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 Table of Contents  
Year : 2022  |  Volume : 24  |  Issue : 1  |  Page : 24-29

Tympanoplasty in high-risk perforation and atelectatic ear using perichondrium-cartilage island graft and temporalis fascia: A comparative analysis

1 Department of Ear, Nose and Throat, INHS Kalyani, Visakhapatnam, Andhra Pradesh, India
2 Department of Ear, Nose and Throat, INHS Asvini, Mumbai, Maharashtra, India
3 Department of Medicine, INHS Kalyani, Visakhapatnam, Andhra Pradesh, India
4 Department of Obs and Gyn, INHS Kalyani, Visakhapatnam, Andhra Pradesh, India

Date of Submission15-Mar-2021
Date of Decision08-May-2021
Date of Acceptance23-May-2021
Date of Web Publication21-Jan-2022

Correspondence Address:
Vaidehi Thakur
INHS Kalyani, Gandhigram (PO), Visakhapatnam - 530 005, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmms.jmms_41_21

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Background: The prevalence of chronic otitis media in the Armed Forces is high. Moreover, management of high-risk perforation and atelectatic ear is an even greater challenge. It is necessary to assess the most viable management approach to achieve an optimal outcome. Aims and Objectives: We aimed to compare anatomical and audiological results in tympanoplasty for high-risk perforation and atelectasis using perichondrium-cartilage island (PCI) graft with temporalis fascia (TF) graft. Materials and Methods: A retrospective study was carried on 110 patients. Fifty-four patients and 56 patients underwent PCI graft and TF tympanoplasty, respectively. Postoperative graft integration rates and hearing outcomes were compared. Chi-square test was carried out to compare postoperative graft uptake. Postoperative audiological outcomes were compared using t-tests. Results: At 2-year follow-up, the graft take-up rate for PCI graft and TF graft was 96.29% and 82.14%, respectively (statistically significant). In the TF group, 17.86% had reperforation and recurrence of retraction pockets. In the PCI group, 3.71% had recurrent perforation. Furthermore, there was a statistically significant in the postoperative long-term improvement in pure-tone average air-bone gap in the cartilage island graft group (15.01 ± 3.53 db vs. 21.96 ± 4.09 db, P < 0.05). Conclusion: PCI graft achieves better morphological and audiological results in comparison to TF graft in high-risk perforation and atelectatic ears. It has a higher graft integration rate and better long-term audiological outcomes.

Keywords: Atelectatic ear, high-risk perforation, perichondrium-cartilage island graft, temporalis fascia

How to cite this article:
Malhotra T, Jha S, Kamal D, Thakur V. Tympanoplasty in high-risk perforation and atelectatic ear using perichondrium-cartilage island graft and temporalis fascia: A comparative analysis. J Mar Med Soc 2022;24:24-9

How to cite this URL:
Malhotra T, Jha S, Kamal D, Thakur V. Tympanoplasty in high-risk perforation and atelectatic ear using perichondrium-cartilage island graft and temporalis fascia: A comparative analysis. J Mar Med Soc [serial online] 2022 [cited 2023 Mar 24];24:24-9. Available from: https://www.marinemedicalsociety.in/text.asp?2022/24/1/24/336192

  Introduction Top

Tympanoplasty aims to achieve a healthy middle ear cavity and optimal hearing. The most commonly used grafting material is temporalis fascia (TF). However, in advanced middle ear pathologies, the clinical outcomes using fascia tympanoplasty are suboptimal, as it tends to undergo atrophy and subsequent failure in the long term. Cartilage has been increasingly reported for the reconstruction of large portions of pars tensa of the tympanic membrane (TM) in recurrent perforations, persistently discharging ears, atelectasis, coexisting craniofacial abnormalities, and cholesteatoma.[1] It is observed that the cartilage graft retains its rigid quality and resists resorption, even in the milieu of continuous  Eustachian tube More Details dysfunction.[2] The aim of this study was to compare the long-term graft viability and hearing outcomes of the perichondrium-cartilage island (PCI) graft and TF graft in high-risk perforation and atelectatic ear.

