The Journal of Laryngology and Otology November 1979. Vol. 93. pp. 1081-1086
Long-term results of myringoplasty with temporalis fascia By HEIKKI PUHAKKA, ERKKI VIROLAINEN and TAPANI RAHKO
(Turku, Finland) THE purpose of myringoplasty is to repair a perforation, of the tympanic membrane and thus improve the patient's hearing and decrease the susceptibility to infection. In previous years full thickness skin from either the postauricular area or the ear canal has been used most frequently as the grafting material (House, 1960; House and Sheehy, 1961; Sheehy, 1964). Subsequently connective tissue material has been used as graft material, e.g. periosteum, vein (Shea, 1960), ear lobe fat (Ringenberg, 1978) or homografts (Brandow, 1976; Marquet, 1976; Smyth, 1976). The primary result with each of these methods is good, starting with 60-70 per cent for the full thickness skin method and improving to 90-98 per cent for connective tissue material. One of the most commonly used connective tissue materials has been the fascia of the temporal muscle (Sheehy and Glasscock, 1967). The primary take rate of Sheehy and Glasscock's method has been 92-99 per cent. It is, however, apparent that the long term results are not so good, and in some cases reperforation has occurred. The purpose of this study was to examine, after a long follow-up period, patients who had undergone myringoplasty with temporalis fascia as the graft material. Material and methods
The study material consisted of 98 patients who had undergone myringoplasty during the period 1966-1974 at the Ear Department of the Turku University Central Hospital (T.Y.K.S.). The myringoplasty was performed under general anaesthesia and the incision was postauricular in 47 ears, endaural in 51 ears. Fascia from the temporal muscle was used as the graft material and it was placed on the outer surface of the tympanic membrane remnant and under the epidermis, as described by Sheehy and Glasscock (1967). At the time of surgery the patients' ages were as follows: 7 per cent 10 years or less, 21 per cent 11-20 years, 19 per cent 21-30 years, 18 per cent 31-40 years, 21 per cent 41-50 years and 12percent51-60years. The patients were invited to follow-up examinations on a random basis. However, patients who were over the age of 70 years were not invited. The follow-up period ranged from 3 to 12 years. 45 per cent of the patients had a follow-up period of 3-5 years, 49 per cent 5-10 years and 6 per cent over ten years. 10S1
1082
H. PUHAKKA, E. VIROLAINEN AND T. RAHKO
Otomicroscopy of the ears, pure tone audiometry and tympanometry were performed in conjunction with the follow-up examination. In addition certain anamnestic data was gathered. Results The etiology of the tympanic membrane perforation was infectious in 85 per cent of cases, traumatic in 13 per cent and unknown in 2 per cent. Prior to the myringoplasty there had been an exudate for less than a year in 37 per cent, for 1-2 years in 2 per cent, for 2-3 years in 8 per cent and for 3-4 years in 47 per cent. There had been no suppuration or exudation in 6 per cent of the cases at any time. Prior to surgery the ear had been dry in 23 per cent for less than 6 months, in 20 per cent for 0-5-1 year, in 20 per cent for 1-2 years, in 32 per cent for 2-3 years and in 4 per cent for over 3 years. In 62 per cent of the ears an attempt had been made to stimulate closure of the hole by means of a paper patch. The rest of the perforations had been considered to be so large that the use of a paper patch had not been attempted. In only 5 per cent of the cases had it been necessary, on account of suppuration, to give more than three courses of oral antibiotics prior to surgery. Preoperatively X-ray examination of the mastoid process showed it to be normal or nearly normal in 22 per cent, slightly sclerotic in 46 per cent, markedly sclerotic in 26 per cent and to be opaque in 6 per cent of the cases. Preoperatively, the perforation was evaluated as being small in 15 per cent, medium sized in 48 per