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Year : 2016  |  Volume : 29  |  Issue : 3  |  Page : 499-503

Pediatric myringoplasty: surgical outcomes of postauricular temporalis fascia graft versus permeatal tragal perichondrial graft in the management of tympanic membrane perforations

Department of Otorhinolaryngology, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission18-Mar-2016
Date of Acceptance04-May-2015
Date of Web Publication23-Jan-2017

Correspondence Address:
Ibrahim A Abdelshafy
Department of Otorhinolaryngology, Faculty of Medicine, Yassin Abdel-Ghaffar Street, Shebein El-Kom, El-Menoufiya, Menoufiya, 32511
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1110-2098.198661

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The aim of this study was to investigate the difference in success rate between temporalis fascia graft and tragal perichondrial graft among pediatric patients undergoing tympanoplasty type 1 for chronic suppurative otitis media with dry central perforation.
Chronic otitis media surgery is the most common procedure in otology in developing countries. Many surgical options with graft materials are used for closure of the tympanic membrane perforations.
Patients and methods
This is a prospective randomized comparative study including 54 pediatric patients (56 ears), between 8 and 18 years of age, with tympanic membrane perforation. Patients were randomly divided into two groups: group A included 30 ears of 28 patients who were subjected to postaural temporalis fascia graft myringoplasty and group B included 26 ears of 26 patients who were subjected to permeatal tragal perichondrial graft myringoplasty. Closure of the perforation within 1 year postoperatively and improvement in hearing with air-bone gap on pure tone audiogram less than 10 dB were considered as success criteria. Sex, age, site and size of perforation, and status of contralateral ear were studied.
The overall success of tympanic membrane perforation closure was 86.7% in group A and 88.4% in group B, with no statistically significant difference between the two groups. No difference was found as regards sex and site of perforation between the two groups. However, bilateral ear affection and the size of perforation had a significant difference in overall success. Moreover, no significant audiological difference was found between the two groups, but the overall improvement was significant.
Tympanoplasty type 1 (myringoplasty) is an appropriate technique for repairing tympanic membrane perforation in pediatric patients. Both postaural temporalis fascia graft and permeatal tragal perichondrial graft are effective, with no significant difference between the two techniques. Bilateral affection of the ears and size of perforation should be considered as determinant factors for success.

Keywords: pediatric myringoplasty, temporalis fascia, tragal perichondrium, tympanic membrane perforation

How to cite this article:
Abdelshafy IA, Hassan AH. Pediatric myringoplasty: surgical outcomes of postauricular temporalis fascia graft versus permeatal tragal perichondrial graft in the management of tympanic membrane perforations. Menoufia Med J 2016;29:499-503

How to cite this URL:
Abdelshafy IA, Hassan AH. Pediatric myringoplasty: surgical outcomes of postauricular temporalis fascia graft versus permeatal tragal perichondrial graft in the management of tympanic membrane perforations. Menoufia Med J [serial online] 2016 [cited 2020 Mar 29];29:499-503. Available from: http://www.mmj.eg.net/text.asp?2016/29/3/499/198661

  Introduction Top

Tympanic membrane perforation is a frequent condition of varied etiology, which can be traumatic or infectious. The frequency is estimated to be between 1 and 3% in the general population [1] .

Ear drum graft or myringoplasty is one of the most frequent interventions in otology. In 1878, Berthold proposed the term of myringoplasty at the nineteen-fifties and which was upgraded into a classification of different types of surgery of the tympanic cavity according to Zollinger and Wullstien [2] .

Tympanoplasty type 1 or myringoplasty is the operation in which the reconstruction process is limited to repairing a tympanic membrane perforation and the ossicular chain is not injured. There are two key objectives when indicating myringoplasty: restoring the integrity of the tympanic membrane and improving hearing in the damaged ear [3] .

Temporalis facia was the first to be used as a graft [4],[5] . At the same time, House and colleagues [6],[7] used tragal perichondrial graft for restoring the tympanic membrane perforation. The characteristics of both graft types, their availability in the operative field, and their ease of handling have made them the most commonly used materials in the repair of tympanic membrane.

