A Prospective Observational Study of Temporalis Fascia With Tragal Perichondrium As Graft Material in Type I Tympanoplasty

International Journal of Science and Research (IJSR)
ISSN: 2319-7064
ResearchGate Impact Factor (2018): 0.28 | SJIF (2018): 7.426
A Prospective Observational Study of Temporalis

Fascia with Tragal Perichondrium as Graft Material
in Type I Tympanoplasty
Dr Sai Kiran Gova1, Dr. V. Krishna Chaitanya2
1
M.B.B.S, Reg. No: M175413021, Department of ENT Narayana Medical College & Hospital Chintha Reddy Palem, Nellore - 524 002,
Andhra Pradesh, India
2
M. S., E.N.T., Professor, Department of ENT Narayana Medical College & Hospital Chintha Reddy Palem, Nellore - 524 002, Andhra
Pradesh, India
Dr N.T.R. University of Health Sciences, Vijayawada, A.P., India
Abstract: A prospective observational study is performed on patients undergoing Type 1 Tympanoplasty after proper evaluation and
obtaining a written informed consent for comparison of Temporalis fascia with Tragal Perichondrium as graft material in Type 1
Tympanoplasty and improvement is assessed with hearing improvement, time taken for graft uptake. A sample size of 100 patients in age
group of 18 to 60 years in CSOM cases were selected for the study. Duration of study 2 years i.e. from October 2017 to September 2019.
Keywords: Temporalis fascia, Tragal perichondrium, Tympanoplasty, Chronic suppurative otitis media
1. Introduction
Chronic suppurative otitis media is highly prevalent
Tympanoplasty is a surgical procedure to eradicate the middle ear disease, particularly in the developing countries
disease in the middle ear and to reconstruct the hearing like India [5, 6]. It is defined as a persistent, disease
mechanism with or without tympanic membrane grafting, affecting the mucoperiosteal lining of the middle ear cleft
whereas Myringoplasty is a surgery in which the more than month which is insidious in onset, and capable
reconstructive procedure is limited to repair of tympanic of causing the destruction and some irreversible sequela,
membrane perforation assuming that middle ear ossicles and also it clinically manifests with ear discharge and hard
are functioning normally, eustachian tube is patent, and the of hearing [7]. It causes numerous pathological changes in
patient has a good cochlear reserve [1, 2]. tympanic membrane, and middle ear such as perforation,
ossicular destruction, myringosclerosis,
Type-1 tympanoplasty is surgical reconstruction limited to tymapanosclerosis, granulation tissue polyp,
repair of tympanic membrane alone. The implicit cholesteatoma, etc. it causes significant conductive hearing
definition is that the ossicular chain is intact and mobile loss. The surgical treatment of chronic suppurative otitis
and that there is no middle ear disease. In early centuries, media primarily aims at eradication of disease process, and
an ear infection with complication was a life threatening reconstruction of conductive hearing mechanism
condition. The introduction of antibiotics and the use of Tympanoplasty is surgical procedure to reconstruct sound
the operative microscope in the surgical field were conducting apparatus, tympanic membrane, ossicular
revolutionary advances in the control of the disease. system with or without grafting.
Chronic suppurative otitis media (CSOM) is a long
standing infection of a part or whole of middle ear cleft. The primary goals of tympanoplasty are:
CSOM is characterized by ear discharge, a permanent
perforation, and impairment of hearing. Tympanic 1. Eradication of the disease
membrane (TM) perforations lead to recurrent ear 2. To improve or maintain hearing mechanism
infections and hearing loss [1]. 3. Establish middle ear cleft ventilation
If the perforations are bilateral, hearing handicap becomes For reconstruction of tympanic membrane, different types
more evident. Persistent perforations occur either due to of materials are used. The most commonly used are
improper treatment of recurrent middle ear infections or temporalis fascia, cartilage, fascia lata etc. Temporalis
infected traumatic perforation. Repair of TM perforation fascia the most frequently used graft material, with closure
was attempted for many years. Different techniques and of the tympanic membrane perforation. Cartilage has
different graft materials like temporalis fascia, tragal shown to be better graft material, to close perforations in
perichondrium and tragal perichondrium with cartilage the tympanic membrane. It gains popularity due to its
were used [3]. resistance to retraction, resorption and reperforation, even
with Eustachian tube dysfunction. The stiffness of
It is the work of two Germans, Wullstein and Zollner, cartilage that prevents reperforations, but it interfere with
which started in 1949, lead to a new concept of the the sound conduction properties of the tympanic
treatment of deafness secondary to chronic infection in the membrane, than temporalis fascia [1].
middle ear and mastoid and the new method was called
―tympanoplasty‖ [4].
Volume 8 Issue 12, December 2019

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Licensed Under Creative Commons Attribution CC BY
Paper ID: ART20203370 DOI: 10.21275/ART20203370 509
ISSN: 2319-7064
The present study is a prospective study which describes Valsalva maneuver in postoperative period on audiological
the influence of various parameters like type of graft used, outcome after surgery.
surgical approach, the time taken for graft uptake,
2. Objectives
To observe and assess the difference between temporalis
fascia, tragal perichondrium as graft material in Type 1
Tympanoplasty.
Objectives
 To evaluate the Improvement in hearing by audiology

with Pure Tone Audiometry
 To study the effect of time taken for graft uptake on
the audiological outcome.
3. Review of Literature
Development of the ear
The human ear development begins at the fourth week of

embryonic life. Figure 1: 1. Oticplacode, 2. Otic cup, 3. Otic cyst, 4. Inner
ear
External ear
The membranous labyrinth develops from the otic placode
The auricle develops from auricular hillocks, derived from which is a thickening of the ectoderm adjacent to the
first and second branchial arches. The six hillocks develop hindbrain. This otic placode invaginates and forms an otic
in the 6-week of embryonic life. The external auditory cup. By the end of the fourth week, the edges of the otic
meatus formed by deepening of the groove between the cup fuse together form the otic vesicle/otocyst. A few of
two arches. At the dorsal end of the first branchial groove, otic epithelial cells in the otic cup and otocyst separates
the ectodermal cells thicken and form the external meatus. from the epithelium and joins to form neurons of the
These ectodermal cells proliferation forms a meatal ―plug‖ eighth cranial nerve. These neurons innervate sensory
that progress medially. Resorption of cells in the center of organs within the inner ear.
this meatal plug forms a tube-like structure which becomes
ear canal. When complete canalization fails to occur that A diverticulum develops in the otocyst elongates to form
leads to External canal atresia [8]. the endolymphatic duct and sac. The remaining portion of
the otocyst enlarges and forms a ventral saccular and
Middle ear cochlear region, and the dorsal region develops into the
utricle and three semicircular ducts.
The middle ear cavity forms as a lateral extension of the
first pharyngeal pouch. The proximal end of this extension The superior and posterior semicircular canals develop
becomes the eustachian tube. The lateral extension joins from a vertical outgrowth in the dorsal region of the
with the ectoderm of the meatal plug and forms the otocyst. The lateral duct develops from a horizontal
tympanic membrane. From Mesoderm of the first outgrowth in the lateral portion of the otocyst [8].
branchial arch, the malleus, incus, anterior malleolar
ligaments and tensor tympani muscle are derived. From The external auditory canal: Normal anatomy:
the mesoderm of second arch, Stapes, stapedius muscle
derived [9]. The external auditory canal is approximately 2.5 cm in
length and serves as a channel for sound transmission to
Inner ear the middle ear. Its lateral onethird is bolstered by elastic
cartilage oriented in an upward and backward fashion; its
It has two components, anterior aspect is pierced by vertical fissures known as the
fissure of Santorini. These fissures are a potential route for
1.Membranous labyrinth. -derived from the ectoderm spread of infections or neoplasms between the external
2.Bony labyrinth- derived from the mesoderm and neural auditory canal and the parotid gland.
crest.
The medial two-thirds of the external auditory canal is
osseous and is oriented in a downward and forward
direction. Hence the auricle must be pulled upward and
posteriorly to achieve lignment during otoscopic
examination. The narrowest portion of the external
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auditory canal or isthmus is located just medial to the
junction of the bony and fibrocartilagenous canal [10].
Figure 2: Anatomy of ear [11]
Figure 3: Middle ear [12]

