Clinical and morphological results of xenografts to use in myringoplasty.

The main aim of our study was to study morphological state of the autograft from the fascia of the temporal muscle in myringoplasty. Until now, there is no consensus on issue of which fabrics are more suitable for use in the eardrum. We decided to study of use of an autograft from the fascia of the temporal muscle for myringoplasty in rabbits in the experiment, and in patients with chronic dry mesotympanitis. An electron microscopic examination of the fascia taken immediately, after 10, 20 min and 1 h after sampling. It was found that there are no gross destructive changes in the fascia structure. Minor changes are detected in the form of a light disorganization of the collagen complex, granular dystrophy with an increase in cell. Inflammatory diseases of the middle ear are widespread among population of all age groups. In the experiment, a positive result was obtained in 29 (82.8%) rabbits. In our research we performed morphological features of xenograft engraftment in an experimental animal on 3, 7, 14, 21 days and 1-3 months. In period from 3 days to 3 months after operation, the animals were euthanized by an air embolism and subjected to pathological examination. Then recovered xenograft, was examined macro and microscopically. Pieces were fixed in a 10% solution of neutral formalin. After washing with water, dehydration was carried out in alcohol and chloroform, and after, waxed with paraffin. Histological sections were stained with hematoxylin-eosin. Collagen fibers were detected by method of Vann-Gieson.

Endoscopic procurement of tympano-ossicular allografts: alternative to the transcranial or retroauricular technique.

A tympano-ossicular tissue bank complying with European Union regulations on human allografts is feasible and critical to assure that the patient receives tissue which is safe, individually checked and prepared in a suitable environment. The transcranial procurement technique has become the standard approach to procure tympano-ossicular allografts since the 1970s because it can provide en bloc allografts. Over the last 10-20 years, en bloc allografts have been abandoned and only the malleus (hammer) is left attached to the tympanic membrane. This modification enables introduction of the transmeatal procurement technique. Transmeatal procurement using readily available nasal 0° and 30° endoscopes is a feasible alternative which avoids contact with the dura mater and is not esthetically invasive to the donor. It involves a more time-consuming procurement but avoids the need for preparation of the temporal bone plug and is therefore generally more time-efficient.

Pathogenesis of middle ear cholesteatoma: a new model of experimentally induced cholesteatoma in Mongolian gerbils.

Middle ear cholesteatoma is characterized by enhanced proliferation of epithelial cells with aberrant morphological characteristics. To investigate the origin of the cholesteatoma cells, we analyzed spontaneously occurring cholesteatomas associated with a new transplantation model in Mongolian gerbils (gerbils). Cholesteatomas were induced in gerbils with a transplanted tympanic membrane by using the external auditory canal (EAC) ligation method. After the pars flaccida of the tympanic membranes were completely removed from male gerbils, corresponding portions of tympanic membranes of female gerbils were transplanted to the area of defect, and then we ligated the EAC (hybrid-model group). As a control group, the EAC of normal male and female gerbils was ligated without myringoplasty. In all ears of each group, the induced cholesteatomas were seen. In situ PCR was then performed to detect the mouse X chromosome-linked phosphoglycerate kinase-1 (pgk-1) gene on the paraffin sections. One pgk-1 spot in the epithelial nuclei was detected in male cholesteatoma, and two pgk-1 spots were detected in female cholesteatoma, respectively. On the other hand, in the hybrid-model group, we detected not only one but also two pgk-1 spots in the epithelial nuclei of cholesteatoma. These results strengthened the evidence that the origin of epithelial cells in cholesteatoma is the tympanic membrane in this model, but not the residential middle ear epithelial cells or the skin of the EAC.

A Systematic Review of Nonautologous Graft Materials Used in Human Tympanoplasty.