  Materials and Methods Top

Study design

A total of 110 patients, who underwent tympanoplasty for high-risk perforation and atelectasis, using two different methods of reconstruction between February 2015 and June 2018, were included in this study. The study was carried out on patients at a Zonal hospital and it consisted of two groups: Group A included 54 patients, who were operated on using PCI graft: 39 patients with high-risk perforations and 15 patients with atelectatic ears. Group B included 56 patients, who were operated on using just TF graft: 42 patients with high-risk perforations and 14 patients with the atelectatic ear. Postoperatively, patients were evaluated for graft take rate, retraction, and hearing outcome. The hospital ethics committee approved the study.

Inclusion criteria

  1. Cases with high-risk perforation-revision surgery (2nd or 3rd attempt), persistently draining perforation, subtotal/total TM perforation, and bilateral perforations
  2. Atelectatic ears – pars tensa atelectasis (Sadé classification: Stage II/III).

Exclusion criteria

Patients with cholesteatoma, adhesive otitis media, ossicular discontinuity, pediatric cases, and sensorineural hearing loss.

Preoperative assessment

All selected patients were assessed by a thorough history and clinical examination, otomicroscopy, and pure-tone audiometry. Tympanometry and naso-endoscopy were also performed for patients with atelectasis. All patients were advised to perform a Valsalva maneuver and use intranasal steroid spray for 6 weeks before surgery. Patients with the associated sinonasal disease (allergy and chronic rhinosinusitis) were managed before surgery.

Patients with otorrhea were treated with antibiotic-steroid ear drops and periodic aural debridement before surgery to achieve dry ear. However, persistently discharging ear at the time of surgery was not a contraindication for surgery. For cases with middle ear atelectasis, the regular outpatient review was carried out during the watchful waiting strategy. In cases with disease progression, i.e., persisting otorrhea, entire retraction pocket (RP) not visualized, and hearing loss, surgical intervention was undertaken to prevent complications of retraction, namely cholesteatoma. Written and informed consent was taken.

Surgical steps

In Group A, the composite cartilage perichondrium graft was harvested from tragal cartilage, as shown in [Figure 1]. Perichondrium from the anterior aspect of cartilage was dissected off leaving thinner perichondrium attached on the reverse side.
Figure 1: Harvesting of composite cartilage graft

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A PCI flap was fashioned in the manner, as displayed in [Figure 2]. Extra cartilage was stripped from the attached perichondrium to produce a peripherally located disc, 10 mm × 8 mm in diameter, for pan-tympanic reconstruction. In other cases, the size of cartilage was fashioned to the size of perforation. A larger perichondrium apron was produced posteriorly to drape over the bony canal under the tympanomeatal flap.
Figure 2: Preparation of perichondrium cartilage island graft

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A complete segment of cartilage 1–2 mm in width was removed vertically from the center to lodge the handle of the malleus and creating two cartilage islands. “V-” shaped radial incisions were also added for easy manipulation. An additional triangular piece of cartilage was removed from the posterior-superior quadrant to accommodate the incus. In atelectatic ears with posterosuperior RPs, semilunar cartilage was fashioned to be seated in the posterior half.

In high-risk perforation cases, severely diseased remnant TM was removed. This included removal of all myringitis, thickened prior graft, devascularized tympanosclerosis, and scar tissue. The entire graft was placed in an underlay fashion, with the cartilage facing medially and perichondrium adjacent to TM remnant and malleus fitting in the groove. Anterosuperiorly, the perichondrium was also tucked for approximately 2–3 mm under the anterior canal wall skin.

In atelectatic ears, the middle ear cleft was entered below RP. The atrophic TM was elevated off mesotympanum and ossicles and excised. If necessary, the posterior bony margin was drilled/curetted. The semilunar cartilage island graft was placed underlay between the manubrium of the malleus and the posterior bony meatal margin. Anteriorly, it is supported by inserting the perichondrium through a pocket created between the manubrium of the malleus and the overlying TM. Posteriorly, the flap of the perichondrium was draped over the posterior canal wall.

In Group B, standard underlay graft technique with TF was carried out in all cases with high-risk perforation and atelectatic ears.