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The Tympanic membrane
Figure 4: Tympanic membrane [13]
The tympanic membrane is irregularly round and slightly

conical in shape. The apex of the cone is located at the
umbo, which marks the tip of the manubrium. In the adult,
it is angulated approximately 140° with respect to the
superior wall of the external auditory canal. The vertical
diameter of the tympanic membrane as determined along
the axis of the manubrium ranges from 8.5 to 10 mm,
while the horizontal diameter varies from 8 to 9 mm.
The anterior and posterior tympanic striae extend from the

lateral process of the malleus to the anterior and posterior
tympanic spines, respectively. These striae divide the
tympanic membrane into larger pars tensa below, and
smaller triangular pars flaccida (or Shrapnell‘s membrane)
above.
Figure 5: Ossicles [14]
The thickened periphery of the pars tensa, the tympanic
annulus anchors the tympanic membrane in a groove The malleus:
known as the tympanic sulcus. The tympanic annulus and
sulcus are absent superiorly in the area of the notch of It has a head, neck, lateral process, anterior process, and
Rivinus. manubrium. It is held to the walls of the petrotympanic
fissure by the anterior malleal ligament which, with the
The pars tensa, as its name suggests, is taut and consists of posterior incudal ligament, serves to establish the axis of
three layers: rotation of the ossicles. On its thinner, medial aspect runs
the chorda tympani nerve as it passes anteriorly to enter
 A lateral epidermal layer the iter chordae anterius at the Glaserian fissure.
 A medial mucosal layer
 An intermediate fibrous layer. The lateral process of the malleus contains a cartilaginous
cap attached to the pars tensa of the tympanic membrane.
The pars flaccida, first described by Shrapnell, also The inferior end of the manubrium is firmly attached to the
consists of epidermal, fibrous, and mucosal layers. Here, tympanic membrane as the pars propria splits to envelop it
the fibrous layer is scanty and consists of irregularly (the umbo).
arranged collagen and elastic fibers [13].
The malleus is held in place by five ligaments, one
articulation, the tensor tympani tendon, and the tympanic
The ossicles:
membrane.
The three ossicles (malleus, incus, stapes) serve to transmit
sound energy from the tympanic membrane to the inner Three of the five ligaments have a suspensory function.
ear [14]. They are:
 The anterior suspensory ligament

 The lateral suspensory ligament

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 The superior suspensory ligament [14]. The sinus tympani lies between the ponticulus (which
bridges the gap between the pyramidal eminence and the
The incus: promontory superiorly) and the subiculum. The anterior
wall of the middle ear (carotid wall) narrows inferiorly
The incus, the largest of the auditory ossicles, consists of a where it is formed by the thin bony shell of the carotid
body, short process, long process, and lenticular process. canal. Located more superiorly in the anterior wall is the
The body of the incus rests in the epitympanum in orifice of the eustachian tube and above it the tensor
association with the head of the malleus. The short process tympani muscle lies in its semicanal.
of the incus extends posteriorly, occupying the posterior
incudal recess (fossa incudis).The long process reaches The roof (tegmental wall, tegmen tympani) separates the
inferiorly, to end in the lenticular process; the convex tympanic cavity from the middle cranial fossa. The lateral
surface of this process articulates with the concave surface boundary (membranous wall) is composed of the tympanic
of the head of the stapes. The long process of the incus is membrane, the bony tympanic ring, and a layer of bone
highly susceptible to osteitic resorption caused by chronic from the squama - the scutum or shield of Leidy. The
otitis media. medial wall (labyrinthine wall) of the tympanic cavity is
marked by two main depressions:
The stapes:
 The round window niche
The stapes is the smallest ossicle. It consists of a head,  The oval window niche
footplate (the basis stapedis), and two crura or legs. The
stapedius tendon attached to the superior aspect of the The round window niche is located anteroinferior to the
posterior crus. The footplate, in association with the subiculum and posteroinferior to the promontory.The latter
annular ligament, seals the oval Window. The head structure is the bulge of the bone overlying the basal turn
articulates with the lenticular process of the incus at its of the cochlea.
fovea.
The oval window niche is anterosuperior to the ponticulus.
The muscles Located posterosuperiorly is the prominence of the facial
canal as it traverses the medial wall and then descends
The Stapedius muscle: along the mastoid wall of the tympanic cavity.
The stapedius muscle, the smallest of the skeletal muscles, The middle ear space is divided into four regions:
emerges from the pyramidal eminence and attaches to the
head and/or posterior crus of the stapes. It is supplied by 1. The mesotympanum (middle ear proper) is that area
facial nerve. located medial to the tympanic membrane and the bony
tympanic annulus.
The tensor tympani muscle:
2. The epitympanum is that area that lies medial to the pars
flaccida and scutum.
The tensor tympani muscle, arises from the cartilage of the
eustachian tube, attach to the concave surface of the 3. The protympanum lies anterior to a frontal plane drawn
cochleariform (spoon-shaped) process, at which point the through to the anterior margin of the tympanic annulus.
main body of the tendon turns laterally to attach to the It leads to the tympanic orifice of the eustachian tube.
medial and anterior surfaces of the neck and the 4. The hypotympanum is that part of the middle ear located
manubrium of the malleus. Its innervation is from the inferior to a horizontal plane through the most inferior
trigeminal nerve. The action of the tensor tympani muscle part of the tympanic annulus.
is to draw the manubrium medially, thus tensing the
tympanic membrane [2, 13, 14]. The Eustachian tube:
The middle ear spaces: The eustachian tube, a mucosally lined pathway between
the nasopharynx and the middle ear, permits ventilation of
The tympanic cavity is a cleft in the sagittal plane the pneumatized spaces of the temporal bone while
measuring about 15 mm in the vertical and anteroposterior safeguarding against bacterial contamination of these
dimensions. In its transverse dimension, it expands spaces. The posterolateral one-third is bony while the
superiorly to 6 mm and inferiorly to 4 mm from a central anteromedial two-thirds is fibrocartilaginous; these two
constriction of 2 mm. At the floor of the tympanic cavity sections are joined at the tubal isthmus. The overall length
(jugular wall) a small plate of bone separates the jugular of the eustachian tube in the adult is 36mm.
bulb. In the posterior wall, the chordal eminence is lateral
to the pyramidal eminence and medial to the posterior rim The middle ear mucosa:
of the tympanic membrane. There is a foramen in this
eminence, known as the iter chordae posterius, through In electron microscopic observations, Hentzer
which the chorda tympani nerve gains access to the middle distinguished five types of cells in the middle ear mucosa:
ear. The facial recess is interposed between the chordal
eminence laterally and the pyramidal eminence medially 1. Nonciliated without secretory granules
and superiorly bounded by the fossa incudis. 2. Nonciliated with secretory granules
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3. Ciliated The canals:
4. Intermediate
The osseous semicircular canals are:
5. Basal
The mucosa of the middle ear represents a modified 1. The lateral
respiratory mucosa. 2. Posterior
3. Superior canals
The Mastoid region:
Each canal expands to double its diameter at its osseous
At birth the mastoid has a single cavity consisting of the ampulla where it communicates with the vestibule. The
antrum and small adjacent mastoid. It occupies a non ampullated ends of the posterior and superior canals
superficial position and is surrounded by diploic bone. In fuse, forming the common crus, while the non ampullated
adult life, the normal mastoid may be fully pneumatized, end of the lateral canal remains independent. Thus, the
diploic, or sclerotic. The anterolateral portion of the vestibule has five apertures for the semicircular canals.
mastoid arises from the squamous part of the temporal
bone; the posteromedial portion, including the mastoid tip, The membranous labyrinth:
arises from the petrous part. In most mastoids, the plane of
junction of these two parts is marked internally by an The membranous labyrinth is encased within the bony
incomplete plate of bone, the petrosquamosal septum, also labyrinth and is surrounded by the perilymphatic space.
known as Koerner‘s septum. The mastoid antrum area is a The constituents are
large superior central space which communicates with the
epitympanic space of the middle ear via the aditus [15, 1.The cochlear duct,
16]. 2.The three semicircular ducts and their ampullae,
3.The otolithic organs (the utricle and saccule), and the
The inner ear
endolymphatic (otic) duct and sac.
The bony labyrinth:
This system of epithelially lined channels and spaces is
filled with endolymph (Scarpa‘s fluid); the utricular duct,
The long axis of the bony labyrinth, measuring 20 mm in
the saccular duct, and the ductus reuniens interconnect the
length, roughly parallels the posterior surface of the
major structures [18].
petrous pyramid. Its components are the vestibule, the
semicircular canals, and the cochlea [17].
Cochlea
Figure 6: Inner ear [17]
The vestibule:
The vestibule is the central chamber. At the

