Surgical and Audiological Outcomes of Cartilage Perichondrial Grafting Myringoplasty

Surgical and Audiological Outcomes of Cartilage Perichondrial Grafting Myringoplasty | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Surgical and Audiological Outcomes of Cartilage Perichondrial Grafting Myringoplasty Yousif Ibrahim Chalabi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4165474/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Myringoplasty, which is type 1 tympanoplasty, is the surgical reconstruction of the tympano-ossicular continuity after thorough disease clearance from a tympano-mastoid portion of the middle ear cleft. The success of the myringoplasty, a reconstruction of the vibrating tympanic membrane, is in hearing improvement and the closure of the tympanic membrane perforation. Objectives: To determine the surgical and audiological results of myringoplasty (tympanoplasty type-1) using cartilage perichondrium graft. Patients & methods: A prospective study was conducted on 100 patients with tympanic membrane perforation (TMP) at Sulaimani Ear-Nose-Throat (ENT) Teaching Center and Azmar Private Hospital, Sulaimaniyah, Iraq, from June 2013 to June 2016. Patients underwent TM repair using an underlay cartilage perichondrium graft and were followed up for three months after surgery. Graft taking with the closure of perforation was considered a surgical success, and hearing improvement of 10 dB as the minimum gain was regarded as an audiological success. Results: The overall success rate was 84%. The graft take rate for large-sized perforation was 80%, and for medium-sized perforation was 90%. The success rate for posterior perforation was 100%, followed by anterior perforation (84.6%) and subtotal perforation (70%). The mean postoperative hearing gain was 11.5 dB. Conclusions: The cartilage perichondrium graft underlay technique for myringoplasty tympanoplasty type 1 is an effective method for closure of the tympanic membrane perforations and, consequently, improving hearing provided that a thorough disease clearance from Middle ear cleft was secured. Audiological outcome graft taking rate myringoplasty cartilage perichondrial graft Introduction The tympanic membrane (TM) or eardrum is a thin pearly grey membrane of 3 layers in its active vibrating part at pares tense, which measures 55 mm 2, whereas the whole TM, including pares flaccid, measures 81 mm2. It transmits sound from the external ear canal to the middle ear ossicles and joints to inner ear fluid across the stapes foot plate at the oval window where the acoustic, mechanical energy is converted into an electrical action potential of cochlear microphonic, which is conducted as nerve electrical impulses across the cochlear nerve to cochlear nuclei and perceived as sound at auditory centre in pre-temporal gyrus at Broca's area. It also plays an important role in hearing and protects the middle ear from dirt, bacteria, and debris entrance [1]. Tympanic membrane perforation (TMP) is a defect resulting from tear/rapture in the TM [2]. It can be caused by otitis media that results in ischemia and necrosis of the TM, leading to breakdown and rupture. Other factors are trauma, whether a caustic or accidental, or rapid changes in pressure (barotraumatic) leading to sudden otalgia, otorrhea, tinnitus, vertigo, substantial pain, aural discharge (including blood) from the ear, and hearing loss [3, 4]. The defect of TM diminishes the impedance mismatch and decreases the pressure differential induced by sounds, leading to decreased ossicular coupling [5]. Multiple factors, such as perforation size, sound frequency tested, middle ear space dimensions, and mastoid volume, determine the hearing loss associated with TMP. The most common region for rupture is in the central region of paras tense anteroinferior, followed by the anterior central and posterior central regions to handle the malleus, respectively, with an intact rim of TM at the circumferential margin, correlating to the pars tensa being the most frequently injured [6]. In most cases, TMP can repair spontaneously, but when it does not heal, such as in chronic otitis media (COM) representing anatomical and functional defects, it requires surgical correction [7]. Tympanoplasty is one of the routine surgeries performed in ENT practice, and it is used to check/reconstruct the ossicular chain integrity and repair the TM and middle ear sound conducting mechanism with clearance of disease [8]. Graft materials, including temporalis fascia, vein graft, fascia lata, cartilage, and perichondrium or cartilage perichondrium, are used to seal the perforations. Using cartilage-perichondrium composite graft in selective cases gives a better outcome. Among these, temporalis fascia remains the commonly used graft with a success rate of 93-97% [8], while in poor eustachian tube dysfunction, adhesive otitis media, tympanic sclerosis or total/subtotal perforation, the results are poor. As cartilage metabolism is slow, and nutrients are acquired via diffusion, cartilage graft is stable and tolerates poor conditions such as negative pressure and eustachian tube dysfunction. Therefore, placement of cartilage grafts during tympanoplasty is common. However, perichondrium is strong, thin, and easier to manipulate than cartilage. In severe cases, cartilage perichondrium is a better alternative as it provides stability against retraction [9]. Thus, in the current study, we aimed to use cartilage-perichondrium composite grafts in the repair of various TMPs and study their functionality and feasibility. Patients and methods Study setting and design A prospective study conducted on 100 patients (100 ears) aged 12-50 years who attended Sulaimani ENT Teaching Center and Azmar Private Hospital, Sulaimaniyah, Iraq, from June 2013 to June2016. Inclusion criteria Patients with inactive mucosal COM and dry central perforation for at least a few weeks pre-operatively with intact ossicular chains were included in the study. Exclusion criteria Patients with cholesteatoma, active mucosal disease with aural discharge, previous tympanic surgery, severe tympanosclerosis, only hearing ear, and sensorineural hearing loss (SNHL) were excluded from the study. Questionnaire The patient's age, gender, myringoplasty (perforation size), site of TMP, the approach used, and pre/postoperative audiogram results were collected using a validated self-created questionnaire. Study protocol Enrolled TMP, the central type with variable size, was divided into three types: subtotal (when the damage affected most of the active vibrating eardrum at pares tense), anterior (when the damage was anterior to the handle of the malleus) and posterior (when