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Year : 2021  |  Volume : 27  |  Issue : 1  |  Page : 40-43

Prospective study of use of Island of tragal cartilage in revision tympanoplasty

Department of ENT, School of Medicine, D.Y. Patil University, Navi Mumbai, Maharashtra, India

Date of Submission11-Oct-2020
Date of Acceptance03-Feb-2021
Date of Web Publication26-Oct-2021

Correspondence Address:
Dr. Bhavika Verma
B-1403, Sai Sanskar, Next to Telecom Factory, Deonar, Mumbai - 400 088, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/indianjotol.indianjotol_224_20

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Background: Ideal graft material in revision tympanoplasty is a topic of much research. Cartilage being sturdy and stable even in negative pressure situations, is a viable option. Aims and Objectives: The aim of the present study was to evaluate graft uptake and hearing improvement using the technique of island of tragal cartilage as a graft material in revision tympanoplasty. Materials and Methods: This was a prospective study of total of 60 Type 1 revision tympanoplasty surgeries which were done using tragal cartilage island graft from December 2017 to December 2019 in our institute with a follow-up of 3 months. Results: Graft uptake in our study was found to be 93.33%. Four patients showed a re-perforation during follow-up. The mean preoperative air-bone gap (ABG) was 28.13 dB, while the postoperative mean ABG was 16.83 dB and the mean gain was 12.83 dB. Conclusion: It is thus worthwhile to consider island of tragal cartilage as a graft material in revision tympanoplasty.

Keywords: Chronic otitis media, island graft, middle ear, revision tympanoplasty, tragal cartilage

How to cite this article:
Verma B, Dawat N, Dabholkar YG, Patil SJ. Prospective study of use of Island of tragal cartilage in revision tympanoplasty. Indian J Otol 2021;27:40-3

How to cite this URL:
Verma B, Dawat N, Dabholkar YG, Patil SJ. Prospective study of use of Island of tragal cartilage in revision tympanoplasty. Indian J Otol [serial online] 2021 [cited 2021 Dec 2];27:40-3. Available from: https://www.indianjotol.org/text.asp?2021/27/1/40/329096

  Introduction Top

Chronic suppurative otitis media of tubotympanic type is a chronic inflammation of the mucoperiosteal lining of the middle ear cleft characterized by ear discharge, perforation of tympanic membrane (TM), and impairment in hearing. It is one of the most common ear diseases encountered in developing countries because of poor socioeconomic standards, poor nutrition and hygiene, and lack of health education.[1] It is a major cause of deafness in India. Surgical treatment is tympanoplasty which involves removal of middle ear disease and reconstruction of hearing mechanism.[2]

The ideal grafting material used in tympanoplasty depends upon various factors such as easy availability, ease of harvesting and placement, preparation time, and finally graft uptake and hearing improvement.

Failure in tympanoplasty may be due to varied reasons which include properties of graft material, operation technique, or patient-related factors. Factors such as atelectasis, tympanosclerosis,  Eustachian tube More Details disorders, condition of middle ear mucosa, active infection, and large perforations are some reasons for low success rates in the use of temporalis fascia as graft material. These difficulties can be overcome by the use of tragal cartilage. Cartilage as graft material is more stable in negative pressure and possesses all other properties of an ideal graft.[3]

In 1963, Salen and Jansen first reported the use of tragal cartilage for TM reconstruction. A number of graft materials can be used for revision tympanoplasty; however, tragal cartilage as a graft has proven to be superior to other materials. Cartilage contributes minimally to an inflammatory tissue reaction and is well incorporated with TM layers; it also provides firm support to prevent retraction. The greatest advantage of the cartilage graft has been thought to be its very low metabolic rate. It receives its nutrients by diffusion, is easy to work with because it is pliable, and it can resist deformation from pressure variations.[4]

As such, treatment of recurrent TM perforation is more difficult than primary surgery, and hence, a robust material which can provide greater structural stability is necessary for reconstruction to allow the middle ear to revert to a normalized environment.

Keeping all these factors in mind, this prospective study of island of tragal cartilage with perichondrium as a graft material in revision tympanoplasty was undertaken to evaluate its success rate as a graft material and assess postoperative graft uptake and hearing improvement. Primary study parameters included the incidence of reperforation of grafted TM, hearing results, and prevalence of other complications. The aim of our study was to evaluate. Success was defined as an intact TM in the postoperative 3-month follow-up, with closure of air-bone gap (ABG) to a value within 15 dB, and absence of any complications.