Postoperative care and follow-up

At 3 weeks, antibiotic-steroid drops and Valsalva were advised for additional 2 weeks. Postoperatively, TM was examined for the following features: reperforation/graft failure and recurrence of RP at 6 months–24 months. Hearing results were reported using a four-frequency (0.5, 1, 2, and 3 kHz) pure-tone average air-bone gap (PTA-ABG). Audiometry was carried out at 6 months (short-term hearing outcome) and 24 months (long-term hearing outcome) [Figure 3].
Figure 3: Postoperative ear with perichondrium-cartilage island graft (left ear)

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Statistical analysis

Appropriate statistical tests were applied to determine the outcome of the comparative study. Descriptive statistics were done for distributions of cases. For quantitative parameters, the mean and standard deviation were measured. A Chi-square test was carried out to compare postoperative graft uptake between the two groups. Pre- and postoperative audiological outcomes in each group were compared using paired t-test. Student's unpaired t-test was applied for evaluation of hearing outcome between the two groups. For data analysis, Statistical Product and Service Solutions (SPSS) is owned by IBM. The headquarter of IBM is situated at New York, United States of America was used and significance was set at P < 0.05.

  Results Top

A total of 110 patients, who met the inclusion criteria, were evaluated for graft integration rate and hearing outcomes (short and long term) in both the groups. In Groups A and B, the mean age of patients was 38.37 years and 32.25 years, respectively. In Group A, 28 patients (51.8%) were female as compared to 31 patients (55.3%) in Group B. In Group A, 26 patients (48.10%) were male as compared to 25 patients (44.6%) in Group B. The distribution of cases with high-risk perforations and atelectasis in Groups A and B is shown in [Table 1].
Table 1: Distribution of cases

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Graft integrity outcome

Cases had a follow-up for 24 months and were observed for long-term graft uptake. The results were documented and studied. The mean graft integration rate in Group A was 96.29%; two patients had a failure with recurrent perforation [Table 2]. The graft take rate in Group B was 82.14%; 10 patients had a failure (reperforation – 8 and recurrence of RP – 2). In Group B, failure was predominantly observed in cases with revision surgery and draining ears at the time of surgery. A Chi-square test was carried out for postoperative graft uptake in two groups (P < 0.05). Better graft take rate was seen in Group A with PCI graft than Group B with TF graft in the long term.
Table 2: Postoperative graft uptake percentage in both groups

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Audiological outcome in Group A

The average pre- and postoperative PTA-ABGs in Group A are shown in [Table 3]. The mean preoperative PTA-ABG was 25.73 ± 7.44 db. The mean postoperative PTA-ABGs for the short-term and long-term hearing were 15.32 ± 5.33 db and 15.01 ± 3.53 db, respectively. Paired t-test was applied to evaluate the audiological outcome postoperatively at 6 months and 24 months. Group A had statistically significant improvement in hearing (P < 0.05).
Table 3: Audiological outcome in Group A

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Audiological outcome in Group B

The mean pre- and postoperative PTA-ABGs in Group B are shown in [Table 4]. The mean preoperative ABG was 25.74 ± 7.21 db, the mean postoperative ABG was 16.19 ± 5.15 db in the short-term hearing, and 21.76 ± 4.09 db in the long-term hearing. Paired t-test was applied to evaluate the audiological outcome postoperatively at 6 months and 24 months. Group B had significantly better short-term postoperative PTA-ABG closure (P < 0.05), but long-term postoperative PTA-ABG closure was not significantly better (P > 0.05).
Table 4: Audiological outcome in Group B

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Comparison of audiological outcomes between Groups A and B

Student t-test (unpaired) was applied for evaluation of hearing outcome between the two groups. While comparing short-term hearing outcomes between Group A and Group B (15.32 ± 5.33 db vs. 16.19 ± 5.15 db), the P value (=0.686374) is > 0.05. It shows that in the short term, there was no significant difference in PTA-ABG closure with either of the graft material. However, on comparing long-term hearing outcomes between Groups A and B (15.01 ± 3.53 db vs. 21.96 ± 4.09 db), the P value (=0.047053) is < 0.05. It shows that in the long term, there was significantly better PTA-ABG closure with PCI graft.