the perforation posterior to the handle of malleus). The TMP was also divided according to their size into medium (>25%, but 50%) active vibrating area of pares tense, which measures 55 mm 2 . All selected cases were dry, and the ossicular chains showed normal mobility at the time of operation. The assessment of the patient was established on the basis of history and general clinical examination otoscopically, microscopically, and audiologically using pure tone audiometry (PTA). Surgery is done under general anaesthesia with local anaesthetic infiltration of tragal, conchal cartilages and canal wall when required. The surgical approach depended on the dimension of the external auditory canal, the site of TMP, and the surgeon's preferences. Canaloplasty for anterior perforation was done through refreshment of the TMP edge using an endaural, postauricular or endometrial approach. In endaural and endometrial approaches, tragal cartilage was used as graft material, whereas ear conchal cartilage was used for the postauricular approach. The tympanometry flap was raised, and ossicles were examined for integrity and mobility, while the middle ear cavity was assessed for any disease or pathology like tympanosclerosis or mringosclerosis and removed accordingly. Composite cartilage perichondrium grafts were used in all cases, and gel foam was used as a support material for the middle ear. The grafts were inserted on the medial surface of the eardrum remnant. Hearing was assessed postoperatively at 3, 6 and 12 weeks by tunning fork and PTA. Pre/postoperative air-bone gap (ABG) was calculated through the average of bone/air conductions at various frequencies (500, 1000, 2000, and 4000 Hz), and a minimum hearing improvement of 10 dB was regarded as an audiological success. Follow-up Patients were followed up at weekly intervals for one month and monthly for three months after surgery. At follow-up examination, the result of the surgery was regarded as successful if the ear was dry and the TMP was covered by successful graft taking and proved mobile by dieselization from the end of 1 st month and subsequent follow-up with a minimum 10 dB hearing gain checked by PTA and tuning fork 256 and 512 HZ (change of negative Rinne test to positive one). Statistical analysis The data were analyzed using Statistical Package for the Social Sciences (SPSS, IBM, USA, version 26). Data were expressed as numbers and percentages (%) for categorical variables and mean ± standard deviation (SD) for numerical data. Results Regarding the patients’ sociodemographic data, their age range was 10 - 50 years, with a mean age of 23.8 ± 3.2 years. Most patients (56%) were in the 10-24 years age group, followed by 25-35 years age group (32%) and only 12 patients (12%) were aged 36 - 50 years. The successful rate of TMP correction using cartilage-perichondrium composite graft was maximum in the 36 - 50 years age group (100%), followed by the 25 - 35 years age group (87.5%), then the 10 - 24 years age group (78.6%). On the other hand, most patients with TMP were females (68%), but the successful rate of TMP correction was higher among males (87.5%). Most patients were successful in taking TM graft (84%) with median-sized myringoplasty (90%) on the posterior site (100%) using a postural approach (85.7%) (Table 1). The highest audiological gain (air conduction threshold) of successful cases (n=84) of TMP closure was 25 - 35 dB (54.8%) preoperatively and 0.0 - 19 dB (52.4%) postoperatively (Table 2). Moreover, the mean ABG of successful cases of TMP closure was 25.3 ± 1.1 dB preoperatively, 13.8 ± 2.7 dB postoperatively, and 11.5 ± 3.4 dB for hearing improvements (Table 3). Furthermore, the preoperative audiological result of successful cases (n=84) of TMP closure was the highest loss at 500 Hz frequency (30.3 ± 0.5). Similarly, the postoperative results reported the highest gain at 500 Hz (18.1 ± 1.0) (Table 4). Discussion The use of cartilage as a grafting material can be advocated in complex perforations of high risk for graft failure such as large, subtotal, total perforations, adhesive tympanic membrane, tympanosclerotic and atropic changes of remnant TM, recurrent perforations and in cases with chronic eustachian tube dysfunction [8]. In the current study, the patient's age with TMP ranged from 10 - 50 years old, with a mean age of 23.8 ± 3.2 years. Age groups 12 - 24 years old (56%) and females (68%) were the most affected. In this regard, Indorewala et al. reported the age range of the patients from 5 - 76 years, with a mean age of 35±15.8 years and the age group 31 - 45 years was the most affected group (33.3%). Also, they stated that most patients (52.6%) with TMP were females [10], which coincides with the current study results. The highest graft-taking success rate was in the 36 - 50 years age group (100%) and regarding gender among males (87.5%). In this regard, Koch et al. reported the highest successful rate (81%) for children aged ≥8 and a 30% successful rate for younger patients [11]. However, Biswas et al. found a better success rate with advancing age, and they indicated that tympanoplasty before age eight results in a high rate of failure due to poor eustachian tube function on account of anatomical variation of shorter, relatively wider and straighter tube and more frequent URIs [12]. At the same time, Adkins and White reported that age has no influence on the success rate [13]. Generally, young age groups are contraindicated for tympanoplasty because children under 3 - 4 years old are more prone to upper respiratory infections and otitis media [14]. Furthermore, in the current study, the most successful patients taking TM graft (84%) had median-sized perforations (90%). Similar successful rates regarding the closure of perforation in type I tympanoplasty were reported in other studies such as Effat, 2005 (83%) [15], Biswas et al. 2010 (85%) [12], Demirpehlivan et al. 2011 (97.7%) [16] and Ben et al., 2008 (97%) using cartilage perichondrium as graft material [17]. Also, we found that most successful cases were on the posterior site (100%), followed by the anterior (84.6%), and then subtotal (70%). Similar results were reported by Biswas et al. 2010 who found the highest successful rate for the posterior site (93.75%), anterior (88.23%), and then subtotal (77.77%) [12]. The higher rate of surgical failure in patients with the anterior sites might be due to the more limited vascularization of the anterior part of the TM, limited access to this site and difficulty in graft placement. On the contrary, Indorewala et al. used an anterior tympanostomy approach that contributed to the highest successful closure of TMP (81.4%) [10]. In the