  Materials and Methods Top

This was a 2-year prospective study conducted of all patients undergoing revision Type 1 tympanoplasty in a tertiary care teaching and research hospital between December 2017 and December 2019. Prior institutional ethical committee approval and informed consent were obtained from all patients explaining to them the procedure and its outcomes. All patients (age: 18–45 years) with residual perforation who had undergone underlay tympanoplasty previously and having pure conductive hearing loss were included in our study. Patients having retraction pocket or middle ear disease with cholesteatoma or polyp or granulations were excluded from our study. A detailed history and clinical examination was first carried out in all 60 patients included in our study. Preoperative anesthetic workup included routine blood and urine analysis along with a digital X-ray mastoid (Schuller's view). In addition, pre- and postoperative pure tone average evaluations for all patients were performed using an Elkon EDA 3N3, calibrated yearly to the International Organization for Standardization standards in a sound-proof room.

Island of tragal cartilage with perichondrium was selected as a choice of graft material since it provided more stability as well as low metabolic rate, which was locally available and easily harvestable. After anesthetizing tragus, (using 2% lignocaine with 1 in 100,000 adrenaline), an incision was made just above the dome of tragal cartilage, slightly on the medial side so that scar was not visible from outside and cosmesis was maintained. Using a pair of small blunt curved scissors, the tragal cartilage along with the perichondrium was harvested. The cartilage was then fashioned as an island of tragal cartilage with perichondrium, as shown in the [Figure 1].
Figure 1: Island of tragal cartilage with perichondrium

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All 60 cases were done using the end aural approach under the Zeiss Movena microscope. The margins of perforation were freshened and tympanomeatal flap was elevated from 6 to 12 O'clock position. After elevating tympanomeatal flap anteriorly, the middle ear was properly examined and ossicular mobility and continuity were confirmed. The cartilage was then trimmed to size and placed into the middle ear medial to handle of malleus. After repositioning tympanomeatal flap, gelfoam pieces soaked in antibiotic solution were placed over the graft to avoid lateralization.

Patients were put on oral antibiotics and analgesics for 7 days. Antihistamines were continued for 3 weeks. Dressing removal and sutures were removed after 7 days. All patients were instructed to take adequate precautions to prevent the entry of water into the ear canal and avoid blowing of the nose and lifting of heavy weights. Every patient was evaluated in the outpatient department after 3 and 6 weeks.

Outcomes measured for the closure of TM perforation were assessed as full take, partial take, or graft rejection 3 months after surgery, while the postoperative hearing of the patients was also assessed. A “full take” was recorded when the TM had complete closure as seen under otomicroscopy, partial take was regarded as <100% closure, and graft failure was defined as a complete rejection of the graft. Air conduction (AC) and bone conduction (BC) pure-tone average (PTA) values were calculated as the mean of the hearing thresholds at frequencies of 0.5, 1, 2, and 4 kHz. ABGs were calculated as the difference between the AC-PTA and BC-PTA thresholds. Postoperative improvement in ABG was documented. Complications, if any, were noted and treated accordingly. Patients with incomplete information and those lost to follow-up were excluded from the study. The data were entered into a spreadsheet and presented in a descriptive form as tables and graphic charts. A statistical analysis was then carried out of these data.

  Results Top

This study included 60 patients, 31 males (51.67%) and 29 females (48.33%) with a male: female ratio of 1.06:1. Patients were in the age range of 18–45 years, with patients presenting in the third and fourth decades of life more commonly, i.e., 26 (43.3%) and 21 (35%), respectively. Demographic characteristics of patients were such that TM perforation was commonly found on the left side (33, 55%), as compared to the right side (27, 45%). The common symptoms with which the patients presented included ear discharge and loss of hearing (in all 60 patients) followed by ear ache (29) and vertigo (18).

