, patients who refused togive consent and patients with very large, total, near total perforation and marginalwere excluded from study. All the patients were evaluated, proper history was taken, otomicroscopicexamination was performed to find out any hidden area of inflammation or Cholesteotoma, clinical assessment of hearing was done by tunning fork tests, audiometry was performed in all cases. Pre op investigations for the sake of anesthesiafitness were ordered.
Patients were divided into 2 groups, A and B. All the patients were subjected toTympanoplastytype I by underlay technique by the same group of surgeons.
In group A; temporalis fascia graft and in group B tragalperichondrial graft was used.
Monthly Post op follow up was done in every case for 6 months. Otomicroscopy andtuning fork tests were done inevery follow up to evaluate graft, to rule out infection and to see improvement in hearing. Postoperative audiometry was done after 3 months in each case to calculate air bone gap. Results were recorded considering improvement inhearing, graft rejection, graft medialisation, postoperative infection and persistent perforation. Statistical analysis of data was done using SPSS 16. Paired t test was applied to compare two groups, P value<0.05 was considered significant.

Results
In our study there were 62% were males and 38% were females. Male to female ratio was 1.6:1. Age limit in our study was between 15-50 years, mean age was 32.5. All the patients were clinically assessed; size of perforations was medium and central in 928 patients and was small and central in 749 cases as seen in Table 1. Rinneswas negative in 1250 and Weber was towards the same ear. In remaining, Rinne's was positive but Weber was lateralized to same ear. In 213 cases disease was bilateral, and both ears were operated with 6 months gap and two ears were considered as separate cases. Ears were dry in all cases, no active mucosal disease was found in these cases. Audiometry results were recorded. In 1250 cases, hearing loss wasbetween 30-35dB with air bone gap of 20-25dB. In 427 patients there was air bone gap of 10-15db. All cases In Group A, 689 patients; had tympanoplasty type1 using temporalis fascia. Under lay technique was used with post aural approach. 374 patients had small and 315 patients had medium perforations. In group B, 988 patients hadMyringoplasty or Type I tympanoplasty usingchondroperichondrial graft by under lay technique. Endaural or per meatalapproach was used keeping in consideration the width of meatal canal. In this group, 613 patients had medium and 375 patients had small perforations. Results were recorded considering post operative infection, medialisation, persistent perforation, hearing improvement and graft uptake as showed in Table 2. Results of two groups were compared, shown in figure 1.

Medialization
This was noted in 30 (4.3%) patients in Group A and 10 (1%) patients in group B.

Postoperative Infection
This was seenin 35 (5%) patients in group A, Postoperative and in 7 (0.7%) patients in group B.

Hearing Improvement
Hearing improvement was seen in 627 (91%) patients in group A and 970 (98%) patients in group B.
Paired t test was applied to compare two groups, P value was <0.05, issignificant.

Discussion
Temporalis fascia graft has always been regarded as an ideal graft for the repair of tympanicmembrane perforations for a long time. Later on it was found that this graft material couldn't withstand the middle ear negative pressure in the postoperative period [10]. It also had the disadvantage of crumbling & shrinkage when coming in contact with tissue fluids, hence leading to medialization, pockets formation and leaving perforation [10]. In revision surgery adequate graft may be difficult to obtain.
Prolongedhealing rate leads to graft uptake failure. Since it has low basal metabolic rateand due to similarity in structure and thickness with the real tympanicmembrane, It can be grafted successfully [11]. It is easily available in sufficient quantity and no separate incision is required. In contrast chondro-perichondrial graft is easy to obtain from tragus of the ear [11]. Itslowmetabolic rate, makes it an ideal graft material [12]. It is sturdier, doesn't crumble and can withstand the postoperative middle ear negative pressure, discouragingmedialization of graft or leaving a perforation [12]. In case of subtotal perforations, atelactatic ears, retraction pockets, long term results of temporal fascia grafts may not be very satisfactory. To overcome thisperichondrial cartilage grafts were used with good results [12,13].
Because of structural similarities with the normal TM and it also provides firm support to prevent retraction, healing is much better with chondro-perichondrialgraft than temporalis fascia [2,14]. The greatest advantage of chondroperichondrialgraft has been thought to be its very low metabolic rate and it can resistdeformationfrom pressure variations so medialisation of graft is less as comparedto temporalis fascia. As seen in our study, with temporalis fascia graft medialisation was 4.3%and with chondroperichodrial was1%. Cartilage takes its nourishment from perichondrium. That's the reason why chondroperichondrial graft lives longer for a better healing. So there are less chances of leaving perforation as compared to temporalis fascia. As seen in ourstudy graft success rate was 85.9% and 97.4% respectively with temporalis fascia and chondrperichondrial graft. This is comparable with previous studies in which it was 80% and 96.7%. In one of the previous study graft uptake success rate has been 80% and 70% respectively for temporalis fascia and tragalcartilage.
Cartillage contributes minimally to an inflammatory tissue reaction and is wellincorporated with tympanic membrane layers [4,6,15]. So there are less chancesof infection ascompared to temporalis fascia graft as seen in our study, 5% with temporalis fascia and 0.1% with chondroperichondrial graft. Ear packing after this procedure was done with ribbon gauze impregnated with Bismuth Iodide Paraffin Paste(BIPP) like any where in the world, for 2-4 weeks. That is the reason for decrease infection.
Previously it was shown in different studies that hearing improvement is less with chondropeichondrial graft as compared to temporalis fascia graft due to itsthickness and stiffness reducing the vibrations of tympanic membrane mechanically [3,16,17]. As in one study performed in Mumbai hearing improvementwas more with temporalis fascia 77.5% as compared to75% seenwith tragal perichondrium. Good hearing results with temporalis fascia were also seenin another study upto90% and 88% with chondroperichondrial graft, these resultsare comparable with ours, in presenting study hearing improvement is more(98%) with chondroperichondrial graft as comparedto temporalis fascia(91%). Reason might be due to fact that graft only provides platform for epithelium to regenerate over it and also better thinning of cartilage in the graft.
In our study like most of previous studies results were not dependent on size and site of perforation, results were same in small and medium perforations. Similar opinions were expressed by other surgeons in different studies that age of patient and size had no significant influence on success rate. Results of myringoplasty were independent of patients' age, sex, location and size ofperforation. Preoperative dry ear should be considered for better results [3,18]. Temporalis fascia and tragal cartilage can both be used effectively with no significant difference in success rate or audio logicaloutcomes but in our study perichondrial cartilage graft was found to be superiorconsidering graft uptake and hearing improvement [5]. Our success rate with tympanoplasty especially with chondroperichondrialgraft was better than most institutes in our area and is almost similar to international figures. Graft was thinned down nicely, removing all the extra fat and connective tissue. Thishelped speedy bridging of perforation. We also made sure that the ears remained dry, free of any residual infection for more than 3 months. Upper respiratory inflammatory conditions were eliminated before weembarkedon this procedure. As this is not an emergency procedure, we can't afford any risk of failure, as this will not only increase the cost but also disappointment.

Conclusion
Temporalis fascia and tregal perichondrium both are excellent material to repair tympanic membrane. Graft uptake rate and hearing improvement are better in perichondrial graft as compared to temporalis fascia. Success rate is not dependent on size and duration of perforation but ears must remain dry for at least 3 months prior to operation.