Central Annals of Otolaryngology and Rhinology

Cite this article: Jiang H, Zhang Z (2014) Cartilage Tends To Be a Better Choice than Temporalis Fascia for Tympanoplasty under the Circumstance of Eusta-chian Tube Dysfunction. Ann Otolaryngol Rhinol 1(3): 1013.

*Corresponding authorZhiGang Zhang, Sun Yat-Sen University, Sun Yat-Sen Memorial Hospital, 107 Yangjiang Road, Guangzhou, 510120, China.Tel:86-020-81332155; E-mail:

Submitted: 13 October 2014

Accepted: 14 November 2014

Published: 17 November 2014

Copyright© 2014 Zhang et al.

OPEN ACCESS

Keywords•Tympanoplasty•Cartilage•Temporalis fascia•Eustachian tube dysfunction•Meta-analysis

Review Article

Cartilage Tends To Be a Better Choice than Temporalis Fascia for Tympanoplasty under the Circumstance of Eustachian Tube DysfunctionHuaili Jiang and Zhigang Zhang*Department of Otolaryngology- Head and Neck surgery, Sun Yat-Sen University, China

Abstract

Objective: to investigate whether cartilage or temporalis fascia is more ideal for tympanoplasty under the circumstance of Eustachian tube (ET) dysfunction.

Material and methods: Firstly, we summarized some biological comparisons among tympanic membrane, cartilage and temporalis fascia. Secondly, we conducted a meta-analysis that involved three randomized controlled trials (RCT) to compare their difference in improving hearing level and morphological success rate.

Results: in terms of biological properties, cartilage was stiffer than temporalis fascia. But cartilage can be cut into different thickness to balance the ability of acoustic sensitivity and resistance to negative pressure induced by ET dysfunction, which was impossible for temporalis fascia. When it came to clinical properties, there was no statistical significance between cartilage and temporalis fascia in postoperative air-bone gap≤ 20dB (p=0.61) and 20dB (p=0.25) in 24 months. However, cartilage showed better morphological success in 12 months with p=0.04.

Conclusions: Cartilage should be cut as thin as possible if ET function was normal. However, under the circumstance of ET dysfunction, cartilage with more than 500um thickness was supposed to be the first choice for tympanoplasty.

ABBREVIATIONSET: Eustachian Tube; RCT: Randomized Controlled Trial;

BET: Balloon Dilation Eustachian Tuboplasty; ABG: Air-Bone Gap; RR: Risk Ratio; CI: Confidence Interval.

INTRODUCTIONSince tympanoplasty was firstly proposed by Wullstein

[1] and Zoellner [2] in 1950s, the past few decades have seen a prevalence of exploring grafts used in tympanoplasty. Lots of materials, including temporalis fascia, fascia lata, veins, periosteum, perichondrium, cartilage, fatty tissue, and skin were applied [3,4]. The most commonly used graft was temporalis fascia with 93%-97% success rate in tympanoplasty [5]. However, the success rate tended to decrease if the aeration of middle ear was not sufficient. During the last decade, increasingly more otologist preferred to select cartilage rather than temporalis fascia. The sufficient stiffness and strength of cartilage rendered it better than temporalis fascia to resist the negative pressure in

middle ear resulted from dysfunction of Eustachian Tube (ET). Nevertheless, some otologist considered the same properties also brought negative effect on sound transmission [5].

Studies of ET began at 500BC when Alkmaeon of Sparta realized its existence [6]. Normal functions of ET include (1) equalizing the pressure between middle ear and atmosphere; (2) preventing middle ear from sound pressure and secretions from nasopharyngeal and (3) draining secretions from middle ear to nasopharynx, described by Bluestone [7]. The incidence of ET dysfunction in adults ranges 1% to 5% [8, 9], and increases with age. Approximately 40% children younger than 10 years old suffer from at least a temporary ET dysfunction [10, 11]. ET dysfunction may result from chronic infection, allergy, anatomical obstruction and laryngopharyngeal reflux. It could lead to a variety of diseases, such as chronic otitis media, secretory otitis media and cholesteatoma [12].