current study, most patients had large perforation size (60%) with a lower successful rate (80%), while 40% had medium-sized perforation with a higher successful rate (90%). Similarly, Biswas et al. reported the highest successful rate for graft in median-sized perforation (91.3%) [12]. Large TMP is relatively more difficult to treat because of the smaller TM remnant margins to support the graft in surviving and the less tension to resist the tympanic retraction postoperatively. Also, Shaikh et al. found that patients with a medium-sized perforation did better than those with a large perforation [18]. The most successful audiological cases were those with 25 - 35 dB (54.8%) preoperatively and 0.0 - 19 dB (52.4%) postoperatively. Moreover, the mean ABG of successful cases was 25.3 ± 1.1 dB preoperatively, 13.8 ± 2.7 dB postoperatively, and 11.5 ± 3.4 dB for hearing improvements. Sergi et al. stated that tympanoplasty resulted in a 57 - 97% improvement in hearing function and that myringoplasty can improve hearing independent of the site and size of perforation, and thus concluded that hearing improvement can be used as an indication for myringoplasty [19]. The preoperative/postoperative audiological results of successful cases were highest at 500 Hz frequency (30.3 ± 0.5 and 18.1 ± 1.0, respectively). In this respect, Duckert et al. reported excellent hearing results with cartilage graft and closure of the ABG within 10 dB was achieved in most cases of type I Tympanoplasty (87%) [20] and Dornhoffer, 2003 found the same results after comparing cartilage to perichondrium [21], while Biswas et al. reported 11dB change in ABG [12]. Conclusions Cartilage perichondrium is an effective material for closure of TM perforation achieving both surgical and audiological acceptable results in myringoplasty (type 1 tympanoplasty), especially for posterior central medium –sized perforation in late young-aged and early middle –aged patients. Cartilage perichondrium provides an excellent surgical results, proper fixed non retractable stabilities and acceptable audiological outcomes. Declarations Ethics approval and consent to participate The Scientific and Ethical Committees of the University of Sulaimani, Sulaimaniyah, Iraq, revised and approved the proposal for this research. Verbal informed consent was obtained and the surgical agreement, reliability to follow-up and probability of failure with remaining of same hearing and even dead ear were discussed with patients. Consent for publication Not applicable. Competing interests The author declares no conflict of interest. Acknowledgements The author would like to thank the authorities from Sulaimani ENT Teaching Center and Azmar Private Hospital, Sulaimaniyah, Iraq, for their great help and support. Authors’ contributions YIC: Conceptualization, data collection, analysis and interpretation, resources, study administration, and writing the original manuscript. Funding This research received no specific grant from any funding agency in the public, commercial, or profit sectors. Availability of data and materials The datasets used and analyzed during the current study are available from the corresponding author upon request. References https://my.clevelandclinic.org/health/body/24642-tympanic-membrane-eardrum, "Tympanic Membrane (Eardrum)," 2023. N. Bozan, A. F. Kiroglu, M. Ari, M. Turan, and H. Cankaya, "Tympanic Membrane Perforation Caused by Thunderbolt Strike," Journal of Craniofacial Surgery, vol. 27, pp. e723-e724, 2016. Z.-C. Lou, Z.-H. Lou, and Q.-P. Zhang, "Traumatic tympanic membrane perforations: a study of aetiology and factors affecting the outcome," American Journal of Otolaryngology, vol. 33, pp. 549-555, 2012. T. E. Habarth-Morales, A. J. Rios-Diaz, E. Isch, R. L. Ni, S. J. Hamou, and E. J. Caterson, "Incidence and epidemiology of traumatic tympanic membrane rupture: a National Trauma Data Bank analysis," Journal of Craniofacial Surgery, vol. 34, pp. 168-172, 2023. S. E. Voss, J. J. Rosowski, S. N. Merchant, and W. T. Peake, "Middle-ear function with tympanic-membrane perforations. I. Measurements and mechanisms," The Journal of the Acoustical Society of America, vol. 110, pp. 1432-1444, 2001. W. Adegbiji, G. Olajide, O. Olajuyin, F. Olatoke, and C. Nwawolo, "Pattern of tympanic membrane perforation in a tertiary hospital in Nigeria," Nigerian Journal of Clinical Practice, vol. 21, pp. 1044-1049, 2018. N. Dolhi and A. D. Weimer, "Tympanic Membrane Perforations," in StatPearls [Internet] , ed: StatPearls Publishing, 2022. M. K. Shekharappa and S. M. Siddappa, "Cartilage myringoplasty: an ideal grafting technique for complex perforations," Journal of Clinical and Diagnostic Research, vol. 11, p. MC06, 2017. M. Cavaliere, G. Mottola, M. Rondinelli, and M. Iemma, "Tragal cartilage in tympanoplasty: anatomic and functional results in 306 cases," Acta Otorhinolaryngologica Italica, vol. 29, p. 27, 2009. S. Indorewala, T. O. Adedeji, A. Indorewala, and G. Nemade, "Tympanoplasty outcomes: a review of 789 cases," Iranian Journal of Otorhinolaryngology, vol. 27, pp. 101-108, 2015. W. M. Koch, E. M. Friedman, T. J. McGill, and G. B. Healy, "Tympanoplasty in children: the Boston Children's Hospital experience," Archives of Otolaryngology–Head & Neck Surgery, vol. 116, pp. 35-40, 1990. S. S. Biswas, M. A. Hossain, M. M. Alam, T. Atiq, and Z. Al-Amin, "Hearing evaluation after myringoplasty," Bangladesh J Otorhinolaryngol, vol. 16, pp. 23-28, 2010. W. Y. Adkins and B. White, "Type I tympanoplasty: influencing factors," The Laryngoscope, vol. 94, pp. 916-918, 1984. M. E. Glasscock III, "Symposium: contraindications to tympanoplasty: II. An exercise in clinical judgment," The Laryngoscope, vol. 86, pp. 70-76, 1976. K. G. Effat, "Results of inlay cartilage myringoplasty in terms of closure of central tympanic membrane perforations," The Journal of Laryngology & Otology, vol. 119, pp. 611-613, 2005. I. A. Demirpehlivan, K. Onal, S. Arslanoglu, M. Songu, E. Ciger, and N. Can, "Comparison of different tympanic membrane reconstruction techniques in type I tympanoplasty," European Archives of Oto-rhino-laryngology, vol. 268, pp. 471-474, 2011. O. Ben Gamra, C. Mbarek, K. Khammassi, N. Methlouthi, H. Ouni, I. Hariga , et al. , "Cartilage graft in type I tympanoplasty: audiological and otological outcome," European Archives of Oto-rhino-laryngology, vol. 265, pp. 739-742, 2008. A. A. Shaikh, M. A. S. Onali, S. M. Shaikh, and T. Rafi, "Outcome of Tympanoplasty type-I by underlay technique," JLUMHS, vol. 8, pp. 80-84, 2009. B. Sergi, J. Galli, E. De Corso, C. Parrilla, and G. Paludetti, "Overlay versus underlay myringoplasty: report of outcomes considering closure of perforation and