cent and large in 37 per cent of the cases. The perforation was located anteriorly in 8 per cent, posteriorly in 29 per cent, centrally in 60 per cent, and in 3 per cent the annulus had been split by erosion. The results of the preoperative pure tone audiometry for air conduction at 500, 1,000 and 2,000 Hz. frequencies were as follows: 0 dB in 2 per cent, 1-10 dB in 32 per cent, 11-20 dB in 35 per cent, 21-30 dB in 24 per cent and 31-40 dB in 7 per cent. The corresponding preoperative results for bone conduction audiometry were as follows: 0 dB in 78 per cent, 1-10 dB in 16 per cent and 11-20 dB in 6 per cent. In conjunction with the surgery the ear canal was judged to be disturbingly narrow in only 9 per cent of the cases. The remainder of the tympanic membrane structures were considered to be normal, or nearly normal, in 82 per cent of cases, atrophic in 9 per cent, sclerotic in 5 per cent and edematous in 4 per cent. In conjunction with the surgery, the squamous epithelium was found to have crept on to the medial surface of the perforation in 7 per cent of cases, to surround the malleus handle in
LONG-TERM RESULTS OF MYRINGOPLASTY WITH TEMPORALIS FASCIA
1083
7 per cent and on to the mucous membrane of the tympanum in 3 per cent. In conjunction with the myringoplasty no support was placed under the graft in the tympanum in 72 per cent of cases, but in the remaining 28 per cent of the ears either plain or penicillin saturated gelfoam was placed in the tympanum. The packing of the ear canal was removed after 7 days in 97 per cent of cases, and in only 3 per cent of cases after a longer period of time. After the removal of the initial packing the ear canal was supported with a cloth packing in 76 per cent of cases for a week, and in 9 per cent for 2 weeks. In 15 per cent of the cases, after the removal of the initial packing, no further packing was applied. Postoperative infection was found in a total of 9 cases, 3 of which occurred during the first week, 3 after 1-4 weeks and the remaining 3 from 1-12 months. Hearing at frequencies greater than 6,000 Hz. was worsened in conjunction with the operation in one ear. The primary take rate of the myringoplasty after 6 months was 94 per cent (92/98). At the follow-up examination an intact tympanic membrane was found on otomicroscopy in 88 per cent of cases. The tympanic membranes were evaluated as follows: 63 per cent normal, 10 per cent too thick, 8 per cent slightly too lateral; 4 per cent (4) had blunting of the anterior meatal angle, 1 per cent adherent and 1 per cent baggy. A perforation was found in 12, of which 10 were dry and 2 exudative. Of these perforations 4 were small, 6 medium-sized and 2 large. The locations of the perforations were as follows: 1 anterior, 3 posterior and 8 central. Postoperative stricture of the ear canal was found in only two ears. 3 months after operation the hearing loss on pure tone audiometry at 500, 1,000 and 2,000 Hz. frequencies for air conduction averaged 0 dB in 21 per cent, 1-10 dB in 48 per cent, 11-20 dB in 13 per cent, 21-30 dB in 16 per cent and 31-40 dB in 1 per cent. 6 months after operation the corresponding values averaged as follows: 0 dB in 24 per cent, 1-10 dB in 53 per cent, 11-20 dB in 9 per cent, 21-30 dB in 12 per cent and 31-40 dB in 1 per cent. At the follow-up examination the average hearing results for the same frequencies were 0 dB in 36 per cent, 1-10 dB in 38 per cent, 11-20 dB in 13 per cent, 21-30 dB in 9 per cent and 31-40 dB in 4 per cent (Table I). There was an abnormal result in 19 per cent (16/86) of the tympanometry tests performed. In these 16 cases the tympanic membrane was found upon otomicroscopy to be normal, or nearly normal, in 8 cases, too thick in 4 cases and located too laterally in 4 cases. In those cases in which preoperative X-rays of the mastoid process had been either normal or slightly sclerotic, the condition of the tympanic membrane and hearing at the follow-up examination was significantly better than in cases in which the process was markedly sclerotic or opaque (p
