Abstract
The objective of this study was to evaluate graft take up rate and hearing improvement in type I and type III endoscopic tympanoplasty using broad palisade cartilage graft and to compare the results with other studies who have used single piece cartilage as graft. This retrospective observational descriptive study was done in a tertiary care hospital. This study included 64 cases, who met the inclusion criteria, which were operated over 2 years and were followed for 3 years. The results were evaluated using graft uptake rates and hearing improvement comparing the preoperative and postoperative air conduction threshold (ACT) and air bone gap closure (ABG). The graft take rate was 92.1% and 87.5% at the end of 1 year and 3 years respectively. The preoperative and post-operative air conduction threshold were 35 ± 6.0 dB HL and 17.5 ± 2.7 dB HL in type I tympanoplasty respectively (p value <0.0001) while in type III tympanoplasty, preoperative and post-operative air conduction threshold (ACT) were 43.3 ± 8.6 dB HL and 23.1 ± 4.2 dB HL respectively (p value <0.0001). The preoperative and postoperative air bone gap (ABG) were 29.0 ± 5.6 dB HL and 14.4 ± 4.20 dB HL in type I tympanoplasty respectively (p value <0.0001). In type III preoperative and post-operative air bone gap were 36. 1 ± 7.5 dB HL and 16.4 ± 3.3 dB HL respectively (p value < 0.0001). Endoscopic broad palisade cartilage tympanoplasty has similar outcomes in morphological and audio logical perspectives as single piece cartilage tympanoplasty. Further studies with long term follow up period are required to corroborate the result of this study.
Keywords: Endoscopic tympanoplasty, Palisade cartilage graft, Single piece cartilage graft, Incus reposition
Introduction
Endoscopic ear surgery is rapidly gaining inroads into otology because of better visualization,ability to address pathologies located in hidden areas of middle ear and less postoperative morbidity due to minimal soft tissue dissection. Temporalis fascia remains the graft of choice by most otologists. For harvesting temporalis fascia we need an external incision which not only carries risk of scar but also chances of numbness in the area and defeats the whole purpose of scarless endoscopic ear surgery. It has been also associated with 25–30% of re-perforations in tympanoplasty [1, 2].
Over the last decade, use of cartilage as graft has gained popularity in high risk cases, such as those with chronic tubal dysfunction, atelectatic cases, recurrent perforation, nasal allergies, unhealthy middle ear mucosa, subtotal or total perforation, bilateral perforation and pediatric cases. Cartilage is a proven ideal graft in these conditions because of its mechanical properties providing greater resistance to re-perforation and retraction. It has low metabolic rate and good acceptance in middle ear [3, 4]. This can be harvested from the same surgical site in endoscopic ear surgery.
In this study on endoscopic earsurgery we used two semilunar broad palisades from tragal cartilage as grafting material which precisely fitted within middle ear cavity with support from tendon of tensor tympani muscle, long process of incus or refashioned autologous incus, bony annulus and gel foam. The tympanmeatal flap was elevated in swing door fashion with superior and inferior flap for wide anterior exposure of annulus. Placing two broad palisade cartilage graft alongsideis easy to perform with precision in comparison to insertion of single piece cartilage as graft.
This retrospective observational descriptive study was undertaken to determine the long term anatomical and functional results of type I and III endoscopic tympanoplasties using full thickness tragal broad palisade cartilage as graft and compare the result with other studies in which single piece cartilage graft was used. Refashioned autologous incus was used for ossciculoplasty in type III tympanoplasties.
Materials and Methods
We conducted a retrospective descriptive observational study of data from 64 cases who underwentendoscopic broadpalisade cartilage tympanoplasties from January 2016 to December 2017 in a tertiary care hospital. All the 64 cases were followed for period of 3 years post-surgery.
Statement of Approval of the Institutions Ethics Committee.
The study underwent ethical clearance by the institutional ethical board vide letter noSGRR/IEC/08/19, dated 19.09.2019. An informed consent for the surgery was received from each participant.
