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Year : 2016  |  Volume : 22  |  Issue : 2  |  Page : 81-84

Butterfly cartilage tympanoplasty: An alternative approach for management of small- and medium-sized perforations

Department of ENT, Peoples Medical College and Research Centre, Bhanpur, Bhopal, Madhya Pradesh, India

Date of Web Publication11-May-2016

Correspondence Address:
Ashish Kumar Maurya
MIG-13-C, PCMS Campus, Peoples Medical College and Research Centre, Bhanpur - 462 037, Madhya Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0971-7749.182283

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Objective: To evaluate the efficacy of butterfly cartilage tympanoplasty for small- and medium-sized central perforations and compare it with temporalis fascia tympanoplasty. Materials and Methods: A prospective, comparative study was conducted on 110 patients, divided into two groups. Patients of tubotympanic type of chronic suppurative otitis media with 2–6 mm size perforation were included in the study. Fifty-five patients were operated by temporalis fascia Type I tympanoplasty and rest 55 by butterfly cartilage tympanoplasty (transcanal technique) under local anesthesia. Results were compared in terms of pre- and post-operative air-bone gap improvement and success rates. Results: In our study, in terms of outcomes, both techniques had similar results. The success rate was 93.7% in butterfly cartilage tympanoplasty and 96.3% in temporalis fascia group. However, in terms of time taken, butterfly cartilage tympanoplasty took less time (about 30 min) than temporalis fascia (about 55 min). Conclusion: Transcanal butterfly cartilage tympanoplasty is a very good alternative in small- and medium-sized perforations for conventional temporalis fascia tympanoplasty as it is simple, takes less time, day care procedure, on table hearing improvement, cosmetically no postoperative scar, no need of post aural preparation, and patient can go home within hours.

Keywords: Butterfly cartilage tympanoplasty, Daycare procedure, Temporalis fascia tympanoplasty

How to cite this article:
Maurya AK, Jadia S, Qureshi S, Jain L. Butterfly cartilage tympanoplasty: An alternative approach for management of small- and medium-sized perforations. Indian J Otol 2016;22:81-4

How to cite this URL:
Maurya AK, Jadia S, Qureshi S, Jain L. Butterfly cartilage tympanoplasty: An alternative approach for management of small- and medium-sized perforations. Indian J Otol [serial online] 2016 [cited 2022 Jan 26];22:81-4. Available from: https://www.indianjotol.org/text.asp?2016/22/2/81/182283

  Introduction Top

Temporalis fascia remains the most common graft material of choice since the development of tympanoplasty procedure. Cartilage tympanoplasty has a long history as Salen was the first person who experimented with cartilage tympanoplasty with good results; he used nasal septal cartilage with a success rate of 92%.[1] Later, Heermann et al. popularized the cartilage palisade tympanoplasty.[2] The tragal cartilages are ideal hard transplants, they are coarser, stiffer and easier to work with. Their adaptation in proper position is easier. Adaptation and immobility of the transplant are the most important factors in the earlier stages of healing process for a successful outcome of the procedure. Many other methods of tympanoplasty such as island technique, palisade technique, shield technique, and wheel technique are described by otologists.[3]

In 1998, Eavey introduced the butterfly technique as inlay cartilage tympanoplasty in children with very good results.[4] Toss classified this inlay cartilage tympanoplasty in “F” group and “A” subgroup of tympanoplasty.[5]

We have adapted Eavey's inlay cartilage butterfly technique for the reconstruction of small- to medium-sized tympanic membrane perforations in 55 patients, and compared results with the results of temporalis fascia tympanoplasty in 55 patients of the same size perforations in the means of air-bone gap pre- and post-operatively.

  Materials and Methods Top

This prospective and comparative study was done in a tertiary care medical college hospital in Central India on 110 patients suffering from chronic suppurative otitis media tubotympanic type with inactive and dry ear. Patients of 10–60 years, both genders, with perforation size 2–6 mm were included in the study. Two groups had been formed of 55 patients for butterfly cartilage and 55 patients for temporalis fascia tympanoplasty. Fifty-five patients were processed for butterfly cartilage tympanoplasty and 55 for the temporalis fascia tympanoplasty alternatively under local anesthesia. The patients with large perforation (>6 mm), atticoantral disease, serous otitis media, only hearing ear, granular myringitis, and sensory neural hearing loss were excluded from the study. Preoperative investigations and evaluations were done as per requirement including pure tone audiometry, tuning fork test, and patch test.

