A Comparative Study of Endoscopic versus Microscopic Cartilage Type I Tympanoplasty

THIEME e80 Original Research A Comparative Study of Endoscopic versus Microscopic Cartilage Type I Tympanoplasty Dipesh Shakya1 Arun KC2 Ajit Nepal3 1 Department of Otorhinolaryngology, Civil Service Hospital, Kathmandu, Nepal 2 Department of Otorhinolaryngology, National Academy of Medical Sciences, Kathmandu, Nepal 3 Department of Otorhinolaryngology, Patan Academy of Health Science, Lalitpur, Nepal Address for correspondence Dr. Dipesh Shakya, Department of otorhinolaryngology, MD, MS, Civil Service Hospital, Minbhawan Kathmandu, Kathmandu, 44600, Nepal (e-mail: ). Int Arch Otorhinolaryngol 2020;24(1):e80–e85. Abstract Keywords ► tympanoplasty ► cartilage ► microscope ► endoscope received April 17, 2019 accepted May 21, 2019 Introduction The use of endoscope is rapidly increasing in otological and neurootological surgery in the last 2 decades. Middle ear surgeries, including tympanoplasty, have increasingly utilized endoscopes as an adjunct to or as a replacement for the operative microscope. Superior visualization and transcanal access to diseases normally managed with a transmastoid approach are touted as advantages with the endoscope. Objectives The present study aimed to compare the outcomes of endoscopic and microscopic cartilage tympanoplasty (Type I) Methods This was a retrospective comparative study of 70 patients (25 males and 45 females) who underwent type I tympanoplasty between March 2015 and April 2016. The subjects were classified into 2 groups: endoscopic tympanoplasty (ET, n ¼ 35), and microscopic tympanoplasty (MT, n ¼ 35). Tragal cartilage was used as a graft and technique used was cartilage shield tympanoplasty in both groups. Demographic data, perforation size of the tympanic membrane at the preoperative state, operation time, hearing outcome, and graft success rate were evaluated. Results The epidemiological profiles, the preoperative hearing status, and the perforation size were similar in both groups. The mean operation time of the MT group (52.63  8.68 minutes) was longer than that of the ET group (48.20  10.37 minutes), but the difference was not statistically significant. The graft success rates 12 weeks postoperatively were 91.42% both in the ET and MT groups, that is, 32/35; and these values were not statistically significantly different. There was a statistically significant improvement in hearing within the groups, both pre- and postoperatively, but there was no difference between the groups. Conclusion Endoscopic tympanoplasty is a minimally invasive surgery with similar graft success rate, comparable hearing outcomes and shorter operative time period as compared to microscopic use. DOI https://doi.org/ 10.1055/s-0039-1693139. ISSN 1809-9777. Copyright © 2020 by Thieme Revinter Publicações Ltda, Rio de Janeiro, Brazil A Comparative Study of Endoscopic versus Microscopic Cartilage Type I Tympanoplasty Shakya et al. Introduction Chronic otitis media (COM) is one of the most common problems in otology, which leads to permanent changes in the tympanic membrane and/or in the structures of the middle ear.1 It is further classified as non-cholesteatomatous and cholesteatomatous.2 Type I tympanoplasty is the repair of the perforation of the tympanic membrane, and it was first performed by Berthold (1878), later popularized by Wullstein and Zollner (1950).3 Although the temporalis fascia is still being used as graft material, it has been largely replaced by cartilage due to its stability and long-term uptake result.4 A microscope was first used by Swedish otologist Carl Olof Nylen in 1921, but it was monocular. Later Binocular microscope was used by Gunner Holmgren in 1922; however, this type of microscope was not popular due to poor light quality, limited field of vision, instability and very short focal distance until new model appeared in 1951 which was perfected by Littmann and the Zeiss company that replaced all other models.5 The microscope gives the advantage of magnified vision, good depth perception, and utilizes two hand techniques. However, it has the disadvantages of giving straight line vision and of not providing a good vision of deep recesses.6 The use of the endoscope is rapidly increasing in otological and neuro-otological surgery in the last 2 decades. Middle ear surgeries, including tympanoplasty, have increasingly utilized endoscopes as an adjunct to or as a replacement for the operative microscope. Superior visualization and transcanal access to diseases normally managed with the transmastoid approach are touted as advantages of the endoscope.7 The objectives of the present study were to compare the outcome of endoscopic and microscopic cartilage Type I tympanoplasty regarding graft uptake rate, hearing outcome, and operation time. Methods We performed a retrospective comparative study of prospectively maintained data of 70 patients (25 males and 45 females) who underwent type I tympanoplasty from March 2015 to April 2016. The subjects were classified into 2 groups: endoscopic tympanoplasty group (ET, n ¼ 35), and microscopic tympanoplasty group (MT, n ¼ 35). All of the surgeries used tragal cartilage as graft and shield technique used. Demographic data, perforation size of the tympanic membrane at the preoperative state, operation time, and graft success rate were evaluated. For the ET group, all of the cases were performed transcanally, whereas in the MT group the permeatal and postaural approaches were used. Three cases of the MT group needed the postaural approach due to the lack of vision of the anterior margin. All of the procedures were performed by two surgeons (the first two authors of the present article). Patients aged < 13 years old were operated under general anesthesia, and those 13 years old were operated under local anesthesia. Cases operated under local anesthesia were performed on a day-case Fig. 1 Preoperative perforation basis without admission. Ethical clearance was obtained from the Institutional Review Board. A local antibiotic and steroid treatment was performed in case of preoperative inflammation of the tympanic cavity. A tragal cartilage graft was harvested, and the perichondrium was removed on both sides. The margin of the perforation was refreshed, and the drum remnant was removed from the handle of the malleus. The mobility of the ossicular chain was checked. The graft was shaped to the size of the perforation. Gelfoams were kept in the middle ear accordingly. For the posterior perforation, the graft was placed in the underlay technique, medial to the handle of the malleus, to the tympanic membrane, and to the annulus. For central, anterior and subtotal perforations, the graft was notched to fit the handle of the malleus and placed in the over-underlay technique. All of the cases were then reinforced using the perichondrium. The tympanomeatal flap was pulled down and the annulus was meticulously inserted in the sulcus. The external auditory canal (EAC) was packed with gelfoam and th (...truncated)