hearing function," Acta Otorhinolaryngologica Italica, vol. 31, pp. 366-371, 2011. L. G. Duckert, J. Müller, K. H. Makielski, and J. Helms, "Composite autograft “shield” reconstruction of remnant tympanic membranes," Otology & Neurotology, vol. 16, pp. 21-26, 1995. J. Dornhoffer, "Cartilage tympanoplasty: Indications, techniques, and outcomes in A 1,000‐patient series," The Laryngoscope, vol. 113, pp. 1844-1856, 2003. Tables Table 1. Patients' basic and clinical characteristics. Variable No of cases. (%) Success percentage (%) Age group (Years) 12-24 56 (56) 44 (78.6) 25-35 32 (32) 28 (87.5) 36-50 12 (12) 12 (100) Gender Male 32 (32) 28 (87.5) Female 68 (68) 56 (82.4) Tympanic membrane perforation closure Graft take 84 (84) Graft failure 16 (16) success rate with relation to (perforation size) Medium 40 (40) 36 (90%) Large 60 (60) 48 (80%) Site of graft intake Anterior 26 (26) 22 (84.6) Posterior 34 (34) 34 (100) Subtotal 40 (40) 28 (70) Approach used Endaural 62(62) 54 (83.9) Endomeatal 10 (10) 8.0 (80) Postural 28 (28) 24 (85.7) Total 100 (100) Table 2. Audiological results of successful cases among TMP patients. Air Conduction Threshold No. (%) Mean Preoperative 0-19 dB 0.0 (0.0) 25.3±4.3 20-24 dB 38 (45.2) 25-35 dB 46 (54.8) Postoperative 0-19 dB 44 (52.4) 13.8±4.1 20-24 dB 28 (33.3) 25-35 dB 12 (14.3) Total 84 (100) Table 3. Air bone gap of successful cases of TMP (n=84). Variable Air Bone Gap Mean ± SD (dB) Preoperative 25.3 ± 1.1 Postoperative 13.8 ± 2.7 Hearing improvement 11.5 ± 3.4 Table 4. Pre- and postoperative audiological results of successful cases (n=84). Variable Mean audiological results at various frequencies (Hz) 500 1000 2000 4000 Preoperative 30.3 ± 0.5 25.7 ± 0.7 17 ± 1.2 24.8 ± 1.4 Postoperative 18.1 ± 1.0 14.5 ± 0.9 10.5 ± 2.1 15 ± 0.5 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4165474","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":289392358,"identity":"2e92cc6a-2c65-4e6f-bebe-6b64bff7c1a4","order_by":0,"name":"Yousif Ibrahim Chalabi","email":"data:image/png;base64,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","orcid":"","institution":"University of Sulaimani","correspondingAuthor":true,"prefix":"","firstName":"Yousif","middleName":"Ibrahim","lastName":"Chalabi","suffix":""}],"badges":[],"createdAt":"2024-03-25 20:14:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4165474/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4165474/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":57019034,"identity":"8844d8a1-98e3-4fee-8f91-43ce4b4ce313","added_by":"auto","created_at":"2024-05-23 13:25:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":471190,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4165474/v1/d70ee205-25f0-4803-ad60-e3e733613b11.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Surgical and Audiological Outcomes of Cartilage Perichondrial Grafting Myringoplasty","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe tympanic membrane (TM) or eardrum is a thin pearly grey membrane of 3 layers in its active vibrating part at pares tense, which measures 55 mm\u003csup\u003e2, \u003c/sup\u003ewhereas the whole TM, including pares flaccid, measures 81 mm2. It transmits sound from the external ear canal to the middle ear ossicles and joints to inner ear fluid across the stapes foot plate at the oval window where the acoustic, mechanical energy is converted into an electrical action potential of cochlear microphonic, which is conducted as nerve electrical impulses across the cochlear nerve to cochlear nuclei and perceived as sound at auditory centre in pre-temporal gyrus at Broca\u0026apos;s area. It also plays an important role in hearing and protects the middle ear from dirt, bacteria, and debris entrance [1]. \u003c/p\u003e\n\u003cp\u003eTympanic membrane perforation (TMP) is a defect resulting from tear/rapture in the TM [2]. It can be caused by otitis media that results in ischemia and necrosis of the TM, leading to breakdown and rupture. Other factors are trauma, whether a caustic or accidental, or rapid changes in pressure (barotraumatic) leading to sudden otalgia, otorrhea, tinnitus, vertigo, substantial pain, aural discharge (including blood) from the ear, and hearing loss [3, 4]. The defect of TM diminishes the impedance mismatch and decreases the pressure differential induced by sounds, leading to decreased ossicular coupling [5]. \u003c/p\u003e\n\u003cp\u003eMultiple factors, such as perforation size, sound frequency tested, middle ear space dimensions, and mastoid volume, determine the hearing loss associated with TMP. The most common region for rupture is in the central region of paras tense anteroinferior, followed by the anterior central and posterior central regions to handle the malleus, respectively, with an intact rim of TM at the circumferential margin, correlating to the pars tensa being the most frequently injured [6]. In most cases, TMP can repair spontaneously, but when it does not heal, such as in chronic otitis media (COM) representing anatomical and functional defects, it requires surgical correction [7]. Tympanoplasty is one of the routine surgeries performed in ENT practice, and it is used to check/reconstruct the ossicular chain integrity and repair the TM and middle ear sound conducting mechanism with clearance of disease [8]. \u003c/p\u003e\n\u003cp\u003eGraft materials, including temporalis fascia, vein graft, fascia lata, cartilage, and perichondrium or cartilage perichondrium, are used to seal the perforations. Using cartilage-perichondrium composite graft in selective cases gives a better outcome. Among these, temporalis fascia remains the commonly used graft with a success rate of 93-97% [8], while in poor eustachian tube dysfunction, adhesive otitis media, tympanic sclerosis or total/subtotal perforation, the results are poor. As cartilage metabolism is slow, and nutrients are acquired via diffusion, cartilage graft is stable and tolerates poor conditions such as negative pressure and eustachian tube dysfunction. Therefore, placement of cartilage grafts during tympanoplasty is common. However, perichondrium is strong, thin, and easier to manipulate than cartilage. In severe cases, cartilage perichondrium is a better alternative as it provides stability against retraction [9]. Thus, in the current study, we aimed to use cartilage-perichondrium composite grafts in the repair of various TMPs and study their functionality and feasibility.\u003c/p\u003e"},{"header":"Patients and methods","content":"\u003cp\u003e\u003cstrong\u003eStudy setting and design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA prospective study conducted on 100 patients (100 ears) aged 12-50 years who attended Sulaimani ENT Teaching Center and Azmar Private Hospital, Sulaimaniyah, Iraq, from June 2013 to June2016.