Outcomes of Palisade Cartilage Tympanoplasty in Chronic Otitis Media: Our Experience at a Tertiary Care Centre

Abstract

To evaluate the anatomical and functional success rates of palisade cartilage tympanoplasty in chronic otitis media. Thirty patients with chronic otitis media with subtotal perforation underwent palisade cartilage tympanoplasty and were assessed prospectively. The outcomes evaluated were graft uptake and hearing gain. Overall graft uptake was 90% with failure in 3 cases. The preoperative mean air conduction threshold was 22.087 ± 6.120 dB which was improved to 13.387 ± 5.253 dB postoperatively at 12 weeks which was statistically significant. The mean postoperative ABG closure was 8.700 dB with a p value of 0.001 which was statistically significant. Palisade cartilage tympanoplasty demonstrates that subtotal perforations, which are at high risk for graft failure, can be treated efficiently and a durable and resistant reconstruction of the tympanic membrane with reasonable hearing can be achieved.

Introduction

Chronic otitis media (COM) is defined as a permanent abnormality of pars tensa or flaccida, which may result from past acute otitis media, negative pressure in the middle ear or otitis media with effusion [1]. There is a chronic infection of the middle ear cleft and a non-intact tympanic membrane (TM) (e.g. perforation) and discharge is present [2]. COM accounts for 3–80% of the burden of hearing impairment [3].

Tympanoplasty is a surgical technique for repairing perforations of TM, restoring hearing ability and preventing recurrent otorrhea [4, 5]. Various materials have been used as grafting materials to create a new TM ranging from temporalis fascia, cartilage, and perichondrium to skin grafts in the past [6]. Temporalis fascia undergoes atrophy, shrinkage and unpredictable changes due to its irregular elastic and fibrous tissue composition, with potential subsequent failure, which has led to a search for a better option. Cartilage has therefore become the material of choice [7]. Furthermore, it is known that cartilage derives its nourishment by simple diffusion by incorporating it into the surrounding tissue where it survives in a relatively avascular condition, increasing the chances of its graft uptake rate in contrast with the temporalis fascia graft. Hence, it can be considered the ideal autograft, particularly in COM with large or subtotal perforations [8].

The palisade technique, in which the TM is fully reconstructed with palisade-shaped cartilage pieces, was first described by Heermann and specifically involved placement of 0.5–3-mm-thick pieces of cartilage placed side by side and often overlapping under the TM remnant until the defect is covered. This technique has been popular in Europe, especially in Germany and has been used with recurrent perforations, TM retractions and other mixed middle ear pathologies [9, 10]. Reconstruction of the TM using the palisade cartilage technique in tympanoplasties allows us to achieve good anatomic and audiological results that are at least similar, if not better than, traditional methods of reconstruction in high-risk cases [11]. Palisade cartilage tympanoplasty has also been indicated in revision surgery for failed myringoplasty or tympanoplasty type I, Anterior and inferior perforation with tubal discharge, retraction pockets, partially or completely atelectatic TM [12].

This study aimed to evaluate the results of palisade cartilage tympanoplasty in thirty COM patients with subtotal perforations. The outcomes evaluated were graft success rate and hearing gains.

Material and Methods

A prospective study was conducted in the Department of Otorhinolaryngology and Head and Neck Surgery, Rajindra Hospital, Patiala on 30 patients with clinically diagnosed cases of COM with subtotal perforation.

The study protocol was approved by the Institutional Review Board for Ethical Clearance of Government Medical College and Rajindra Hospital and it was performed in accordance with the Code of Ethics of the World Medical Association according to the Declaration of Helsinki of 1975, as revised in 2000.

Inclusion Criteria were patients of both sexes in the age group of 15–60 years with subtotal perforation with intact ossicular chain. It included both primary and revision cases of COM inactive mucosal type having a dry ear for more than 4 weeks. Exclusion criteria included patients with COM squamous type, patients who underwent radical and modified radical mastoidectomy, patients with actively discharging ears and those with ossicular discontinuity (Figs. 1 and 2).

Fig. 1.

a Preoperative image of tympanic membrane left side, b postoperative image of tympanic membrane left side at 12 weeks

Fig. 2.

a Preoperative image of tympanic membrane left side, b postoperative image of tympanic membrane left side at 12 weeks