OBJECTIVES: Nonautologous graft materials may solve several dilemmas in tympanoplasty by obviating the need for graft harvest, facilitating consistent wound healing, and permitting graft placement in the clinical setting. Prior studies of nonautologous grafts in humans have shown variable outcomes. In this systematic review, we aim to 1) summarize clinical outcomes and 2) discuss limitations in the literature regarding nonautologous grafts for tympanoplasty in humans. METHODS: A literature review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. The study size, etiology and duration of perforation, type of nonautologous graft, and postoperative closure rate were assessed. RESULTS: The PRISMA approach yielded 61 articles, including 3,247 ears that met inclusion criteria. Studies evaluated nonautologous grafts including paper patch, gelatin sponge, growth factors, porcine small-intestinal submucosa, among others. Traumatic perforations (62.3%) were most commonly studied, whereas postinfectious perforations (31.9%) and other etiologies (5.8%) comprised a minority of cases. Acute perforations of <8 weeks duration constituted just over half of all treated ears. Overall closure rate was 82.1%, with significantly higher closure rates in acute (89.9%) versus chronic perforations (64.9%, P < .01), regardless of material. A median postoperative air-bone gap of 5.6 dB was found in the 23% of studies reporting this metric. CONCLUSIONS: The majority of publications reviewing nonautologous materials in tympanoplasty evaluate acute or traumatic perforations, and few rigorously report hearing outcomes. Given available data, porcine submucosa and basic fibroblast growth factor may hold promise for chronic perforation closure. Future studies should report closure rates and hearing outcomes in perforations >8 weeks duration. Laryngoscope, 131:392-400, 2021.

Long-Term Follow-Up After Fat Graft Myringoplasty: Do Size and Location Matter?

OBJECTIVE: To assess clinical and functional outcomes of a fat graft myringoplasty under local in an office setting. STUDY DESIGN: Prospective case series. SETTING: Tertiary care facility. PATIENTS: Patients with a tympanic membrane (TM) perforation presenting between December 2005 and June 2019. Inclusion criteria included perforation size >25% of the surface of the pars tensa of the TM, entire perforation margins visualized through a transcanal view, and lack of spontaneous closure at the 6-month follow-up. The exclusion criteria were the presence of cholesteatoma, wet appearance of the mucosa in the tympanic cavity, ear discharge in the 3 months before surgery, or signs of ossicular inconsistency. INTERVENTION: In-office fat graft myringoplasty technique under local anesthesia. MAIN OUTCOME MEASURES: Complete perforation closure rate and audiometric outcomes. RESULTS: A total of 121 patients underwent the procedure, of whom 21 had bilateral sequential procedures (total 142 ears). Average age was 51.1 ± 18.4 years (range, 3-78 years). The size of perforation was <25% of TM in 39 (27.5%) ears, 25% to 50% of TM in 49 (34.55%) ears, 50% to 75% of TM in 34 (23.91%) ears, and 75% to 100% of TM in 20 (14.10%) ears. Complete perforation closure was evident in 130 (91.55%) of the 142 ears. Preoperative mean air conduction threshold was 59.3 dB (17-95 dB) and significantly improved into 35.6 dB (10-85 dB; P < .0004) after surgery. Preoperative air-bone gap was 30.2 dB (5-70 dB) and also significantly improved into 10.2 dB (5-65 dB; P < .0001) after surgery. CONCLUSION: In office fat graft myringoplasty, in adult and pediatric patients with variable perforation sizes, is a well-tolerated procedure with very satisfactory clinical results.

[Tympanic membrane perforation and tympanoplasty]. / Les perforations tympaniques et les greffes de tympan.

OBJECTIVES: To report anatomic and physiologic characteristics of the tympanic membrane, to discuss the etiology and pathogenesis of tympanic perforation, and to discuss its management. MATERIAL AND METHODS: After a review of the literature, different surgical techniques and the postoperative results were evaluated. RESULTS: The rate of tympanic membrane closure is greater than 90% for the majority of authors. Age, mucosa inflammation, pathological contralateral ear (perforation, otitis media, cholesteatoma), and surgical experience influence this result. DISCUSSION: Even if surgical results are good, abstention must always be proposed and all complications must be explained. CONCLUSION: Palisade cartilage tympanoplasty is an effective technique for both tympanic membrane closures.