posterosuperior aspect of its medial wall is a depression
known as the elliptical recess which accommodates part of
the utricular macula. The spherical recess is a similar
depression for the saccular macula, located
anteroinferiorly. The vestibular crest is an oblique
elevation between these two recesses. The opening for the
cochlea lies anteriorly, while the openings for the Figure 7: Cochlea [18]
semicircular canals are located posteriorly. The oval
window is an opening on the lateral wall, adjoining the The cochlea is snail shaped and has a spiral configuration
tympanic cavity. The vestibular aqueduct with its with two and a half turns. The center portion of the spiral
contained endolymphatic duct opens into the is called the modiolus. The portion of the cochlea that is
posteroinferior aspect of the vestibule [16]. closest to the oval window is the base, whereas the portion

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of the cochlea that is farthest away from the oval window into the nasopharynx and is closed at rest. The tensor veli
is the apex. palatini opens the Eustachian tube orifice during
swallowing, for a transient period that lasts 0.3–0.5s.This
The cochlea is having three compartments: scala tympani, results in pressure equalization with the atmospheric
scala vestibuli and scala media. The basilar membrane pressure.
separates the scala tympani and the scala media, Reissner's
membrane separates the scala media and the scala vestibuli Middle ear mucosal gas exchange
The scala tympani and the scala vestibuli communicates
with each other at helicotrema. In the scala media, the Middle ear mucosa has a well-developed capillary
organ of Corti rests on the basilar membrane. Basilar structure close to its surface. This helps in gas exchange In
membrane and organ of Corti are referred to as the normal conditions middle ear pressure is equal to
cochlear partition. The organ of Corti has the inner and the atmospheric pressure, approximately760 mmHg at sea
outer hair cells. The inner hair cells are arranged in a level. These gases are bi-directionally exchanged.
single row and outer hair cells are arranged in three rows. Nitrogen gas level in middle ear is higher than that of
These hair cells have hair like projections called venous blood. This gradient results in gas exchange
stereocilia, which is responsible for the signal transduction between the middle ear space and venous blood. The
in hair cells. The scala vestibuli and the scala tympani are absorption of nitrogen into the venous blood results in
filled with perilymph, which resemble the extracellular negative pressure in the middle ear. This is equalized by
fluid (high in sodium, low in potassium) in composition. opening of the Eustachian tube. Prolonged Eustachian tube
The scala media filled with end lymph, which resemble dysfunction hampers this mechanism results in negative
intracellular fluid (low in sodium, high in potassium) in middle ear pressure, transudation of fluid, and the
composition. The electrolyte composition of the scala development of a middle ear effusion and increases the
media causes the endocochlear potential, which is +60 to middle ear acoustic impedence.
+100 mV relative to the perilymph [18].
Transmission of sound energy in the Cochlea
Physiology
When sound energy travels through the ear, it causes the
The difference between the impedance of air and the stapes footplate to vibrate. The vibration of the stapes
impedance of fluid is great; thus, in the transmission of footplate produces a compressional wave in the perilymph,
sound energy from Air to Fluid medium, there would be a which travels to the scala vestibuli, through the
99.9% loss which is approximately 30 dB loss. The above helicotrema, and out across the scala tympani towards the
loss can be overcome by impedence matching, which round window. An inward motion of the stapes results in
allows optimum sound energy transmission [19]. outward movement of the round window. When the organ
of corti and basilar membrane are deflected in response to
Hydraulic lever the compression wave, it produces a shearing force
between the tectorial membrane and the stereocilia of the
This is the ratio of the surface area of the tympanic hair cells. This shearing force produces a deflection of
membrane to that of the oval window. The tympanic stereocilia toward the direction of tallest row results in
membrane surface area is 55 mm2 and stapes foot plate opening of stretch- sensitive cationic channels located on
surface area 3.2 mm2. This difference represents a 17-fold the stereocilia. The opening of these stretch- sensitive
increase in surface area. Sound energy striking the much cationic channels causes a influx of cationic current, which
larger tympanic membrane is transmitted through to a results in hair cell depolarization.
much smaller surface area of the stapes footplate.
When inner hair cells are depolarized, it opens voltage-
Lever ratio gated calcium channels. The resulting calcium current
triggers neurotransmitter release across the synapse, which
The length of the manubrium, when compared the long results in activation of the auditory nerve fibers [16, 19].
process of the incus, is 1.3times longer. Hence the
leverage gain is 1.3. Combined effects of these two Tympanoplasty - An overview
mechanisms, the Hydrualic ratio and the lever ratio, the
approximate gain is 22 dB. Tympanoplasty (TM) is the procedure of removal of
disease from the middle ear and reconstruction of the
The two factors help in the transmission of sound energy hearing mechanism along with TM grafting.
are
History of Tympanoplasty:
1.Optimal Eustachian tube Function
2.Gas exchange within the middle ear Mucosa  1640-Banzer
Eustachian tube  First attempt at repair of TM