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients with inactive mucosal COM and dry central perforation for at least a few weeks pre-operatively with intact ossicular chains were included in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExclusion criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients with cholesteatoma, active mucosal disease with aural discharge, previous tympanic surgery, severe tympanosclerosis, only hearing ear, and sensorineural hearing loss (SNHL) were excluded from the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuestionnaire\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patient\u0026apos;s age, gender, myringoplasty (perforation size), site of TMP, the approach used, and pre/postoperative audiogram results were collected using a validated self-created questionnaire.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy protocol\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEnrolled TMP, the central type with variable size, was divided into three types: subtotal (when the damage affected most of the active vibrating eardrum at pares tense), anterior (when the damage was anterior to the handle of the malleus) and posterior (when the perforation posterior to the handle of malleus). The TMP was also divided according to their size into medium (\u0026gt;25%, but \u0026lt;50%) and large (\u0026gt;50%) active vibrating area of pares tense, which measures 55 mm\u003csup\u003e2\u003c/sup\u003e. All selected cases were dry, and the ossicular chains showed normal mobility at the time of operation. The assessment of the patient was established on the basis of history and general clinical examination otoscopically, microscopically, and audiologically using pure tone audiometry (PTA). Surgery is done under general anaesthesia with local anaesthetic infiltration of tragal, conchal cartilages and canal wall when required. The surgical approach depended on the dimension of the external auditory canal, the site of TMP, and the surgeon\u0026apos;s preferences. Canaloplasty for anterior perforation was done through refreshment of the TMP edge using an endaural, postauricular or endometrial approach. In endaural and endometrial approaches, tragal cartilage was used as graft material, whereas ear conchal cartilage was used for the postauricular approach. The tympanometry flap was raised, and ossicles were examined for integrity and mobility, while the middle ear cavity was assessed for any disease or pathology like tympanosclerosis or mringosclerosis and removed accordingly. Composite cartilage perichondrium grafts were used in all cases, and gel foam was used as a support material for the middle ear. The grafts were inserted on the medial surface of the eardrum remnant. Hearing was assessed postoperatively at 3, 6 and 12 weeks by tunning fork and PTA. Pre/postoperative air-bone gap (ABG) was calculated through the average of bone/air conductions at various frequencies (500, 1000, 2000, and 4000 Hz), and a minimum hearing improvement of 10 dB was regarded as an audiological success.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFollow-up\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients were followed up at weekly intervals for one month and monthly for three months after surgery. At follow-up examination, the result of the surgery was regarded as successful if the ear was dry and the TMP was covered by successful graft taking and proved mobile by dieselization from the end of 1\u003csup\u003est\u003c/sup\u003e month and subsequent follow-up with a minimum 10 dB hearing gain checked by PTA and tuning fork 256 and 512 HZ (change of negative Rinne test to positive one).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data were analyzed using Statistical Package for the Social Sciences (SPSS, IBM, USA, version 26). Data were expressed as numbers and percentages (%) for categorical variables and mean \u0026plusmn; standard deviation (SD) for numerical data.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eRegarding the patients\u0026rsquo; sociodemographic data, their age range was 10 - 50 years, with a mean age of 23.8 \u0026plusmn; 3.2 years. Most patients (56%) were in the 10-24 years age group, followed by 25-35 years age group (32%) and only 12 patients (12%) were aged 36 - 50 years. The successful rate of TMP correction using cartilage-perichondrium composite graft was maximum in the 36 - 50 years age group (100%), followed by the 25 - 35 years age group (87.5%), then the 10 - 24 years age group (78.6%). On the other hand, most patients with TMP were females (68%), but the successful rate of TMP correction was higher among males (87.5%). Most patients were successful in taking TM graft (84%) with median-sized myringoplasty (90%) on the posterior site (100%) using a postural approach (85.7%) (Table 1). The highest audiological gain (air conduction threshold) of successful cases (n=84) of TMP closure was 25 - 35 dB (54.8%) preoperatively and 0.0 - 19 dB (52.4%) postoperatively (Table 2). Moreover, the mean ABG of successful cases of TMP closure was 25.3 \u0026plusmn; 1.1 dB preoperatively, 13.8 \u0026plusmn; 2.7 dB postoperatively, and 11.5 \u0026plusmn; 3.4 dB for hearing improvements (Table 3). Furthermore, the preoperative audiological result of successful cases (n=84) of TMP closure was the highest loss at 500 Hz frequency (30.3 \u0026plusmn; 0.5). Similarly, the postoperative results reported the highest gain at 500 Hz (18.1 \u0026plusmn; 1.0) (Table 4).\u003c/p\u003e\n"},{"header":"Discussion","content":"\u003cp\u003eThe use of cartilage as a grafting material can be advocated in complex perforations of high risk for graft failure such as large, subtotal, total perforations, adhesive tympanic membrane, tympanosclerotic and atropic changes of remnant TM, recurrent perforations and in cases with chronic eustachian tube dysfunction [8]. \u003c/p\u003e\n\u003cp\u003eIn the current study, the patient\u0026apos;s age with TMP ranged from 10 - 50 years old, with a mean age of 23.8 \u0026plusmn; 3.2 years. Age groups 12 - 24 years old (56%) and females (68%) were the most affected. In this regard, Indorewala et al. reported the age range of the patients from 5 - 76 years, with a mean age of 35\u0026plusmn;15.8 years and the age group 31 - 45 years was the most affected group (33.3%). Also, they stated that most patients (52.6%) with TMP were females [10], which coincides with the current study results. \u003c/p\u003e\n\u003cp\u003eThe highest graft-taking success rate was in the 36 - 50 years age group (100%) and regarding gender among