Presently, there is no common concern about whether

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cartilage is more ideal than temporalis fascia in tympanoplasty under the circumstance of ET dysfunction. This article aims to investigate whether cartilage or temporalis fascia is more ideal for tympanoplasty under the circumstance of Eustachian tube (ET) dysfunction after comparing their biological and clinical properties.

MATERIAL AND METHODSData sources and searches

Cochrane Library, Pubmed and Embase were systematically searched to indentify relative articles that comparing cartilage with temporalis fascia. RCTs were involved in meta-analysis. Ongoing studies were obtained from meta Register and World Health Organization International Clinical Trial Registry Platform.

Study selection: Two authors independently determined study eligibility after reading titles, abstracts and full texts. No limitations to studies included in reviewing biological properties. However, only RCTs were involved in meta-analysis in evaluating their clinical properties. Different views were resolved by discussion.

Data extraction and quality assessment: Two authors independently extracted data, including study characteristics (eg, title, publication time, and patients amount), patients characteristics (eg, age, gender and hearing level), intervention, control, method (eg, randomization, allocation, blinding, and loss to follow-up), and outcomes.

Methodological quality of included RCTs was conducted by two authors independently using Criteria for risk of bias from Cochrane Handbook for Systematic Review of Interventions.

Data synthesis and analysis: Review manager software (version 5.0.2) was applied to analyze data and a fixed-effect model was used. The value of p lower than 0.05 indicated a statistical significance. In terms of heterogeneity among studies, the chi-square test and the I2 index statistic were involved. I2≤ 25% combined with p0.10 indicated a low level of heterogeneity.

Resul Biological properties of cartilage and temporalis fascia: Theoretically, an ideal graft for tympanoplasty should possess biological properties similar with tympanic membrane. The properties include elastic modulus, stability to static pressures and acoustic sensitivity.

The elastic modulus and stability to static pressures: Tympanic membrane consists of two parts with different values of the elastic modulus. To be more specific, the elastic modulus of pars tensa is 3.3×107N/m2, and that of pars flaccida 1.1×107N/m2. The elastic modulus of temporalis fascia, conchal cartilage and tragal cartilage are 1.5×107N/m2, 0.6×107N/m2 and 0.3×107N/m2, respectively[13-15].

The measurement of the elastic modulus of different grafts with the same thickness indicates that temporalis fascia is obviously flexible than tympanic membrane, which demonstrates that temporalis fascia is more likely to be unstable, however; cartilage is stiffer than tympanic membrane and its compliance to pressures depends on thickness.

A measurement of deflection-pressure curves indicates that 500-600um thickness cartilage disk shows a slope similar with tympanic membrane within atmospheric air-pressure. Temporalis fascia and cartilage disk thinner than 500um have a sharper slope than tympanic membrane. However, cartilage disk thicker than 600um has a softer slope [16-18].

Acoustic sensitivity: Acoustic sensitivity of different grafts was measured as amplitude-frequency curves. The curve for tympanic membrane is much smooth within a wide range of frequencies, revealing its good sound transmission property. Cartilage thinner than 500um have an amplitude-frequency curve similar with tympanic membrane. 500um and original thickness (1mm) cartilage have a loss of about 5 and 30dB, respectively, at 1 kHz. The curve for temporalis fascia is much rough, which indicates that its acoustic sensitivity property is quite different from that of tympanic membrane [16, 17].

To keep the best sound transmission, it is recommended that cartilage should be cut as thin as possible if ET function is normal. However, the thickness of cartilage should not thinner than 500um if ET function is impaired to keep the balance between acoustic sensitivity and stability [19].

Clinical measurement of cartilage and temporalis fascia

3 high-level RCTs [20, 21, 22] were included in this review to evaluate the temporalis fascia and cartilage in the aspects of both hearing results and Morphological success. A total of 232 patients (ears) were involved in meta-analysis to evaluate clinical properties and different rate of loss to follow-up among three RCTs was present. Statistical outcomes were performed by RR, 95%CI and p.