Long-term results of myringoplasty with temporalis fascia By HEIKKI PUHAKKA, ERKKI VIROLAINEN and TAPANI RAHKO
(Turku, Finland) THE purpose of myringoplasty is to repair a perforation, of the tympanic membrane and thus improve the patient's hearing and decrease the susceptibility to infection. In previous years full thickness skin from either the postauricular area or the ear canal has been used most frequently as the grafting material (House, 1960; House and Sheehy, 1961; Sheehy, 1964). Subsequently connective tissue material has been used as graft material, e.g. periosteum, vein (Shea, 1960), ear lobe fat (Ringenberg, 1978) or homografts (Brandow, 1976; Marquet, 1976; Smyth, 1976). The primary result with each of these methods is good, starting with 60-70 per cent for the full thickness skin method and improving to 90-98 per cent for connective tissue material. One of the most commonly used connective tissue materials has been the fascia of the temporal muscle (Sheehy and Glasscock, 1967). The primary take rate of Sheehy and Glasscock's method has been 92-99 per cent. It is, however, apparent that the long term results are not so good, and in some cases reperforation has occurred. The purpose of this study was to examine, after a long follow-up period, patients who had undergone myringoplasty with temporalis fascia as the graft material. Material and methods
The study material consisted of 98 patients who had undergone myringoplasty during the period 1966-1974 at the Ear Department of the Turku University Central Hospital (T.Y.K.S.). The myringoplasty was performed under general anaesthesia and the incision was postauricular in 47 ears, endaural in 51 ears. Fascia from the temporal muscle was used as the graft material and it was placed on the outer surface of the tympanic membrane remnant and under the epidermis, as described by Sheehy and Glasscock (1967). At the time of surgery the patients' ages were as follows: 7 per cent 10 years or less, 21 per cent 11-20 years, 19 per cent 21-30 years, 18 per cent 31-40 years, 21 per cent 41-50 years and 12percent51-60years. The patients were invited to follow-up examinations on a random basis. However, patients who were over the age of 70 years were not invited. The follow-up period ranged from 3 to 12 years. 45 per cent of the patients had a follow-up period of 3-5 years, 49 per cent 5-10 years and 6 per cent over ten years. 10S1
1082
H. PUHAKKA, E. VIROLAINEN AND T. RAHKO
Otomicroscopy of the ears, pure tone audiometry and tympanometry were performed in conjunction with the follow-up examination. In addition certain anamnestic data was gathered. Results The etiology of the tympanic membrane perforation was infectious in 85 per cent of cases, traumatic in 13 per cent and unknown in 2 per cent. Prior to the myringoplasty there had been an exudate for less than a year in 37 per cent, for 1-2 years in 2 per cent, for 2-3 years in 8 per cent and for 3-4 years in 47 per cent. There had been no suppuration or exudation in 6 per cent of the cases at any time. Prior to surgery the ear had been dry in 23 per cent for less than 6 months, in 20 per cent for 0-5-1 year, in 20 per cent for 1-2 years, in 32 per cent for 2-3 years and in 4 per cent for over 3 years. In 62 per cent of the ears an attempt had been made to stimulate closure of the hole by means of a paper patch. The rest of the perforations had been considered to be so large that the use of a paper patch had not been attempted. In only 5 per cent of the cases had it been necessary, on account of suppuration, to give more than three courses of oral antibiotics prior to surgery. Preoperatively X-ray examination of the mastoid process showed it to be normal or nearly normal in 22 per cent, slightly sclerotic in 46 per cent, markedly sclerotic in 26 per cent and to be opaque in 6 per cent of the cases. Preoperatively, the perforation was evaluated as being small in 15 per cent, medium sized in 48 per cent and large in 37 per cent of the