Inclusion Criteria
All cases between 12 and 50 years of age, patients with mucosal COM with large or subtotal perforations, patients with perforations with tympanosclerotic plaques or atrophic membranes, patients with primary endoscopic type I and endoscopic type III (incus remodeled) tympanoplasties where palisade tragal cartilage was used as graft material were included in this study.
Exclusion Criteria
All cases less than 12 years and more than 50 years of age, patient with squamosal COM with narrow external auditory canal, cases where palisade cartilage is not used as graft material, cases where remodelled incus is not used in type III tympanoplasty, cases which were done via post aural incision using microscope and cases who were lost in follow up were excluded from this study.
All patients underwent detailed history taking, properclinical examination, otoendoscopy and if required cleaning of ear using micro suction under otoendoscope. Adequate radiological investigations were done.
All cases underwent pure tone audio logical evaluation preoperatively, with post-operative pure tone audio logical evaluation at 12 month or later. The average pure tone threshold wascalculated using3 frequencies 500, 1000, 2000 and 3000 Hz. The air bone gap (ABG), calculated as difference between the average air and bone conduction thresholds.
Surgical Technique
In all cases transcanal endoscopic type I/ III tympanoplasty was done using broad palisade cartilage graft. It was performed using wide angle 0°, 30° and 45° degree endoscopes. Graft was harvested from tragus leaving the apex rim of 2 mm of tragal cartilage and lateral perichondrium to prevent cosmetic deformity. Full thickness broad palisade tragal cartilage was used to prevent curling. Tragal cartilage graft of diameter up to 1.2 cm can be harvested in our experience. Twobroad palisade was made after measuring the size of cartilage graft required for closure of perforation in semilunar fashion. Size of graft required was measured using opening the tip of micro crocodile forceps. Perforation margins were freshened and tympanosclerotic patches were dissected and removed. Incision at osseocartilaginous junction was made and tympan meatal flap elevated in swing door fashion with superior and inferior based flap placed anteriorly. Entire Middle ear cavity with all the ventilation pathways including anterior and posterior tympanic isthmus was inspected for glue, granulations and disease. If any was removed. If tensor tympani fold was present it was removed using Thomassin dissectors. In cases requiring osscicular reconstruction, it was done using refashioned autologus incus. Ossicular integrity was checked and round window reflex was elicited. In few cases where handle of malleus was too medialized, handle of malleus was cut using malleus nipper. The middle ear was filled with gel foam pledgets. Broad palisade cartilage graft was placed anteriorly first and then posterior graft was placed so that large area of graft is in contact with long process of incus or autologus refashioned incus without displacing the refashioned incus. In all cases side with perichondrium of the graft were placed facing external auditory canal. Anterior edge of anterior broad palisade graft was placed medial to remnant of anterior annulus margin. Edges of grafts were approximated as close as possible in midline (Fig. 1). It was also reconfirmed that no gap remains between postero superior edge of graft and posterior canal wall to avoid post-operativeretraction. Tympanomeatal flap or canal skin was reposited back. Gel foam impregnated with topical antibiotic and wick was kept in external auditory canal.
Fig. 1.
Endoscopic placement of Broad Palisade Cartilage graft
Follow–Up
Patients were given oral antibiotics(amoxicillin with clauvanic acid 625 mg TDS), along with analgesics and antihistamines as needed in postoperative period. Ear pack was removed on 10th day. Antibiotic ear drops 2drops 3 times daily were started from 11th day for a week. Adequate postoperative instructions were given. Follow was done on 10th day, 3 months (Fig. 2), 6th months (Fig. 3) and 12th months (Fig. 4) post operatively, and then yearly for 3 yrs. Post-operative audiological testing was done on 12th month follow up and repeated only at patients request or if patient complained of decreased hearing. Otoendoscopy was done and graft was checked for uptake, reperforation or lateralization.
Fig. 2.
Post op graft at 3 months
Fig. 3.
Post op graft at 6 months
Fig. 4.
Post op graft at 12 months
Statistical Analysis
At the end of the study, statistical analysis was done. Paired t test using MedCalc software limited version 20.006 was done for preoperative and post-operative hearing comparison. p value of less than 0.05 was considered significant and less than 0.001 as highly significant.