All the patients were operated under local anesthesia. Well informed and written consent was taken. The patient taken to operation theater, painting and draping done, local anesthesia achieved by injecting 2% xylocaine with 1:100,000 adrenalin all around the external auditory canal and tragus, tragal cartilage with both side perichondrium harvested, the size of perforation measured by taking imprint of methylene blue painted over margins of the perforation on gelfoam sheet and measured with the help of scale. A 2 mm larger tragal cartilage with perichondrium on both sides harvested. The cartilage held in vein press, a 2 mm deep groove created in cartilaginous rim all around, care was taken not to peel the perichondrium on both sides [Figure 1]. This grooved graft was fitted in the freshened rim anteroinferiorly, then posteriorly with the help of microelevator. Sometimes, gentle dialing of the graft also helps to fit the graft nicely. The graft checked whether it is in position or not by pressing the graft with the help of microelevator. An ill fitted graft usually falls medially in the middle ear. After confirmation of graft position, canal packed with medicated gel foam with gentle pressure on margins of the graft. Tragal incision sutured with 3–0 cutting silk.
Figure 1: Butterfly cartilage graft

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After postoperative monitoring of 4 h, the patient was allowed to go home with oral medication. The patient was reviewed after 1 week for suture removal and after 2 weeks for inspection of tympanic membrane. Follow-up on 1, 3, and 6 months was done.

Butterfly cartilage tympanoplasty considered successful if tympanic membrane found intact with remnant cartilage at 3-month follow-up [Figure 2]. At the same time, a pure tone audiometry test was done and pre- and post-operative results were compared.
Figure 2: Butterfly graft at 3 months follow-up

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  Results Top

From 2012 to 2014, in the period of 2 years, 55 Type 1 tympanoplasties using temporalis fascia and 55 butterfly cartilage tympanoplasties were performed. Mean age groups were 12–59 years for butterfly graft tympanoplasty and 14–60 years for temporalis fascia graft tympanoplasty. There were 33 (60%) males and 22 (40%) females in temporal fascia group and 36 (65.5%) males and 19 (34.5%) females in butterfly cartilage group.

Mean perforation size [Figure 3] for temporalis fascia and butterfly cartilage group was 3.61 mm and 3.12 mm, respectively (P = −0.001).
Figure 3: Mean perforation size

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Among 110 patients, 80 (72.73%) were from urban/suburban background (38 patients in butterfly cartilage group and 42 in temporalis fascia group) and rest 30 (27.27%) (19in butterfly cartilage group and 11 in temporalis fascia group) were from rural area.

For both the groups, follow-up period of 6 months was decided.

In both of the groups, temporalis fascia and butterfly cartilage groups, there was statistically significant improvement in air-bone gap, but it was statistically insignificant (P = −0.158) [Figure 4].
Figure 4: Postoperative gain in air bone gap

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Rate of successful closure of the perforation were 92.7% (52 patients) in butterfly cartilage group and 96.3% (53 patients) in temporal fascia group. Success rates of both the groups were comparable but statistically insignificant (P = −0.647). Failure rate was 7.27% (3 patients) in butterfly group and 3.7%

(2 patients) in temporalis fascia group [Figure 3] and [Figure 4]. The cause of failure was lateralization in 2 patients and postoperative otomycosis after 1 month in butterfly group, re-perforation in 1 patients, and 1 medialization in temporalis fascia group.

Statistical analysis was done by using SPSS software (developed by Softonic, Barcelona, Ketalonia Spain based software company). Chi-square test was applied to compare and P value was fixed equivalent and <0.05.

  Discussion Top

In the surgical closure of tympanic membrane perforation following tubotympanic type of chronic suppurative otitis media, the most commonly accepted graft material worldwide is temporalis fascia. Many other graft materials such as skin, cartilage, perichondrium, vein graft, and fascia lata were used, but cartilage graft was found to be the second most suitable graft material. After Eavey,[4] cartilage tympanoplasty gained popularity. Eavey [4] for the first time used tragal cartilage with both side perichondrium for myringoplasty in children with small perforations.

In situations like residual perforations, chronic mucosal dysfunction, atelactatic tympanic membrane where temporalis fascia or perichondrium undergoes atrophy and subsequent failure [6] a tough graft material is required and cartilage fulfils the requirement. Cartilage is increasingly accepted as grafting material as it has more resistance and stability against negative middle ear pressure. It also has low metabolic rate to serve longer and is well-accepted in the middle ear.[7] Cartilage grafts are easy to harvest from tragus and conchal bowl. It has been shown to reduce the incidences of retraction pocket recurrence because of its rigidity.[8]

However, cartilage graft is criticized regarding hearing results because of its thickness.[9] In a study by Gerber et al.,[10] the results of temporalis fascia tympanoplasty and cartilage tympanoplasty were comparable. In a recent study by Mohamad et al.[11] and Lin et al.,[12] better results were observed with cartilage in comparison to temporal fascia.