Study of steroid effects on graft and inner ear outcomes in tympanoplasty: Randomized controlled trial.

More studies are needed to investigate the side effects of steroids in tympanoplasty, owing to the paucity of such studies in the literature. This randomized, controlled clinical trial included 59 patients with chronic otitis media who underwent tympanoplasty and were randomized after surgery to a systemic steroid or no steroid treatment. Patients were randomized into two groups. Perforation size, graft outcome, and complications such as tinnitus and hearing loss were compared between the two groups. Postsurgical steroid injection had no effect on graft outcome (p = 0.927) or tinnitus (p = 0.478). Tympanic membrane perforation (p = 0.92), plaque size (p = 0.94), bleeding amount (p = 0.38), and mucosal status (p = 0.96) during surgery had no effect on graft outcome after the tympanoplasty. In conclusion, administration of steroids after tympanoplasty failed to improve outcome and may put the patient at risk of side effects.

Use of AlloDerm in type I tympanoplasty: a comparison with native tissue grafts.

OBJECTIVES: AlloDerm, an acellular human dermis allograft, has been shown to be an effective option as a tympanic membrane (TM) graft in animals and humans and has several potential advantages, including eliminating donor site morbidity, reducing operative time, and preserving native tissues for later use. We compared AlloDerm and native tissue grafts in type I tympanoplasty with regard to operative time, graft success rate, and audiologic outcome. STUDY DESIGN: A retrospective chart review of tympanoplasties performed at a major tertiary referral hospital over a 31 month period, starting with the first use of AlloDerm for TM grafting at this institution. METHODS: The medical charts of all patients undergoing tympanoplasty were reviewed. Only those patients undergoing type I tympanoplasty without mastoidectomy or ossicular chain reconstruction were included. These 114 patients (25 AlloDerm, 56 fascia reconstruction, and 33 fascia plus cartilage reconstruction) were compared for operative time, success rate of the graft, and change in audiologic outcome. RESULTS: There was a statistically significant reduction in operative time in the AlloDerm group when controlled for surgeon and choice of approach. All groups showed no statistically significant difference in the success rate of the graft and closure of audiologic air-bone gap, regardless of graft material used. CONCLUSIONS: AlloDerm is an effective TM graft when used in type I tympanoplasty. It is as effective as native tissues in closing the air-bone gap on audiogram as well as in graft success rate. AlloDerm may also significantly reduce operative time, depending on the surgeon's technique.

Bone cement ossiculoplasty: incus to stapes versus malleus to stapes cement bridge.

OBJECTIVE: In this study, our purpose was to evaluate results of our experience with bone cement repair of ossicular discontinuity between the incus and stapes and between the malleus and stapes. METHODS: Medical records of patients who underwent surgery for chronic otitis media between March 2000 and December 2002 were evaluated retrospectively. Fifty-seven patients who underwent bone cement ossiculoplasty and had appropriate follow-up data were included in the study. Bone cement reconstruction of the ossicular chain was performed 1) from incus to stapes (I-S) in the absence of long arm or lenticular process of the incus and 2) from malleus to stapes (M-S) in the absence of the incus. The clinical data of the patients were evaluated by otoscopic examination and audiometry. RESULTS: The graft take rate was 84.1%. I-S procedure was performed in 42 and M-S in 8 patients. Pre- and postoperative PTAs of all patients were compared, which showed a significant improvement in air PTA (p < 0.001) while bone PTA did not change (p > 0.05). In I-S and M-S groups, successful hearing restoration could be achieved in 78.6.1% and 87.5% of the patients, respectively. Hearing results of different aural pathologies (chronic otitis media and conductive hearing loss) and surgeries (tympanotomy and tympanoplasty with or without mastoidectomy) were not significantly different (p > 0.05). CONCLUSION: Bone cement ossiculoplasty offers cost effective and significant improvement in conductive hearing loss.

Tympanoplasty using homograft tympanic membranes and ossicles.