 Used pigs bladder as a lateral graft
The Eustachian tube has cartilaginous and bony portion.
The lateral bony portion of the canal opens in the anterior
wall of Middle Ear. The medial cartilaginous part, opens
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 1853-Toynbee 2. Eradicate middle ear disease and create an air containing
middle ear space
 Placed a rubber disc attached to a silver wire over the 3. Restore hearing by sound pressure transformation
TM between the eardrum and the cochlea
 Reported significant hearing improvement
Techniques:-
 1863-Yearsley
 Overlay (lateral grafting)
 Placed a cotton ball over a perforation Overlay - Surface epithelium was removed around the
perforation site and graft was put on the fibrous layer of
 1877-Blake TM [1].
 Paper patch
 1876-Roosa
 Chemical cautery
 1878-Berthold
 Coined the term Myringoplasty
 1950-Wullstein and Zollner
 Described 5 types of Tympanoplasty
 1960-Heerman Figure 8: Tympanoplasty (Tympanic membrane

perforation) [20]
 First used temporalis fascia grafting material in
tympanoplasty.
 1961-Storrs
 Temporalis fascia grafting
 1967-House Glasscock and Sheehy
 Techniques for lateral grafting

Indications for surgery:
1. Conductive hearing loss due to TM perforation or

ossicular dysfunction
2. Chronic or recurrent otitis media secondary to
contamination
3. Progressive hearing loss due to chronic middle ear Figure 9: Tympanoplasty (Graft insertion) [21]
pathology
Over lay grafting Advantages:
Contraindications for surgery:
1. Malignant tumours 1. Graft remains vascularised

2. Unusual infections like malignant otitis externa. 2. Exposure of anteriormeatal recess
3. Intracranial complications 3. Middle ear space not reduced
4. Cholesteatoma Disadvantages:
Goals of the surgery:
1. Lateralisation of the graft
1. Establish an intact TM 2. Blunting of anterior meatal recess

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3. Chance of iatrogenic cholesteatoma formation Healing Various surgical techniques
may take longer (4-8 weeks)
1. Overlay-underlay technique
1. Technically more demanding 2. Combined technique
2. Formation of epithelial pearl
Two grafts-one under the handle of malleus Second on the
Underlay (Medial grafting) fibrous layer of tm
Underlay technique was introduced by SHEA. The graft 3. Circumferential sub annular graft technique
was placed medial to the handle of malleus and TM 4. Swing door technique
remnant. 5. Butterfly and palisade technique cartilage
ADVANTAGES: Tympanoplasty
6. Cartilage shield tympanoplasty
1. Less blunting or lateralisation 7. The button graft technique
2. High graft uptake 8. Cartilage tympanoplasty with island technique
Disadvantages: 9. Endoscopic vs microscopic tympanoplaty [23].
1. Limited visualization of anterior meatal recess

2. Difficult with small EAC.
3. Less suitable in large anterior perforation
4. Reduction in middle ear space TM grafts
Histologically TM grafts become lined by squamous
epithelium on the ear canal side and the middle ear mucosa
on the tympanic cavity side [22].
Grafting materials
1. Temporalis fascia graft

2. Cartilage graft
3. Fat graft Figure 10: Classification of Tympanoplasty [24]
4. Hyaluronic acid fat graft
5. Tragal perichondrium and cartilage
6. Vein graft
7. Conchal cartilage
8. Fascia lata
9. Subcutaneous tissue
10. Periosteum
Approach
1. Transcanal
Posterior moderate sized perforations Favourable EAC
anatomy.
2. Endaural
Visualisation of annulus and anterior sulcus is difficult.
3. Postaural
All perforation sizes
Better angle of visualization
Figure 11: Wullstein classification of Tympanoplasty [25]