Success rate of butterfly cartilage tympanoplasty in our study were 92.7% which were comparable to other studies, Eavey [4] in 1998 demonstrated 100% results, but the sample size was very small, i.e., nine cases; Lin et al.[12] in 2007 and Kim et al.[13] in 2014 showed 82.1% in 28 and 96.4 in 29 patients, respectively.

Toss classified 23 different types of cartilage tympanoplasty in 6 groups. Butterfly inlay cartilage tympanoplasty falls in the sixth group. Eavey [4] used butterfly cartilage tympanoplasty in children since children are more susceptible to recurrent attack of upper respiratory tract infections.

The thickness and availability of tragal cartilage make it more ideal for butterfly cartilage tympanoplasty. Grooving and placement of graft are easier with tragal cartilage-perichondrium graft. This graft is well-tolerated and well-accepted as other grafts. It is nourished by diffusion and gets well-incorporated in tympanic membrane.[14] Ayache described butterfly cartilage tympanoplasty by transcanal endoscopic procedure. He achieved 96% success rate with no cases of anterior blunting or lateralization, and the procedure were minimally invasive.[15] Butterfly cartilage tympanoplasty is a better option for small- to medium-sized perforations but not suitable for large, subtotal, and total tympanic membrane perforations.

  Conclusion Top

While comparing with temporalis fascia tympanoplasty, we found butterfly cartilage tympanoplasty better in regards of operation time, hospital stay, and immediate hearing improvement. Butterfly cartilage tympanoplasty is a simpler technique, takes less time to perform, and patient can go home within hours with minimal medication and minimum scar. Hearing improvement is immediate on the operation table. There is no requirement of shaving the head around ear, especially in females.

Hence, we advocate butterfly cartilage tympanoplasty be accepted as routine procedure for repairing small- to medium-sized tympanic membrane perforations.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Salen B. Myringoplasty using septum cartilage. Acta Otolaryngol Suppl 1964;188 Suppl 188:82.  Back to cited text no. 1
Heermann J Jr, Heermann H, Kopstein E. Fascia and cartilage palisade tympanoplasty. Nine years' experience. Arch Otolaryngol 1970;91:228-41.  Back to cited text no. 2
Goodhill V. Tragal perichondrium and cartilage in tympanoplasty. Arch Otolaryngol 1967;85:480-91.  Back to cited text no. 3
Eavey RD. Inlay tympanoplasty: Cartilage butterfly technique. Laryngoscope 1998;108:657-61.  Back to cited text no. 4
Toss M. Cartilage Tympanoplasty: Classification of Methods-Techniques-Results. New York: Thieme Stuttgart; 2009. p. I-432.  Back to cited text no. 5
Chen XW, Yang H, Gao RZ, Yu R, Gao ZQ. Perichondrium/cartilage composite graft for repairing large tympanic membrane perforations and hearing improvement. Chin Med J (Engl) 2010;123:301-4.  Back to cited text no. 6
Yung M. Cartilage tympanoplasty: Literature review. J Laryngol Otol 2008;122:663-72.  Back to cited text no. 7
Poe DS, Gadre AK. Cartilage tympanoplasty for management of retraction pockets and cholesteatomas. Laryngoscope 1993;103:614-8.  Back to cited text no. 8
Mürbe D, Zahnert T, Bornitz M, Hüttenbrink KB. Acoustic properties of different cartilage reconstruction techniques of the tympanic membrane. Laryngoscope 2002;112:1769-76.  Back to cited text no. 9
Gerber MJ, Mason JC, Lambert PR. Hearing results after primary cartilage tympanoplasty. Laryngoscope 2000;110:1994-9.  Back to cited text no. 10
Mohamad SH, Khan I, Hussain SS. Is cartilage tympanoplasty more effective than fascia tympanoplasty? A systematic review. Otol Neurotol 2012;33:699-705.  Back to cited text no. 11
Lin YC, Wang WH, Weng HH, Lin YC. Predictors of surgical and hearing long-term results for inlay cartilage tympanoplasty. Arch Otolaryngol Head Neck Surg 2011;137:215-9.  Back to cited text no. 12
Kim HJ, Kim MJ, Jeon JH, Kim JM, Moon IS, Lee WS. Functional and practical outcomes of inlay butterfly cartilage tympanoplasty. Otol Neurotol 2014;35:1458-62.  Back to cited text no. 13
Levinson RM. Cartilage-perichondrial composite graft tympanoplasty in the treatment of posterior marginal and attic retraction pockets. Laryngoscope 1987;97:1069-74.  Back to cited text no. 14
Ayache S. Cartilaginous myringoplasty: The endoscopic transcanal procedure. Eur Arch Otorhinolaryngol 2013;270:853-60.  Back to cited text no. 15


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

This article has been cited by
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[Pubmed] | [DOI]


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