The graft was taken up successfully in 56 cases (93.33%). Mean and standard deviation of average thresholds at 0.5, 1, 2, and 4 kHz on PTA were calculated. As shown in [Figure 2], the comparison of pre-operative and post-operative PTA were calculated. In the 56 cases, the mean preoperative ABG was 28.13 dB and the postoperative mean ABG was 16.83 dB and the mean gain was 12.83 dB as shown in [Figure 3]. Four patients had a complication of reperforation. Two of these patients had intraoperative findings of tympanosclerotic plaques in the middle ear, while another patient had diseased middle ear mucosa. In the fourth patient, no obvious cause of failure could be identified.
Figure 2: Comparison between pre- and postoperative pure-tone average across the participants

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Figure 3: Mean pre- and postoperative air-bone gain across speech frequencies

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  Discussion Top

Our study showed a successful graft uptake in 56 of 60 patients (93.33%). These results are similar to a study conducted by Boone et al. in 2004 in which he obtained successful closure without reperforation in 90 of 95 patients (94.7%).[5]

In 2012, Altuna et al. carried out a retrospective study on 60 patients who underwent revision tympanoplasty using cartilage with island technique. Successful closure without reperforation was obtained in 87% of cases.[6] In 2009, Cavaliere et al., used tragal cartilage in Type 1 tympanoplasty in 306 patients, of which 70 were revision cases to study the efficacy of tragal cartilage as graft material. Graft uptake was achieved in 304 patients (99.35%) and there were no immediate postoperative complications. Furthermore, the cartilage is easily accessible, easy to adapt, resistant to negative middle ear pressures and resorption, stable, elastic, and well tolerated by the middle ear.[7]

Factors affecting the success rate of surgery are age, localization and size of perforation, the condition of the middle ear mucosa, the function of the Eustachian tube, the type of graft used, and surgical experience.[8]

It is known that age and sex differences do not affect the closure of TM.[9] In elderly patients, the mental state and metabolic (diabetes mellitus) and cardiovascular diseases are more important than the age, whereas in children (especially in those younger than 6 years of age), the risk of perforation or retraction is related to underdeveloped immunity, serous otitis media, and recurring middle ear infections.[10] Furthermore, the small middle ear structure and narrow external ear canal lower the success of tympanoplasty. In our study, women (1 case of re-perforation) had a more successful better outcome than males (3 cases). In Lin's study, the success rate of graft was 78% in males and 95% in females. This difference was related to higher tobacco use by males. In the same study, the success rate of graft in tobacco users was reported as 63% and 93% in nonusers.[11]

Our study showed an average improvement in ABG of 12.83 db. Similar findings have been documented in other studies. A study by Boone et al. showed postoperative pure-tone average ABG of 12.2 ± 7.3 dB as compared with 24.6 ± 13.8 dB preoperatively.[5] A study conducted in 2011 by Altuna X et al. showed an average postoperative ABG of 13 ± 7 dB compared with 21 ± 11 dB preoperatively.[6] Similarly, Cavaliere et al. in 2009 concluded that the overall average preoperative pure-tone average ABG was 43.79 ± 7.07 dB, whereas the postoperative (1 year after surgery) pure-tone average ABG was 10.43 ± 5.25 dB. A statistically significant improvement was observed up to 5 years after surgery.[7] These studies concluded island cartilage grafting to be a reliable procedure for revision cases with excellent anatomic results as well as significant hearing improvement.

One of the main concerns with the use of tragal cartilage was the idea that due to the thickness of graft, postoperative improvement in hearing would be less compared to improvement found with temporalis fascia. Gerber et al. studied 11 cartilage and 11 temporalis fascia graft tympanoplasties in 2000. They observed comparable hearing results in both the groups.[12] Furthermore, many studies have shown that there is no difference in the use of cartilage or fascia in morphological as well as hearing aspects.[13],[14] In our study, two patients had a postoperative ABG more than 15 dB. In one of these patients, the postoperative ABG was 21.6 in spite of a gain of 18.4 in hearing. The other patient had postoperative deterioration of hearing even with successful graft uptake. Both these patients had tympanosclerosis in the middle ear. Overall, postoperative audiologic evaluations of hearing improvement were satisfactory.

Another concern with the use of cartilage is that it undergoes alteration in shape and size with time due to resorption.[4] There is the gradual replacement of cartilage with fibrous tissue and deeper proliferation of blood vessels. Sufficient nourishment of the graft is ensured because cartilage and chondrocytes are bradytrophic tissues. This fact is supported by a low metabolic rate of cartilage in general and the ability of receiving nutrients by diffusion. This is extremely important in the early postoperative weeks in which nourishment is absent. Fibroblasts which are present in fascia require fresh blood circulation for survival. As a result, cartilage can stay viable for a longer time as compared to fascia.