Results
64 cases who underwent endoscopic broad palisade cartilage tympanoplasties from January 2016 to December 2017 were studied and followed up for 3 years post-surgery.
Table 1: Distribution of enrolled patients.
Table 1.
Preoperative and Post-operative ACT evaluation in type I tympanoplasty
| Preoperative ACT in dB HL | Post-operative ACT in dB HL | |
|---|---|---|
| Mean | 35 | 17.5 |
| SD | ± 6 | ± 2.7 |
p value between preoperative and post-operative ACT < 0.0001
Total number of patients: 64.
-
Age in years
- Range: 12–50.
- Mean: 31.18 ± 10.50.
Mean age of patients was 31.18 years and ranged from 12 to 50 years in this study.
-
Gender
36 patients were males and 28 cases were females with ratio of 1.2 in this study.
-
Disease
Of the 64 cases, 45 patients had unilateral disease and 19 cases had bilateral disease.
-
Type of tympanoplasty:
In this study out of 64 cases operated, 47 cases underwent type I tympanoplasty and 17 cases underwent type III tympanoplasty.
Graft status at 1 year
Out of total 64 cases at one year follow up, 59 cases (92.2%) cases had successful graft uptake. Failure of graft uptake was found in 5(7.8%) cases.
-
(f)
graft status at 3 yrs
Out of total 64 cases at three year follow up, 56 cases (87.5%) cases had successful graft uptake. Failure of graft uptake was found in 8(12.5%) cases. Out of 8 failures, there was laterization of graft in 2 cases.
-
(g)
Failure according to type of tympanoplsty at the end of 3 yrs
Out of 47 cases of type I tympanoplasty, there were 6 (12.7%) cases of graft failure. Whereas out of 17 cases of type III tympanoplasty, there were 2 (11.7%) cases of graft failure.
-
(h)
Failure according to involvement of disease at 3 yrs
Out of 45 cases of unilateral disease, there were 3 (4.6%) cases of graft failure. Whereas out of 19 cases of type III tympanoplasty, there were 5 (7.8%) cases of graft failure.
Table 2: Hearing assessment.
Table 2.
Preoperative and Postoperative ABG evaluation in type I tympanoplasty
| Preoperative ABG in dB HL | Post-operative ABG in dB HL | |
|---|---|---|
| Mean | 29.04 | 14.44 |
| SD | ± 5.64 | ± 4.20 |
p value between preoperative and postoperative ABG < 0.0001
-
A.
Type I tympanoplsty
In 47 cases of type I tympanoplasty, pre-operativeACT was 35 ± 6.0 dB and the post-operative ACT was 17.5 ± 2.7 dB. p value between preoperative and post-operative ACT in type I tympanoplasty is < 0.0001 (Table 1). Pre-operativeABG was29.04 ± 5.64 dB and the post-operative ACT was 14.44 ± 4.20 dB. p value between preoperative and post-operative ABG in type I tympanoplasty is < 0.0001. (Table 2).
-
B.
Type III Tympanoplasty:
In 17 cases of type I tympanoplasty, pre-operative ACT was 43.35 ± 8.6 dB and the post-operative ACT was 23.17 ± 4.20 dB. p value between preoperative and post-operative ACT in type I tympanoplasty is < 0.0001. (Table 3).Pre-operativeABG was 36.17 ± 7.5 dB and the post-operative ACT was 16.4 ± 3.3 dB. p value between preoperative and post-operative ABG in type I tympanoplasty is < 0.0001. (Table 4).
Table 3.
Preoperative and Post-operative ACT evaluation in type III tympanoplasty
| Preoperative ACT in dB HL | Post-operative ACT in dB HL | |
|---|---|---|
| Mean | 43.35 | 23.17 |
| SD | ± 8.6 | ± 4.20 |
p value between preoperative and post-operativeACT < 0.0001
Table 4.
