Inlay “butterfly” cartilage tympanoplasty

Inlay “butterfly” cartilage tympanoplasty

Available online at American Journal of Otolaryngology–Head and Neck Medicine and Surgery 34 (2013) 41 – 43

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Available online at

American Journal of Otolaryngology–Head and Neck Medicine and Surgery 34 (2013) 41 – 43

Inlay “butterfly” cartilage tympanoplasty☆

Roy Hod, MD a, b,⁎, Inon Buda, MD a, b , Alain Hazan, MD a , Ben I. Nageris, MD a, b a

Department of Otolaryngology, Head and Neck Surgery, Rabin Medical Center, Petach Tikva, Israel b Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel Received 24 July 2012


Objectives: The aim of this study was to analyze the outcome of inlay “butterfly” cartilage tympanoplasty. Methods: The files of 42 patients (24 were male, 18 were female) who underwent primary or revision inlay butterfly cartilage tympanoplasty in 2005 to 2011 at a tertiary medical center were reviewed. Patients were regularly observed by otoscopy and audiometry. Results: The mean patient age was 27 years (range, 14–75 years), and the mean duration of followup was 24 months (range, 3–36 months). The postoperative period was uneventful. The technical (anatomical) success rate was 92% at 1 year. There was a significant decrease in the mean air-bone gap in 32 patients (preoperatively, 49.6 dB; postoperatively, 26.2 dB; P = .006). Results were suboptimal in 3 patients with persistent small perforations of the operated ear. Conclusion: Inlay butterfly cartilage tympanoplasty appears to be effective in terms of defect closure and improved hearing, comparable with temporalis fascia graft tympanoplasty. Follow-up is necessary for at least 1 year when some perforation may reappear. © 2013 Elsevier Inc. All rights reserved.

1. Introduction Tympanoplasty was introduced in the 1950s by Zollner [1] and Wullstein [2], who used numerous graft materials and tissues to close tympanic membrane perforations. Since then, both the underlay and overlay approaches have been found to be reliable [3], depending on the surgical indications, technical variants, and patient follow-up [4]. The most common grafting materials are the temporalis fascia and perichondrium [5], which are associated with a successful tympanic membrane closure rate of about 90% and improved hearing in about 60% of patients [6]. However, both require incision of the canal skin, which poses a risk of morbidity and need for postoperative care [7]. To simplify the procedure, several studies have proposed refreshing the perforation edges and then inserting a graft, such as cartilage, fat [8], or a synthetic device, through the perforation [9]. This makes the graft easy to apply and ☆

There are no financial/commercial potential conflicts of interest. ⁎ Corresponding author. Department of Otolaryngology–Head and Neck Surgery, Rabin Medical Center, Beilinson Hospital, Petach Tikva 49100, Israel. Tel.: +972 3 9376456; fax: +972 3 9376467. E-mail address: [email protected] (R. Hod). 0196-0709/$ – see front matter © 2013 Elsevier Inc. All rights reserved.

reduces operating and recovery time, leading to lower costs. The newer techniques can also be done under local anesthesia on an ambulatory basis and may be applicable even for myringosclerotic tympanic membranes. Furthermore, they eliminate the need for tympanomeatal flap elevation and postoperative ear packing, as well as the risk of cartilage atrophy [10]. The aim of the present study was to analyze the outcome of one of these alternative techniques, inlay “butterfly” cartilage tympanoplasty, first reported in 1998 by Eavey [10], in which the graft is harvested from the tragal cartilage. 2. Materials and methods The study sample included 42 patients (42 ears) who underwent primary or revision inlay butterfly cartilage tympanoplasty between January 2005 and March 2011 at the Department of Otolaryngology–Head and Neck Surgery of a major tertiary hospital. At our center, pure-tone average audiometric examination is routinely conducted before tympanoplasty. Only ears that have been dry for at least 3 months and tympanic membrane perforations that are fully visible threw the external auditory canal are considered eligible for inlay cartilage technique, all other situations undergo a “normal”


