Discussion:
For many years the so called conservative methods of radical mastoid operations (Barany, Bondy, Citelli, Heerman, Stacke) were done in the clearance of disease but none of these proved better. At later dates Farrior, House, Lempert, Morrison added some minor variations in the technique of reconstructive tympanoplasty but still could not achieve the good results because the recurrence of the disease was very high. To modify these Victor Goodhill, Heerman and Heerman demonstrated their new techniques which prevented the recurrence of the cholesteatoma and gained the high success rates.

In this study 600 ear operations were performed with tragal perichondrium and cartilage as a composite graft in various types of middle ear reconstructions such as myringoplasty, ossiculoplsty, osseous reconstructions and mastoid obliterations. This study was done at K.E.M. Hospital E.N.T. department, Pune during 1980–2000. We have presented our observations of this reconstructive study of 20 years and found that the tragal cartilage is an ideal graft for the reconstructive middle ear surgery.

In the simple myringoplasty group the tragal perichondrium and cartilage achieved 96% success rate, the small, large and subtotal central perforations healed well in six weeks time. The inlay and onlay methods were used in the neotympanic reconstruction. In the total perforations and missing annulus the perichondrium angle was appropriate fit in forming the new annulus the perichondrium angle was appropriate fit in forming the new annulus. By this technique the blunting and lateralisation of the graft was prevented from the various cartilage assemblies in ossicular reconstruction achieved excellent stability and contact to bridge the gap in transformer mechanism. The incudostapedial gap was restored by cartilage sturt and maintained assembly. The malleostapedial, malleofootplate assembly proved good in restoring hearing.

In TORP. & PORP ossicular graft the interposed tragal cartilage and drum have increased the ossicular stability and improved hearing to 75% (Victor Goodhill). Chronic endotympanic depression is a pathological entity which leads to atelectasis, retraction pockets and cholestestoma formation. The tragal cartilage and perichondrium composite graft intervention has prevented the recurrence of the cholesteatoma pocket adhesions and tympanosclerosis. The postop results were dryhealed middle ears with good hearing.

During the study it was observed that middle ear patology of 40% perforaytions of safe and unsafe types, 4% adhesive otitis media, 6% tympaosclerosis, 30% retraction pockets and 20% cholesteatoma sacs. All these pathologies were corrected by radical removal and tragal cartilage reconstruction.

In mastoid obliteration the palisade cartilageplasty proved in gaining dry cavities in 70% of the cases. The Eustachian tubal obstruction was relieved by tunnelplasty and improved the good middle ear aeration. The cartilage bridge over promontory and hypotympanum assures the proper contact with stapes and in the combined approach tymparoplasty procedure the recurrence of cholesteatoma in the sinus tympani and facial recess could be prevented by incorporating the composite tragal cartilage and perichondrium. In open cavities the tympanocartige stapedopexy improved the hearing. It was our observation that biological material like tragal cartilage, perichondrium, facia or ossicles etc. are much better than nonbiological materials in reconstructive surgery. The survival rate of tgragal graft material is much better than nonbiological materials.

The extrusion rate of cartilage is very minimal as compared to the other graft materials. The review of literature revealed the different extrusion rates of different materials, such as autologous, 1.19%, isografts 3.06% the synthetics 5.04%, human dentine 7.14%, gold prosthesis 8.7%. Overall the tragal cartilage and perichondrium proved to be the best graft materials in reconstructive tympanoplasty which is universally accepted.



Table VIII :Extrusion rates of commonly used graft materials:

Graft material	Extrusion rate (%)
Autograft	1.19
Isograft	3.06
Synthetic	5.04
Human Dentine	7.14
Gold prosthesis	8.70

Table IX :Results of cartilage tympanoplasty: P=0.0001 by chi square:

Group	Success (%)	Failure (%)
Myringoplasty	96	04
Ossiculoplasty	84	16
Osseusplasty	75	25
Mastoid obliteration	70	30

Table X – Poor results in cartilageplasty:

Causes	No. of cases
Displacement	12
Fibrosis	10
Absorption	06
Infection	08
Total	36

TABLE V – Pathological Defects:

Type of Pathology	No. of Cases	Percet
Performation	240	40
Adhesive Otitis media	24	04
Tympanosclerosis	36	06
Retration pocket	180	30
Cholesteatoma	120	20
Total	600	100

Table VI – Ossiculoplasty:

Lesion	No. of cases	Percent
Attic	55	50
Posterosuperior quadrant	33	30
Posterior canal wall	11	10
Eustachian tube	11	10
Total	110	100

Table VII – Ossicular Status (300 cases): –P=0.0001 by Chi square:

Structure	Normal	Eroded	Destroyed
Maleus	120	72	108
Incus	000	96	204
Stapes	108	00	192

In view of the above study we strongly recommend the tragal perichondrium and cartilage composite graft in various tympanoplasty reconstructions. The main reason being the cartilage is easily available at the site of operation, nontoxic, less, extrusion, minimum shrinkage, and lateralisation above all it is very cost effective to our patients. The hearing improvement within 15db of bone conduction has become almost a standard criterion for the analysis of surgical success.



References

Extrusion Rate of Commonly Used Graft Material
• Aeaham Evitor and Bronx NY: Tragal perichondrium and cartilage in reconstructive ear surgery, Laryngoscopy, 88 (Suppl.): 1–23,1978.
• Heerman and Heerman tympanoplasty and mastoidoplasty, Laryngorhinootology, 46:370–382, May 1968.
• Plester D.: Myringoplasty methods, Archieves otolaryngology, 78:310–316, Sept.1963.
• House H. P.: Surgical repair of the perforated drum, Annales otorhinolaryngology, 62 : 1072–1093, 1956.
• Goodhill Victor, Harris I., and Brockman S. J.: Tympanoplsty with perichondrium graft, Archieves otolaryngology, 79, 131, 1963.
• Claus Jansen : Cartilage tympanoplasty, Laryngoscope, 73: 1288, 1963.
• Heerman and Heerman: Fascia and cartilage palisade tympanoplasty, Archieves otology, 91 : 228–241, 1970.
• Victor Goodhill: Tragal perichondrium and cartilage in tympanoplasty, Archieves otology, 85:480–491,1963.
• Jansen C.: Use of perichondrium for tympanoplasty, Archives ohren, 182:610–614, 1963.
• Shea J. J.: Vein graft in tympanic reconstruction, Journal of laryngootology, 74:358–362, 1960.

Contributed by Dr. K. K. Desarda