Preoperative and Postoperative ABG evaluation in type III tympanoplasty
| Preoperative ABG in dB HL | Post-operative ABG in dB HL | |
|---|---|---|
| Mean | 36.17 | 16.4 |
| SD | ± 7.5 | ± 3.3 |
p value between preoperative and postoperative ABG < 0.0001
Discussion
There are different techniques of cartilage tympanoplasty described in literature. It was Heerman from Germany who first described the cartilage palisade technique in 1962 [2]. In Heerman’s technique, six to eight palisades are required to close the perforations.
This retrospective study determined the outcomes of endoscopic tympanoplasty using autologus broad palisade tragal cartilage as a graft. The studyfocusses on use of two broad palisades as agraft and easy placement of graft pieces over autologus refashioned incus with single handed transcanal endoscopic approach.
In this study we supported the anterior end of broad palisade on tensor tympani muscle superiorly and anteroinferior bony annulus inferiorly while posteriorly it was supported directly on long process of incus or autologus refashioned incus and inferiorly on bony annulus over hypotympanum. An additional support was given with stuffing the middle with dexamethasone soaked gel foam pieces. In this study no medialization was seen.
The swing door technique of elevation of tympanomeatal flap gives us better and wide anterior exposure of middle ear cavity, thereby allowing precise placement of graftanteriorly. Furthermore it lessens the chances of displacement of refashioned incus while placing the posterior graft. In our opinion as we divide the tympanomeatal flap into superior and inferior pedicle it can be manipulated easily both superiorly and inferiorly,thereby providing surgeon easy maneuverability for graft placementcorrectly. No epithelial pearls were observed in all the 64 cases during the follow up period of 3 years.
The potential of full thickness autologus cartilage graft to resist retraction and negative middle ear pressure is well established in laser vibromatic studies [5]. Moreover, cartilage resists infection, thus its use intympanic membrane reconstruction is indicated in “high risk” tympanoplasties [6].
Several studies have documented their results using the technique described by Heerman with modifications using full thickness or split thickness cartilage using microscope and the follow up period was short in most studies.With long term follow up the success rate of tympanoplasty tends to be lower [7].
Bernel-Sprekelsen used cartilage palisade graft in 300 cases of type III tympanoplasty using autologus incus, Ceravital and Ionos prosthesis in both canal wall up and down situations with reperforation rate of 1.7% over mean time period of 54 months [6].
This study showsour experience of transcanal endoscopic technique of type 1 and III tympanoplasty, in which broad palisade tragal cartilage graft was usedwith long follow up period of 3 yrs.This study had thegraft uptake rate of 87% at the end of 3 years follow up while it was 92.1% at the end of one year. In type I tympanoplasty, failure rate was 12.7% and in type III tympanoplasty group it was 11.7%.This difference may be due to small number of cases in type III tympanoplasty group. One aspect which we would like to emphasize is graft failure was more in those cases with bilateral ear diseases (7.8%) as compared to unilateral disease (4.6%). The limitation of this study is that it is a retrospective study with small sample size and less years of follow up.
In present study initial graft failure occurred in first 3 months in all 5 cases. In 2 cases where perforation occurred after 1 year there was complete resorption of cartilage. Both these cases had bilateral ear disease while in 1 there was lateral displacement of anterior edge of cartilage graft with perforation near anterior annulus.
In our study in type I tympanoplastiesthe pre-operative air conduction threshold (ACT) was 35.0 ± 6.0 dB HL and the postoperative air conduction (ACT) was 17.5 ± 2.7 dB HL (p value < 0. 0001) which is statistically significant. Moreover, thepreoperative air bone gap (ABG) was 29.04 ± 5.6 dB HL and the postoperative air bone gap (ABG) was 14.4 ± 4.2 dB HL (p value < 0.0001) which wasalso statistically significant.
In type III tympanoplastiesthe preoperative air conduction threshold (ACT) was 43.3 ± 8.6 dB HL and the post-operative air conduction threshold (ACT) was 23.1 ± 4.2 dB HL (p value < 0.001) which is statistically significant.The preoperative air bone conduction gap (ABG) was 36.17 ± 7.5 dB HL and the postoperative air bone conduction gap (ABG) was 16.4 ± 3.3 dBHL (p value < 0.0001) which is also statistically significant.