All the patients selected were evaluated based on history, general physical examination as well as complete ear, nose and throat examination. Written consent from each of the patients was obtained. Pure tone audiometry (PTA) and High-resolution computed tomography (HRCT) temporal bone were done. The patients underwent palisade cartilage tympanoplasty, which was performed under general anaesthesia, using a postauricular approach. The postauricular area was infiltrated with 1% xylocaine with 1:100,000 adrenaline. The cartilage was obtained from the cymba because its natural curve mimics the conical curvature of the TM and being adherent to the temporal bone posteriorly, postoperative cosmetic deformities were avoided. Care was taken to obtain the cartilage grafts in a way that allowed perichondrium to adhere only to one side of the cartilage. The cartilage graft was cut in an oblique manner resulting in cartilage strips that were wider than they were thick, and the thickness of the blade served as a rough optical measure during the sectioning process to achieve strips as thin as 0.5 mm. Following freshening of the perforation edges, the elevation of the tympanomeatal flap and packing of the middle ear cavity with ciprofloxacin-soaked gelfoam, the cartilage strips were positioned in an over-underlay fashion from anterior to posterior direction, parallel to the manubrium of malleus and slightly overlapping each other. After this, the tympanomeatal flap was placed in its original position, the external auditory canal was packed with Gelfoam again to support the reconstructed membrane laterally. Postauricular incision was sutured. A mastoid bandage was applied. All patients were put on injectable antibiotics, analgesics, and antihistaminics in the postoperative period for the first 3 days. The patients were then shifted to oral antibiotics on the fourth postoperative day. All patients were instructed to take adequate precautions to prevent the entry of water into the ear canal. Antibiotics were continued for 1 week and antihistaminics for 3 weeks. Skin stitches were removed after 7 days and the pack was completely suctioned from the external auditory canal 4 weeks after the surgical procedure.

Postoperatively, all patients were followed in the OPD on the 4th, 8th and 16th week. Follow-up of the patients was done to evaluate the status of graft uptake rate and hearing outcome by pure-tone audiometry at 3 months and to evaluate air–bone gap closure. Pure tone averages at 0.5, 1, 2 and 4 kHz were taken preoperatively and postoperatively at 12 weeks. The hearing outcome was evaluated considering the criteria stated by the Committee on Hearing and Equilibrium Guidelines, 1995 [11].

Results

Out of the thirty patients enrolled in the study, there were 21 (70%) females and 9 (30%) males. The age of the patients ranged between 15 and 60 years with a mean age of 31.47 ± 13.29 years (Table 1).

Table 1.

Demographic distribution

	No. of patients	Percentage
Sex
Male	21	70%
Female	9	30%
Age group (in years)
15–20	7	23.33%
21–30	9	30%
31–40	6	20%
41–50	5	16.67%
51–60	3	10%
Total	30	100%
Mean ± SD	31.47 ± 13.29 years
Range	15–60 years

The most common complaint was hearing loss with ear discharge in 15 (50%) cases followed by ear discharge in 10 (33.33%) cases, tinnitus in 2 (6.67%) patients and hearing loss in 1 patient (3.33%).

By the end of 3rd month, the graft uptake success rate was 90% with graft failure in 3 patients (Table 2). Amongst these, 1 patient had ear discharge, 1 patient had ear discharge with lateralization of graft, and 1 patient had ear discharge with dermatitis.

Table 2.

Cartilage graft uptake success rate at 12 weeks

Graft uptake at 12 weeks	Patients (N = 30)	Percentage (%)
Present	27	90
Failure	3	10
Total	30	100

The mean preoperative PTA was 40.375 dB ± 11.842 dB, and at the time of postoperative evaluation, the mean PTA was 30.100 dB ± 11.436 dB at 12 weeks. The mean difference was 10.275 dB, which was statistically significant (p value 0.001) (Table 3).

Table 3.

Pure tone audiometry (pre and post operative PTA)

PTA	Preoperative PTA		Post operative PTA at 12 weeks
	Patients	Percentage	Patients	Percentage
10–15 dB	0	0%	1	3.33%
16–25 dB	2	6.67%	13	43.33%
26–40 dB	15	50%	12	40%
41–55 dB	9	30%	2	6.67%
56–70 dB	4	13.33%	2	6.67%
Total	30	100%	30	100%
Mean	40.375 ± 11.842 dB		30.100 ± 11.436 dB
p value	0.001 (significant)

The mean air–bone gap (AB gap) was 22.087 dB ± 6.120 dB preoperatively, and the mean postoperative AB gap was 13.387 dB ± 5.253 dB at 12 weeks. The mean difference was 8.700 dB, which was statistically significant (p value 0.001) (Table 4). AB gap closure of < 15 dB was seen in 24 (80%) patients, 3 (10%) patients showed AB gap closure of > 15 dB, and 3 (10%) patients did not show any improvement.

Table 4.

Air bone gap (pre and post-operative air bone gap)

ABG	Preoperative PTA		Post operative PTA at 12 weeks
	Patients	Percentage	Patients	Percentage
0–10 dB	1	3.33%	11	36.67%
11–20 dB	12	40%	18	60%
21–30 dB	13	43.33%	1	3.33%
> 30 dB	4	13.33%	0	0%
Total	30	100%	30	100%
Mean	22.087 ± 6.120 dB		13.387 ± 5.253 dB
p value	0.001 (significant)

Discussion

The cartilage palisade technique is also known as the Heermann technique. He used full-thickness cartilage strips with perichondrium preserved on the outer surface, placed parallel to the handle of malleus making sure that they covered the middle-ear cavity completely. The technique was modified by Tos (2008), where he increased the width of palisades to 4–5 mm and used only two to three of them [7].

