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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 28  |  Issue : 1  |  Page : 41-44

Comparison of tragal cartilage and conchal cartilage in tympanoplasty


Department of ENT, Dr. MK Shah Medical College and Research Centre, Ahmedabad, Gujarat, India

Date of Submission18-Sep-2021
Date of Decision19-Oct-2021
Date of Acceptance25-Jan-2022
Date of Web Publication25-Apr-2022

Correspondence Address:
Dr. Sohil I Vadiya
Department of ENT, Dr. MK Shah Medical College and Research Centre, Visat - Gandhinagar Highway, Chandkheda, Ahmedabad - 383 2424, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/indianjotol.indianjotol_142_21

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  Abstract 


Aim and Objectives: The aim and objective of the study are to compare results in terms of graft uptake and hearing improvement in cases undergoing tympanoplasty with the use of conchal or tragal cartilage. Materials and Methods: A total of 74 cases of more than 18 and <50 years of age included in this study, where full-thickness cartilage tympanoplasty was performed. Thirty-seven cases included in Group A where tragal full-thickness cartilage was used and 37 cases included in Group B where full-thickness conchal cartilage was used. Results: Thirty-six (97.3%) cases in Group A and 35 (94.6%) cases in Group B had successful and complete graft uptake in this study. Hearing improvement was found to be better with the cases in Group B than Group A. Conclusion: Full-thickness conchal cartilage and tragal cartilage give good graft uptake results and hearing improvement is significantly better with the use of conchal cartilage.

Keywords: Cartilage tympanoplasty, conchal cartilage, tragal cartilage, tympanoplasty


How to cite this article:
Vadiya SI, Makwana P, Khetani S, Mehta N. Comparison of tragal cartilage and conchal cartilage in tympanoplasty. Indian J Otol 2022;28:41-4

How to cite this URL:
Vadiya SI, Makwana P, Khetani S, Mehta N. Comparison of tragal cartilage and conchal cartilage in tympanoplasty. Indian J Otol [serial online] 2022 [cited 2022 Nov 29];28:41-4. Available from: https://www.indianjotol.org/text.asp?2022/28/1/41/343749




  Introduction Top


Perforation of the tympanic membrane is a common condition encountered in day-to-day ENT practice. Many of the patients require surgical intervention for this condition. Tympanoplasty is a routine procedure for repair and reconstruction of tympanic membrane and/or ossicles. Various grafting materials have been used to close the perforation with different success rates. This includes temporalis fascia, fascia lata, vein graft, cartilage graft, peri-chondrium graft, etc., temporalis muscle fascia shows disorderly arrangement of elastic fibers (loose, crisscross, and interrupted). Shrinkage of the temporalis muscle fascia is unpredictable.[1] Cartilage offers better success rates, as it is a stronger material. There are number of studies described in literature that suggests various techniques through which a cartilage can be used. In most studies, cartilage appears to give better success rates than fascia alone. Tragal cartilage shield tympanoplasty is a reliable technique, in fact, it has a high degree of graft uptake and hearing results are satisfactory.[2] The graft take-up rates are excellent for both partial thickness and full-thickness tragal cartilage material in modified cartilage shield technique of tympanoplasty. Hearing gain is very much similar between thin and thick cartilage groups, except at 4000 Hz, as observed in a study.[3] Yetiser and Hidir[4] have analyzed that the hearing gain in patients with cartilage shield grafting was better than that in those who had temporalis fascia tympanoplasty, although experimental analysis shows loss of acoustic energy for thick and large shield cartilage grafts. Cartilage can be obtained from tragal area or conchal area of pinna of the same patient and from the same ear as auto-graft. The total average thickness of tragal cartilage was found to be 1.228 ± 0.204 mm in males and 1.090 ± 0.162 mm in females in the study by Khan and Parab[5] whereas mean thickness of tragal cartilage was found to be 1.22 mm and that of conchal cartilage was 1.36 mm in the study by Rana et al.[6] In both these studies, thickness has variations in different age groups and genders. We want to study if there is any difference in results in terms of graft uptake and/or hearing improvement with the use of cartilage material from conchal area and tragal area.