Hearing results: Hearing results include postoperative air-bone gap (ABG) ≤ 20dB and 20dB after 24 months. Meta analysis reveals that tympanoplasty using cartilage and temporalis fascia show no statistical significance in both postoperative ABG ≤ 20dB and 20dB (p=0.61 and p=0.25 respectively) (Table 1). Interestingly, this is quiet different from previous concepts that cartilage have a poorer sound transmission property compared to temporalis fascia for its high stiffness and strength. Thus, we believe that cartilage tympanoplasty could also perform satisfied hearing results as temporalis fascia tympanoplasty could.

Outcomes CT, n (%) TF, n (%) RR 95%CI Z p

ABG≤20dBABG>20dB

Morphological success

80 (73.4)19 (26.6)96 (84.2)

74 (78.7)20 (21.3)83 (72.8)

0.960.731.16

0.83 to 1.120.43 to 1.241.03 to 1.33

0.511.162.06

0.610.250.04*

Table 1: Postoperative ABG after 24months and Morphological success after 12months.

ABG indicates air-bone gap; CT, cartilage; TF, temporalis fascia; n, number of patients; RR, risk ratio; CI, confidence interval; p, the level of statistical significance.

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Figure 1 Postoperative ABG≤20dB. There is no statistical significance between cartilage and temporalis fascia.

Figure 2 Postoperative ABG>20dB. There is no statistical significance between cartilage and temporalis fascia.

Figure 3 Morphological Success. Cartilage performs better morphological outcomes than temporalis fascia in 12 months.

Morphological success: “Morphological Success” is defined as a composite variable that includes the absence of perforation, atelectasis, lateralization, atrophy, blunting and otorrhea [20]

after 12 months. Meta analysis demonstrates that cartilage tympanoplasty shows higher morphological success rate than temporalis fascia tympanoplasty and the difference is statistically significant (p=0.04) (TABLE 1).

ET dysfunction affects reconstructed tympanic membrane functions

Many middle ear diseases result from ET dysfunction, especially from ET obstruction, such as cholesteatoma in middle ear, secretory otitis media, etc [23,24]. Under this circumstance, middle ear pressure is persistently negative [25], which means that reconstructed tympanic membrane should possess sufficient property to resist negative pressure. Although temporalis fascia is ideal in the aspect of primary hearing improvement, it is softer than normal tympanic membrane, which suggests that it is far more likely to be retracted or reperforated after tympanoplasty [26], which affects hearing improvement finally. By contrast, Cartilage tympanoplasty is less likely to be retracted and reperforated for its sufficient stiffness and strength. Meanwhile, its sound transmission property could be controlled as good as

tympanic membrane through cutting it into different thickness, which is impossible for temporalis fascia.

DISCUSSION AND CONCLUSIONBeside from graft properties, surgical techniques are also

essential. Cartilage is supposed to be cut as thin as possible in good ET function condition. Otherwise, it should be cut not thinner than 500um (approximately half of original thickness). Most patients with ET dysfunction suffer from serious aural fullness which may be alleviated if tympanic membrane perforates. Tympanoplasty renders open middle ear closed, which could lead patients with ET dysfunction to suffer from aural fullness again. Therefore, cartilage palisade technique is very effective for patients with severe ET dysfunction and that is impossible for temporalis fascia tympanoplasty.

Cabra et al. used the method called cartilage palisade that cut the cymba conchae cartilage into strips with full thickness and positioned them in an underlay fashion described by Eavey [27]. There was statistical difference between cartilage and temporalis fascia in morphological success both within 6, 12 and 24 months. However, there was no different in the aspect of air conduction threshold, bone conduction threshold and air-bone gap. Similarly, Yung et al. also used underlay technique in all

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cases. But they cut cartilage into 500-800um. And they concluded no different both in morphological success and hearing results. Mauri et al. compared inlay cartilage tympanoplasty described by Lubianca-Neto [28] that was different from original report of Eavey [27] with underlay temporalis fascia tympanoplasty. The morphological success and hearing results showed no significant difference between cartilage and temporalis fascia.