The use of homograft materials in reconstructive, mastoid, and middle ear surgery is increasing. Not only are they useful and practical, but they also do the job well in both anatomical and functional restoration. Many encouraging reports have been written to support their use. Their advantages, in the opinion of the author, outweigh their cost since they can offer a more efficient, versatile, and better method of restoration of hearing in tympanoplasty surgery.

The homograft myringoplasty and the lamina propria of the tympanic membrane.

The lamina propria of the tympanic membrane is composed of a unique system of radial and nonradial fibers which contribute importantly to its function. Over 1000 patients have undergone operations for the transplantation of the homograft tympanic membrane. Animal experiments have been presented to determine whether or not the fiber system of the lamina propria of the tympanic membrane is preserved in the homograft tympanic membrane. In conjunction with this, a small series of experiments was conducted to determine the appearance of the fiber system in perforations that heal spontaneously. Current knowledge concerning the function of the fiber network is discussed. The results of the present study indicate that the lamina propria fiber network is at least partially preserved in the homograft tympanic membrane and that the fiber network of the lamina propria is not reconstituted in spontaneously healed tympanic membranes.

Results of homografts in middle ear surgery.

Anatomical and hearing results following the use of the homograft tympanic membrane and ossicles either in combination or separately are reported for the period 1968 through 1975. The study is divided into two parts, the first covering the primary years 1968 through 1971, and the latter covering the last four years, 1972 through 1975. The original technique was to cover completely the homograft tympanic membrane with a canal skin graft. During the year 1969 new and different techniques were attempted. Unfortunately this resulted in a marked increase of graft failures; therefore, there was a prompt return to the original technique, which has been used without change throughout the study. The graft take rate for the first four years which included 1969 was 92%. There was a slight increase to 96% during the second part of the study. The hearing results show a greater discrepancy for the two periods with 89% of the patients receiving a satisfactory hearing result during the last four years, compared to 77% for the earlier period.

Results of tympanoplasty for congenital aural atresia and stenosis, with special reference to fascia and homograft as the graft material of the tympanic membrane.

The surgical management of congenital aural atresia is a challenging, complex procedure, and the risks are great. The otologic surgeon is responsible for keeping a patent external auditory canal and for achieving satisfactory hearing. The present report studied hearing changes that occurred after tympanoplasty and the long-term results of tympanoplasty in 12 cases of congenital aural atresia or stenosis. Patients were followed for more than 2 years after surgery. In four ears, an allograft of the tympanic membrane with an attached malleus was used, with a good graft take and hearing results. An autograft of temporal fascia was used in eight ears. Hearing acuity decreased in six of the eight ears and was maintained in two ears. Three primary surgery patients required revision surgery for postoperative restenosis of the external auditory canal. Some comments have been made with regard to this problem. Emphasis is also placed on the selection of patients for surgery using a thorough audiologic and roentgenologic evaluation.

Ossiculotympanic transplantation.

Continued investigations into current tympanoplasty problems have been carried out in the Eye and Ear Clinic, Royal Victoria Hospital, Belfast. Retrospective studies have been helpful in identifying some of the main problems responsible for many of our unsatisfactory results, both in the irradication of disease and the restoration of aural function. Prospective studies into the behavior of grafting materials for tympanic reconstruction in the experimental animal have led us to an overwhelming preference for natural materials as opposed to plastics or stainless steel. Both homologous and autologous bone and cartilage appear to offer good prospects in ossicular replacement techniques. The most satisfactory material we have used for repair of tympanic membrane defects continues to be either autologous or homologous temporalis fascia. The long-term success of these materials in functional restoration is utterly dependent on continued aeration of the tubotympanic cleft.

Homograft replacement of the tympanic membrane.