  Materials and Methods Top


This is an analytical type of prospective study with two comparison groups. Approval was taken from Institutional Ethical Committee before commencement of the study. A total of 74 cases of more than 18 years and <50 years of age who underwent tympanoplasty in the year 2019 were included in this study, where full-thickness cartilage tympanoplasty was performed. 37 cases were included in Group A where tragal full-thickness cartilage was used and 37 cases were included in Group B where full-thickness conchal cartilage was used. A detailed informed consent was taken from all participants of the study before surgery. All the cases where the ear had been dry for minimum of 15 days and where all ossicles were found intact were included in the study. Oto-endoscopy was done before surgery and cases with central perforation, dryness, and without tympanosclerosis were included in the study. Mastoid X ray Schuller's view was done in all cases and cases with pneumatized mastoid were included in the study to add uniformity. Pure tone audiogram (PTA) was done 1 day before surgery in all cases and hearing threshold for air conduction, bone conduction, and air bone gap (ABG) were noted at different frequencies with an audiometer with standard calibration. Cases with bone conduction threshold more than 25 db were excluded from the study to avoid cases with sensory neural deafness. Standard postauricular Wilde's incision was used in all cases. Temporalis fascia graft was used in all cases in addition to a piece of full-thickness tragal [Figure 1] or conchal cartilage with perichondrium attached on the lateral side. Edges of the perforation were trimmed and posterior annulus was raised to examine middle ear. Ossicular mobility was checked by gently moving handle of Malleus and seeing movement of Incus and Stapes and also observing the round window reflex. Cases with normal ossicular mobility and intact ossicular chain were included in the study. Tip of the handle of Malleus was cut to further improve middle ear space. [Figure 2] shows that this makes grafting of cartilage piece easy. Malleus head nipper is a good instrument to perform this step.
Figure 1: Tragal cartilage being harvested

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Figure 2: Handle of malleus cut

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Either conchal or tragal piece of cartilage with perichondrium attached on one side was used for grafting and the piece was kept lateral to the incudo-stapedial joint and medial to the remnant of handle of Malleus. The anterior border of the cartilage does not touch the anterior wall of middle ear but remains approximately 1 mm away from it. Small pieces of Gelfoam were placed medial to the cartilage and Temporalis fascia graft was kept lateral to the cartilage piece in an underlay fashion. Enough gel foam pieces were kept in the external ear after replacing the tympano-meatal flap. Skin sutures were removed on 7th postoperative day. Patients were requested to come for follow-up at 3 weeks, 6 weeks, and 12 weeks after surgery. Oto-endoscopy and PTA examinations were done at 12 weeks after surgery and results are compared for graft uptake and hearing improvement. On oto-endoscopy at 12 weeks, cases with complete closure of tympanic membrane defect were labeled as successful graft uptake [Figure 3].
Figure 3: Graft appearance at 3 months after surgery

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  Results and Analysis Top


Thirty-six (97.3%) cases in Group A and 35 (94.6%) cases in Group B had successful and complete graft uptake in this study. One case in Group A and 1 case in Group B required a revision surgery whereas 1 case in Group B had a complete closure of tympanic membrane defect with conservative measures in 1 month. Two cases in Group A and 1 case in Group B developed granulations in posterior canal wall area, which healed completely with local drops of Ciprofloxacine + Dexamethasone for 10 days.

Statistical analysis about hearing assessment is done with the help of Microsoft Excel software. Hearing assessment: For 500, 1000, and 2000 Hz frequencies, average preoperative ABG in Group A was 26.9 db and postoperative ABG was 14.01 db with average gain of 12.9db. In Group B, for the same frequencies, the average ABG gain was 14.5 db. The P value for this comparison was found to be 0.01987, which indicates that the difference is significant statistically and that Group B cases have better gain in terms of ABG closure in [Table 1]. For higher frequencies also (at 4000 and 8000 Hz), the hearing improvement is significantly better in Group B than Group A cases. This indicates that the conchal cartilage gives better hearing in terms of ABG closure. According to AAO-HNS criteria, all the successful cases in Group A and Group B had ABG <20 db after surgery whereas 15 cases in Group A and 17 cases in Group B had <10 db ABG after surgery. Worsening of bone conduction threshold was not found in any cases in both groups.
Table 1: Comparison of hearing gain between Groups A and B