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 Wullstein and Zollner (1956): TYPE I 3. It has a good chance of postoperative survival.
4. It has a conical contour.
TM is grafted to an intact ossicular chain 5. It is sufficiently large for myringoplasty of a total
perforation [26].
TYPE II
4. Clinical Review
Malleus is partiallyeroded
In 2013 Adip K. Shetty et al used tragal perichondrium as
TM is grafted to the long process of incus/ remaining graft material in type 1 tympanoplasty with a success rate
malleus of 96% in the perichondrium group as compared with 92%
in the control group. In perichondrium- cartilage group
TYPE III shows mean gain in AirBone gap was 16.5 + 7.27 dB as
compared to 15 + 7.07 dB in temporalis fascia group. In
Columella effect /Myringostapediopexy Malleus and incus this study there is no statistical significant difference in
are eroded graft taken up and hearing gain between both groups [27].
TM is grafted to the stapes suprastructure with cartilage in In the study by M. Mohsen Wafaie et al in 2010 shows.
between Anatomical closure of TM perforations in 95% of patients
in the cartilage group, and in 90% of patients in the
TYPE –IV temporalis fascia group with value p more than 0.05. The
mean acoustic gain in two group with no significant
Stapes suprastructure is eroded but foot plate is mobile TM statistical difference [28].
is grafted to a mobile footplate
R. K. Mundra et al (2013) did study. to evaluate the
Sound protection of the roundwindow and formation of results of closure of subtotal perforation by tympanoplasty
airspace in the hypotympanum using underlay technique., with the perichondrium
temporalis fascia graft supported by single sliced cartilage
TYPE V [29].
TM is grafted to a fenestration in the lateral semicircular Emily Iacovou et al, 2012 to compare the hearing results.,
canal in cases with no ossicles and a fixed footplate. and graft take up rate in patients undergoing
myringoplasty for the reconstruction of the tympanic
In this thesis, study about the comparison of two different membrane, with the use of cartilage or fascia temporalis.
grafting materials were Temporalis fascia and Tragal The mean graft uptake rate was 92.4 % in the cartilage
perichondrium used in the patients undergoing type 1 group and 84.3 % in the fascia temporalis group. The
tymnoplasty [25]. obtained audiometric results are comparable to temporalis
muscle facia group and the rate of reperforation is lower
Temporalis fascia: [30].
Temporalis fascia was first used in myringoplasty by In 2011 Matthew Yung, Senthilnathan, Vivekanandan
Ortegtran (1958-59), Heerman (1961) and Storrs (1961). It and Philip Smith study compares outcomes of
is most commonly used autogenous material. It is myringoplasty procedures, using fascia and cartilage
preferred for various reasons: grafts. The graft integration of fascia and cartilage grafts at
24 months, were 84.2% and 80%, respectively. The
1. It is easy to harvest. postoperative AB gaps and audiological gains at 24
2. It can be used asonlay, intermediate or underlay graft. months were 16.97 dB and 13.63 dB, respectively, in the
3. For primary operation, there are no size limitations. fascia group and 20.63 dB and 12.60 dB respectively in
4. Fascia is quite similar to tympanic membrane with low the cartilage group. There was no statistical significant
basal metabolic rate. difference, in the graft taken up or postoperative
5. For reconstruction of the tympanic cavity and ear canal, audiological gain between the two groups. In this study,
fascia is the only suitable autogenous material, because they pointed out their limitation as very low sample size,
of its size. so interpreted with caution [31]. In 2014 Rajeev Reddy
conducted ―study of results. of cartilage-perichondrium vs
Tragal perichondrium: temporalis fascia grafting in chronic suppurative otitis
media.‖ temporalis fascia group showed a good
Tragal perichondrium was introduced into myringoplasty neotympanum about 60 patients (84.5%), 7 patient
by Victor Goodhill et al (1964), after being used in (9.85%) had reperforation and 5 (7.04%) had retraction
stapedectomy as an oval window graft for some years pockets. About 60 (98.6%) Patients showed a healed
before that. Like temporalis fascia, tragal perichondrium Tympanic membrane and only 1 (1.63%) had
has several advantages: reperforations in tragal cartilage perichondrium group.
Patients with temporalis fascia graft showed an AB gap of
1. It is easily accessible. less than 10 dB in 49 (82%) patients and more than 10 dB
2. It is a mesodermal graft. in 11 (18%) patients. AB gap closure with tragal cartilage
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perichondrium was less than 10 dB in 45 (78%) patients Uzun et al. achieved 100%.graft up, take with type 1
and more than 10 dB in 13 patients (12%). ―Tragal palisade - cartilage grafting, whereas 84.2% only success
cartilage perichondrium (<0.5 mm) seems to be an ideal rate was observed in temporalis fascia type 1
graft material for tympanic membrane, in terms of tympanoplasty [40].
postoperative healing and acoustic properties‖ [32].
In Korea LEE HY et al conducted. a study of change of
In the study by Kazikdas et al, 2007 reported graft middle ear mechanics after sliced cartilage type 1
acceptance rate about 97.5% with palisade cartilage tympanoplasty and compare with fascia tympanoplasty.43
tympanoplasty, for the anatomical closure of subtotal Period of study. 2002 to 2005 and followed up after 6
perforations compare with 75% of the fascia group. month. They founded there was no statistical. significant
Regarding acoustic gain, they found no statistical between two group in impedance audiometry [41].
difference between cartilage and fascia groups [33].
Cabra et al did at randomized. controlled trial between
Zahnert et al. (13) reported that the ideal acoustic 1997 to 2002 in general hospital. They allocated 64 patient
thickness of cartilage should be approximately 0.5 mm to cartilage group. and 59 patient into fascia temporalis,
instead.of full thickness of 0.7 to 1 mm to achieve better group. 1st they analyzed outcome after 24 month
audiological outcome [34]. anatomical. success was 82.26% (51 of 64) in cartilage.
tympanoplasty and 64.41 % (38 of 58) in TM fascia group.
Yakup Yegi̇ n et al between 2009 to 2014 .did The functional; outcome comparable. between both 2
comparative ―study of temporalis muscle fascia and full- groups [42].
thickness cartilage grafts in type 1 tympanoplasty ―in 247
patients. in the cartilage tympanoplasty patien.t show Juveria Majeed, Naveed Ahamed, 2016 reported the
higher graft take rate 91.3% than fascia tympanoplasty patients with tubotympanic type of chronic suppurative
patient 68.9% with p<0.001, but audioulogical gain are not otitis media were selected from all patients attending to the
statistically significance, in with full thickness cartilage ENT department of Gandhi Hospital, Secunderabad
tympanoplasty.compare to fascia [35]. between July 2014 to March 2016. This study includes 60
patients out of which 30 were subjected to myringoplasty
M M KHAN, S R PARAB conduct.study on sliced with temporalis fascia and remaining 30 to myringoplasty
cartilage. and temporalis fascia myringoplasty. Period of with tragal perichondrium. In all patients, discharging ears
study 2005-2008. On four year follow up anatomic closure and associated nasal pathologies were excluded. The
of perforation 97.5%. in cartilage group, and 82.63% in comparative study was done on following parameters-
fascia group. Hearing gain comparable.on both group graft uptake, audiological outcome, donor site
(average AirBone gap 7.10 dB in cartilage vs 8.05db in complications and any late complications such as
other group) [36]. reperforation, retraction, worsening of hearing and
adhesions. Our study included a follow up of post
In 2010 M. Mohsen, Wafaie Abdelaziz., M.Elsherif M. operative cases for 1 year 8 months. Out of 60 cases
Salama Bakr were did study at ENT Dept. AL-Azhar operated, 11 cases didn‘t come for follow up. Hence they
university. They got 95% of tympanicmembrane closure in were excluded. The remaining 49 cases were 25 temporalis
cartilage as compared to 90% fascia group. Audiological fascia group and 24 tragal cartilage group. The youngest
gain in. cartilage group was 12.4±6.4 dB, and14.8±9.9 dB patient in our group was 13 years while the oldest was 56
in fascia group with no significant statistical difference years old. The overall male: female ratio was 27:22. The
between the two groups [37]. patients who underwent temporalis fascia grafting, 86.73%
had a gain of 15dB while 13.7% had a gain of > 15 dB. Of
In 2016 Rahul K. Jaiswal did study. in Nepal the patients underwent tragal perichondrium grafting 50%
‗Comparison of outcomes of palisade cartilage with had a gain of 15 dB while 10% had a gain of >15dB. The
temporalis fascia.following tympanoplasty‖. 40 His study graft uptake rate was 85.7% for both temporalis fascia as
shows closure of AB gap within. 30 dB was achieved in well as tragal perichondrium.4% of the patients of the
71.87% of temporalis fascia group and 88.89% in palisade temporalis fascia group had seroma and 4% had
cartilage group and anatomical closure. of perforation was persistantpain..Residual perforation was seen in 3 patients
comparable in both group [38]. of temporalis fascia group and 4 patients of tragal
perichondrium group. 1 case of each group showed canal
In 2015 Sohil Vadiya et al study conducted in Gujarat to stenosis [43].
compare the outcome of cartilage shield tympanoplasty
with TM fascia type 1 tympanoplasty in cartilage group. Methodology
Graft uptake about 98.46% as compare to 89.61 of TM Source of data

fascia group. In this study graft uptake rate. show
statistical significant in both group. And audiological A sample size of in age group of 18 to 60 years in CSOM
improvement in both group almost equal except at 8 kHz cases were selected for the study. Duration of study 2
frequency where improvement in TM fascia group than years i.e. from a total of 100 patients in age group of 18 to
cartilage group [39]. 60 years with CSOM tubo tympanic disease who
underwent Type 1 tympanoplasty by underlay technique in
the Department of ENT, Narayana Medical College &
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Hospital were studied in the period of two years. (Between Figure 12: Audiometer (Elcon 3N3 Multi)
October 2017 to September 2019).
The test was performed in acoustically treated room with
Inclusion criteria no ambience noise the audiometry was done following
standard protocol. Patient was explained about the
1. Patient with CSOM (Tubotympanic) with a hearing loss procedure before audiometry and adequate time was taken
upto 45 dB for testing. The technique followed was Carhart & Jerger‘s
2. Patient in the age group of 17 — 60 years of either sex technique which is mostly used (technique of 5 up and 10
were selected for the study. down method).
Exclusion criteria For calculation of average of hearing loss (air conduction