Many factors should be taken into consideration when choosing the graft material, such as stability, rigidity, postoperative audiometric results, resistance to infection, high tolerance for prolonged period of malnutrition, nonappearing of scar retractions, and cost of those materials.

This study was conducted to compare the results of the use of postaural temporalis fascia graft and permeatal tragal perichondrial graft for closure of tympanic membrane perforations in pediatric patients and their postoperative hearing outcome and to study the various factors that can affect the success rate.

  Patients and methods Top

Study design

This prospective randomized comparative study was conducted in Menoufia University Hospital and Al-Eman General Hospital during the period between March 2010 and March 2014. Patients were randomly divided into two groups: group A underwent postaural temporalis fascia myringoplasty and group B underwent permeatal tragal perichondrial graft myringoplasty. All patients were followed up clinically at 1, 2, and 4 weeks postoperatively, and clinically and audiologically at 3, 6, and 12 months postoperatively.


Patients who fulfilled the following criteria were included in the study: patients between 8 and 18 years of age with central tympanic perforation and no active infection for at least 3 months before the procedure and those with mild (25-40 dB) or moderate (41-55 dB) conductive hearing loss coinciding with the perforation on audiological evaluation with pure tone audiometry. Sex of the patient, size (less or greater than 50% of tympanic membrane) and site (anteriorly or posteriorly located) of perforation, and bilateral affection of both ears were also recorded. The type of procedure and graft was selected using simple random sampling method by asking the patient to choose between two cards representing the two graft materials. Patients above 18 years of age, those with active ear infection, those with attic perforation and/or retraction, those with audiometric loss not consistent with sole involvement of tympanic membrane, revision cases, patients who did not complete 1 year of follow-up postoperatively, those with a history of upper airway infection within 3 months before the operation, and patients with diagnosis of adenoid hypertrophy or previous history of adenoidectomy were excluded from our study. Audiometric values were taken at frequencies 500, 1000, 2000, and 4000 Hz preoperatively and at 3 months and 1 year postoperatively.

Operative technique

Postaural temporalis fascia graft was performed by trimming the edges of tympanic membrane remnants. An incision was made 0.5-1 cm behind the postauricular crease with harvesting of the deep temporalis fascia graft ([Figure 1]). Thereafter, the external auditory meatus was entered raising the tympanomeatal flap and annulus and the graft was fixed using the underlay technique. Repositioning of the flap was performed, followed by closure of the wound.
Figure 1: Temporalis fascia graft.

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Permeatal tragal perichondrial graft was performed by trimming the edges of tympanic membrane remnants. The tragal perichondrial graft was harvested by injecting the tragus with adrenaline in saline solution (1: 100 000) to achieve adequate hemostasis and visualization. Thereafter, a small incision was made just medial to the tragus edge, so that the scar was hidden in the shallow area of the external meatus. An incision was made in the tragal perichondrium, followed by its dissection to harvest an adequate graft ([Figure 2]). An incision was made permeatally 4-5 mm lateral to the annulus. Tympanomeatal flap was created and elevated, including the annulus, to reach the middle ear cavity. Tympanic membrane remnant was lifted forward and tragal perichondrial graft was inserted medial to it.
Figure 2: Incision of the tragus for harvesting the tragal perichondrium.

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Both grafts were performed using the underlay technique, and a gel foam soaked with antibiotic ear drop was used to cover the graft. All incisions were sutured using vicryl 2/0. Patients were given a systemic antibiotic (amoxicillin - clavulanate) and an analgesic (NSAID - ibuprofen) and followed up regularly postoperatively for 1 year.

Outcome measurements

Closure of the perforation within 1 year postoperatively and improvement in hearing with air-bone gap on pure tone audiogram less than 10 dB were considered as success criteria.

