Journal of Otology & RhinologyISSN: 2324-8785

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Research Article, J Otol Rhinol Vol: 4 Issue: 5

The Concept of Shrinkage of Temporalis Fascia Graft

Gautam Bir Singh*, Ruchir Dhawan, Sandeep Jha and Manish K Aggarwal
Department of Otorhinolaryngology - Head & Neck Surgery, LHMC & Assoc Hospitals, New Delhi, India
Corresponding author : Professor (Dr.) Gautam Bir Singh
House No: 1433/Sector: 15, Faridabad-121007 [NCR], Haryana, India
Tel: +91-9818836242
E-mail: [email protected]
Received: April 19, 2015 Accepted: August 07, 2015 Published: August 12, 2015
Citation: Singh GB, Dhawan R, Jha S, Aggarwal MK (2015) The Concept of Shrinkage of Temporalis Fascia Graft. J Otol Rhinol 4:4. doi:10.4172/2324-8785.1000242

Abstract

Objective: To analyse the concept of shrinkage of temporalis fascia graft.

Study design: A prospective cohort study.

Materials and Methods: Fifty adult patients of chronic suppurative otitis media-mucosal disease/ tubotympanic type were recruited in the study design and temporalis fascia graft was procured by post auricular incision while doing underlay tympanoplasty. Surface area of fresh, dry and rehydrated graft was measured by a graticule to deduce any significant shrinkage. The results were tabulated and statistically analysed in accordance with evidence-based medicine.

Results: A statistically significant shrinkage of temporalis fascia graft was recorded in this study for wet grafts as compared to dry grafts (more than 20%).

Conclusions: There is a significant shrinkage of temporalis fascia graft when it is rehydrated, which could be an important factor influencing the outcome of tympanoplasty done by underlay technique.

Keywords: Shrinkage of temporalis fascia graft; Underlay tympanoplasty

Keywords

Shrinkage of temporalis fascia graft; Underlay tympanoplasty

Introduction

Hermann for the first time introduced temporalis fascia graft in 1960 [1]. Since then this graft has become the most widely used graft for tympanoplasty across the world as it is easy to procure, easy to handle, strong and durable [1,2]. Moreover it has a low metabolic rate and high collagen content. In addition, the total surface area of 260mm2 of this graft on each side assures it’s availability in revision tympanoplasty surgeries [3].
Wormald PJ and Alun Jones in 1991 were probably the first to highlight that rehydration of temporalis fascia graft results in its shrinkage [4]. However the surgical impact of this factor on tympanoplasty was documented much later by England’s RJ et al. in 1997 [5]. They reasoned that a dry graft when placed by a surgeon in what is deemed to be a satisfactory position may lead on to underlay tympanoplasty failure, because the placed graft would subsequently rehydrate and shrink causing change in its size. With this background and in view of marked paucity of literature on the cited subject a prospective (cohort) study was carried out to analyze whether there is a significant shrinkage of temporalis fascia graft affecting the success rate of tympanoplasty by underlay technique?

Materials and Methods

A prospective cohort study was conducted at the department of Otorhinolaryngology, Institute of Medical Sciences, Banaras Hindu University, UP, India with the prior approval of the institutional board from Jan 2005 to Dec 2006. Fifty consecutive adult patients of either sex, suffering from chronic suppurative otitis media [CSOM] - mucosal disease/tubotympanic type for a minimum period of 6 months were recruited in the study design. All patients with previously operated ear were excluded from the study design. An informed consent was mandatory.
All the patients recruited in the study design underwent tympanoplasty type I by post auricular inlay technique under local anaesthesia in accordance with the ethical guidelines for research. As the post auricular route was used, the graft was harvested from the same incision in the post auricular region. After incision, by blunt dissection the glistening white graft was identified. Plane of separation was created by injecting 2% xylocaine and the graft was procured using a no:15 surgical blade and “Adson” non-toothed forcep. The post auricular wound was closed after the surgical procedure. The graft was placed in a graft press immediately: to clear the attached extraneous tissue and to flatten it. The temporalis fascia graft surface area was measured using a graticule [5] (Figure 1). Graticule is an optical instrument with a “Graph” like pattern in the focal plane of the eye piece usually used for two dimensional measurements. The graft specimen was laid flat on the graticule and the surface area was measured right after harvesting it and then after drying it by a simple hair dryer at minimum speed for 3 to 5 min. Subsequently, the graft was rehydrated by dipping it in normal saline for 10minutes and once again the surface area was measured. The data was tabulated (Table 1). The tabulated patient data was statistically analyzed using Student “t” test. The requisite “p” value for statistical interpretation was calculated by SPSS software version 17.
Figure 1: Graticule used for measuring the surface area of temporalis fascia graft.