threshold) three frequencies were selected. They were 500
Hz, 1000Hz and 2000Hz. These frequencies were selected
1. Patients with active discharge. because they represent speech frequency range and
2. Patients with attic disease. elevation of threshold in these frequencies will be
3. Patients with systemic diseases like diabetest Hyper clinically significant.
tension, Ischemic Heart disease.
All surgeries were performed under local or general
All the patients who presented with symptoms and signs anesthesia using a microscope with a lens of 250mm. In
suggesting tubotympanic type CSOM were submitted to an most of the cases postauricular approach was used. In
assessment protocol, based on a guided history taking, cases where the external acoustic meatus was wide and the
specific physical exam (otoscopy), and subjected to perforation borders were visible endaural or transcanal
audiogram. During history taking, the patients were approach was performed. Temporalis fascias, Tragal
questioned about disease onset, and if they had undergone perichondrium, were taken as graft materials for cases and
previous otologic surgeries. underlay grafting done in all cases.
A detailed proforma was filled for each patient with regard All the patients were followed after surgery every week for
to history, clinical examination, investigations, surgical 1 month but the puretone audiograms were done at 1
procedures, postoperative period &follow up visits. month and 3 month postoperativerly
Audiological evaluation (pure tone audiometry) done
preoperatively, 1 month & 3 months after surgery and the Graft materials used for the procedure were
results were tabulated.
Autologous temporalis fascia
Pure tone threshold audiometry has become the standard Autologous tragal perichondrium
behavioral procedure for describing audiometry
sensitivity. Therefore pure tone audiometry had been used Temporalis fascia:
for assessment of hearing level in this study.
Temporalis fascia was obtained during the surgical
The Audiometer (Elcon 3N3 Multi) used in this study was procedure. In cases using postauricular incision &
manual. endaural incision as shown in the figure 16 & 17
respectively. The same incision was extended to harvest
the temporalis fascia. In transcanal surgeries, a separate
transverse incision was placed above the pinna on the
temporal region to obtain a graft from temporalis fascia or
over tragus (Figure 18) to obtain perichondrium and
cartilage. After obtaining the graft, it was spread on to a
graft spreader and teased to remove excessive muscle
fibres; fat and fibrous tissues so that it appears like
parchment when dry (Figure 19). The temporalis fascia
graft is seen after one month and three months of
tympanoplasty as shown in figure 20 and 21 respectively.
Autologous tragal perichondrium: It was obtained

during the surgical procedure from the tragal cartilage is as
shown in the figure.

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Figure 13: Tympanoplasty instrument set
Figure 14: Post aural incision

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Figure 15: Endaural incision
Figure 16: Transcanal approach with tragal perichondrium as graft
Figure 17: Prepared temporalis fascia

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Figure 18: Tragal perichondrium
Figure 19: Temporalis fascia graft-1 month post tympanoplasty

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Figure 20: Temporalis fascia graft-3 months post tympanoplasty
5. Results and Observations Table 2: Age factor and audiological improvement

No. Average
Age (in years)
In our series we studied 100 ears (100 patients) of type 1 of cases audiological gain
Tympanoplasties. The age and sex incidence and various 15-40
82 9.67 dB
years
factors influencing the audiological benefit in a successful
Above 40 years 18 9.45 dB
type 1 tympanoplasty were analysed after 1 month and 3 Total 100
months and the results were analysed based on the
observations of the second follow up Pure tone In our series, 18 tympanoplasties were performed in
audiograms (after 6 months). patients aged over 40 years. The average audiological gain
was found to be lower in these patients (9.45 dB)
Table 1: Age distribution of patients compared to that of the younger age group 82 (9.67 dB).
Age (in years) No. of patients Percentage
15-20 22 22%
21-30 42 42%
31-40 18 18%
41-50 15 15%
51-60 3 3%
Total 100 100.00%
Patients under 15 years of age were not included in this

study. In this study maximum numbers of patients were
seen in the age group of 21-30 years (42%).
Graph 2: Age factor and audiological improvement
Table 3: Sex distribution of patients

Sex No. of patients Percentage
Males 51 51%
Females 49 49%
Total 100 100.00%
In our study, the sex distributions among patients were

males 51 (51%) than females 49 (49%).
Figure 1: Age distribution of patients

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In our study of 100 cases, 97 (97%) cases showed
audiological improvement. There is no big difference of
average audiological gain in rest of the cases.
Figure 3: Pie chart of sex distribution of patients
Table 4: Sex incidence and audiological benefit Figure 5: Pie chart of audiological assessment in Type-I
No. Average tympanoplasty
Gender
of cases audiological Gain
Males 51 9.48 dB
Table 7: Effect of different grafts on audiological
Females 49 9.83 dB
improvement in Type I tympanoplasty
Total 100
Average audiological
Type of graft No. of cases
gain
Temporalis fascia 47 10.07 dB
Tragal perichondrium 53 9.28 dB
Total no. of cases 100
The audiological improvement (average audiological gain)

is more with temporalis fascia (10.07 dB) when compared
to tragal perichondrium (9.28 dB).
Figure 4: Graph of sex incidence and audiological benefit
In this study, the audiological benefit observed more in

females could be an incidental finding as no reason could
be attributed to this observation.
Table 5: Time taken for graft uptake and audiological

benefit
TIME (in No. Average Graph 6: Effect of different grafts on auological
weeks) of cases audiological gain improvement in Type I tympanoplasty
3 86 9.61 dB
>3 14 9.93 dB Table 8: Statistical analysis of different graft on
Total 100
audiological improvement in Type I tympanoplasty
N Mean SD F Value P Value
Audiological benefit was found to correlate with the time Preop TF 47 31.03 3.44271
0.781
taken for graft take up, as the time taken for graft uptake ave.AC TP 53 30.72 3.75556
0.675 (Not
increases, the hearing gain was found to decrease post threshold
Total 100 30.87 3.59723 Sig.)
(dB)
operatively. Postop 3 TF 47 20.96 2.56191
months TP 53 21.42 2.78343 0.667
Table 6: Audiological assessment in Type-I ave.AC 0.743 (Not
tympanoplasty threshold Total 100 21.20 2.67800 Sig.)
(dB)
Hearing results Audiological outcome
TF 47 10.07 3.37184 0.161
Improved 97 (97%) Audiological TP 53 9.28 2.85766 1.553 (Not
No much change 3 (3%) gain (dB) Total 100 9.65 3.16370 Sig.)
Total cases 100
Statistical analysis has been done by Annova test using
IBM SPSS Version 22.0. P values which are less than 0.05
are considered as statistical significant.