R. Hod et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 34 (2013) 41–43

tympanoplasty. Surgery is performed under general anesthesia with endotracheal intubation. Patients are usually hospitalized for 1 day. Postoperatively, they are observed regularly at the clinic on postoperative day 5, for removal of the external gauze, and at 1 and 6 months for otoscopy and audiometry. A third otoscopic evaluation is performed at 1 year. 2.1. Surgical technique Patients are prepared and draped for a sterile procedure. The meatal surface of the tragus and the external ear canal are injected with 1 to 3 mL of a local anesthetic mixture (9 mL lidocaine 1% and 0.6 mL adrenaline). The operations were performed through an aural speculum. If the edge of the perforation is obscured by a bony canal overhang, the anterior canal skin is elevated to expose the overhang and a drill is used to widen the canal. The dimensions and shape of the perforation are then estimated using a surgical hook, and the perforation edges are refreshed with a pick. As described by Eavey [10], the tragal cartilage graft is harvested making a linear incision on the tragal skin, removing the cartilage, followed by carving of the cartilage to the desired size and shape of the perforation and preserving the perichondrium on both surfaces. The graft should measure 1 to 2 mm more in every dimension than the actual perforation. We try to leave at least 5 mm of tragal cartilage for cosmesis. A No. 11 surgical blade is used to incise the thin cartilage edge between the 2 sheets of perichondrium. The cartilage is then inserted throughout the perforation, yielding a butterfly configuration, with one “wing” remaining in the lateral position and the other wing lying medial to the perforated ear drum. Several small pieces of self-absorbing Gelfoam (Pfizer, New York, NY, USA) are placed in the external ear canal and the external ear is covered with a gauze pad. No packing is placed in the middle ear, and no stitches are necessary for the tragal incision, which is closed by secondary intention. The gauze is removed on the fifth postoperative day. 2.2. Data collection For the present study, data on background variables, surgical approach, complications, and anatomical and functional outcome were collected from the patients' medical charts. Technical (anatomical) success was defined as a finding of an intact repaired tympanic membrane repair at the end of the follow-up period. Functional success was defined as a significant decrease in the air-bone gap at the end of follow-up compared with baseline (N10 dB). The significance of the change in air-bone gap was analyzed using the Pearson χ 2 test. 3. Results The study sample consisted of 24 male (57%) and 18 female patients aged 14 to 75 years (mean, 27 years). All had a nonmarginal perforation of the eardrum, small (measuring up to one third of the tympanic membrane's area) in 10

patients, medium size (one third to two thirds the area) in 27 patient, and large (more than two thirds the area) in 5 patients. The procedure was performed on one side in all cases. One patient had preexisting moderate sensorineural hearing loss, and the aim of the tympanoplasty was only to close the perforation. Twelve patients had a history of ear surgery (tympanoplasty, ventilation tube insertion. etc). During surgery, the tympanic membrane was approached through the external ear canal in 39 cases. In the remaining 3 ears, tympanomeatal flap elevation was necessary because the tympanic membrane perforation was associated with ossicular chain lesions. The duration of follow-up ranged from 3 to 36 months (mean, 24 months).The postoperative period was uneventful in all patients. The technical (anatomical) success rate was 92% (39/42) at the end of the follow-up period; there were no instances of graft lateralization or medialization. In 32 patients, there was a significant decrease in the mean air-bone gap from the preoperative period to the last follow-up (Speech Reception Threshold, 49.6–23.2 dB; P = .006). Suboptimal results were documented in 3 patients who had persistent small perforations of the operated ear at the last follow-up. All 3 were operated on for medium-size perforations; 2 had had previous tympanoplasties, and 1 had undergone ventilation tube insertion during childhood. Ten ears had mild myringitis at the end of followup, without clinical symptoms.

4. Discussion Inlay cartilage butterfly tympanoplasty is a relatively new technique [9,10] based on clinical and experimental findings of the use of cartilage grafting in middle ear surgery [5,11]. Usually, the cartilage becomes part of the tympanic membrane. Studies on the use of inlay cartilage grafts for the treatment of attical retraction pockets reported good anatomical results [5], but they did not mention postoperative changes in hearing. The aim of the present retrospective single-center study was to assess both its anatomical and functional outcomes. Our 92% closure rate is similar to values reported in the literature (Table 1), demonstrating the reproducibility of the results of this technique for the reconstruction of tympanic membrane perforations. In addition, 76% of patients (32/42 ears) showed a significant postoperative hearing gain (from a mean of SRT 49.6 to 23.2 dB). No cases of postoperative hearing loss or complications were documented. These anatomical and functional results are similar to those obtained with facial graft material [11,12]. Our success rate was unrelated to the size of the perforation: all 3 patients with residual perforations at 1 year initially had medium-sized perforations, and none of the large perforations recurred. It is noteworthy that the present study was conducted on children and adults (14–75 years) with perforations of all sizes, whereas Couloigner et al [13] and Ghanem et al [14] operated only on young patients, Wang and Lin [15] only on

