IJCRR

IJCRR - 13(13), July, 2021

Pages: 129-133

Date of Publication: 05-Jul-2021

A Comparative Study on Mastoidectomy Cavity Obliteration with Soft Tissue Graft and Cartilage Graft in Canal Wall Down Mastoidectomy

Author: Sivasubramanian Thirani, Rajkamal Pandian Durairaj, Radhakrishnan Kailasm Ramamoorthy, Balasubramanian Covindarasu, Sneka Periasamy

Category: Healthcare

Abstract:Introduction: Chronic suppurative otitis media is a long-standing infection of apart or whole of the middle ear cleft characterised by ear discharge. In conditions of Atticoantral type of pathology and cholesteatoma disease clearance from the middle ear cleft, mastoid antrum is done using modified radical mastoidectomy. Aim: This study aims to compare the mastoidectomy cavity obliteration with soft tissue graft and cartilage graft in canal wall down mastoidectomy. Methods: This prospective comparative study on mastoidectomy cavity obliteration with soft tissue graft in 20 patients (Group A) and cartilage graft in 20 patients (Group B) in canal wall down mastoidectomy surgeries conducted on patients diagnosed with chronic suppurative otitis media of atticoantral pathology. Postoperative outcome was compared between 2 groups. Results: The outcome showed that the patients obliterated with cartilage showed a faster rate of epithelialization and formation of the dry cavity when compared to patients obliterated with soft tissue with a statistically significant difference (Pvalue=0.003). There was a gradual decrease in ear discharge in Group A patients compared to Group B at the end of the third month with a significant statistical difference (Pvalue=0.046); however, there was no statistical difference by the end of the sixth month. There was no statistically significant difference in the postoperative hearing in terms of the Air-bone gap between the groups. Conclusion: From this study, we concluded that obliteration with cartilage provided much better results regarding the cavity's epithelialization, thereby forming dry ear at a faster rate both statistically and clinically, along with good anatomical configuration than soft tissues.

Keywords: Mastoidectomy, Cholesteatoma, Suppurative, Cartilage, Mastoid cavity, Obliteration

Full Text:

INTRODUCTION

Chronic suppurative otitis media is a prolonged standing infection of a part or whole of the middle ear cleft, characterised by ear discharge. There are two types of chronic suppurative otitis media: Tubotympanic type/ Mucosal ear and Atticoantral type/ Squamous type. From a historical point of view, Moscher¹was the first to introduce this concept in 1911, ever since many obliteration techniques are in practice using different obliteration materials. These include soft tissues (muscle pedicled flaps, muscle, fascia), Cartilages (autogenous conchal, tragal cartilage), hydroxyapatite crystals, glass isomers, ceramides.¹ Various material have been used for obliteration, which is divided into two categories as free grafts (biologic and non-biologic); such as cartilage, fat tissue, fascia, hydroxyapatite crystals, and local flaps; such as Palva flap (musculoperiosteal flap), temporoparietal fascia flap, and postauricular myocutaneous flap.^2-8Different materials and techniques are in vogue in the present scenario, and the merits and demerits of each of these techniques are still under research.

Atticoantral type/ Squamous type involves attic, antrum, mastoid, associated with bone eroding, such as cholesteatoma, granulations, and osteitis. This type is more prone to complications. In cholesteatoma cases, surgical intervention is mandatory wherein we prefer   Canal wall down mastoidectomy procedures, otherwise called Modified radical mastoidectomy. This procedure provides complete clearance of the disease, thereby leaving behind a wide, open mastoid cavity. However, the creation of a wide cavity is associated with   Chronic discharging problems from the cavity. Collection of debris. In this surgical procedure, the disease is eradicated from the middle ear cleft,  followed by conversion of mastoid cavity, middle ear, external auditory canal into a    single smooth self-cleansing cavity exteriorised through the external auditory canal, leaving behind healthy tissues for future reconstruction.⁹ Complication of chronic otitis media includes direct bony erosion, acute mastoiditis, petrositis, facial paralysis, labyrinthitis, meningitis, brain abscess and thromphobhebitis. Our study compares mastoidectomy cavity obliteration with soft tissue graft (temporalis muscle pedicled flap, temporalis muscle fascia, temporalis muscle) and cartilage graft (autogenous conchal and tragal cartilage) and their postoperative outcomes.

