Chronic tympanic membrane perforation closure: from historical aspects to modern methods

The article presents the different grafts for chronic tympanic membrane perforation closure. The types of surgical treatment of chronic otitis media are described in a historical aspect. The initially proposed vascularized skin grafts were quickly replaced by a range of connective tissue autografts. Authors indicated a few studies in which fascia lata, venous wall, periosteum were used for myringoplasty. However, these tissues are not widely used in otosurgery. The special attention is given to the comparative studies on the outcomes of closure with fascial and cartilage grafts. The last ones are currently most commonly used for myringoplasty. Nonetheless, the use of each of these grafts is associated with indicated in the literature advantages and disadvantages. The cartilaginous grafts allow to close rather big perforations, but with lack of flexibility and pliability. On the other hand, flexible perichondrium and fascia improve the mechanical properties of neotympanic membrane yet increasing the risk of retraction and reperforation. Therefore, the search of alternative treatment for chronic tympanic membrane perforation is lasting at present. There are many studies on regenerative medicine in foreign literature. The tissue engineering approach allows to repair the damaged tissue due to proliferation of pluripotent cells and activation of their migration. The tympanic membrane regenerative potential eliminates the need for external stem cells and allows to use less complicated “in situ” tissue engineering technique. The key of this technique is the combination of the regeneration regulating factors with temporary supporting scaffolds. The authors also describe the advantages of the modern tissue engineering approach and prospects for its further application to clinical practice. 

1. Sarkar S., Roychoudhury A., Roychaudhuri B.K. Tympanoplasty in children. Eur Arch Otorhinolaryngol. 2009;266(5):627–633. doi: 10.1007/s00405-0080908-1.

2. Alicandri-Ciufelli M., Marchioni D., Grammatica A., Soloperto D., Carpeggiani P., Monzani D., Presutti L. Tympanoplasty: an up-to-date pictorial review. J Neuroradiol. 2012;39(3):149–157. doi: 10.1016/j.neurad.2011.05.004.

3. Storrs L. Myringoplasty. The Laryngoscope. 1966;76(2):185–195. doi: 10.1288/00005537-196602000-00001.

4. Wullstein H. Theory and Practice of Tympanoplasty. Laryngoscope. 1956;66(8):1076–1093. doi: 10.1288/00005537-195608000-00008.

5. Zöllner F. The Principles of Plastic Surgery of the Sound-Conducting Apparatus. The Journal of Laryngology & Otology. 1955;69(10):637–652. doi: 10.1017/s0022215100051240.

6. House W.F., & Sheehy J.L. Myringoplasty: Use of Ear Canal Skin Compared with Other Techniques. Archives of Otolaryngology – Head and Neck Surgery. 1961;3(4):407–415. doi: 10.1001/archotol.1961.00740020417009.

7. Haynes D.S., Vos I.D., Labadie R.F. Acellular allograft dermal matrix for tympanoplasty. Curr Opin Otolaryngol Head Neck Surg. 2005;13(5):283–286. doi; 10.1097/01.moo.0000172820.97322.8d.

8. Schuknecht H.F. Myringoplasty. Clin Otolaryngol Allied Sci. 1976;1(1):53–65. doi: 10.1111/j.1365-2273.1976.tb00642.x.

9. Van Deinse, J.B., van den Borg R.E. Attico-antrotomy with Abdominal Fat Transplantation and Myringoplasty. ORL. 1958;20(4–5):327–332. doi: 10.1159/000274163.

10. Acar M., Yazıcı D., San T., Muluk N., Cingi C. Fat-plug myringoplasty of ear lobule vs abdominal donor sites. European Archives of Oto­Rhino­aryngology. 2014;272(4):861–866. doi: 10.1007/s00405-014-2890-0.

11. Kwong K., Smith M., Coticchia J. Fat graft myringoplasty using umbilical fat. International Journal of Pediatric Otorhinolaryngology. 2012;76(8):1098– 1101. doi: 10.1016/j.ijporl.2012.04.007.