RCTs were strictly included for high level of evidence, however; there were more retrospective study that comparing cartilage with temporalis fascia. Zhang (corresponding author of this article) et al [29]. Suggested that cartilage had superior long-term benefit regarding with both hearing results and morphology. Similar outcomes were presented in some other retrospective studies.

In addition, some secondary outcomes were measured. To be more specific, Mauri et al. reported that cartilage was less likely to be infected than temporalis fascia (p=0.03). Yung et al. reported that there were no significant differences between cartilage and temporalis fascia regarding with the incidence of myringitis, otorrhea and pars tensa retraction after 3, 12 and 24 months. Mauri’s study also revealed that temporalis fascia tympanoplasty tended to be more time-consuming than cartilage tympanoplasty (mean: 62.9 min versus 33.6 min, p<0.0001). And temporalis fascia tympanoplasty was far more likely to make patients suffer from longer period and high rank pain (p<0.0001 and p=0.0002 respectively) reported by Mauri et al.

It is worthy to point that all available studies that comparing cartilage and temporalis fascia have never studied ET dysfunction as an independent factor. We hope there will be sufficient RCTs to explore better grafts when considering the ET dysfunction.

Temporarily, balloon dilation Eustachian tuboplasty(BET) is a novel technique that has been proved to be feasible, safe and effective to improve ET function [30,31]. As a result, we guess its prevalence would render tympanoplasty more effective no matter cartilage or temporalis fascia are selected in the treatment of patients with ET dysfunction.

In concluded, cartilage tympanoplasty is more practical and effective than temporalis fascia tympanoplasty, especially under the circumstance of ET dysfunction.

REFERENCES1. Wullstein HL. Functional operations in the middle ear with split-

thickness skin graft. Arch Othorhinolaryngol. 1953; 161: 422-435.

2. ZOLLNER F. The principles of plastic surgery of the sound-conducting apparatus. J Laryngol Otol. 1955; 69: 637-652.

3. Van Rompaey V, Farr MR, Hamans E, Mudry A, Van de Heyning PH. Allograft tympanoplasty: a historical perspective. Otol Neurotol. 2013; 34: 180-188.

4. Mohamad SH, Khan I, Hussain SS. Is cartilage tympanoplasty more effective than fascia tympanoplasty? A systematic review. Otol Neurotol. 2012; 33: 699-705.

5. Lee JC, Lee SR, Nam JK, Lee TH, Kwon JK. Comparison of different grafting techniques in type I tympanoplasty in cases of significant middle ear granulation. Otol Neurotol. 2012; 33: 586-590.

6. Rich AR. Physiological study of the Eustachian tube and its related muscles. John Hopkins Hospital Bulletin 1920; 352: 206-214.

7. Bluestone CD. Current concepts in eustachian tube function as related to otitis media. Auris Nasus Larynx. 1985; 12 Suppl 1: 1-4.

8. Browning GG, Gatehouse S. The prevalence of middle ear disease in the adult British population. Clin Otolaryngol Allied Sci. 1992; 17: 317-321.

9. Martino E, Di Thaden R, Krombach GA, Westhofen M. [Function tests for the Eustachian tube. Current knowledge]. HNO. 2004; 52: 1029-1039.

10. Goldman JL, Martinez SA, Ganzel TM. Eustachian tube dysfunction and its sequelae in patients with cleft palate. South Med J. 1993; 86: 1236-1237.

11. Gudziol V, Mann WJ. [Chronic eustachian tube dysfunction and its sequelae in adult patients with cleft lip and palate]. HNO. 2006; 54: 684-688.

12. Pahnke J. Morphology, function, and clinic of the eustachian tube [in German]. Laryngorhinootologie 2000; 79(suppl): 1–22.

13. Bekesy Gv. Experiments in hearing (Reprint). Huntington/NY: Robert E. Krieger Publ. Comp. 1960/1980.

14. Vorwerk U, Hey M, Steinicke G, Begall K. High-speed digital videoimaging of fast eardrum motions during Valsalva maneuver. ORL J Otorhinolaryngol Relat Spec. 1998; 60: 138-142.