The better air conduction threshold in preoperative findings may be due to younger sample size 12- 50 years (mean31.8 ± 10.5) as no other issues were found. Our results are similar to studies done by Kazikdas et al., Shakya et al., Singh et al. and Shisegar et al. in type I tympanoplasties [2, 8–10].
RomualdWielgosz and Edward Mroczkowski, in their study in the assessment of the hearing results in tympanoplasties with the use of palisade technique found that thepost-operative air bone gap (ABG) closure was < 10 dB among 67.8% of patients and 11–20 dB among 21.4% of patients in type I tympanoplasties [11].Pradhan P et al. and Larrosa F et al. also concluded similar post-operative air bone gap (ABG) closure in type I tympanoplasty in cartilage tympanoplsty [12, 13].
They concluded that the cartilage is a good autograft for reconstruction of the tympanic membrane, middle ear and the auditory wall because of stability and lack of secondary perforations. Long term results are also satisfactory [11]. Vashishth A et al. in their study on type III tympanoplsties had similar results, the pre- and post-operative mean pure tone air-bone gaps were 32.4 ± 25 and 8.8 ± 15 dB, respectively [14].
Arora et al. in their article on cartilage palisade tympanoplasty suggested one more advantage of palisade technique. They stated that palisade reconstruction facilitates mobility and also decrease the acoustic impedance in comparison with large pieces of cartilage [15].
Varma et al. in their article further concluded that functional results validated both tragal perichondrium and tragalperichondrial cartilage composite graft as the grafting material while anatomical results are slightly better in tragalperichondrial cartilage composite graft group in term of re perforation and retraction. More over with use of tragal grafts endoscopic tympanoplasty fulfils its true meaning as no visible scar and post op patient morbidity is prevented [16].
The thickness and rigidity of a single sheet of cartilage affecting hearing results remains a debatable and contestable argument. The tragal cartilage is typically less than 1 mm thick and therefore is used as full thickness graft. Using the Doppler interferometer Zahnert et al. suggested a slight acoustic benefit by thinning the cartilage to 0.5 mm, but this advantage is offset by the curling of graft [17]. This concept was supported by the results of laboratory study of Lee et al. as well as the clinical studies done by Khan et al. and Mokbel et al [18–20]. While many other authors Velepic et al., Dornhoffer et al., Parelkar et al. and Atef et al. in their studies concluded excellent AB gap closure in full thickness tragal cartilage graft with excellent hearing results [21–24]. Our result is in agreement with full thickness tragal cartilage graft for reconstruction of perforated tympanic membrane to avoid curling of partial thickness tragal cartilage graft. However, to overcome the impedance of single piece cartilage, palisade reconstruction of tympanic membrane is advisable. Arora et al. in their study stated palisade reconstruction brings about mobility and reduces the acoustico-mechanical impedance in comparison to single piece cartilage graft [15]. Bernel–sprekelstein in his study concluded that palisade adapt more easily to varying confines of middle ear cavity [25].
This article is also an attempt to find an ideal graft material that can be used in endoscopic ear surgery without compromising graft uptake and functional results.
Conclusion
This study concludes that two piece full thickness broad tragal cartilage endoscopic tympanoplsty has similar results in comparison to single piece cartilage tympanoplsties. Moreover it is easier to place precisely those palisades in middle ear with great ease of maneuverability and overcomes acoustic- mechanical impedance seen with full thickness single piece cartilage tympanoplasties. More such studies with long term follow up are required to reconfirm the results.
Funding
There are no financial interests the authors may have in companies or other entities that have an interest in the information in the Contribution (e.g., grants, advisory boards, employment, consultancies, contracts, honoraria, royalties, expert testimony, partnerships, or stock ownership in medically related fields). The authors have no financial interest.
Declarations
Conflict of interest
Dr Arvind Varma, Dr Chetan Bansal and Dr Apoorva Kumar Pandey declares that they have no conflict of interest.