12. Salen B. Myringoplasty Using Septum Cartilage. Acta Otolaryngol. 1964;188(Suppl 188):82. doi: 10.3109/00016486409134544.

13. Heermann J. Jr., Heermann H., Kopstein E. Fascia and cartilage palisade tympanoplasty. Nine years’ experience. Arch Otolaryngol. 1970;91(3):228– 241. doi: 10.1001/archotol.1970.00770040334004.

14. Shea J. Jr. Vein graft closure of eardrum perforations. J Laryngol Otol. 1960;74(6):358–362. doi: 10.1017/s002221510005670x.

15. ElTaher M., Othman Y., Mohammed I., Ali K. Periosteal Graft Myringoplasty: Our Experience. International archives of otorhinolaryngology. 2018;22(4):374–377. doi: 10.1055/s-0037-1613716.

16. Lee D.H., Jun B.C., Jung S.H., Song C.E. Deep temporal fascial-periosteal flap for canal wall down mastoidectomy. The Laryngoscope. 2006;116(12):2229–2231. doi: 10.1097/01.mlg.0000245976.01691.c6.

17. Full-Thickness Skin, Fascia and Cartilage with its Perichondrium in Myringoplasty: A summary and analysis of the results of 232 consecutive clinical operations. Acta Oto­Laryngologica. 1968;66(Suppl 244):47–57. doi: 10.3109/00016486809123533.

18. Jalali M.M., Motasaddi M., Kouhi A., Dabiri S., Soleimani R. Comparison of cartilage with temporalis fascia tympanoplasty: A meta-analysis of comparative studies. Laryngoscope. 2017;127(9):2139–2148. doi: 10.1002/lary.26451.

19. Sheehy J.L., Anderson R.G. Myringoplasty. A review of 472 cases. Ann Otol Rhinol Laryngol. 1980;89;4(1):331–334. doi: 10.1177/000348948008900407.

20. Buckingham R.A. Fascia and perichondrium atrophy in tympanoplasty and recurrent middle ear atelectasis. Ann Otol Rhinol Laryngol. 1992;101(9):755–758. doi: 10.1177/000348949210100907.

21. Mouna B., Khalifa M., Ghammem M. et al. Cartilage and Fascia Graft In Type 1 Tympanoplasty: Comparison of Anatomical and Audological Results. J Craniofac Surg. 2019;30(4):e297–e300. doi: 10.1097/scs.0000000000005278.

22. Tos M. Cartilage tympanoplasty methods: proposal of a classification. Otolaryngol Head Neck Surg. 2008;139(6):747–758. doi: 10.1016/j.otohns.2008.09.021.

23. Lou Z., Tang Y., Yang J. A prospective study evaluating spontaneous healing of aetiology, size and type-different groups of traumatic tympanic membrane perforation. Clinical Otolaryngology. 2011;36(5):450–460. doi: 10.1111/j.1749-4486.2011.02387.x .

24. Holmes D. Eardrum regeneration: membrane repair. Nature. 2017; 546:5. doi: 10.1038/546S5a.

25. Knutsson J., von Unge M., Rask-Andersen H. Localization of Progenitor/ Stem Cells in the Human Tympanic Membrane. Audiology and Neurotology. 2011;16(4):263–269. doi: 10.1159/000320612.

26. Hong P., Bance M., Gratzer P. Repair of tympanic membrane perforation using novel adjuvant therapies: A contemporary review of experimental and tissue engineering studies. Int J Pediatr Otorhinolaryngol. 2013;77(1):3–12. doi: 10.1016/j.ijporl.2012.09.022.

27. Kanemaru S., Umeda H., Kitani Y., Nakamura T., Hirano S., Ito J. Regenerative Treatment for Tympanic Membrane Perforation. Otology & Neurotology. 2011;32(8):1218–1223. doi: 10.1097/mao.0b013e31822e0e53.