AIM

This study compares the mastoidectomy cavity obliteration with soft tissue graft and cartilage graft in canal wall down mastoidectomy.

MATERIALS AND METHODS

This study comprised 40    patients who attended the ENT   department, Thanjavur    Medical   College   Hospital, Thanjavur, from November    2018   to    September   2019. Ethical committee approval was received (EC/approval no.580/2018). Patients were diagnosed to have chronic suppurative otitis media of   Atticoantral pathology by clinical history and otoscopic examination. Exclusion criteria include Chronic suppurative otitis media -  Tubotympanic type (safe type), Chronic suppurative otitis media -Intracranial complication, age less than five years, pregnant and lactating mothers. Informed and written consent was obtained before proceeding with the surgery. The patients underwent the following evaluation like History taking, General examination, Systemic examination, ENT   examination, Specific investigations like Aural swab culture and sensitivity, Tuning fork test, X-ray both mastoids, pure tone audiometry, CT  temporal bone and Examination under the microscope, Nonspecific investigations like Complete haemogram, Urine analysis and Blood sugar,  urea,  serum creatinine and assessment of the patient for general anaesthesia.

The   40   patients included in our study underwent    Canal wall down mastoidectomy procedure after their fitness for surgery was ensured. They were divided into two groups, each containing 20 patients.  Cartilage graft was used for  20 patients (Group A), and soft tissue was used for the remaining 20 patients for obliteration (Group B). Autogenous Conchal cartilage and tragal cartilage, temporalis muscle pedicled flap, temporalis muscle fascia were the graft materials used for obliteration.

Postoperatively the patients were treated with intravenous antibiotics, analgesics, anti-inflammatory drugs. One week after the procedure, mastoid bandage, postauricular sutures were removed, and ear canal pack and discharged.  Advised to review at   ENT op at corresponding interval seven days.  They were given steroid ear drops for two weeks and vinegar with normal saline (1:4)   for the next four weeks to ensure average PH   balance and proper epithelialisation. The patients were followed up regularly at the second, third, sixth month, respectively.  By the end of the third month, the patients were subjected to     Puretone audiometry. The postoperative outcomes were compared between the two groups.

RESULTS

Out of 40 patients, 20 patients included in Group A and 20 patients included in Group B. In Group A, 9 patients were females, and 11 were males. In Group B, 3 cases were females, and 17 were males. (Table 1)

Out of 40 patients, 20 patients included in Group A and 20 patients included in Group B. In Group A 5 were in the age group between 10-20years, 7 patients between 21-30 years, 5 were in age between 31-40 years, 1 patient between 41-50 years and 2 patients between 51-60 years. In Group B 3 were in the age group between 10-20years, 8 patients between 21-30 years, 6 were in age between 31-40 years, 2 patients between 41-50 years and 1 patient between 51-60 years. (Table 2).

Out of 40 patients, 20 patients included in Group A and 20 patients included in Group B. In Group A, five patients had attic perforation, 4 patients had attic retraction, 2 patients had cholesteatoma, 3 patients had posterosuperior granulation, and 6 patients had posterosuperior retraction. In Group B, 6 patients had attic perforation, 2 patients had attic retraction, 1 patient had cholesteatoma, 3 patients had posterosuperior granulation, and 8 patients had posterosuperior retraction. (Table 3)

Out of 40 patients, 20 patients included in Group A and 20 patients included in Group B. In Group A, 2 patients had a large cavity, 13 patients had a medium cavity, and 5 patients had a small cavity. In Group B 1 patient had a large cavity, 11patients had a medium cavity, and 8 patients had a small cavity. (Table 4)

Out of 40 patients, 20 patients included in Group A and 20 patients included in Group B. In Group A, based on the duration of postoperative ear discharge, 12 patients had 2 months, 4 patients had 3 months, 1 patient had 6 months, based on postoperative hearing status improvement seen in 13 patients, 2 patients had deterioration, 5 patients had no changes, 1 patient had persistent ear discharge. In Group B based on the duration of postoperative ear discharge, 16 patients had 2 months, 10 patients had 3 months, 4 patients had 6 months, based on postoperative hearing status improvement seen in 11 patients, 3 patients had deterioration, 5 patients had no changes, 4 patients had persistent ear discharge, and 2 patients had a recurrence. (table 5)