Results

The surface area of the graft immediately harvested, dried and rehydrated was measured using graticule and tabulated (Table 1). The mean surface area of the dry graft was 268 mm2 and of dehydrated graft was 210 mm2. The data was statistically analysed by Students “t” test and the value of “p” was found to be significant (p=0.001). This means that drying of the graft increases the surface area which is reduced once the graft is wet by normal saline. In our case there was significant reduction by more than 20% for the wet graft.
Table 1: Surface area of Temporalis Fascia Graft.

Discussion

There is not much in the medical literature on “Shrinkage of temporalis fascia” and its impact on underlay tympanoplasty. Wormold PJ in his study for the first time probably highlighted this concept. Using “Youngs modulus” for elasticity, he promulgated that elasticity of temporalis fascia graft is directly proportional to the content of dehydration [4]. Later on England RJ in his study clearly indicated that rehydrated graft decreases in diameter by 10.9% and overall surface area of the graft is decreased by a mean of 18% [5]. The said concept also finds mention in a study by Chow et al. on temporalis fascia. In this study the authors have highlighted the importance of adequate size of the harvested temporalis fascia graft w.r.t shrinkage of temporalis fascia [6]. Similar to the findings of the aforesaid studies we too recorded a statistically significant reduction in overall surface area of the wet graft as compared to dry (more than 20%).
On the basis of the results reported here in we believe that shrinkage of the temporalis fascia graft is yet another important factor which leads to poor outcome of underlay tympanoplasty. In this study a significant shrinkage was recorded in the surface area of temporalis fascia graft once it is rehydrated. This was also statistically validated (Table 1). Thus, physiologically once the dry graft is placed in the moist environment of middle ear it shrinks, thereby losing surface contact with the anterior margin of the perforation if not tucked in adequately leading to failure of tympanoplasty.
Further it is imperative to note that a minimal failure rate of less than 10% associated with post auricular inlay technique using temporalis fascia graft is primarily attributed to Eustachian tube dysfunction or improper placement of graft i.e. technique failure [6,7]. It would be prudent to note that the role of Eustachian tube stands disputed today and it is not regarded as an important factor for the outcome of tympanoplasty. There exists no definitive clinical test for the evaluation of Eustachian tube function [8], and the gas diffusion theory by Jacob and Sade is now regarded as a more plausible explanation for various middle ear diseases [9]. This has led to the complete elimination of evaluation of Eustachian tube function prior to tympanoplasty. The failure of tympanoplasty is thus directly proportional to the surgical skill of the operating surgeon i.e. the ability to adequately tuck in the graft under the remnant of the tympanic membrane anteriorly and to give adequate gelfoam support to this placed graft. Thus in view of shrinkage of temporalis graft vigil is required while tucking this graft under the tympanic membrane remnant anteriorly. The study also makes a strong point for the use of wet temporalis fascia graft for tympanoplasty for obvious reasons. In this context it would be prudent to note that worldwide most of the otologists use a dry graft for underlay tympanoplasty.
Last but not the least, we would like to emphasise that this is our limited professional experience and is being presented to offer debate on the cited subject and thereby provide directions for future research.

Conclusion

From the above discussion we conclude that there is a significant shrinkage of temporalis fascia graft which could surgically influence the outcome of underlay tympanoplasty and thus should be given due consideration.

Acknowledgments

The authors would like to acknowledge the kind co-operation extended to them by Dr. SK Srivastva, Professor of Emeritus, Department of Physics, Banaras Hindu University, Uttar Pradesh, India in calculating the surface area of temporalis fascia by graticule.

References

  1. Rizer FM (1997) Overlay versus Underlay tympanoplasty. Part I: Historical review of the literature. Laryngoscope 107: 1-25.

  2. Wehrs RE (1999) Grafting techniques. Otolaryngol Clin North Am 32: 443-455.

  3. Abul Hassan HS, Von Drasek Ascher G, Acland RD (1986) Surgical anatomy and blood supply of the fascial layers of the temporal region. Plastic & Reconstructive Surgery 77: 17-28.

  4. Wormald PJ, Alun-Jones T (1991) Anatomy of temporalis fascia. J Laryngol otol 105: 522-524.

  5. England RJ, Strachan DR, Buckley JG (1997) Temporalis grafts shrink. J Laryngol Otol 111: 707-708.

  6. Chow LCK, Hui Y, Wei WI (2004) Permeatal temporalis fascia graft harvesting for minimally invasive myringoplasty. Laryngoscope 114: 386-388.

  7. Athanasiadis-Sismanis A (2010) Tympanoplasty: tympanic membrane repair. In: Gulya AJ, Minor LB, Poe DS (Eds), Glasscock-Shambaugh Surgery of the ear. PMPH, Connecticut.

  8. Manning SC, Cantekin EI, Kenna MA, Bluestone CD (1987) Prognostic value of Eustachian tube function in paediatric tympanoplasty. Laryngoscope 97: 1012-1016.

  9. Sade J, Amos AR (1998) The Eustachian tube. In: Ludman H, Wright T (Eds), Diseases of the ear. Hodder Arnold, London.

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