The cartilage meets the requirements for managing conditions like subtotal perforations, tympanosclerosis, and adhesive otitis because of its bradytrophic properties and stiffness. Whereas temporalis fascia radically and unpredictably changes its shape because of uneven shrinking and thickening even on the fifth day of the grafting. This instability becomes critical in cases in which the perforation is large, and the remnant TM area under (or over) which the graft overlaps is limited. Cartilage grafts are nourished mainly by diffusion and imbibition, resulting in excellent incorporation into the remaining TM. Palisade cartilage tympanoplasty is performed on ears with difficult indications, such as subtotal perforations, tympanosclerosis, adhesive otitis, and revision surgery because these conditions are likely to show unsatisfactory results [9].

Successful closure rate varies significantly throughout the literature and ranges from 35 to 95% [13]. In our study, 27 patients (90%) had successful graft uptake, whereas 3(10%) patients had graft failure. Shishegar et al. reported graft uptake of 100% in the palisade group and 92.5% in the temporalis fascia group at a follow-up period of 6 months in a study among 54 patients. In both graft failures in the temporalis fascia tympanoplasty group, a small perforation developed at the central part of the TM but the cartilage strips resisted well resulting in an intact TM. There were no significant complications such as graft lateralization, blunting, or infection [11].

Vashishth et al. conducted a study on 90 patients and revealed a graft uptake of 90% in the palisade group, which was in accordance with our study, and 83.3% in the temporalis fascia group at a follow-up period of 6 months and 1 year. All three perforations in the cartilage group were located centrally with two small-sized and one moderate-sized defect [14]. Pradhan et al. did a study on the comparison of temporalis fascia and full-thickness cartilage palisades in type 1 underlay tympanoplasty for large/subtotal perforations observed graft uptake of 96.7% in the palisade group and 80% in temporalis fascia group at follow up period of 24 months among 60 patients [8]. Shakya et al. reported graft uptake of 87.17% in the palisade group and 66.6% in the comparison group at follow-up period of 5 years in a study on long-term results of type I tympanoplasty with perichondrium-reinforced cartilage palisade versus temporalis fascia for large perforations among 96 patients. With long-term follow-up, the success rate of tympanoplasty tends to decrease as compared to the short-term follow-up [7]. We can conclude that in most studies, graft uptake of 90–95% was present, which was comparable to our study.

In our study, evaluation of audiological improvement was done at 12 weeks. Pure tone averages were calculated at frequencies of 0.5, 1, 2 and 4 kHz. The preoperative mean PTA was 40.375 ± 11.842 dB which improved to the post-op mean PTA at 12 weeks was 30.100 ± 11.436 dB. The p value was 0.001, which was statistically significant. The postoperative hearing gain (ABG closure) at 12 weeks was 8.700 dB which was also statistically significant (p = 0.001).

Shishegar et al. reported that the mean preoperative ABG was 28.5 dB, and the mean postoperative ABG was 14.8 dB (p = 0.001) with a hearing gain of 13.7 dB in a study among 54 patients. The mean ABG changes between the two groups were not statistically significant (p > 0.05) [11]. In a study conducted on 90 patients by Vashishth et al. pre-op ABG was 29 ± 6.21 dB, and post-operative ABG was 7.33 dB ± 3.88 dB in the palisade group, with a mean hearing gain of 21.67 ± 6.73. Highly significant results (p = 0.000) were obtained in favour of cartilage palisades in terms of improvement in the air–bone gap pre- and post-operatively [14]. Pradhan et al. found the mean closure of the ABG in the cartilage tympanoplasty group to be 11 dB (p = 0.512). In total 88% of patients in the cartilage palisade group showed significant improvement in hearing (ABG ≥ 10 dB) [8]. Shakya et al. also found a significant improvement in hearing with pre-op ABG being 24.35 ± 6.31 dB and postoperative ABG being 13.25 ± 8.38 dB in the cartilage palisade group (p < 0.0005) [7].

Thus, cartilage palisades can effectively be used for TM grafting in difficult perforations. It is considered a better autograft, not only because of superior graft uptake but also because of a comparable hearing outcome with temporalis fascia [8].

Limitations

The sample size in the present study was small, i.e., 30 patients. Another limitation of our study is the short follow-up period of 3 months. Therefore, a larger sample size with a longer follow-up duration is required to evaluate the long-term outcomes of cartilage tympanoplasty.

Conclusion

Cartilage palisade tympanoplasty offers excellent graft take rates and good postoperative hearing outcomes for subtotal perforations and both primary and revision cases. This technique has good anatomic and audiologic results that are at least similar, if not better, than the traditional methods of reconstruction in high-risk cases.

Declarations

Conflict of interest

The authors have no conflict of interest.

Ethics Approval

Ethics approval has been obtained from the ethics committee of Government Medical College, Patiala. The study protocol was approved by the Institutional Review Board for Ethical Clearance of Government Medical College and Rajindra Hospital and it was performed in accordance with the Code of Ethics of the World Medical Association according to the Declaration of Helsinki of 1975, as revised in 2000. Informed consent has been taken from the patients for publication.

Informed consent

Informed consent has been taken from the patient for publication.