Comparative Study of Tympanoplasty Using Temporalis Fascia and Cartilage at Al Hada Hospital, Taif, Saudi Arabia

The intact tympanic membrane serves an important role in transferring and amplifying sounds from the outer perimeter into the middle ear. It also works to protect the middle ear from entering the water. Bacteria, microbes, and exotic objects, where the middle ear is considered a clean, non-pollutant place, and if a hole in the tympanic membrane migration of bacteria back into middle ear occur and causing infections [1].


Introduction
The intact tympanic membrane serves an important role in transferring and amplifying sounds from the outer perimeter into the middle ear. It also works to protect the middle ear from entering the water. Bacteria, microbes, and exotic objects, where the middle ear is considered a clean, non-pollutant place, and if a hole in the tympanic membrane migration of bacteria back into middle ear occur and causing infections [1].
A tympanic membrane perforation (ruptured eardrum or a perforated eardrum) is a tear or hole in the thin tissue separating eardrum from the ear canal. Usually, a tympanic membrane perforation will heal itself without treatment within a few weeks. However, in some cases, it requires surgical repair for it to heal properly. Perforation of your TM may cause Tinnitus, Vertigo, bleeding, pain and in severe cases hearing loss [2].
In the present study, we aim to compare the outcomes between using temporalis fascia and cartilage at Al Hada Hospital.in hearing improve and protection of middle ear from particles and water.
• Results of air-bone gap (ABG) on audiometry has also been recorded which plays a crucial role in the interpretation of puretone audiograms.
The air-bone gap (ABG) can be 0 dB, positive, or negative and is used to classify audiograms as conductive, sensorineural, or mixed hearing losses. In cases of normal hearing for pure tones and sensorineural hearing loss, the mean ABG is expected to be 0 dB. In cases of conductive and mixed hearing losses, the ABG is expected to be positive (greater than 10 dB). Negative ABGs are usually interpreted as resulting from measurement error or from the variability inherent in air-conduction (AC) and bone-conduction (BC) thresholds [3].
In order to assess baseline hearing and compare hearing outcomes of the two groups, preoperative and post-operative PTA were done to all patients, pure tone and air bone gap averages of three frequencies were calculated.
• Kruskal-Wallis H; which is a rank-based nonparametric test was used to determine if there are statistically significant differences between Age and Size of perforation on the results of Pre-and Postoperative PTA and ABG while Mann-Whitney U test was also used to compare differences between AB with variability in gender, side and type of the graft ( temporalis fascia versus cartilage graft) [4,5].

Participants' Characteristics
Age: The table below shows the distribution of the study sample according to age. Study Population can be divided into age groups:15% between 12 and 20 years, 42.5% between 21 and 40 years and 40% between 41 and 60 years, as also shown in ( Figure 1) and (Table 1). Table 2 shows the distribution of the study sample according to gender. 37.5% were males while 62.5% were females. Table 3 shows the distribution of the study sample according to the size of perforation, we noticed that 36.3% of the study sample had a moderate perforation size, 43.8% were subtotal, while 12.5% of the study sample had a marginal size of perforation while only 6.3% of the study sample has a total perforation as also shown in Figure 2.

Size of Perforation:
Side of the Perforation: 45% of the study sample had perforation on the right side while 53.8% had a left perforation as shown in Table  4 and Figure 3.

Type of Graft:
The Table 5 below shows the distribution of the study sample according to type of graft, we noticed that 48.75% of the study sample had undergone Cartilage graft while 50% had undergone temporalis fascia as also shown in Figure 4.
Tympanoplasty Approach: The Table 6 below shows the distribution of the study sample according to the approach used. Majority; 86.25% was Retro auricular followed by Trans-canal (11.25%) then Endural (1.25%) ( Figure 5). Table 7 below shows the distribution of the study sample according to technique of graft placement, 77.5%underlay while 7.5% overlay as also shown in Figure 6.    Table 4. Distribution of study sample according to Side

Main Outcome and Measures
Multivariate analysis comparing preoperative and postoperative hearing results of the included patients with respect to preidentified variables such as: Age: Data for 78 patients was available and given in Table 8.
• There are differences in the pre pure tone average according to the age variable in favour of 41 to 60 years with an average grade of (39.22).
• There are differences in the pre air bone gap average according to the age variable in favour of 12 to 20 years with an average grade of (37.06). • There are differences in the post air bone gap average according to the age variable in favour of 12 to 20 years with an average grade of (38.11).
Gender: See Table 9 • There are differences in the pre pure tone average according to the gender variable in favour of male with an average grade of (41.29).
• There are differences in the pre air bone gap average according to the gender variable in favour of male with an average grade of (36.96).
• There are differences in the post pure tone average according to the gender variable in favour male with an average grade of (41.91).
• There are differences in the post air bone gap average according to the gender variable in favour of male with an average grade of (38.35). Table 10 • There are differences in the pre pure tone average according to the variable in favour of Total with an average grade of (50.63).