Statistical analysis

Quantitative data were expressed as mean and SD, whereas qualitative data were expressed as number and percentage. Student's t-test was used to compare quantitative data of both groups, whereas the χ2 -test and Fisher's exact test were used to compare qualitative data of both groups. Quantitative data were compared using the Mann-Whitney U-test. Confidence interval was considered as 95%. SPSS, 16 program (IBM, New York, USA) was used to analyze the results and study all preoperative and postoperative factors.

  Results Top

A total of 71 patients were included in the study and underwent the surgery, of whom 54 patients (56 ears) completed the follow-up program. Their ages ranged from 8 to 18 years. Demographic data of the patients are shown in [Table 1].
Table 1 Baseline characteristics of group A and group B preoperatively

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The overall take rate - that is, complete closure of the tympanic membrane perforation after 1 year postoperatively - for group A it was 86%, whereas that for group B was 88.5%, with no statistically significant difference between the two groups (P > 0.05) ([Table 2]).
Table 2 Comparison of postoperative success

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Bilateral ear affection always indicates poor  Eustachian tube More Details dysfunction and this was observed in two patients in this study (four ears) who belonged to group A, between whom three ears out of four failed. Most of them presented with large-sized perforations ([Table 2]).

Average audiometric values preoperatively and postoperatively showed that the hearing was improved greatly in both groups, with better improvement in group A than in group B ([Table 3]).
Table 3 Average audiometric values preoperatively, at 3 months, and 1 year postoperatively

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  Discussion Top

Myringoplasty is a famous technique that meets its primary objective, the closure of tympanic membrane perforation and improvement of hearing. The anatomical success of this surgery, in addition to versatility of the techniques, led to the publication of numerous works using different methodologies and results. However, most authors offer complete closure figures of around 85% ([Table 4]) [8],[9],[10],[11],[12],[13],[14] .
Table 4 Percentage of closure of tympanic membrane perforations according to the literature reviewed

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In this study, we chose to operate among patients in this age group because most tympanic membrane perforations are presented in this age group, to give the patients the benefits of early operation, and to save patients from hearing loss in this age. Moreover, in our study, we compared the most common techniques and graft materials used for closure of tympanic membrane perforation. The postaural temporalis fascia graft technique achieved a success rate 'graft taken' of 86.7% (26 of 30 cases), and it is a satisfactory result in comparison with other studies. These good results may be due to proper selection of the cases (cases with no active infection for more than 3 months before the procedure and most perforations were less than 50% of tympanic membrane). Pediatric age favors the healing process and also a close follow-up of patients to manage any postoperative infections. Failure rate was about 13.3%, represented by four cases, all of whom had large-sized perforation. One of these patients had bilateral ear affection and this may indicate the role of Eustachian tube function in the net results.

In contrast, the permeatal tragal perichondrial graft group achieved success results of 88.4% (23 of 26 cases), and this was also considered good result. Failure rate in this group was 11.6%, represented by three cases, most of whom had large perforations.

As regards the sex of the patient as a determinant factor for success, we found that there was no difference between male and female patients in both groups. The site of perforations either anteriorly predominant located or posteriorly predominant located had no effect on the success rate. As regards the size of the perforations, the study showed excellent results with perforations less than 50% of size of tympanic membrane in both groups. The success results dropped markedly in large perforations in both groups.

To analyze the hearing gain obtained after ear surgery, different assessment methods have been used in the studies, such as change in air hearing threshold [15],[16] and measurements of postoperative air-bone difference (comparing prior bone conduction with subsequent air conduction) [17],[18] . In our study, we measured bone conduction, air conduction, and air-bone gap for the two groups and followed up these parameters after 3 months and 1 year postoperatively to detect hearing improvement.

Bone conduction thresholds between the two groups were not significantly affected before and after surgery, but both techniques showed highly significant difference in air conduction thresholds preoperatively, at 3 months, and 1 year postoperatively ([Table 3]). Early tympanic membrane perforation closure in children not only allows for rapid restoration of the middle ear functions but also helps in preventing further complications. It also enables these children to participate in water-sport activities without having to worry about water precautions; thus, we advocate early surgery for patients in this age group.

