Surgical Procedure
A local antibiotic was given in case of preoperative inflammation of the
tympanic cavity. The surgery was only performed was the middle ear
cavity was dry clinically. A tragal cartilage graft was harvested in the
case of a transcanal approach and conchal cartilage was obtained in case
of a postaural approach. The perichondrium was removed on both sides in
both grafts tragal and conchal.
The margin of perforation was freshened. Two vertical incisions were
given at 12 o’clock and 5 o’clock, which related to a horizontal
incision about 10mm lateral to the annulus. Tympanomeatal flap was
elevated from the posterior canal wall. The posterior annulus was
elevated out of the sulcus and the mobility of the ossicular chain was
checked.
Gelfoams (SPONGOSTAN™ Special, Ferrosan Medical Devices A/S, Soeborg,
Denmark) were kept in the middle ear accordingly. The barred cartilage
shaped according to the size needed was negotiated under the malleus
handle (underlay technique). If the middle ear space was compromised due
to a medialized handle of malleus, the cartilage was notched to fit the
handle of malleus. Then the perichondrium was placed as reinforcement
using the underlay technique under the handle of malleus and pushed
anteriorly up to anterior margin. The tympanomeatal flap was placed back
in the posterior canal wall. The perichondrium was adjusted to fit and
tug around the anterior margin of perforation. Thus, perichondrium
reinforced barred cartilage graft technique was used in both MT and ET
groups. A Final check was done to ensure there was a touch of
perichondrium cartilage graft with anterior margin and annulus (Figure).
The EAC was packed with gelfoam and then with ear pack (Osseous Ear
Pack, EonMeditech Pvt ltd.), which was removed after 7 days. No suture
was applied in the graft site in case of a transcanal approach. For the
postaural approach, the incision site was sutured, and the mastoid
bandage was applied.
Patients were followed up at 6 weeks, 12 weeks, 6 months, and with a
minimum of 12 months, and thereafter as needed. The average on four
frequencies (0.5, 1, 2, and 3 kHz) of hearing thresholds in air and bone
conduction and the Air Bone Gap (ABG) was evaluated 7 days before
surgery and 12 weeks after.