  Discussion Top

The choice of graft material is influenced by the intricacies of the TM repair and the status of any underlying chronic ear disease. For a successful tympanoplasty, it is important to assess not only the graft characteristics that directly influence hearing via the acoustic features of repaired TM but also its ability to counter future diseases, such as repeat perforation, retraction, or adhesions, given that these will also affect the ultimate hearing result.[3] Traditional techniques using TF have been used to repair TM with perforation or retraction. However, the following elements have been highlighted as the potential causes of failure in TF graft tympanoplasty, i.e., revision surgery, presence of ongoing infection, near-total perforation, atelectasis, and eustachian tube dysfunction. These situations are associated with graft atrophy and reperforation, irrespective of placement technique. In such high-risk conditions, cartilage tympanoplasty may produce more stable results.[4],[5] Similar results were obtained in our study.

In our study, successful graft take was seen in 96.29% in the PCI group versus 82.14% in the TF group, which is statistically significant. The graft integration rate is higher with cartilage tympanoplasty, in comparison with fascia reconstruction, and the rate of reperforations is significantly lower. Our observation is in line with Onal et al., who compared the functional results of tympanoplasty with either graft, in patients with bilateral Chronic Otitis Media with subtotal perforation.[6] The graft success rate was 92.3% for the cartilage group and 65.9% for the TF group. Postoperatively, the mean PTA air conduction thresholds were 22.97 ± 8.37 db for the cartilage group and 28.54 ± 14.20 db for the TF group, while the mean PTA bone conduction thresholds were 7.15 ± 5.56 db for the cartilage group and 11.71 ± 8.50 db for the TF group. They concluded that cartilage tympanoplasty provides better hearing results and graft success rates. Similarly, Heo studied the outcome of tympanoplasty using a cartilage shield graft in 94 patients with poor prognostic factors, namely revision cases, near-total perforation, and adhesive otitis media.[7] Postoperatively, the graft success was seen in 91.5%, and the mean PTA-ABG reduced significantly (P < 0.0001). Likewise, another study by Altuna et al. reported their experience with island cartilage tympanoplasty in sixty revision cases.[8] They achieved a 92% successful closure rate, and the average postoperative PTA-ABG was 13 ± 7 db compared with 21 ± 11 db preoperatively (P = 0.004). However, the results of a randomized controlled trial study in 69 patients with high-risk perforation, conducted by Durán-Padilla et al., are at variance with our findings.[9] 93.9% was graft integrity success rate for the cartilage island group and 83.3% for the TF group (P = 0.17). Hearing improvement was neither different between the groups (33.1 vs. 33.6 db; P = 0.88), respectively. However, in this study, outcome evaluation was carried out till 60 days, unlike our study, wherein the long-term follow-up was till 24 months. Moreover, many retrospective comparative studies have recommended cartilage-perichondrial graft over TF even in tympanoplasty with a low-middle ear risk index, with better graft take rate and superior/similar audiological outcomes.[10],[11]

The tissue rigidity of cartilage and its resilience to resorption and retraction, even in the background of continuing eustachian tube dysfunction, has led to its adoption in high-risk middle ear reconstruction.[12] Cartilage grafts can withstand infection, pressure changes, and compromised vascular supply. The perichondrium enhances graft stability and facilitates ingrowth of fibrous tissue and epithelization. Many types of cartilage tympanoplasty have been described. Tos suggested a classification of different techniques divided into six groups.[13] These procedures differ in the tragal or conchal cartilage alignments used: sliced plates or thick foils, overlapping or close to each other, palisades or rods, and underlay or onlay placements. In our study, tragal cartilage was used as a chondroperichondrial island graft. It is thin, flatter, sufficiently elastic, and available in sufficient amount to reconstruct pan-tympanic perforations. Moreover, it is physiologically similar to the nature of TM as it consists of collagen type II.