Data Availability
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
Ethical Approval
Ethics approval: YES, Taken wide letter no SGRR/IEC/08/19, Dated: 19.09.2019. Name of the ethics committee: Institutional Ethics Committee: Shri Guru Ram Rai Institute of Medical & Health Sciences
Human Animals or Participants
No data, images or videos is displayed which can disclose the identity of any patient or subject involved. Informed consent and ethical permission taken.
Informed Consent
Consent status: Yes, Taken on Institutional Consent Form.
Footnotes
Work was done at Shri Mahant Indiresh Hospital, Dehradun, Uttarakhand, India.
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Contributor Information
Arvind Varma, Email: drvarmaarvind@gmail.com.
Chetan Bansal, Email: drchetanent@yahoo.in.
Apoorva Kumar Pandey, Email: Pande.apoorva@gmail.com.
References
- 1.Ozbek C, Ciftçi O, Tuna EE, Yazkan O, Ozdem C. A comparison of cartilage palisades and fascia in type 1 tympanoplasty in children: anatomic and functional results. OtolNeurotol. 2008;29:679–683. doi: 10.1097/MAO.0b013e31817dad57. [DOI] [PubMed] [Google Scholar]
- 2.Kazikdas KC, Onal K, Boyraz I, Karabulut E. Palisade cartilage tympanoplasty for management of subtotal perforations: a comparison with the temporalis fascia technique. Eur Arch Otorhinolaryngol. 2007;264:985–989. doi: 10.1007/s00405-007-0291-3. [DOI] [PubMed] [Google Scholar]
- 3.Yung M. Cartilagetympanoplasty: literaturereview. J Laryngol Otol. 2008;122:663–672. doi: 10.1017/S0022215108001813. [DOI] [PubMed] [Google Scholar]
- 4.Dornhoffer JL. Cartilage tympanoplasty. Otolaryngol Clin North Am. 2006;39:1161–1167. doi: 10.1016/j.otc.2006.08.006. [DOI] [PubMed] [Google Scholar]
- 5.Hüttenbrink KB. Middle ear mechanics and their interface with respect to implantable electronic otologic devices. Otolaryngol Clin North Am. 2001;34(2):315–335. doi: 10.1016/s0030-6665(05)70334-0. [DOI] [PubMed] [Google Scholar]
- 6.Bernal-Sprekelsen M, RomagueraLilso MD, Sanz Gonzalo JJ. Cartilage palisades in type III tympanoplasty: anatomic and functional long term results. Otol Neurotol. 2003;24:38–42. doi: 10.1097/00129492-200301000-00009. [DOI] [PubMed] [Google Scholar]
- 7.Yegin Y, Yazici ZM, Celik M, Gunes S, Sayin I, Kayhan FT. Comparison of temporalis muscle fascia and full-thickness cartilage graft in type I tympnoplasties. Int J Clin Exp Med. 2016;9:8731–8736.9. [Google Scholar]
- 8.Shakya D, Nepal A. Long term results of type I tympanoplasty with perichondrium reinforced cartilage palisade vs temporalis fascia for large perforations: a retrospective study. J Otol. 2021;16:12–17. doi: 10.1016/j.joto.2020.07.004. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Singh VP, Sharma N, Bansal C. Comparison of myringostapediopexy and malleostapediopexytympanoplasty with sculptured incus in case of hearing reconstruction in tubotympanic chronic otitis media: a case series. Indian J Otol. 2017;23:189–192. doi: 10.4103/indianjotol.INDIANJOTOL_58_17. [DOI] [Google Scholar]
- 10.Shishegar M, Farmarzi A, Taraghi A. A short term comparison between result of palisade cartilage tympanoplasty and temporalis fascia technique. Iran J Otorhinolaryngol. 2012;24:105–112. [PMC free article] [PubMed] [Google Scholar]
- 11.Wielgosz R, Mroczkowski E. Assessment of the hearing results in tympanoplasties with the use of palisade-technique. Otolaryngol Pol. 2006;60(6):901–905. [PubMed] [Google Scholar]