males (87.5%). In this regard, Koch et al. reported the highest successful rate (81%) for children aged \u0026ge;8 and a 30% successful rate for younger patients [11]. However, Biswas et al. found a better success rate with advancing age, and they indicated that tympanoplasty before age eight results in a high rate of failure due to poor eustachian tube function on account of anatomical variation of shorter, relatively wider and straighter tube and more frequent URIs [12]. At the same time, Adkins and White reported that age has no influence on the success rate [13]. Generally, young age groups are contraindicated for tympanoplasty because children under 3 - 4 years old are more prone to upper respiratory infections and otitis media [14]. \u003c/p\u003e\n\u003cp\u003eFurthermore, in the current study, the most successful patients taking TM graft (84%) had median-sized perforations (90%). Similar successful rates regarding the closure of perforation in type I tympanoplasty were reported in other studies such as Effat, 2005 (83%) [15], Biswas et al. 2010 (85%) [12], Demirpehlivan et al. 2011 (97.7%) [16] and Ben et al., 2008 (97%) using cartilage perichondrium as graft material [17]. Also, we found that most successful cases were on the posterior site (100%), followed by the anterior (84.6%), and then subtotal (70%). Similar results were reported by Biswas et al. 2010 who found the highest successful rate for the posterior site (93.75%), anterior (88.23%), and then subtotal (77.77%) [12]. The higher rate of surgical failure in patients with the anterior sites might be due to the more limited vascularization of the anterior part of the TM, limited access to this site and difficulty in graft placement. On the contrary, Indorewala et al. used an anterior tympanostomy approach that contributed to the highest successful closure of TMP (81.4%) [10].\u003c/p\u003e\n\u003cp\u003eIn the current study, most patients had large perforation size (60%) with a lower successful rate (80%), while 40% had medium-sized perforation with a higher successful rate (90%). Similarly, Biswas et al. reported the highest successful rate for graft in median-sized perforation (91.3%) [12]. Large TMP is relatively more difficult to treat because of the smaller TM remnant margins to support the graft in surviving and the less tension to resist the tympanic retraction postoperatively. Also, Shaikh et al. found that patients with a medium-sized perforation did better than those with a large perforation [18]. \u003c/p\u003e\n\u003cp\u003eThe most successful audiological cases were those with 25 - 35 dB (54.8%) preoperatively and 0.0 - 19 dB (52.4%) postoperatively. Moreover, the mean ABG of successful cases was 25.3 \u0026plusmn; 1.1 dB preoperatively, 13.8 \u0026plusmn; 2.7 dB postoperatively, and 11.5 \u0026plusmn; 3.4 dB for hearing improvements. Sergi et al. stated that tympanoplasty resulted in a 57 - 97% improvement in hearing function and that myringoplasty can improve hearing independent of the site and size of perforation, and thus concluded that hearing improvement can be used as an indication for myringoplasty [19]. \u003c/p\u003e\n\u003cp\u003eThe preoperative/postoperative audiological results of successful cases were highest at 500 Hz frequency (30.3 \u0026plusmn; 0.5 and 18.1 \u0026plusmn; 1.0, respectively). In this respect, Duckert et al. reported excellent hearing results with cartilage graft and closure of the ABG within 10 dB was achieved in most cases of type I Tympanoplasty (87%) [20] and Dornhoffer, 2003 found the same results after comparing cartilage to perichondrium [21], while Biswas et al. reported 11dB change in ABG [12].\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eCartilage perichondrium is an effective material for closure of TM perforation achieving both surgical and audiological acceptable results in myringoplasty (type 1 tympanoplasty), especially for posterior central medium \u0026ndash;sized perforation in late young-aged and early middle \u0026ndash;aged patients. Cartilage perichondrium provides an excellent surgical results, proper fixed non retractable stabilities and acceptable audiological outcomes.\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Scientific and Ethical Committees of the University of Sulaimani, Sulaimaniyah, Iraq, revised and approved the proposal for this research. Verbal informed consent was obtained and the surgical agreement, reliability to follow-up and probability of failure with remaining of same hearing and even dead ear were discussed with patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author declares no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author would like to thank the authorities from Sulaimani ENT Teaching Center and Azmar Private Hospital, Sulaimaniyah, Iraq, for their great help and support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYIC: Conceptualization, data collection, analysis and interpretation, resources, study administration, and writing the original manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analyzed during the current study are available from the corresponding author upon request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ehttps://my.clevelandclinic.org/health/body/24642-tympanic-membrane-eardrum, \u0026quot;Tympanic Membrane (Eardrum),\u0026quot; 2023.\u003c/li\u003e\n\u003cli\u003eN. Bozan, A. F. Kiroglu, M. Ari, M. Turan, and H. Cankaya, \u0026quot;Tympanic Membrane Perforation Caused by Thunderbolt Strike,\u0026quot; \u003cem\u003eJournal of Craniofacial Surgery, \u003c/em\u003evol. 27, pp. e723-e724, 2016.\u003c/li\u003e\n\u003cli\u003eZ.-C. Lou, Z.-H. Lou, and Q.-P. Zhang, \u0026quot;Traumatic tympanic membrane perforations: a study of aetiology and factors affecting the outcome,\u0026quot; \u003cem\u003eAmerican Journal of Otolaryngology, \u003c/em\u003evol. 33, pp. 549-555, 2012.\u003c/li\u003e\n\u003cli\u003eT. E. Habarth-Morales, A. J. Rios-Diaz, E. Isch, R. L. Ni, S. J. Hamou, and E. J. Caterson, \u0026quot;Incidence and epidemiology of traumatic tympanic membrane rupture: a National Trauma Data Bank analysis,\u0026quot; \u003cem\u003eJournal of Craniofacial Surgery, \u003c/em\u003evol. 34, pp. 168-172, 2023.\u003c/li\u003e\n\u003cli\u003eS. E. Voss, J. J. Rosowski, S. N. Merchant, and W. T. Peake, \u0026quot;Middle-ear function with tympanic-membrane perforations. I. Measurements and mechanisms,\u0026quot; \u003cem\u003eThe Journal of the Acoustical Society of America, \u003c/em\u003evol. 110, pp. 1432-1444, 2001.\u003c/li\u003e\n\u003cli\u003eW. Adegbiji, G. Olajide, O. Olajuyin, F. Olatoke, and C. Nwawolo, \u0026quot;Pattern of tympanic membrane perforation in a tertiary hospital in Nigeria,\u0026quot; \u003cem\u003eNigerian Journal of Clinical Practice, \u003c/em\u003evol. 21, pp. 1044-1049, 2018.