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6. Discussion obviously very much alike. Hearing results were worse in
the above 40 years age group, compared to young age
Type I tympanoplasty is a surgical procedure in which the group. Vartiainen10 et al found that results in elderly
reconstruction procedure is limited to the repair of patients were found to be as good as in younger patients
tympanic membrane perforation alone. Implicit definition [44].
is that the ossicular chain is intact and mobile, and that
there is no middle ear disease such as infected mucosa or Table 12: Sex incidence and audiological benefit
in growth of skin [1]. The present study describes various Age (in years) No. of cases Audiological benefit
parameters in assessing the hearing improvement after Males 51 9.48 dB
tympanoplasty. Post operative audiological evaluations Females 49 9.83 dB
Total 100
were done after 1 month and 3 months following type I
tympanoplasty.
In this study, the audiological benefit observed more in
Table 9: Age Incidence males could be an incidental finding as no reason could be
Present study Ortegren [44] attributed to this observation.
Age in No. of Age in No. of
Percentage Percentage Table 13: Graft taking time and audiological benefit
years patients years patients
0-10 0 0 0-10 5 5 Time (in weeks) No. of cases Audiological benefit
3 86 9.61 dB
11-20 11-20 20 22.9 >3 14 9.93 dB
22 22%
Total 100
21-30 21-30 13 14.9
42 42%
31-40 31-40 12 13.7
In our study, the audiological benefit was found to
18 18% correlate with graft take up time.
>40 18 18% >40 37 42.5
Total 100 100 Total 87 100 Akayleh R et al has similar outcomes as that of our study
[49].
Patients under 15 years of age are not included in this
study. In this study maximum numbers of patients are seen Table 14: Audiological assessment in tympanoplasty
in the age group of 21-30 years (42%). This is in contrast Hearing results Audiological benefit
to the study conducted by Ortergren, where the maximum Improvement 97 (97%)
number of the patients are in the age group of >40 years No change 3 (3%)
(42.5%) [44]. Total 100 (100.00%)
Table 10: Age distribution in different studies In our study of 100 cases, 97 (97 %) cases showed
Year of Total no. Commonest audiological improvement. There is no big difference of
Sl. No. Author
study of cases age group average audiological gain in rest of the cases.
Saha A K et al
1 2006 40 14-34
[45] Table 15: Comparison of hearing improvement in various
2 Fukuchi et al [46] 2006 37 15-35
studies
3 Nagle et al [47] 2009 100 21-30
Hearing improvement
4 Goyal Rashmi [48] 2010 80 11-40 Sl.No Study
(% of cases)
5 Present study 2019 82 11-40
1 Saleem et al [50] 85.88
2 Karela et al [51] 91.5
All the studies showed 15 – 40 yrs of age as the most 3 Fukuchi et al [46] 92
common group and are correlating with the present study. 4 Present study 97
The reason behind this may be that this is the socially
active and health conscious age group. The most likely explanation for lack of complete success
from a hearing stand point is that in most cases of CSOM,
Table 11: Age factor and audiological improvement even though ossicular chain may appear normal, there is
Age (in years) No. of cases Audiological benefit some factor of scar tissue that prevents total restoration of
15-40 years 82 9.67 dB hearing (Sheehy et al 1980). Sheehy has reported a loss of
Above 40 years 18 9.45 dB BC of 10dB or more at 2K or 4K in 3% of cases, probably
Total 100
due to trauma to the ossicular chain [52].
In our series, 18 tympanoplasties were performed in Gibb & Klat (1982) have also found that a persistent
patients aged over 40 years. The audiological benefit was conductive hearing loss can result from underlay
found to be lower in these patients (9.45 dB) compared to technique. If the handle of malleus is severely retracted
that of the younger age group (9.67 dB). especially if it is touching or adherent to the promontory,
difficulties arise due to possible reduction in the depth of
Ortegren has reported that there is a limit at 40 years the tympanic cavity when the graft is placed medial to the
beyond which hearing results are markedly worse than in malleus handle. To overcome this problem, they suggested
younger cases. In Ortegren‘s study, the hearing that one could leave the malleus in its original retracted
improvement in the various groups below 40 years was position and a split graft be pulled upon each size of
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malleus handle and tucked behind its upper part or as graft in 45 patients. They observed a mean hearing gain
amputate 2-3mm from the tip of handle [53]. of 11.14 dB in their study [57].
Vartiainen and Nauutinene (1993) in their series had 11 According to study done by Lee et al., 2012, in a
audiological failures. The cause of persistent hearing loss retrospective analysis of 40 patients with CSOM,
was found to be due to fixation or erosion of ossicles compared the anatomical and audiological results of type I
overlooked by the surgeon [54]. tympanoplasty using fascia temporalis, cartilage tissue,
and cartilage palisade. No statistically significant
Saeed Ghamdi et al 1994 reported a permanent hearing differences were observed between the three groups
loss in 3% of the patients. Ghamdi also reported that one regarding the closure of tympanic membrane perforations.
patient developed a profound SN hearing loss in the Regarding auditory improvement, the cartilage palisade
operated ear in his study. The unchanged audiological technique showed slightly poorer results than the others
status in tympanoplasty can be explained by disorders that [58].
can interfere with the ventilatory or conducting function of
the middle ear viz. tympanosclerosis, stiffness of ossicles Ortegren during the period 1957 to 1961 did a comparison
and Eustachian tube dysfunction that have not been dealt study of 87 patients of tympanoplasty-1 using temporalis
during the surgery (Rance. W. Rancy in 1995) [55]. fascia and canal skin graft. The relation of age on hearing
and hearing results, importance of tubal function and
Alan G Gibb proposed the following reasons for causes of failures were discussed [44].
worsening of hearing loss. They stated that a conductive
loss can result from damage to the ossicular chain. Palva et al in 1969 reported that they achieved a
practically useful hearing (0 to 40 dB, ISO standard) in
Sensorineural hearing loss appearing for the first time post 93% of cases postoperatively out of 160 myringoplasties.
operatively generally iatrogenic and the result of some They used an operative method termed as ‗swing door
technical error at operation. Thus it is essential to exercise myringoplasty‘ [59].
extreme care throughout the operation and avoid undue
commotion of ossicular chain which might cause cochlear In 1973, Glasscock analysed 237 myringoplasty cases
damage [53]. using temporalis fascia. He found that the results were
better using the underlay technique [60].
If underlay grafting is employed, special care should be
taken to avoid touching the incus or stapes when scarifying P. Packer et al, in 1982 compared preoperative and
the postero superior are of the tympanic membrane postoperative hearing evaluation in 604 patients. He also
remnant. If due care is not taken in this procedure it is compared the different techniques and different graft
possible to hook up the ossicles or incudostapedial joint materials used in his series [61].
with a scraper. It is also important to exercise extreme care
when taking the graft into position in this area, as at this G.S. Bawa et al in 1987 studied 50 cases of
stage of operation, the ossicles are often obscured by the myringoplasties and showed a postoperative hearing
graft itself. In either event the stapes may be shaken and if improvement in 74% patients [62].
the trauma is severe, the foot plate may even be cracked,
sever or even total SN deafness may result. Sato H, Nakamura H, Honjo I, Hayashi M. in 1990
examined about the Prognostic value of preoperative
The introduction of toxic solutions in the middle ear at the Eustachian tube function in 77 ears, subjected to type 1
time of operation is another possible cause of SN deafness tympanoplasty. Eustachian tube function was evaluated by
as previously reported by Alan G. Gibb et al [53]. positive and negative pressure equalization tests, and
clearance test and found that positive pressure equalization
Valsalva maneuver may add some audiological benefit and clearance tests of the tube were correlated with the
when effectively incorporated which is supported by outcome of ear surgery, although the negative pressure
Seung Hyo Choi et al. The criteria of successful equalization test had no correlation with it and concluded
myringoplasty and tympanoplasty-1 surgery was a positive that the preoperative tubal function test including positive
graft take and followed by improvement in hearing [56]. pressure test and clearance test are useful for predicting the
prognosis of ear surgery [63].
Table 16: Effect of different grafts on audiological
improvement in Type I tympanoplasty Vartiainen et al in 1993 did a follow up study 404 cases of
Average audiological myringoplasties. In audiological failures the cause of
Ear discharge No. of cases
gain persistent conductive hearing loss was found to be due to
Temporalis fascia 47 10.07 fixation or erosion of ossicles overlooked by the surgeon
Tragal perichondrium 53 9.28 [64].
Total 100
Kotecha B et al in 1999 presented a prospective audit
The average audiological gain is more with temporalis study of myringoplasty.73 surgeons participated in this
fascia (10.07) in the present study. Jain K, Pandey A, study and they got data from 1070 individual patients.
Gupta S, Rahul, 2016, did a clinical Study on hearing Where hearing loss was the main indication for surgery,
outcome after type1 tympanoplasty using temporalis fascia hearing improvement was seen in 67% [65].
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Mak D et al in 2000 January published a paper on a field Haruo Takahashia, Hiroaki Satob, Hajime Nakamurac,
assessment of the surgical outcome in middle ear disease Yasushi Naitod, Hiroshi Umekia. In 2007 examined the
in remote aboriginal Australia during the period 1986 to correlation between the middle-ear pressure regulation
1995.Success was defined by an intact tympanic functions including active eustachian tube (ET) functions
membrane and air-bone gap of 25 dB at 6 month follow up and transmucosal gas exchange function, and outcome of
after operation. A success rate of 53% was observed. tympanoplasty and concluded that impairment of all the
Successful outcomes were more likely in adults and middle- ear pressure-regulation functions was likely to
children aged more than 10 years [66]. cause poor outcome of tympanoplasty, and also allowed us
reconfirm that ears with mechanically obstructed ETs were
Elluru RG, Dhanda R, Neely JG, Goebel JA. in 2001 contraindicated for tympanoplasty. Therefore, assessment
studied about the efficacy and safety of anterior of mastoid condition is important as well as the ET
subannular tympanostomy in 38 consecutive patients with function before tympanoplasty [72].
a diagnosis of Eustachian tube dysfunction, adhesive otitis
media, or chronic otitis media with a perforation who H. Vijayendra, C. J. Ittop and R. Sangeetha in 2008 found
underwent a tympanoplasty and concluded that Anterior that canaloplasty is an integral part of tympanoplasty and
subannular tympanostomy is a safe and effective method concluded that Canaloplasty gives 9 dB gain in hearing
for long-term middle ear ventilation in patients with compared to without canaloplasty and gives better
chronic eustachian tube dysfunction [67]. visualization, better graft placemen and better post-
operative care [73].
Nepal A, Bhandary S, Mishra SC, Singh I, Kumar P. in
2003-04 studied 100 cases with dry, clean central Matsuda Y, Kurita T, Ueda Y, Ito S, Nakashima T. in
tympanic membrane perforations due to various causes 2009 found significant correlation between the degree of
like chronic suppurative otitis media-tubotympanic, post sound conduction disturbance and the perforation area; this
acute suppurative otitis media residual perforations or correlation was greater at low frequencies following a
simple traumatic perforations with conductive hearing loss traumatic perforation [74].
and without pre existing hearing loss were
clinicoaudiologically evaluated and analyzed. The study Ibekwe TS, Nwaorgu OG, Ijaduola TG, in 2009 studied
concluded that hearing loss was found to be directly the relationship between the location of perforation on TM
proportional to the size of perforation irrespective of their and hearing loss and concluded that the location of
cause. Overall, perforations involving posterioinferior perforation on the tympanic membrane (TM) has no effect
quadrant were found to have maximum hearing loss [68]. on the magnitude of hearing loss in acute TM perforations
while it is significant in chronic ones [75].
Gierek T, Slaska-Kaspera A et al.2004, compared the
audiological results with temporalis fascia and tragal Warren Y. Adkins, M.D., Benjamin White, M.D.in 2009
perichondrium and they concluded no statistically studied about Type I tympanoplasties utilizing an underlay
significant difference between the two [69]. technique with temporalis fascia performed at the Medical
University associated hospitals over a 5-year period were
Yetiser S, Hidir Y, Karatas E, Karapinar U. conducted a reviewed. In their study 40 adults were analyzed for
study on 30 patients who underwent ossicular chain influencing factors. The overall success rate was 89% and
reconstruction between 1990 and 2005, concluded that the concluded that the age of the patient, the length of time the
success of the surgery was dictated by the location and the ear had been dry, and the presence of infection at the time
extent of tympanosclerotic involvement [70]. of surgery had no influence on the success rate [76].
Mehta RP, Rosowski JJ, Voss SE, O'Neil E, Merchant SN. Kazim Bozdenir et al., 2011, in their comparative study,
in 2006 studied patients with tympanic membrane Tympanoplasty with island cartilage graft versus
perforations without other middle-ear disease. They Temporalis fascia concluded that postoperatively, the pure
concluded that the conductive hearing loss resulting from a tone averages and air-bone gap closure were better with
tympanic membrane perforation is frequency-dependent, temporalis fascia compared to cartilage grafting [77].
with the largest losses occurring at the lowest sound
frequencies; increases as size of the perforation increases; Rasha A, Ahmed SAO, 2015, in their study on outcome of
varies inversely with volume of the middle ear and hearing improvement in myringoplasty of 51 Sudanese
mastoid air space (losses are larger in ears with small Patients concluded that the temporalis fascia graft had
volumes); and does not vary appreciably with location of better hearing threshold improvement [78].
the perforation. Effects of location, if any, are small [71].
Abhay Kumar, Prabhu Narayan, Prem Narain, Jaypal
Gierek T, Slaska-Kaspera A, Majzel K, Klimczak-Gołab Singh, Prateek Kumar Porwal, Sanjay Sharma, Daya
L. in 2006 published a study that aimed to establish Shankar in 2018 did a comparative study between result of
through a systemic review what is the best technique to Temporalis muscle fascia and tragal cartilage
treat tympanic perforations and concluded that there is no perichondrium as a graft material in Type 1 tympanoplasty
technique considered sure for every perforation neither in 60 patients, dividing them into two groups. They
technique definitive for type of perforation [69]. concluded that in comparison to tragal cartilage
perichondrium, tympanoplasty with temporalis fascia had
better mean air conduction values [79].
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International Journal of Science and Research (IJSR)