This paper presents the authors' experiences with one method of reconstruction of the tympanic membrane when it is totally absent or when there is a fixed, retracted, defective, or absent malleus. Ten patients undergoing surgery for chronic suppurative otitis media between April, 1971, and January, 1973, had homograft tympanic membranes and/or ossicles used to reconstruct the defect in the tympanic membrane or ossicular mechanism. The patients had certain clinical and surgical characteristics in common: 1. all had either an absent tympanic membrane or almost total perforation of it; 2. all were operated upon in the absence of acute infection or active drainage; cholesteatoma, if present, was totally removed; 3. all had patent eustachian tubes; 4. all had intact middle ear mucosa at the time of utilization of the homograft; 5. all patients were operated upon by the same surgeon; 6. all of the homografts were obtained within 24 hours and were used within one month after the death of the donor; 7. all of the homografts used had been preserved in 70 percent ethyl alcohol; 8. all of the homograft materials came from donors who were under 40 years of age at the time of death and who died of accidental causes. (None of the donors was known to have any pre-existing disease); 9. all homografts, after being placed in proper position in the recipient, were covered with ear canal skin; 10. all patients received homografts that were from the corresponding ear of the donor. (In other words, right ear homografts were used in the patient's right ear, etc.); 11. whenever the tympanic ring was greater than the size of the homograft, the patient's temporalis fascia was used in conjunction with the homograft tympanic membrane to bridge the defect; 12. all patients had the middle ear packed with gelfoam prior to inserting the homograft (compressed gelfoam was used also for the outer packing); 13. none of the patients had tissue-typing procedures carried out in an effort to match the donor and the recipient, nor was any attempt made to match the sex of the donor and the recipient; and 14. all patients received antibiotics postoperatively; however, none received immunosuppressive therapy postoperatively. In 3 of 10 patients receiving homografts, the malleus was normal, and only the tympanic membrane was reconstructed. In seven others there was a fixed, retracted, defective or absent malleus in addition to the tympanic membrane defect.(ABSTRACT TRUNCATED AT 400 WORDS)

Results of reconstructive mastoidectomy with homograft knee cartilage.

The technique of reconstructing the posterior canal wall with homograft knee cartilage originally described in 1972 is reviewed and refinements are presented along with additional cases. The homograft knee cartilage is used in conjunction with the homograft tympanic membrane and ossicles to rebuild the middle ear and mastoid as near as possible to anatomical configuration and function. Anatomical follow-up of one year or more is reported on 63 ears. Satisfactory results were obtained in 36 of these ears or 57% of the total. Hearing results are reported overall and in relation to different types of reconstruction. One year or more follow-up demonstrates satisfactory hearing with an air-bone gap of 20 db or less in 77% of the postoperative ears.

Risk of transmission of human immunodeficiency virus infection during tympano-ossicular homograft: an experimental study.

It is generally agreed that middle ear reconstructive surgery performed with tympano-ossicular homografts produces superior functional results compared with prosthetic material, especially with respect to extrusion rate. The use of homografts, though, has been seriously hampered recently by the fear of transmission of human immunodeficiency virus (HIV) infection. In HIV-infected patients, the virus is primarily found in the cells of the lymphoid and monocytic lineage. The nature of the tissues in the eardrum and ossicles, mostly fibrous tissue and compact bone without marrow, suggests that little virus load should be found in homografts. Indeed, culturing minced homograft tissue from two HIV-infected donors with acquired immune deficiency syndrome (AIDS) in a sensitive culture system with PHA-stimulated lymphoblasts produced no virus. Before use, homografts undergo a fixation procedure in 5% formaldehyde and then are kept in a solution containing Cialit as a preservative. The authors therefore examined the capacity of formaldehyde and Cialit to reduce the infectivity of HIV in models of infected tissue as measured in vitro. The reduction of in vitro infectivity due to these treatments was at least 10(5)-fold and 10(2)-fold, respectively. Coupled with the low virus burden in tympano-ossicular tissue, our data suggests that the fixation procedure affords such a reduction in infectivity that the risk of HIV transmission, even from an HIV-infected donor, is vanishingly low.

Hearing results in tympanoplasty.