\u003c/li\u003e\n\u003cli\u003eN. Dolhi and A. D. Weimer, \u0026quot;Tympanic Membrane Perforations,\u0026quot; in \u003cem\u003eStatPearls [Internet]\u003c/em\u003e, ed: StatPearls Publishing, 2022.\u003c/li\u003e\n\u003cli\u003eM. K. Shekharappa and S. M. Siddappa, \u0026quot;Cartilage myringoplasty: an ideal grafting technique for complex perforations,\u0026quot; \u003cem\u003eJournal of Clinical and Diagnostic Research, \u003c/em\u003evol. 11, p. MC06, 2017.\u003c/li\u003e\n\u003cli\u003eM. Cavaliere, G. Mottola, M. Rondinelli, and M. Iemma, \u0026quot;Tragal cartilage in tympanoplasty: anatomic and functional results in 306 cases,\u0026quot; \u003cem\u003eActa Otorhinolaryngologica Italica, \u003c/em\u003evol. 29, p. 27, 2009.\u003c/li\u003e\n\u003cli\u003eS. Indorewala, T. O. Adedeji, A. Indorewala, and G. Nemade, \u0026quot;Tympanoplasty outcomes: a review of 789 cases,\u0026quot; \u003cem\u003eIranian Journal of Otorhinolaryngology, \u003c/em\u003evol. 27, pp. 101-108, 2015.\u003c/li\u003e\n\u003cli\u003eW. M. Koch, E. M. Friedman, T. J. McGill, and G. B. Healy, \u0026quot;Tympanoplasty in children: the Boston Children\u0026apos;s Hospital experience,\u0026quot; \u003cem\u003eArchives of Otolaryngology\u0026ndash;Head \u0026amp; Neck Surgery, \u003c/em\u003evol. 116, pp. 35-40, 1990.\u003c/li\u003e\n\u003cli\u003eS. S. Biswas, M. A. Hossain, M. M. Alam, T. Atiq, and Z. Al-Amin, \u0026quot;Hearing evaluation after myringoplasty,\u0026quot; \u003cem\u003eBangladesh J Otorhinolaryngol, \u003c/em\u003evol. 16, pp. 23-28, 2010.\u003c/li\u003e\n\u003cli\u003eW. Y. Adkins and B. White, \u0026quot;Type I tympanoplasty: influencing factors,\u0026quot; \u003cem\u003eThe Laryngoscope, \u003c/em\u003evol. 94, pp. 916-918, 1984.\u003c/li\u003e\n\u003cli\u003eM. E. Glasscock III, \u0026quot;Symposium: contraindications to tympanoplasty: II. An exercise in clinical judgment,\u0026quot; \u003cem\u003eThe Laryngoscope, \u003c/em\u003evol. 86, pp. 70-76, 1976.\u003c/li\u003e\n\u003cli\u003eK. G. Effat, \u0026quot;Results of inlay cartilage myringoplasty in terms of closure of central tympanic membrane perforations,\u0026quot; \u003cem\u003eThe Journal of Laryngology \u0026amp; Otology, \u003c/em\u003evol. 119, pp. 611-613, 2005.\u003c/li\u003e\n\u003cli\u003eI. A. Demirpehlivan, K. Onal, S. Arslanoglu, M. Songu, E. Ciger, and N. Can, \u0026quot;Comparison of different tympanic membrane reconstruction techniques in type I tympanoplasty,\u0026quot; \u003cem\u003eEuropean Archives of Oto-rhino-laryngology, \u003c/em\u003evol. 268, pp. 471-474, 2011.\u003c/li\u003e\n\u003cli\u003eO. Ben Gamra, C. Mbarek, K. Khammassi, N. Methlouthi, H. Ouni, I. Hariga\u003cem\u003e, et al.\u003c/em\u003e, \u0026quot;Cartilage graft in type I tympanoplasty: audiological and otological outcome,\u0026quot; \u003cem\u003eEuropean Archives of Oto-rhino-laryngology, \u003c/em\u003evol. 265, pp. 739-742, 2008.\u003c/li\u003e\n\u003cli\u003eA. A. Shaikh, M. A. S. Onali, S. M. Shaikh, and T. Rafi, \u0026quot;Outcome of Tympanoplasty type-I by underlay technique,\u0026quot; \u003cem\u003eJLUMHS, \u003c/em\u003evol. 8, pp. 80-84, 2009.\u003c/li\u003e\n\u003cli\u003eB. Sergi, J. Galli, E. De Corso, C. Parrilla, and G. Paludetti, \u0026quot;Overlay versus underlay myringoplasty: report of outcomes considering closure of perforation and hearing function,\u0026quot; \u003cem\u003eActa Otorhinolaryngologica Italica, \u003c/em\u003evol. 31, pp. 366-371, 2011.\u003c/li\u003e\n\u003cli\u003eL. G. Duckert, J. M\u0026uuml;ller, K. H. Makielski, and J. Helms, \u0026quot;Composite autograft \u0026ldquo;shield\u0026rdquo; reconstruction of remnant tympanic membranes,\u0026quot; \u003cem\u003eOtology \u0026amp; Neurotology, \u003c/em\u003evol. 16, pp. 21-26, 1995.\u003c/li\u003e\n\u003cli\u003eJ. Dornhoffer, \u0026quot;Cartilage tympanoplasty: Indications, techniques, and outcomes in A 1,000‐patient series,\u0026quot; \u003cem\u003eThe Laryngoscope, \u003c/em\u003evol. 113, pp. 1844-1856, 2003.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003ePatients\u0026apos; basic and clinical characteristics.\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo of cases. (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuccess percentage (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge group (Years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12-24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e56 (56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e44 (78.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25-35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e32 (32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e28 (87.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e36-50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMale\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e32 (32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e28 (87.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemale\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e68 (68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e56 (82.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTympanic membrane perforation closure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.075471698113205%\" valign=\"top\"\u003e\n \u003cp\u003eGraft take\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"67.9245283018868%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e84 (84)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.075471698113205%\" valign=\"top\"\u003e\n \u003cp\u003eGraft failure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"67.9245283018868%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e16 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;success rate with relation to \u0026nbsp;(perforation size)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMedium\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40 (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e36 (90%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLarge\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e60 (60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e48 (80%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSite of graft intake\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAnterior\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e26 (26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22 (84.