www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
ORIGINAL
ARTICLE
Comparison
between
clinical
and
audiological
results
of
tympanoplasty
with
modified
sandwich
technique
and
underlay
technique
夽
Sanjana
Vijay
Nemade
∗,
Kiran
Jaywant
Shinde,
Chetana
Shivadas
Naik,
Haris
Qadri
Smt.KashibaiNavaleMedicalCollegeandGeneralHospital,PuneMaharashtra,IndiaReceived19December2016;accepted23March2017 Availableonline21April2017
KEYWORDS Tympanoplasty; Temporalisfascia graft;
Areolarfasciagraft; Sandwichtechnique; Postoperative hearinggain
Abstract
Introduction:Surgicalrepairofthetympanic membrane, termedatype onetympanoplasty isatriedandtestedtreatmentmodality.Overlay orunderlaytechniqueoftympanoplastyis common.Sandwichtympanoplastyisthecombinedoverlayandunderlaygraftingoftympanic membrane.
Objective:To describeand evaluate the modified sandwich graft(mediolateral graft) tym-panoplastyusingtemporalisfasciaandareolarfascia.Tocomparetheclinicalandaudiological outcomeofmodifiedsandwichtympanoplastywithunderlaytympanoplasty.
Methods:A total of88 patients of chronic otitis media were studied. 48 patients (Group A) underwenttype onetympanoplasty with modified sandwichgraft. Temporalis fascia was underlaid and the areolar fascia was overlaid. 48 patients (Group B) underwent type one tympanoplastywithunderlaytechnique.Weassessedthehealingandhearingresults.
Results:Successful graft take up was accomplished in47 patients (97.9%) inGroup A and in40 patients(83.3%)Group B.The averageAir-BonegapclosureachievedinGroup A was 24.4±1.7dBwhileinGroupB;itwas22.5±3.5dB.Statisticallysignificantdifferencewasfound ingrafthealingrate.Differenceinhearingimprovementwasnotstatisticallysignificant.
Conclusion:Doublelayeredgraftwithdrum-malleusasa‘meat’ofsandwichmaintainsaperfect balancebetweensufficientstabilityandadequateacousticsensitivity.
© 2017 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).
夽 Pleasecitethisarticleas:NemadeSV,ShindeKJ,NaikCS,QadriH.Comparisonbetweenclinicalandaudiologicalresultsoftympanoplasty withmodifiedsandwichtechniqueandunderlaytechnique.BrazJOtorhinolaryngol.2018;84:318---23.
∗Correspondingauthor.
E-mail:[email protected](S.V.Nemade).
PeerReviewundertheresponsibilityofAssociac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial.
https://doi.org/10.1016/j.bjorl.2017.03.009
1808-8694/©2017Associac¸˜aoBrasileiradeOtorrinolaringologiaeCirurgiaC´ervico-Facial.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).
PALAVRAS-CHAVE Timpanoplastia; Enxertodefáscia temporal; Enxertodefáscia aureolar; Técnica ‘‘sanduíche’’; Ganhoauditivo pós-operatório
Comparac¸ãoentreosresultadosclínicoseaudiológicosdetimpanoplastiacoma técnica‘‘sanduíche’’modificadaeatécnicaunderlay
Resumo
Introduc¸ão: Oreparocirúrgicoda membranatimpânica, denominadotimpanoplastiatipo1, é umamodalidade detratamentojá bemestabelecida.Astécnicasoverlay ouunderlayde timpanoplastiasãocomuns.Atimpanoplastiapelatécnica‘‘sanduíche’’éatécnicadeenxerto demembranatimpânicaoverlayeunderlaycombinadas.
Objetivo: Descrevereavaliaratimpanoplastiacomatécnica‘‘sanduíche’’modificada (tim-panoplastia mediolateral)utilizando fásciatemporalefásciaaureolar.Comparar odesfecho clínicoeaudiológicodatimpanoplastiacomatécnica‘‘sanduíche’’modificadacomoda tim-panoplastiacomatécnicaunderlay.
