BrazJOtorhinolaryngol.2014;80(4):275---276
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
www.bjorl.org
EDITORIAL
The
role
of
different
types
of
grafts
in
tympanoplasty
夽
O
papel
dos
diferentes
tipos
de
enxertos
nas
timpanoplastias
In1878, EmilBertholdwasthefirst todescribethe surgi-calprocedureofmyringoplasty,usingafreeskingraftfrom theforearm,1althoughEdwardElyarguedinalater
publi-cationthathehadbeenthepioneerinthisprocedure.2But
itwasonlyinthe1950sthattympanoplasty-relatedarticles reappearedintheliterature.Thefundamentalprinciplesof thesurgicalprocedureweredescribedbyWullstein3in1952,
usingafreeskingraft,andZoellner4in1955,usingapedicle
graft.
Sincethen,severaltypesofmaterialshavebeenusedto reconstructthetympanicmembrane.Amongtheautologous grafts,thefollowingcanbementioned: temporalisfascia, fascialata,periosteum,perichondrium,cartilagewithand withoutperichondrium,veins,fattytissue,andskin.5,6
Sev-eralallograftsarementionedintheliteratureandinclude: duramater,pericardium,temporalisfascia,amniotic mem-brane,skin, cornea,peritoneum,veins,andaortic valve.6
Recently,alloplasticgraftssuchaspaper,absorbablegelatin sponge,andacellulardermalmatrixhavealsobeenused.7
Thetrendtowardincreasinglylessinvasivemedical pro-cedures, with shorter hospitalization stay, has led to a demandformaterialstoreplaceautologousgrafts. Theoret-icaladvantagesincludetheeliminationofmorbidityrelated tograftharvesting,fasterhealing,novisiblescarring,less pain,andlessriskofinfection,inadditiontoafaster proce-dureandearlydischarge.Thesegrafts,however,makethe proceduremoreexpensive andhaveshown noreal advan-tagessofar.7
Thefasciatemporalisisthemostcommonlyusedgraft, withsuccess rates between 93% and 97% in primary tym-panoplasty,especiallyinwell-aeratedmiddleears.5,8Inthe
lastdecade, however,therehas been anincreasing inter-estinusingcartilagegraftsastheprimaryalternativetoits use.The stiffnessandstrengthofcartilage confergreater stabilitytothegraftandhaveakeyroleintheresistance against shrinkage. There is some concern, however, that
夽
Pleasecitethisarticleas:deFreitasMR,deOliveiraTC. The roleofdifferenttypesofgraftsintympanoplasty.BrazJ Otorhino-laryngol.2014;80:275---6.
thesesamecharacteristics mayhave a negativeeffecton soundconduction.5,8
Lee et al.,8 in a retrospective analysis of 40 patients
withchronicotitismediaandgranulationtissueinthe mid-dleear,comparedtheanatomicalandaudiological results oftype Itympanoplasty using fasciatemporalis, cartilage tissue,andcartilagepalisade.Nostatisticallysignificant dif-ferenceswereobservedbetweenthethreegroupsregarding theclosureoftympanicmembraneperforations.Regarding auditory improvement, the cartilage palisade technique showedslightlypoorerresultsthantheothers.Asforthe car-tilageharvestsite,Zahnertetal.,9inanexperimentalstudy,
concludedthatboththeconchalandthetragalcartilagehad thesameeffectsregardingtheauditorypropertiesandthe thicknessof 0.5mm wasconsidered sufficienttomaintain shrinkageresistance characteristics and sound conduction comparabletoanormaltympanicmembrane.
Inasystematicliteraturereview(recommendationgrade A),Mohamadetal.5foundthattympanoplastyusingfascia
temporalisandcartilagegraftsshowedsimilarand compa-rablefunctionaloutcomes(hearingimprovement).However, thereareevidencelevels1,3,and4thatshowbetter mor-phological findings (intact tympanic membrane) with the useofcartilagegrafts,withorwithoutperichondrium.The useof cartilage grafts wasshown to bea safe option for tympanicmembrane reconstruction, both in adultsandin children,accordingtothesamestudy.
Thepossibilityofinfectiousdiseasetransmissionandthe costofsyntheticmaterialsmaintainautologousgraftsasthe preferredtypebymostotologistswhenperforminga tym-panoplasty.Thecostfactorbecomesevenmoreimportant whentakingintoaccountthehigherprevalenceofchronic suppurative otitis in populations of lower socioeconomic level,whoareassistedbythepublichealthsystem.Finally, anotherkeyfactoristhesurgeon’sexperience.Goodresults cannotbeexpectedwhenthephysicianisnotfamiliarwith thesurgicaltechniquetobeemployed.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
http://dx.doi.org/10.1016/j.bjorl.2014.05.018
276 EDITORIAL
References
1.Berthold E. Ueber myringoplastik. Wien Med Blätter. 1878;26:627---39.
2.ElyET.Skin-graftinginchronic suppurationofthemiddleear. ArchOtol.1880;9:343---5.
3.WullsteinHL.Functionaloperationsinthemiddleearwith split-thicknessskingraft.ArchOthorhinolaryngol.1953;161:422---35. 4.Zoellner F. The principles of plastic surgery of the
sound-conductingapparatus.JLaryngolOtol.1955;69:567---9. 5.MohamadSH,KhanI,HussainSS.Iscartilagetympanoplastymore
effectivethanfasciatympanoplasty?Asystematicreview.Otol Neurotol.2012;33:699---705.
6.VanRompaey V,FarrMRB,HamansE, MudryA, Vande Heyn-ingPH.Historyofotologyallografttympanoplasty:ahistorical perspective.OtolNeurotol.2012;34:180---8.
7.HaynesDS,VosJD,LabadieRF.Acellularallograftdermalmatrix for tympanoplasty. Curr Opin Otolaryngol Head Neck Surg. 2005;13:283---6.
8.Lee JC, Lee SR, Nam JK, Lee TH, Kwon JK. Comparison of differentgraftingtechniques intypeI tympanoplastyincases ofsignificantmiddle ear granulation. OtolNeurotol.2012;33: 586---90.
9.ZahnertT, HottenbrinkKB, MürbeD, BornitzM. Experimental investigationsof the use of cartilage in tympanic membrane reconstruction.AmJOtol.2000;21:322---8.
MarcosRabelodeFreitasa,∗, ThiagoCorrêadeOliveiraa,b
aDepartmentofSurgery,FaculdadedeMedicina,
UniversidadeFederaldoCeará(UFC)---CampusSobral, Fortaleza,CE,Brazil
bDepartamentofMorphology,FaculdadedeMedicina,
UniversidadeFederaldoCeará(UFC)-CampusSobral, Fortaleza,CE,Brazil
∗Correspondingauthor.