In our study, we have used cartilage along with perichondrium. The advantage of using perichondrium is that it can be tucked in the rim of the perforation margin by underlay technique. Furthermore, it can be placed below the tympanomeatal flap which is not possible in the case of cartilage.

Cartilage grafts can be preferred in the reconstruction of TMs in revision cases because of their resistance to poor nutrition, recurring infections, and retractions. Thus, tragal cartilage is a robust option as a graft material with excellent postoperative hearing results in the challenging circumstances of revision tympanoplasty. The use of island of tragal cartilage with perichondrium in revision tympanoplasty shows a good functional outcome in terms of hearing results and the absence of complications.

  Conclusion Top

With an average of improvement in ABG 12.82 dB observed at the end of 3 months of regular follow-up of patients in our study and a successful graft uptake without reperforation seen in 93.33%, we conclude that cartilage tympanoplasty using island of tragal cartilage with perichondrium has excellent hearing results and functional outcome with absence of major complications.


We would like to express our gratitude to Dr. Vijay D Patil, Chancellor, D. Y. Patil University, for his continuous encouragement and support.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Jung TT, Hanson JB. Classification of otitis media and surgical principles. Otolaryngol Clin North Am 1999;32:369-83.  Back to cited text no. 1
Lierle DM. Standard classification for surgery of chronic ear infection: I. Of the technical procedures in surgery for chronic ear infection: II. Of the gross pathology found at such operations: III. For the reporting of postoperative results of the surgical procedures mentioned: The committee on conservation of hearing of the american academy of ophthalmology and otolaryngology. Arch Otolaryngol 1965;81:204-5.  Back to cited text no. 2
Milewski C. Composite graft tympanoplasty in the treatment of ears with advanced middle ear pathology. Laryngoscope 1993;103:1352-6.  Back to cited text no. 3
Yung M. Cartilage tympanoplasty: Literature review. J Laryngol Otol 2008;122:663-72.  Back to cited text no. 4
Boone RT, Gardner EK, Dornhoffer JL. Success of cartilage grafting in revision tympanoplasty without mastoidectomy. Otol Neurotol 2004;25:678-81.  Back to cited text no. 5
Altuna X, Navarro JJ, Algaba J. Island cartilage tympanoplasty in revision cases: Anatomic and functional results. Eur Arch Otorhinolaryngol 2012;269:2169-72.  Back to cited text no. 6
Cavaliere M, Mottola G, Rondinelli M, Iemma M. Tragal cartilage in tympanoplasty: Anatomic and functional results in 306 cases. Acta Otorhinolaryngol Ital 2009;29:27-32.  Back to cited text no. 7
Westerberg J, Harder H, Magnuson B, Westerberg L, Hydén D. Ten-year myringoplasty series: Does the cause of perforation affect the success rate? J Laryngol Otol 2011;125:126-32.  Back to cited text no. 8
Callioglu EE, Ceylan BT, Kuran G, Demirci S, Tulaci KG, Caylan R. Cartilage graft or fascia in tympanoplasty in patients with low middle ear risk index (anatomical and audological results). Eur Arch Otorhinolaryngol 2013;270:2833-7.  Back to cited text no. 9
Ozbek C, Ciftçi O, Tuna EE, Yazkan O, Ozdem C. A comparison of cartilage palisades and fascia in type 1 tympanoplasty in children: Anatomic and functional results. Otol Neurotol 2008;29:679-83.  Back to cited text no. 10
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. 11
Gerber MJ, Mason JC, Lambert PR. Hearing results after primary cartilage tympanoplasty. Laryngoscope 2000;110:1994-9.  Back to cited text no. 12
Couloigner V, Baculard F, El Bakkouri W, Viala P, François M, Narcy P, et al. Inlay butterfly cartilage tympanoplasty in children. Otol Neurotol 2005;26:247-51.  Back to cited text no. 13
Gierek T, Slaska-Kaspera A, Majzel K, Klimczak-Gołab L. Results of myringoplasty and type I tympanoplasty with the use of fascia, cartilage and perichondrium grafts. Otolaryngol Pol 2004;58:529-33.  Back to cited text no. 14


  [Figure 1], [Figure 2], [Figure 3]


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