Método: Foramestudados88pacientescomotitemédiacrônica.48pacientes(GrupoA)foram submetidosàtimpanoplastiatipo1comenxerto‘‘sanduíche’’modificado.Afásciatemporalfoi utilizadanatécnicaunderlayeafásciaareolarnatécnicaoverlay.48pacientes(GrupoB)foram submetidosàtimpanoplastiatipo1comatécnicaunderlay.Foramavaliadososresultadosda cicatrizac¸ãoedaaudic¸ão.
Resultados: Osucessodoenxertoocorreuem47pacientes(97,9%)noGrupoAeem40pacientes (83,3%)doGrupoB.Ofechamentomédiodogapaéreo-ósseonoGrupoAfoide24,4±1,7dB, enquantonoGrupoBfoide22,5±3,5dB.Houvediferenc¸aestatisticamentesignificativana taxa de cicatrizac¸ãodo enxerto.A diferenc¸ana melhoraauditiva não foi estatisticamente significante.
Conclusão:Oenxertodecamadaduplaeotímpano-marteloposicionadoscomoo‘‘recheio’’ dosanduíchemantémumequilíbrioperfeitoentreaestabilidadenecessáriaeadequada sensi-bilidadeacústica.
© 2017 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Publicado por Elsevier Editora Ltda. Este ´e um artigo Open Access sob uma licenc¸a CC BY (http:// creativecommons.org/licenses/by/4.0/).
Introduction
Chronicotitismediawithperforationofthetympanic mem-braneisacommoncauseofhearinglossandeardischarge.1 There are two popular surgical techniques, the underlay andoverlaymethodsfortympanoplasty.Theunderlay tech-niqueisquickerandeasiertoperform,andthecreationof atympano-meatalflapwithelevationoftheannulusallows inspectionoftheossicularchain.2However,thereisariskof medialdisplacementofthegraft,especiallyinlargeand/or anteriorperforations.3Theoverlaytechniqueavoidsthis pit-fall, but there is a risk of keratinpearl formation within thetympanicmembrane,andalsoariskofbluntingofthe angle betweenthedrum andtheanteriormeatalwall.2 A numberofothertechniques oftympanicmembranerepair have been described. Theterm ‘sandwich technique’was coined by Farrior in 1983 to describe a method in which sheets of areolar fascia were placed medial and lateral to the drum, with the fibrous layer as the ‘meat’ in the sandwich.4,5Raghavanetal.usedthesametermtodescribe atechniqueinwhichapedicleskinflapisusedtopartially cover an overlay tympanic membrane graft of temporalis fascia.6Wehavemodifiedthesandwichgraftbyusingtwo different graft materials, i.e. temporalisfascia and areo-lar fascia; and drum-malleus is sandwiched between the two.Wecomparedthehealingandhearingresultsof tym-panoplastywithunderlaytechniqueandmodifiedsandwich technique.
Methods
We prospectively studied 96 patients during 2014---2016. InstitutionalReviewBoardapprovalwastaken.Theapproval protocol number is Ref. SKNMC No/Ethics/App/2014/236 dated 23/07/2014. The Registration number is ECR/275/Inst/MH/2013.
Objectives
1. To comparetheclinical outcomeintermsofhealingof the graft in tympanoplasty by underlay technique and modifiedsandwichtechnique.
2. To compare the audiological outcome in terms of post operative hearing gain in tympanoplasty by underlay techniqueandmodifiedsandwichtechnique.
Inclusioncriteria
Patientswithtubotympanictypeofchronicotitismediawith largeorsubtotalperforation.
Exclusioncriteria
Patientswithatticoantraltypeofchronicotitismedia, revi-sionearsurgery,patientsrequiringossicularreconstruction, patientswithmixedhearingloss.
Group A(n=48)includes patientswhounderwent tym-panoplastybymodifiedsandwichtechnique.
Group B(n=48) includes patientswhounderwent tym-panoplastyby underlaytechnique. Datacollectedof each patient included: age, gender, previous ear surgery, pre-operative pure tone audiometry and clinical findings, surgicaldetails,postoperativeclinicalfindingsandpuretone audiometry.In all casesthe earwasdry and withnormal middleearmucosaforatleastonemonthpriortosurgery.
