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.