  Conclusion Top

Tympanoplasty type 1 (myringoplasty) is an appropriate technique for restoring tympanic membrane perforation in pediatric patients. Both postaural temporalis fascia graft and permeatal tragal perichondrial grafts are effective techniques for tympanic membrane closure, with better improvement in hearing thresholds in fascial graft than in cartilage graft. Bilaterality, poor Eustachian tube functions, and large-sized perforations are important determinant factors for failure.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Crovetto De La Torre M, Fiz Melsió L, Escobar Martínez A. Myringoplasty in chronic simple otitis media. Comparative analysis of underlay and overlay techniques. Acta Otorrinolaringol Esp 2000; 51 (2) :101-104.  Back to cited text no. 1
Sckolnick JS, Mantle B, Li J, Chi DH. Pediatric myringoplasty: factors that affect success: a retrospective study. Laryngoscope 2008; 118 (4) :723-729.  Back to cited text no. 2
Wullstein H. Theory and practice of tympanoplasty. Laryngoscope 1956; 66 (8) :1076-1093.  Back to cited text no. 3
Rizer FM. Overlay versus underlay tympanoplasty. Part I: historical review of the literature. Laryngoscope 1997; 107(Pt 2) :1-25.  Back to cited text no. 4
Saraç S, Gürsel B. Use of homograft dehydrated temporal fascia in tympanoplasty. Otol Neurotol 2002; 23 (4) :416-421.  Back to cited text no. 5
House W. Myringoplasty. AMA Arch Otolaryngol 1960; 71 :399-404.  Back to cited text no. 6
Karkanevatos A, De S, Srinivasan VR, Roland NJ, Lesser TH. Day-case myringoplasty: five years' experience. J Laryngol Otol 2003; 117 (10) : 763-765.  Back to cited text no. 7
Puhakka H, Virolainen E, Rahko T. Long-term results of myringoplasty with temporalis fascia. J Laryngol Otol 1979; 93 (11) :1081-1086.  Back to cited text no. 8
Lau T, Tos M. Tympanoplasty in children. An analysis of late results. Am J Otol 1986; 7 (1) :55-59.  Back to cited text no. 9
Adkins W, White B. Type I tympanoplasty: influencing factors. Laryngoscope 1994; 94 :916-918.  Back to cited text no. 10
Halyk J, Smyth G. Long-term results of tympanic membrane repair. Otolaryngol Head Neck Surg 1988; 98 :162-169.  Back to cited text no. 11
Sakagami M, Yuasa R, Yuasa Y. Simple underlay myringoplasty. J Laryngol Otol 2007; 121 (9) :840-844.  Back to cited text no. 12
Caye-Thomasen P, Rubek T, Tos M. Bilateral myringoplasty in chronic otitis media. Laryngoscope 2007; 117 :903-906.  Back to cited text no. 13
Yuasa Y, Yuasa R. Postoperative results of simple underlay myringoplasty in better hearing ears. Acta Otolaryngol 2008; 128 (2) :139-143.  Back to cited text no. 14
Santos S, Herróiz C, Gomez-Ullate R, Olaizola G. Criteriafor evaluation of functional outcomes in middle ear surgery [article in Spanish]. Acta Otorrinolaring Esp 1996; 47 :15-20.  Back to cited text no. 15
Kotecha B, Fowler S, Topham J. Myringoplasty: a prospective audit study. Clin Otolaryngol Allied Sci 1999; 24 (2) :126-129.  Back to cited text no. 16
Viladot J, Meda C, Esteller E, Armestic A. Myringoplasty. A prospective study 238 prospective cases [article in Spanish]. An Otorrinolaringol Ibero Am 1991; 18 :625-638.  Back to cited text no. 17
Caylan R, Titiz A, Falcioni M, de Donato G, Russo A, Taibah A, Sanna M. Myringoplasty in children: factors influencing surgical outcome. Otolaryngol Head Neck Surg 1998; 118 (5) :709-713.  Back to cited text no. 18


  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4]


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