A Prospective Observational Study of Temporalis

Volume 8 Issue 12, December 2019

 To evaluate the Improvement in hearing by audiology

The human ear development begins at the fourth week of

Figure 2: Anatomy of ear [11]

Figure 3: Middle ear [12]

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Figure 4: Tympanic membrane [13]

The tympanic membrane is irregularly round and slightly

The anterior and posterior tympanic striae extend from the

 The anterior suspensory ligament

Volume 8 Issue 12, December 2019

Figure 6: Inner ear [17]

The vestibule is the central chamber. At the

Volume 8 Issue 12, December 2019

Eustachian tube  First attempt at repair of TM

 Coined the term Myringoplasty

 1950-Wullstein and Zollner

 Described 5 types of Tympanoplasty

 1960-Heerman Figure 8: Tympanoplasty (Tympanic membrane

 Temporalis fascia grafting

 1967-House Glasscock and Sheehy

 Techniques for lateral grafting

1. Conductive hearing loss due to TM perforation or

1. Malignant tumours 1. Graft remains vascularised

Volume 8 Issue 12, December 2019

1. Limited visualization of anterior meatal recess

1. Temporalis fascia graft

Better angle of visualization

Figure 11: Wullstein classification of Tympanoplasty [25]

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Graft uptake about 98.46% as compare to 89.61 of TM Source of data

Exclusion criteria For calculation of average of hearing loss (air conduction

Autologous tragal perichondrium: It was obtained

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Figure 13: Tympanoplasty instrument set

Figure 14: Post aural incision

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Figure 15: Endaural incision

Figure 16: Transcanal approach with tragal perichondrium as graft

Figure 17: Prepared temporalis fascia

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Figure 18: Tragal perichondrium

Figure 19: Temporalis fascia graft-1 month post tympanoplasty

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Figure 20: Temporalis fascia graft-3 months post tympanoplasty

5. Results and Observations Table 2: Age factor and audiological improvement

Patients under 15 years of age were not included in this

Graph 2: Age factor and audiological improvement

Table 3: Sex distribution of patients

In our study, the sex distributions among patients were

Volume 8 Issue 12, December 2019

Figure 3: Pie chart of sex distribution of patients

The audiological improvement (average audiological gain)

Figure 4: Graph of sex incidence and audiological benefit

In this study, the audiological benefit observed more in

Table 5: Time taken for graft uptake and audiological

Volume 8 Issue 12, December 2019

Volume 8 Issue 12, December 2019

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