Size of perforation: See
• There are differences in the pre air bone gap average according to the Size of perforation variable in favour of Total with an average grade of (58.52).
• There are differences in the post pure tone average according to the Size of perforation variable in favour Total with an average grade of (49.75).
• There are differences in the post air bone gap average according to the Size of perforation variable in favour of Subtotal with an average grade of (37.06). Table 11 • There are differences in the pre pure tone average according to the

Discussion
The present study is a retrospective study enrolling 80 patients between the age of 12 to 60 years, who were admitted in the Department of E.N.T and Head and Neck Surgery at Al Hada Hospital, Taif, Saudi Arabia between January 2008 to December 2016. This entire study group of patients suffered from Chronic Suppurative Otits Media. Patients in this study were from all socioeconomic groups, including patients referred from other practitioners also. Tympanoplasty is a term used to describe reconstruction of the tympanic membrane and sound conducting mechanism of the ear. Since its first description in 1952 by Wullstein and Zollner various materials have been used for Tympanoplasty [6].
Tympanoplasty is the final step in the surgical conquest of conductive hearing loss and is the culmination of over 100 years of development of surgical procedures on the middle ear to improve hearing [7].

Effect of Age and Gender on Tympanoplasty outcome (hearing improvement)
Some studies suggested that the success of the graft integration in children is slightly lower than in adults and that this is due to the fact that children have persistent dysfunction of the Eustachian tube, recurrent infections of the respiratory tract with otorrhea, and lack of development of the immune system [8].
In our study, the age varied from 12 to 60 years old and the tympanic membrane hearing improvement was slightly improved for the age group 12-20 years old with no significance for older groups like other studies which also indicated that age is not a prognostic factor. In our study, females were predominant over males (63% vs 38%). However, there was no statistically significant correlation between sex and success rate, which was similar in other studies [9].

Effect of Side and Size of Perforation on Tympanoplasty outcome
In our study, only moderate perforation encountered a noticeable improvement when comparing pre-and post-operative in the PTA results (58.52 to 35.37) while no significance was observed for the total, subtotal and marginal sizes On the other hand, in a study done by Wu et al. comparing the short-and long-term hearing outcomes of patients with small and large eardrum perforations who underwent successful inlay cartilage Tympanoplasty, no differences were apparent between the short-and long term air bone gap closure (p=0.689) of small perforations [10]. However, a significant difference between short-and long-term closure (p=0.029) was evident in patients with large perforations.

Effect of type of Graft on Tympanoplasty outcome
Many studies have been conducted to compare the hearing results of patients with cartilage tympanoplasty, using perichondrium and it was concluded that hearing results after cartilage tympanoplasty are comparable to temporalis fascia and perichondrium [11]. Furthermore, Dornhoffer J suggested that Cartilage graft is preferred by some surgeons due to its easy technique, minimal scarring and no significant postoperative morbidity. However, it is preferred especially in cases of large or anteriorly placed perforations or those with associated Eustachian tube dysfunction [12].
Conversely, Cavaliere M et al. suggested that temporalis fascia is considered superior with respect to the rate of graft uptake driven by its low basal metabolic rate. In addition to its availability and firm thickness comparable to normal tympanic membrane which is in line with the results of our study where an improvement was observed for the average preoperative vs. postoperative PTA (36.04 vs 32.84) and ABG (32.56 vs 28.18) compared to outcome of the cartilage graft where average preoperative vs. postoperative PTA (37.99 vs 40.37) and ABG (38.62 vs 40.82).
Is it statistically significant?
Thus, we can conclude that Temporalis Fascia has better hearing improvement outcome than cartilage graft. surgery nor in hearing development influenced by age, gender, size and site of perforation. Both temporalis fascia and tragal cartilageperichondrium are suitable graft materials for Tympanoplasty. However, temporalis fascia was superior to cartilage graft in hearing improvement, although the results were not statistically significant. Nevertheless, large prospective trials are necessary to collect highquality data. Our result based on Post op audio-logic assessment from 2-6 months (short term), on the long term.

Conclusion
Outcomes may be similar or even in favour of cartilage. Any studies available?