The use of cartilage as a grafting material can be advocated in complex perforations of high risk for graft failure such as large, subtotal, total perforations, adhesive tympanic membrane, tympanosclerotic and atropic changes of remnant TM, recurrent perforations and in cases with chronic eustachian tube dysfunction [8].
In the current study, the patient's age with TMP ranged from 10 - 50 years old, with a mean age of 23.8 ± 3.2 years. Age groups 12 - 24 years old (56%) and females (68%) were the most affected. In this regard, Indorewala et al. reported the age range of the patients from 5 - 76 years, with a mean age of 35±15.8 years and the age group 31 - 45 years was the most affected group (33.3%). Also, they stated that most patients (52.6%) with TMP were females [10], which coincides with the current study results.
The highest graft-taking success rate was in the 36 - 50 years age group (100%) and regarding gender among males (87.5%). In this regard, Koch et al. reported the highest successful rate (81%) for children aged ≥8 and a 30% successful rate for younger patients [11]. However, Biswas et al. found a better success rate with advancing age, and they indicated that tympanoplasty before age eight results in a high rate of failure due to poor eustachian tube function on account of anatomical variation of shorter, relatively wider and straighter tube and more frequent URIs [12]. At the same time, Adkins and White reported that age has no influence on the success rate [13]. Generally, young age groups are contraindicated for tympanoplasty because children under 3 - 4 years old are more prone to upper respiratory infections and otitis media [14].
Furthermore, in the current study, the most successful patients taking TM graft (84%) had median-sized perforations (90%). Similar successful rates regarding the closure of perforation in type I tympanoplasty were reported in other studies such as Effat, 2005 (83%) [15], Biswas et al. 2010 (85%) [12], Demirpehlivan et al. 2011 (97.7%) [16] and Ben et al., 2008 (97%) using cartilage perichondrium as graft material [17]. Also, we found that most successful cases were on the posterior site (100%), followed by the anterior (84.6%), and then subtotal (70%). Similar results were reported by Biswas et al. 2010 who found the highest successful rate for the posterior site (93.75%), anterior (88.23%), and then subtotal (77.77%) [12]. The higher rate of surgical failure in patients with the anterior sites might be due to the more limited vascularization of the anterior part of the TM, limited access to this site and difficulty in graft placement. On the contrary, Indorewala et al. used an anterior tympanostomy approach that contributed to the highest successful closure of TMP (81.4%) [10].
In the current study, most patients had large perforation size (60%) with a lower successful rate (80%), while 40% had medium-sized perforation with a higher successful rate (90%). Similarly, Biswas et al. reported the highest successful rate for graft in median-sized perforation (91.3%) [12]. Large TMP is relatively more difficult to treat because of the smaller TM remnant margins to support the graft in surviving and the less tension to resist the tympanic retraction postoperatively. Also, Shaikh et al. found that patients with a medium-sized perforation did better than those with a large perforation [18].
The most successful audiological cases were those with 25 - 35 dB (54.8%) preoperatively and 0.0 - 19 dB (52.4%) postoperatively. Moreover, the mean ABG of successful cases was 25.3 ± 1.1 dB preoperatively, 13.8 ± 2.7 dB postoperatively, and 11.5 ± 3.4 dB for hearing improvements. Sergi et al. stated that tympanoplasty resulted in a 57 - 97% improvement in hearing function and that myringoplasty can improve hearing independent of the site and size of perforation, and thus concluded that hearing improvement can be used as an indication for myringoplasty [19].
The preoperative/postoperative audiological results of successful cases were highest at 500 Hz frequency (30.3 ± 0.5 and 18.1 ± 1.0, respectively). In this respect, Duckert et al. reported excellent hearing results with cartilage graft and closure of the ABG within 10 dB was achieved in most cases of type I Tympanoplasty (87%) [20] and Dornhoffer, 2003 found the same results after comparing cartilage to perichondrium [21], while Biswas et al. reported 11dB change in ABG [12].