Technique
Apost-auricularapproachwasusedunderintravenous seda-tionsupplementedwithlocalinfiltrationof2%Xylocainwith 1:200,000 adrenaline. Areolar fascia (Fig. 1) and tempo-ralisfascia(Fig.2)washarvested. Inunderlay technique, onlytemporalisfasciawasharvested.Posteriormeatotomy wasdone. Theedges oftheperforationwerescrupulously denudedtopromotegoodcapillarybloodflow.Mucosal sur-face of tympanic membrane was freshened with Rosen’s knife tocreatea raw undersurface.In modified sandwich
Figure1 Areolarfasciaharvesting.
Figure2 Temporalisfasciaharvesting.
Figure3 Removingtheepitheliallayer.
technique, epithelial layer of anterior part of tympanic membranewasremovedupto theannulustocreatea raw surface laterally(Fig.3). Epithelial layer of theposterior aspect of tympanicmembrane was kept intact. The han-dle of malleus was also denuded off the epithelium. In underlay technique, we do not need to remove epithe-liumof theanteriorpartof tympanicmembrane.Vascular stripeincisionwastakenandposteriortympanomeatalflap waselevated.Themiddleearwasexposed.Ossicularchain mobilitywasconfirmed.Inunderlaytechnique,temporalis fascia wasunderlaidmedial tohandleof malleusand the tympanomeatal flap was reposited. In modified sandwich technique,temporalisfasciagraftwasunderlaidmedialto thehandleofmalleus(Fig.4).Nowtheareolarfasciagraft was overlaidlateral to handleof malleus and the fibrous layerof tympanicmembrane (Fig.5).The tympanomeatal flapwasthen reposited.Trappingtheepitheliumandskin beneaththegraftwasavoided.Thusthehandleofmalleus andthefibrouslayeroftympanicmembranewassandwiched betweenthetwograftsonlyintheanterioraspect,whereas
Figure5 Areolarfasciaoverlaid.
intheposterioraspect,thegraftwaslateraltomalleusand medialtotympanicmembrane. Asthechancesof medial-isationor lateralizationofthegraft arefoundtobemore intheanterioraspect,thissandwichintheanterioraspect was expected to provide adequate stability to the graft. Gelfoam was placed over the graft for stabilization. The post-auricularincisionwasclosedintwolayersandmastoid dressingwasapplied.
Asuccessfulanatomicaloutcomewasconsideredto com-prise full,intacthealing ofthe graft withoutperforation, retraction, lateralization or blunting post-operatively and withimprovementofhearing.Grafthealingwasevaluated inallpatientsandpostoperativecomplicationswerenoted. AveragepreoperativeAir-Bonegap,postoperativeAir-Bone gapandtheAir-BonegapclosureindBat500Hz,1000Hz, 2000Hzwerenoted.
Post-operativecare
Antibioticsweregivenfor5days.Sutureremovalwasdone oneweekaftersurgeryandthegelfoamwassuctionedfrom theearcanal3weekspost-operatively.Antibiotic steroid-containingdropswereusedforafurther2weekstoclearthe residualgelfoamwhichcanleadtogranulation andfibrous tissueformationifnotcompletelyremovedfromthe tym-panic membrane. An audiogram wasperformed 3 months after surgery in patients with healed graft. The ear was examinedat6monthsand,thereafter,everyyear.
Results
The meanagewas34.3±7.9yearswitharangeof15---45 years. The male to female ratio was 1:0.76. In Group A (n=48), we observed a successful graft take up in 47 patients (97.9%). One patient (2.1%) had postoperative infection and rejection of graft. In Group B (n=48), 40 patients (83.3%) had well accepted graft. Five patients (10.5%) had rejection of graft due to medialisation and 3 patients (6.2%) had reperforation of graft due to post
Table1 Analysisofgrafthealing. Graftstatusonfollowup GroupA
(n=48) GroupB (n=48) 1st(7thpost-opday) Intact 48(100%) 47(97.9%) Rejected 0(0%) 1(2.1%)
2nd(1monthpostop)
Intact 47(97.9%) 41(85.4%) Rejected 1(2.1%) 7(14.6%)
3rd(2monthspostop)
Intact 47(97.9%) 40(83.3%) Rejected 1(2.1%) 8(16.4%)
4th(3monthspostop)
Intact 47(97.9%) 40(83.3%) Rejected 1(2.1%) 8(16.4%)
GroupA,modifiedsandwichtympanoplasty;GroupB,underlay tympanoplasty.