Recent reports from Scandinavian authors have put forth the concept that hearing improvement following tympanoplasty is seldom satisfactory and difficult to obtain. This view is contradictory to the experience of most American authors. A study, therefore, was undertaken to evaluate the hearing results obtained by this author through the use of homograft material in middle ear and mastoid reconstruction. These hearing results are categorized according to time periods, types of reconstruction, and materials used. The hearing statistics are all taken from audiograms obtained one year or more postoperatively. These correspond with the type of reconstruction employed such as an intact ossicular chain, absence of the malleus, absence of the superstructure of the stapes, or both. Other categories include tympanoplasty with mastoidectomy or reconstruction of the posterior canal wall with homograft knee cartilage. The surgical techniques are not discussed in this article because they have been detailed in previous publications.

Allograft tympanoplasty: predictive value of preoperative status.

The functional and anatomical results of a series of 181 consecutive allograft tympanoplasties for ears with drum perforation and an intact ossicular chain were retrospectively reviewed and related to preoperative factors. Drum closure was realized in 92% (166 of 181 cases evaluated 1 year after surgery), and 96.6% of the reconstructed drums were still intact 3 years after surgery (118 cases evaluated). An air-bone gap of less than 21 dB was reached in 79.6% (of a total of 162 cases) 1 year after surgery, and in 78% (of a total of 118 cases) 3 years after surgery. Age, contralateral pathology, the wet or dry status of the ear preoperatively, and the preoperative air-bone gap had no influence on anatomical results. The preoperative air-bone gap did not predict the postoperative air-bone gap. The influence of age and existence of contralateral pathology on hearing gain was only visible in some of the strictly defined patient groups. The wet preoperative status of the ear generally predicted lower functional gain.

Homograft tympanoplasty in perspective. A long-term clinical-histologic study of formalin-fixed tympanic membranes used for the reconstruction of 125 severely damaged middle ears.

This seven and a half year clinical-histologic study evaluates the effectiveness of buffered, formaldehyde-fixed homograft tympanic membranes for reconstructing the severely damaged middle ear in 125 consecutive patients. Indications for use of homograft tympanoplasty were limited to those cases in which standard tympanoplasty had already failed to produce a satisfactory hearing or anatomic result (i.e., recurrent perforations or draining radical mastoidectomy cavity), or to those cases in which there was a high risk of unsatisfactory result with standard tympanoplasty techniques (i.e., total perforation with absent malleus or congenital aural atresia). Anatomic data was documented with serial postoperative photomicrography. Audiograms were performed at yearly intervals and long-term hearing results were analyzed. Histologic studies were performed on 2 homograft tympanic membranes removed 6 months and 6 years postoperatively. Postoperative photographs of the healing donor tympanic membrane and histologic studies confirmed that the homograft collagen attracts host angioblasts, fibroblasts and epithelial cells. The initial inflammatory response (primarily lymphocytic) subsides and the host produces collagen and elastin fibers interspersed among the donor collagen. Gradually the donor collagen is resorbed. At the completion of this study, 95% (119/125) of the homograft tympanoplasties are currently intact. There were 13 immediate postoperative perforations, but 11 were repaired with a second stage underlay fascia tympanoplasty. Long-term hearing results were analyzed according to the type of ossicular reconstruction employed (mean follow-up 4 years). In 87 patients with chronic otitis media, 94% of the type I repairs maintained an air-bone gap of 25 dB or less, 85% of the type II, and 81% of the type III. Forty-four patients presented with an absent malleus and absent tympanic membrane and were reconstructed with a homograft tympanic membrane with attached malleus and a shaped incus columella. At 4 years postoperatively, 83% of these patients maintained an average air-bone gap of 25 dB or better. A similar group of 38 patients presenting with absent malleus, incus, and stapes were reconstructed with isograft temporalis fascia and a cartilage covered TORP. Only 18% of the TORP patients maintained an air-bone gap of 25 dB 4 years postoperatively. Thirty-three patients with draining radical mastoidectomy cavities were reconstructed; 97% (32/33) had a dry, self-cleansing ear with no activity restriction. Only 59% maintained an air-bone gap closure of 25 dB or better in the long-term follow-up; 30% (10/33) developed persistent eustachian tube dysfunction, usually in the second through fourth postoperative years.(ABSTRACT TRUNCATED AT 400 WORDS)