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  Discussion Top


The purpose of this study is to identify if there is any difference in results produced by the use of a conchal cartilage or a tragal cartilage in cartilage tympanoplasty. Cartilage is a very good material for grafting in tympanoplasty, as established in many studies and there are various techniques of placement as well. There are many studies that show that a full-thickness cartilage can be effectively used in tympanoplasty. Parelkar et al.[7] concluded in their study that the thickness of the tragal cartilage does not affect the hearing results significantly. The technique that has been used in the current study is a modification of the technique described by Duckert et al.[8] The results show more than 94% graft uptake rates with the use of either full-thickness tragal or conchal cartilage. Hearing improvement is better with the use of conchal cartilage than tragal cartilage and the difference is statistically significant at all frequencies as P < 0.05. Tip of handle of malleus is cut in all cases in this study and this makes it easy to place the cartilage piece and maintains good middle ear space as well. The natural curve of the conchal cartilage may be of help that should add to hearing improvement and also that the conchal cartilage appears softer even though the thickness of tragal and conchal cartilage is different with conchal cartilage thicker than tragal, but these need to be further investigated. Aarnisalo et al.[9] have concluded that the placement of cartilage on the medial surface of TM reduces the motion of the TM that opposes the cartilage. These obvious local changes had little effect on the sound-induced motion of the stapes, as observed with stroboscopic holography. Another study by Mohamad et al.[10] has concluded that tympanoplasty using cartilage with or without perichondrium has better morphological outcome than tympanoplasty using temporalis fascia. However, there was no statistically significant difference in hearing outcomes between the 2 grafts. Comparison of results of the current study with other studies is shown in [Table 2]. [Table 2] shows that the findings of this study are very much similar to most other studies and it also shows that cutting the tip of Handle of Malleus does not affect grossly graft uptake results or hearing gain. None of the patients in the current study developed retraction or lateralization of graft.[11]
Table 2: Comparison of results of this study with other studies

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  Conclusion Top


Cartilage tympanoplasty with the use of full-thickness tragal or conchal cartilage provides excellent graft uptake rates. Hearing gain is better with the use of conchal cartilage than tragal cartilage and the difference is statistically significant at all frequencies with P < 0.05.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Indorewala S. Dimensional stability of the free fascia grafts: An animal experiment. Laryngoscope 2002;112:727-30.  Back to cited text no. 1
    
2.
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. 2
    
3.
Vadiya S, Bhatt S. Comparison of partial thickness and full thickness tragal cartilage graft during modified cartilage shield tympanoplasty for Type I procedures. Indian J Otolaryngol Head Neck Surg 2016;68:30-3.  Back to cited text no. 3
    
4.
Yetiser S, Hidir Y. Temporalis fascia and cartilage-perichondrium composite shield grafts for reconstruction of the tympanic membrane. Ann Otol Rhinol Laryngol 2009;118:570-4.  Back to cited text no. 4
    
5.
Khan MM, Parab SR. Average thickness of tragal cartilage for slicing techniques in tympanoplasty. J Laryngol Otol 2015;129:435-9.  Back to cited text no. 5
    
6.
Rana AK, Sharma R, Sharma VK, Mehrotra A, Upadhyay D. Intraoperative tragal and conchal cartilage thickness: Comparative study for cartilage tympanoplasty. Am J Otolaryngol 2020;41:102690.  Back to cited text no. 6
    
7.
Parelkar K, Thorawade V, Marfatia H, Shere D. Endoscopic cartilage tympanoplasty: Full thickness and partial thickness tragal graft. Braz J Otorhinolaryngol 2020;86:308-14.  Back to cited text no. 7
    
8.
Duckert LG, Müller J, Makielski KH, Helms J. Composite autograft “shield” reconstruction of remnant tympanic membranes. Am J Otol 1995;16:21-6.  Back to cited text no. 8
    
9.
Aarnisalo AA, Cheng JT, Ravicz ME, Furlong C, Merchant SN, Rosowski JJ. Motion of the tympanic membrane after cartilage tympanoplasty determined by stroboscopic holography. Hear Res 2010;263:78-84.  Back to cited text no. 9
    
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. 10
    
11.
Iacovou E, Kyrodimos E, Sismanis A. Cartilage “shield” tympanoplasty: An effective and practical technique. Eur Arch Otorhinolaryngol 2014;271:1903-8.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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Abstract
Introduction
Materials and Me...
Results and Analysis
Discussion
Conclusion
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