R. Hod et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 34 (2013) 41–43 Table 1 Studies on cartilage inlay technique in the literature

Eavey [10] Couloigner et al [13] Ghanem et al [14] Wen-Hung [15] Nageris (Current study)


on the surgeon's preference, status of the ossicular chain, the presence of cholesteatoma, and other factors. However, the simplicity, reproducibility, and lower cost of inlay butterfly cartilage tympanoplasty make it a promising option.


Age (y)




9/11 51/59

6–19 Pediatric

b1/3 All

10/11 As good as



No change


28 inlay 20 under 42

56 ± 15

N4 mm (total) b1/3

11/11 71% 83% 92%



82% 85% 92%

6.3 dB 9.3 dB 32/42 (Improvement N10 dB)

[1] Zollner F. The principles of plastic surgery of the sound-conducting apparatus. J Laryngol Otol 1955;69:567-9. [2] Wullstein H. Theory and practice of tympanoplasty. Laryngoscope 1956;66:1076-93. [3] Rizer FM. Overlay versus underlay tympanoplasty. Part II: the study. Laryngoscope 1997;107:26-36. [4] Postic WP, Winawer MR, Marsh RR. Tympanoplasty for the anteriorposterior perforation in children. Am J Otol 1996;17:115-8. [5] Dornhoffer JL. Hearing results with cartilage tympanoplasty. Laryngoscope 1997;107:1094-9. [6] Lau T, Tos M. Tympanoplasty in children: an analysis of late results. Am J Otol 1986;7:55-9. [7] Sheehy JL. Tympanoplasty: outer surface grafting technique. Otologic surgery. Philadelphia: WB Saunders; 1994. p. 121-32. [8] Gross CW, Bassila M, Lazar RH, et al. Adipose tissue plug myringoplasty: an alternative to formal myringoplasty techniques in children. Otolaryngol Head Neck Surg 1989;101:617-20. [9] Kartush JM. Tympanic membrane patcher: a new device to close tympanic membrane perforations in an office setting. Am J Otol 2000; 21:615-20. [10] Eavey RD. Inlay tympanoplasty: cartilage butterfly technique. Laryngoscope 1998;108:657-61. [11] Glasscock III ME, Jackson CG, Nissen AJ, et al. Postauricular undersurface tympanic membrane grafting: a follow-up report. Laryngoscope 1982;92:718-27. [12] Mauri M, Lubianca Neto JF, Fuchs SC. Evaluation of inlay butterfly cartilage tympanoplasty: a randomized clinical trial. Laryngoscope 2001;111:1479-85. [13] Couloigner V, Baculard F, El Bakkouri W, et al. Inlay butterfly cartilage tympanoplasty in children. Otol Neurotol 2005;26:247-51. [14] Ghanem MA, Monroy A, Alizade FS, et al. Butterfly cartilage graft inlay tympanoplasty for large perforations. Laryngoscope 2006;116: 1813-6. [15] Wang WH, Lin YC. Minimally invasive inlay and underlay tympanoplasty. Am J Otolaryngol 2008;29:363-6.

small perforations, and Eavey [10] only on young patients with small perforations (less than one third of tympanic membrane area). Theoretically, the superficial layer of the tympanic membrane might migrate below the lips of the cartilage graft, leading to a risk of cholesteatoma formation. However, neither studies in the literature [10,12,13] nor the present study had any cases of cholesteatoma formation. In children, perforations are often due to extrusion of ventilation tubes and, as such, are usually small and anteriorly located. Therefore, inlay butterfly cartilage tympanoplasty is appropriate in these cases. It can be done quickly and reliably and even bilaterally in a single session. 5. Conclusion Inlay butterfly cartilage tympanoplasty appears to be safe and efficient in terms of both anatomical closure of the defect and improvement in hearing. Hearing results of the procedure are comparable with those for temporalis fascia graft tympanoplasty [5]. We recommend a follow-up of at least 1 year, when some perforation may reappear [11]. The choice of technique for tympanic membrane closure depends