Double-Layer Tympanic Membrane Graft in Type I Tympanoplasty

Abstract

Background: Some discussion remains among otologists regarding the best grafts for tympanic membrane closure. It is unclear whether double-layer grafts are superior to single-layer and whether single-layer cartilage is superior to fascia or perichondrium alone. The objective of the current study was to examine the relative efficacy of single-layer versus double-layer tympanic membrane grafting techniques. Materials and Methods: A retrospective review of the medical records was used to address the objective of the study. Patients operated on in an over/under technique by the same surgeon underwent single-layer perichondrium or single-layer perichondrium with a cartilage island, or a double-layer of perichondrium combined with periochondrium with a cartilage island. The outcomes assessed were tympanic membrane reperforation and hearing improvement. Results: A total of 135/177 (76%) perichondrium grafts had no reperforation, and 43/55 (78%) perichondrium with cartilage island grafts had no reperforation; 352/390 (90%) of the double-layer closures had no reperforation. There was no statistically significant difference in reperforation rates between the 2 single-layer techniques ( P = .926). The difference in reperforation rates after the double-layer closure versus the perichondrium single-layer closure was statistically significant ( P = .001), as was the difference in reperforation rates after the double-layer closure versus the cartilage island single-layer closure ( P = .02). All 3 groups showed statistically significant hearing improvement postoperatively ( P < .0001). Preoperative hearing levels ( P = .179), postoperative hearing ( P = .857), and decibels of hearing improvement ( P = .356) were the same for all 3 groups. Conclusion: Double-layer closure gives lower tympanic membrane reperforation rates than does single-layer closure, as well as similar hearing outcomes.

Over-under cartilage tympanoplasty: technique, results and a call for improved reporting

“…Concurrent articles on cartilage tympanoplasty frequently report hearing thresholds or averages using the highest frequency of 2000 Hz, 3,5,13,29 3000 Hz 1 , 8,28,[30][31][32] or 4000 Hz. 2,4,6,12,14,15,[33][34][35][36] Were we to narrow our reporting to these same levels or simply present a pure tone average, the high frequency loss presented here would have been missed, since statistical significance was only noted at 4000, 6000 and 8000 Hz.…”

“…The 97 per cent closure rate presented compares well to the 84-95 per cent rate in over-under temporalis fascia grafts, [20][21][22] and the rate of 88-98 per cent in other over-under cartilage tympanoplasty procedures. 3,4,6,[11][12][13][14] This was reliable in younger patients as well, though we avoided performing tympanoplasty on young patients with active Eustachian tube dysfunction. The closure rate presented in this article is likely due to the use of cartilage for grafting material, the placing of the graft snugly onto the malleus and the addition of the cartilage shim, which, when required, brings the graft in contact with the native tympanic membrane.…”

“…1 Various techniques of cartilage tympanoplasty have been proposed. [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15] We use an over-under technique, where the cartilage-perichondrial island graft is placed lateral to the malleus and medial to the annulus. We also use a cartilage shim between the native tympanic membrane and the cartilage graft when the graft does not make contact with the tympanic membrane, and we believe this additional step is unique.…”

“…We have found overunder cartilage tympanoplasty to be a flexible and versatile approach in addressing the tympanic membrane, but the available articles on this only briefly describe the approach. [2][3][4][5][6][10][11][12][13][14][15] The objectives of this article are to describe the technique we use for the microscopic over-under cartilage tympanoplasty and to report the hearing outcomes and complications. We hypothesised that hearing would be shown to improve across the hearing spectrum and that reperforation would be rare.…”

The effect of surgeon experience on tympanic membrane closure

“…Figure shows the orientation of the double‐layer grafts. The double‐layer grafts were used because of documented increased success with perforation closure over single‐layer closure …”