15. Dancer A, Franke R. Biomechanique de I’oreille moyenne. Rev Laryngol Otol 1992; 71: 11-14.

16. Helmholtz H. Die Mechanik der Gehorknochelchen und des Trommelfells. Pflugers Archiv Ges Physiol 1868; 1: 1-60.

17. Magnan P, Dancer A. Probst R, Sumurzynski J. Avan P. Middle ear transfer functions and cochlear input impedance in the guinea pig. In: Huttenbrink K-B(Hrsg). Middle Ear Mechanics in Research and Otosurgery. Dresden: Dept. of Oto-Rhino-Laryngology. Uni. Hospital, Univ. of Technology. 1997: 56-60.

18. Vorwerk U, Hey M, Steinick G, Begall K. High speed digital vedio imaging of fast eardrum motions under static pressure changing. In: Huttenbrink KB (Hrsg.). Middle Ear Mechanics in Research and Otosurgery. Dresden: Dept. of Oto-Rhino-Laryngology, Univ. Hopsital, Univ. of Technology, 1997: 100-106.

19. K.-B. Huttenbrink. Biomechanical Aspects of Middle Ear Reconstruction. Middle Ear Surgery: Recent Advances and Future Directions 23-51.

20. Cabra J, Moñux A. Efficacy of cartilage palisade tympanoplasty: randomized controlled trial. Otol Neurotol. 2010; 31: 589-595.

21. Mauri M, Lubianca Neto JF, Fuchs SC. Evaluation of inlay butterfly cartilage tympanoplasty: a randomized clinical trial. Laryngoscope. 2001; 111: 1479-1485.

22. Yung M, Vivekanandan S, Smith P. Randomized study comparing fascia and cartilage grafts in myringoplasty. Ann Otol Rhinol Laryngol. 2011; 120: 535-541.

23. Keereweer S, Metselaar RM, Dammers R, Hardillo JA. Chronic serous otitis media as a manifestation of temporal meningioma. ORL J Otorhinolaryngol Relat Spec. 2011; 73: 287-290.

24. Buckingham RA. Changes in the tympanic membrane with eustachian tube malfunction. Otolaryngol Clin North Am. 1970; 3: 15-44.

25. Magnuson B. On the origin of the high negative pressure in the middle ear space. Am J Otolaryngol. 1981; 2: 1-12.

26. Jesic SD, Dimitrijevic MV, Nesic VS, Jotic AD, Slijepcevic NA.Temporalis Fascia Graft Perforation and Retraction After Tympanoplasty for Chronic Tubotympanic Otitis and Attic Retraction Pockets. Arch Otolaryngol Head Neck Surg. 2011;137 (2):139-143.

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Jiang H, Zhang Z (2014) Cartilage Tends To Be a Better Choice than Temporalis Fascia for Tympanoplasty under the Circumstance of Eustachian Tube Dysfunc-tion. Ann Otolaryngol Rhinol 1(3): 1013.

Cite this article

27. Eavey RD. Inlay tympanoplasty: cartilage butterfly technique. Laryngoscope. 1998; 108: 657-661.

28. Lubianca-Neto JF. Inlay butterfly cartilage tympanoplasty (Eavey technique) modified for adults. Otolaryngol Head Neck Surg. 2000; 123: 492-494.

29. Zhang ZG, Huang QH, Zheng YQ, Sun W, Chen YB, Si Y,. Three autologous substitutes for myringoplasty: a comparative study. Otol Neurotol.

2011; 32: 1234-1238.

30. Ockermann T, Reineke U, Upile T, Ebmeyer J, Sudhoff HH. Balloon dilation eustachian tuboplasty: a feasibility study. Otol Neurotol. 2010; 31: 1100-1103.

31. Ockermann T, Reineke U, Upile T, Ebmeyer J, Sudhoff HH. Balloon dilatation eustachian tuboplasty: a clinical study. Laryngoscope. 2010; 120: 1411-1416.