cases. The perforation was located anteriorly in 8 per cent, posteriorly in 29 per cent, centrally in 60 per cent, and in 3 per cent the annulus had been split by erosion. The results of the preoperative pure tone audiometry for air conduction at 500, 1,000 and 2,000 Hz. frequencies were as follows: 0 dB in 2 per cent, 1-10 dB in 32 per cent, 11-20 dB in 35 per cent, 21-30 dB in 24 per cent and 31-40 dB in 7 per cent. The corresponding preoperative results for bone conduction audiometry were as follows: 0 dB in 78 per cent, 1-10 dB in 16 per cent and 11-20 dB in 6 per cent. In conjunction with the surgery the ear canal was judged to be disturbingly narrow in only 9 per cent of the cases. The remainder of the tympanic membrane structures were considered to be normal, or nearly normal, in 82 per cent of cases, atrophic in 9 per cent, sclerotic in 5 per cent and edematous in 4 per cent. In conjunction with the surgery, the squamous epithelium was found to have crept on to the medial surface of the perforation in 7 per cent of cases, to surround the malleus handle in
LONG-TERM RESULTS OF MYRINGOPLASTY WITH TEMPORALIS FASCIA
1083
7 per cent and on to the mucous membrane of the tympanum in 3 per cent. In conjunction with the myringoplasty no support was placed under the graft in the tympanum in 72 per cent of cases, but in the remaining 28 per cent of the ears either plain or penicillin saturated gelfoam was placed in the tympanum. The packing of the ear canal was removed after 7 days in 97 per cent of cases, and in only 3 per cent of cases after a longer period of time. After the removal of the initial packing the ear canal was supported with a cloth packing in 76 per cent of cases for a week, and in 9 per cent for 2 weeks. In 15 per cent of the cases, after the removal of the initial packing, no further packing was applied. Postoperative infection was found in a total of 9 cases, 3 of which occurred during the first week, 3 after 1-4 weeks and the remaining 3 from 1-12 months. Hearing at frequencies greater than 6,000 Hz. was worsened in conjunction with the operation in one ear. The primary take rate of the myringoplasty after 6 months was 94 per cent (92/98). At the follow-up examination an intact tympanic membrane was found on otomicroscopy in 88 per cent of cases. The tympanic membranes were evaluated as follows: 63 per cent normal, 10 per cent too thick, 8 per cent slightly too lateral; 4 per cent (4) had blunting of the anterior meatal angle, 1 per cent adherent and 1 per cent baggy. A perforation was found in 12, of which 10 were dry and 2 exudative. Of these perforations 4 were small, 6 medium-sized and 2 large. The locations of the perforations were as follows: 1 anterior, 3 posterior and 8 central. Postoperative stricture of the ear canal was found in only two ears. 3 months after operation the hearing loss on pure tone audiometry at 500, 1,000 and 2,000 Hz. frequencies for air conduction averaged 0 dB in 21 per cent, 1-10 dB in 48 per cent, 11-20 dB in 13 per cent, 21-30 dB in 16 per cent and 31-40 dB in 1 per cent. 6 months after operation the corresponding values averaged as follows: 0 dB in 24 per cent, 1-10 dB in 53 per cent, 11-20 dB in 9 per cent, 21-30 dB in 12 per cent and 31-40 dB in 1 per cent. At the follow-up examination the average hearing results for the same frequencies were 0 dB in 36 per cent, 1-10 dB in 38 per cent, 11-20 dB in 13 per cent, 21-30 dB in 9 per cent and 31-40 dB in 4 per cent (Table I). There was an abnormal result in 19 per cent (16/86) of the tympanometry tests performed. In these 16 cases the tympanic membrane was found upon otomicroscopy to be normal, or nearly normal, in 8 cases, too thick in 4 cases and located too laterally in 4 cases. In those cases in which preoperative X-rays of the mastoid process had been either normal or slightly sclerotic, the condition of the tympanic membrane and hearing at the follow-up examination was significantly better than in cases in which the process was markedly sclerotic or opaque (p