GrafttakeuprateisGroupAis97.9%.GrafttakeuprateisGroup Bis83.3%.
Chi-squarevaluewithYatescorrectionis4.414with1degreesof freedom.Twotailedp-value=0.0356.WithFisher’sexact prob-abilitytest,2-tailedp-valueis0.0356.
Statisticallysignificantdifferenceisobserved.
operative infection. Statistical comparative analysis was doneforthegrafthealingrateofthetwogroups.Chi-square value with Yates correction was 4.414 with 1 degrees of freedom.Twotailedp-valuewas0.0356.WithFisher’sexact probabilitytest, 2tailed p-valuewas 0.0356.Statistically significantdifferencewasfoundinthegrafthealingrateof thetwogroups(p=0.0356)(Table1).
In Group A, the preoperative average Air-Bone gap in speech frequencies (500Hz, 1000Hz, 2000Hz) was 41.0±3.9dB and the post-operative average Air-Bone gap was 16.6±2.6dB. Average Air-Bone gap closure (dB) achieved was 24.4±1.7dB. In Group B, the preopera-tive average Air-Bone gap in speech frequencies (500Hz, 1000Hz,2000Hz)was43.6±4.4dBandthepost-operative average Air-Bone gap was21.0±4.6dB.Average Air-Bone gapclosure(dB)achievedwas22.5±3.5dB.Statistical anal-ysiswasdonewithPairedt-test.Thetvaluewas0.9074with standarderrorofdifference1.873.WithConfidence Inter-val95%,twotailedp-valuewas0.460. Thepost operative hearinggainassessedafterhealedgraftinthetwogroups wasstatisticallynotsignificant(Table2).
Discussion
Successfultympanoplastydependsontheintegrityand sta-bility of tympanic membrane (TM) which in turn affects thefinalpositionofthereconstructedtympanicmembrane. Thoughavarietyofmaterialslikeskin,perichondrium,vein, duraandcartilageareavailablefor closureofTM perfora-tions, temporalis fascia is the most commonly used graft withitscertainadvantagesasitiseasilyavailablein suffi-cient quantity and through same incision, itsthickness is similarto TM withlow basal metabolic rate.7 Final posi-tionofthegraftdependsuponthepressurechangesinthe
Table2 Analysisofhearingresults. Preoperativeaverage
Air-Bonegap(dB)
Post-operativeaverage Air-Bonegap(dB)
AverageAir-Bonegap closure(dB)
GroupA(n=48) GroupB(n=48) GroupA(n=48) GroupB(n=48) GroupA(n=48) GroupB(n=48)
500Hz 36.5 38.5 13.6 16.7 22.9 21.8 1000Hz 43.9 46.9 17.5 20.5 26.4 26.4 2000Hz 42.7 45.4 18.7 25.9 24.0 19.5 Mean±SD 41.0±3.9 43.6±4.4 16.6±2.6 21.0±4.6 24.4±1.7 22.5±3.5 SD 3.971 4.479 2.666 4.623 1.789 3.513 VariationofSD 15.77 20.07 7.112 21.37 3.20 12.34 SD,standarddeviation.
Pairedt-test:tvalueis0.9074;df=2withstandarderrorofdifference1.873. With95%confidenceinterval,twotailedp-valueis0.460.