- 12.Larrosa F, de Osso JT, Dura MJ, Bernal-Sprekelsen M. Palisade cartilage tympanoplasty compared to one-piece composite cartilage-perichondrium grafts for transcanal endoscopic treatment of subtotal tympanic membrane perforations: a retrospective study. Eur Arch Otorhinolaryngol. 2020;277(7):1955–1959. doi: 10.1007/s00405-020-05947-3. [DOI] [PubMed] [Google Scholar]
- 13.Pradhan P, Anant A, Venkatachalam VP. Comparison of temporalis fascia and full thickness cartilage palisades in type i underlay tympanoplasty for large/subtotal perforations. Iran J Otorhinolaryngol. 2017;29(2):63–68. [PMC free article] [PubMed] [Google Scholar]
- 14.Vashishth A, Mathur NN, Verma D. Cartilage palisades in type III tympanoplasty: functional and hearing results. Indian J Otolaryngol Head Neck Surg. 2014;66(3):309–313. doi: 10.1007/s12070-014-0717-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Arora N, Passey JC, Agarwal AK, Bansal R. Type 1 tympanoplasty by cartilage palisade and temporalis fascia technique: a comparison. Indian J Otolaryngol Head Neck Surg. 2017;69(3):380–384. doi: 10.1007/s12070-017-1137-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Varma A, Bansal C, Singh VP. Tragal perichondrium and composite cartilage graft complimenting endoscopic tympanoplasty in true sense: a comparison. Iran J Otorhinolaryngol. 2021;33(3):137–142. doi: 10.22038/ijorl.2021.48789.2613. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Zahnert T, Huttenbrink KB, Murbe D, Bornitz M. Experimental investigations of the use of cartilage in tympanic membrane reconstruction. Am J Otol. 2000;21:322–328. doi: 10.1016/S0196-0709(00)80039-3. [DOI] [PubMed] [Google Scholar]
- 18.Lee CF, Chen JH, Chou YF, Hsu LP, Chen PR, Liu TC. Optimal graft thickness for different sizes of tympanic membrane perforation in cartilage myringoplasty: a finite element analysis. Laryngoscope. 2007;117(4):725–730. doi: 10.1097/mlg.0b013e318031f0e7. [DOI] [PubMed] [Google Scholar]
- 19.Khan M, Parab SR. Comparative study of sliced tragal cartilage and temporalis fascia in type I tympanoplasty. J Lryngol Otol. 2015;129(1):16. doi: 10.1017/S0022215114003132. [DOI] [PubMed] [Google Scholar]
- 20.Mokbel KM, Thabet ESM. Repair of subtotal tympanic membrane perforation by ultrathin cartilage shield: evaluation of take rate and hearing result. Eur Arch Otorhinolaryngol. 2015;270(1):33–36. doi: 10.1007/s00405-011-1903-5. [DOI] [PubMed] [Google Scholar]
- 21.Velepic MM, Manestar D, Starcevic R, Velepic BC, Velepic SZ, Linsak Z. Full thickness cartilage palisade tympanoplasty with malleus interposition: a study of the long term results. Coll Antropol. 2014;38:283–287. [PubMed] [Google Scholar]
- 22.Dornhoffer JL. Cartilage tympanoplasty: indications, techniques and outcomes in a 1000-patient series. Laryngoscope. 2003;113:1844–1856. doi: 10.1097/00005537-200311000-00002. [DOI] [PubMed] [Google Scholar]
- 23.Parlelkar K, Thorawade V, Marfatia H, Shere D. Endoscopic cartilage tympanoplsty: full thickness and partial thickness tragal graft. Braz J Otorhinolaryngol. 2020;86:308–314. doi: 10.1016/j.bjorl.2018.12.006. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Atef A, Talaat N, Fathi A, Mosleh M, Safwat S. Effect of the thickness of the cartilage disk on the hearing results after perichondrium /cartilage island flap tympanoplasty. ORL J Otorhinolaryngol Relat Spec. 2007;69:207–211. doi: 10.1159/000101540. [DOI] [PubMed] [Google Scholar]
- 25.Bernal-Sprekelsen M. Cartilage palisade tympanoplasty. In: Hildeman H, Sudhoff H, editors. Middle ear surgery. New York: Springer, Verlag; 2006. pp. 44–48. [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.