DISCUSSION

There were previous studies where different materials were used for obliteration. A retrospective study was conducted on 30 patients regarding mastoidectomy cavity obliteration using Conchal cartilage from   May 2014 to January   2017   in Al- Sulaimania city in Iraq. Their patients showed complete epithelialization at the end of the follow-up period.  The mean Air-bone gap   was 42.2dB +/-10.8, preoperatively   that became 27.4dB (+/-12.9) with   p-value <0.05. Finally, obliteration of the cavity with conchal cartilage was proven to be an effective technique in canal wall downprocedures.¹⁰

Another study was published in the year2012, a retrospective study with   56   patients diagnosed with chronic suppurative otitis media of Atticoantralpathology and underwent canal wall down procedure. Mastoid cavities were obliterated with    Conchal cartilage graft and temporalis muscle fascia graft after being sorted into two groups, and postoperative results were observed.   A completely dry cavity was achieved in 49 patients out of 56(approx. 88%, 95% confidence interval 77-95%). An overall statistically improved hearing (P < 0.05) was obtained, with the mean pure-tone average air-bone gap decreasing from   33.4+/-8.2 dB (average +/- SD) to 18.3 +/- 9.7Db.It was concluded that both the Group of patients obtained the benefit   of obliteration, but still, there were better results in patients obliterated with conchal cartilage.¹¹

A  study was published in   Andhra Pradesh in   2016, a   prospective study with  100   patients of atticoantral pathology subjected to canal wall down mastoidectomy. Their mastoid cavities were obliterated with conchal cartilage, and postoperative results observed. A completely dry cavity was observed in nearly  80-85%   of the patients with an overall improvement in hearing and the mean preoperative and the postoperative   Air-bone gaps were   29.2 +/- 13.5Db  and  25+/-15.4  dB. There was a reduced incidence in discharge and a faster rate of epithelialization with this technique.  Thus usage of conchal cartilage was considered to be the best material in mastoid cavity obliteration procedures.¹²

In the study done by Walker et al., ABG improved to 23.4dB from 27.8dB, 13% recidivism of cholesteatoma  second-look ossiculoplasty.¹³

To the removal of cholesteatoma, Kronenberg et al. removed the posterior canal wall during mastoidectomy and reimplanted the canal wall again.12% of recurrent cholesteatoma noted in all ears by non-EPI diffusion-weighted MRI.¹⁴

Harris et al. found that in CWD mastoidectomy, the frequency of ear discharge was greater (27%) than in CWU mastoidectomy (3.3%). In contrast, the reconstruction of the meat wall occurred in 9.7% of the ears.¹⁵

The patients placed under group A   - cartilage variety showed a faster rate of epithelialization when compared to group B – Soft tissue and the difference was found to be statistically significant with a value of 0.0032(P< 0.05). Patients under   Group A    also showed a good and a   gradual decrease in ear discharge when compared to    Group B   by the end of the third month with a significant difference of 0.046 (P<0.05), however by the end of six months, there was no statistical significance though the results were clinically in favour of group A (cartilage).

There was an improvement in postoperative hearing in Bone Gap in group A patients; however, 10   patients in both groups did not show any significant improvement. At the end of six months, there were 5 patients with persistent ear discharge, 1 (5%)   belonged to   Group A, 4(20%) belonged to Group B.Out of the   2 (10%)   patients in GroupB had granulation tissue along with foul-smelling ear discharge that needed to be repeated follow-ups and examination. The remaining two patients of Group   B and the remaining one patient in Group A   developed wax in due course of time. There was an overall improvement in hearing in terms of the Air-Bone gap clinically, though the comparison between the two materials did not show any significant difference statistically.

At the end of the study, patients under group A (cartilage) showed a faster rate of epithelialization and a more rapid rate formation of dry cavity compared to group B with a statistically significant difference, which appears to be the primary purpose of this cavity obliteration study. Other parameters were found to have a similar impact statistically on both groups.

CONCLUSION

To conclude, obliteration with cartilage provided much better results regarding the epithelialization of the cavity, thereby forming dry ear at a   faster rate both statistically and clinically, along with good anatomical configuration than soft tissues. However, the other criteria were statistically similar to both groups.

Acknowledgement: Authors acknowledge the immense help received from the scholars whose articles are cited and included in references to this manuscript.

Conflict of interest: Nil

Financial support: No

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