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePosterior\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e34 (34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e34 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSubtotal\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40 (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e28 (70)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eApproach used\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEndaural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e62(62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e54 (83.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEndomeatal\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8.0 (80)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePostural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e28 (28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24 (85.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e100 (100)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u0026nbsp;\u003c/strong\u003eAudiological results of successful cases among TMP patients.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAir Conduction Threshold\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo. (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreoperative\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0-19 dB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e25.3\u0026plusmn;4.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20-24 dB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e38 (45.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25-35 dB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e46 (54.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0-19 dB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e44 (52.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e13.8\u0026plusmn;4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20-24 dB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e28 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25-35 dB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12 (14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e84 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u0026nbsp;\u003c/strong\u003eAir bone gap of successful cases of TMP (n=84).\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAir Bone Gap\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMean \u0026plusmn; SD (dB)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePreoperative\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25.3 \u0026plusmn; 1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePostoperative\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13.8 \u0026plusmn; 2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHearing improvement\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11.5 \u0026plusmn; 3.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4.\u0026nbsp;\u003c/strong\u003ePre- and postoperative audiological results of successful cases (n=84).\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean audiological results at various frequencies (Hz)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e500\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e1000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e2000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e4000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreoperative\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e30.3 \u0026plusmn; 0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25.7 \u0026plusmn; 0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17 \u0026plusmn; 1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24.8 \u0026plusmn; 1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18.1 \u0026plusmn; 1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14.5 \u0026plusmn; 0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10.5 \u0026plusmn; 2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15 \u0026plusmn; 0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Audiological outcome, graft taking rate, myringoplasty, cartilage perichondrial graft ","lastPublishedDoi":"10.21203/rs.3.rs-4165474/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4165474/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eMyringoplasty, which is type 1 tympanoplasty, is the surgical reconstruction of the tympano-ossicular continuity after thorough disease clearance from a tympano-mastoid portion of the middle ear cleft. The success of the myringoplasty, a reconstruction of the vibrating tympanic membrane, is in hearing improvement and the closure of the tympanic membrane perforation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjectives:\u003c/strong\u003e To determine the surgical and audiological results of myringoplasty (tympanoplasty type-1) using cartilage perichondrium graft.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatients \u0026amp; methods: \u003c/strong\u003eA prospective study was conducted on 100 patients with tympanic membrane perforation (TMP) at Sulaimani Ear-Nose-Throat (ENT) Teaching Center and Azmar Private Hospital, Sulaimaniyah, Iraq, from June 2013 to June 2016. Patients underwent TM repair using an underlay cartilage perichondrium graft and were followed up for three months after surgery. Graft taking with the closure of perforation was considered a surgical success, and hearing improvement of 10 dB as the minimum gain was regarded as an audiological success.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The overall success rate was 84%. The graft take rate for large-sized perforation was 80%, and for medium-sized perforation was 90%. The success rate for posterior perforation was 100%, followed by anterior perforation (84.6%) and subtotal perforation (70%). The mean postoperative hearing gain was 11.5 dB.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e The cartilage perichondrium graft underlay technique for myringoplasty tympanoplasty type 1 is an effective method for closure of the tympanic membrane perforations and, consequently, improving hearing provided that a thorough disease clearance from Middle ear cleft was secured.\u003c/p\u003e","manuscriptTitle":"Surgical and Audiological Outcomes of Cartilage Perichondrial Grafting Myringoplasty","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-10 12:45:21","doi":"10.21203/rs.3.rs-4165474/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4c8c8381-2f06-407b-896d-cf4a011c0661","owner":[],"postedDate":"April 10th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-05-23T13:16:58+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-10 12:45:21","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4165474","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4165474","identity":"rs-4165474","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}