Statisticallynosignificantdifferenceisobservedinpostoperativehearinggainintwogroups.
middle earandexternal ear.Normal tympanicmembrane canwithstandthepressurechangesduetoitsintegrityand stability.Atthesametime,thesoundconductionisalso opti-mal.Anidealgraftshouldfindaperfectbalancebetween the stability as well as sound conduction.7 A single lay-ered temporalis fascia graft has thickness similarto that oftympanicmembrane thusgiving optimalsound conduc-tion.But thepressurechangesin themiddleearcanlead to medialisation or lateralization of the graft leading to failureof Tympanoplasty. Dueto thisreason,the average rateof successful tympanoplasty varies between 85% and 90%.7,8
Thesandwichgrafttympanoplasty,describedbyFarrior,4 isdoublelayertechniqueinwhichbothamedialandlateral layer ofareolar fascia areused. Ithas been shown tobe highlyeffective in restoringtheintegrityof the tympanic membrane.4We havemodified thisby usingtwodifferent graftmaterials,i.e.temporalisfasciaandtheareolarfascia whichisexpectedtoprovideaperfectbalancebetweenthe stabilityandtheacousticsensitivityofthetympanic mem-brane.Temporalis fasciais underlaid andareolarfascia is overlaid.ThustheFibrouslayeroftympanicmembraneand the handle of malleus are sandwiched between the two. Thicknessof graftis always theconcernfor the audiolog-icaloutcomeof thesurgery.6,7 Areolarfascia beingathin connectivetissuedoesnotaddtothethicknesstoanextent tohamperthesoundconduction.
The sandwich tympanoplasty or the over-under tym-panoplasty is a combination of the underlay and overlay techniquesandhasbeendevelopedwiththeaimof minimiz-ingthedisadvantagesinherentintheothertwotechniques. This may explain why the sandwich graft is becoming popular.1,9 Thereare a few studies onthis relatively new techniquein theliterature.StageandBak-Pedersen10 who supportedtheover-under procedurewhen usedfor perfo-rations anteriorto thehandle of the malleus, reporteda successrateof91%in39ears.Asimilarsuccessrate(90%) wasattainedbyKartush etal.9in aseriesof120patients whounderwentover-undertympanoplasty.Itwasreported as90%byImranetal.11Mills1reporteditas97%with hear-ingimprovementin98%patientsinhisstudyof123patients. Inallthesetechniquestemporalisfasciahasbeenusedfor double layer of sandwich. With modified Sandwich tech-nique, we could achieve success rate of 97.9% in healing
of graft, while that in underlay technique it was 83.3%, thus giving statistically significant difference (p=0.0356) (Table1).
TheaverageAir-Bonegapclosurewhichgivesan indica-tionofthedegreeofhearingimprovementwas24.4±1.7dB in Group A and 22.5±3.5dB in Group B (Table 2). This impliesthatmanypatientshadausefulimprovementinthe hearingandobtainedadryeartoo.Sheetal.12 described hearing improvement of 9.7dB in the over-under tym-panoplasty (n=30). In the study done by Yagit et al.13 it was 16.96dB (n=58). Another study by Ahmed et al.14 usingmediolateralgraftshowedahearingimprovementof 12.65dB.
Asweexperienced,theadvantagesofmodifiedsandwich tympanolastyare:
1.Stabilityofthegraft,likeabuttoninabuttonhole. 2.Preventsmedialisationorlateralizationofgraft. 3.Temporalisfasciaandareolarfasciabothcanbe har-vestedthroughthesameincision.
4.Easytoperformbecauseepithelial layerofonly the anterior half of tympanic membrane remnant is elevated ratherthantheentireTM.
5.Thoughitisadoublelayerofgraft,thicknessis opti-mumforacousticsensitivity.
Conclusion
Single-layer graft techniques in tympanoplasty (especially inlargeandsubtotalperforation)havepersistentproblems likefasciagraftmedialisation,lateralizationandrecurrent perforations.Adoublelayeredgraftwithtemporalisfascia (underlay)andareolarfascia(overlay)usingdrum-malleus sandwich technique gives excellent results in postopera-tive healing of graft. Considerable audiological outcome is also achieved.This modified sandwich graft technique, and its results are presented to help the practicing oto-logicsurgeonobtainabetterunderstandingofthiseffective tympanoplasty.
Conflicts
of
interest
References
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