Progressive eustachian tube dysfunction, with resultant negative pressure within the middle ear cleft, may produce TM atelectasis that differs in size, localization, pathogenesis, and biological behavior. In the early stage, TM retractions are asymptomatic. However, growing atelectasis of the middle ear may give rise to conductive hearing loss and otorrhea. Adhesive otitis media is the far advanced grade of atelectasis. Treatment options for atelectasis vary from watchful waiting to small procedures (e.g., grommet insertion or adenoidectomy) to intensive surgical procedures. In progressive retracted atelectatic TM, early intervention with cartilage tympanoplasty prevents re-atrophy, retraction, and complications, namely cholesteatoma and ossicular necrosis. In line with the results of our analysis, several studies have also confirmed the advantage of cartilage tympanoplasty over fascia in the atelectatic ear.[14],[15]

In our study, the mean 6-month postoperative PTA-ABGs were 15.32 ± 5.33 db in the PCI group and 16.19 ± 5.15 db in the TF group, while at 24 months, the corresponding values were 15.01 ± 3.53 db and 21.76 ± 4.09 db, respectively. In the long-term follow-up of the TF group, relatively worse PTA-ABGs were observed due to potential perforation, retraction, and adhesion. However, in the PCI group, functional results were good with a statistically significant improvement in hearing. With regard to functional outcomes, our observation is in line with that of Iacovou et al., in which 117 patients with total TM perforation who had undergone cartilage “shield” tympanoplasty had a postoperative follow-up for 24 months.[16] The average pre- and postoperative PTA-ABG was 32.06 ± 11.21 db and 18.69 ± 10.53 db, respectively. The overall average ABG improvement was 13.37 ± 9.34 db. Hearing improvement was statistically significant in all cases (P < 0.0001).

We used tragal cartilage as a full-thickness graft, which is slightly < 1 mm thick. Although a study using the laser Doppler interferometer and cadaver cartilage suggested that a slight acoustical gain could be obtained by thinning the cartilage to 0.5 mm, this benefit is nullified by undesirable curling of graft, which occurs when the cartilage is thinned and perichondrium is left adhered to one side.[17] Yang et al. carried out a systemic review based on retrospective trials that compared the varying thickness of cartilage grafts and TF grafts in tympanoplasty for mean PTA-ABG gains and take rates.[18] In the full-thickness cartilage graft subgroup, the pooled mean difference (MD) for mean PTA-ABG gain was 2.56 (95% confidence interval [CI] =1.02–4.10; P = 0.14) and the difference was significant, which means that this group got a better hearing outcome than the TF group. On the contrary, the pooled MD of the sliced cartilage graft subgroup was 0.12 (95% CI = −0.44–0.69; P = 0.61), and there was no significant difference between sliced cartilage grafts and the TF group. Many studies have demonstrated the efficacy of cartilage grafts in tympanoplasty and shown no adverse effect on hearing.[19],[20],[21],[22]

There are some limitations to our current study. First, in the postoperative period, there can be otitis media with effusion with conductive hearing loss. It can be difficult to diagnose in cases of pan-tympanic reconstruction due to graft opacity. Since tympanogram is not useful in these cases, hearing results, computed tomography scan, and diffusion-weighted magnetic resonance imaging are the best indicators of the middle ear function. Furthermore, there is no specific clinical finding or test to reliably predict, preoperatively, eustachian tube function. While the requirement of a postoperative grommet tube is rare, it is a difficult step in pan-tympanic cartilage reconstruction, highlighting the need to enhance tube function and continue research to better predict the outcome. This study has included a wide spectrum of complex middle ear conditions for surgical intervention to study the efficacy of cartilage graft over conventional techniques. The fate of the neomembrane is ascertained despite adverse middle ear conditions, namely continuing infection, deficient vascular supply, and pressure changes. Furthermore, the use of full-thickness cartilage in the study had prevented unacceptable curling and re-retraction of the graft. Moreover, the long follow-up of the cases over 24 months enabled us to draw a significant conclusion and substantiate our findings. Furthermore, the uniform management protocol and robust data analysis were undertaken in the study.

  Conclusion Top

PCI graft, when used for the management of high-risk perforation and atelectatic ear, results in better graft integration rate and hearing outcome in the long term, as compared to the TF graft. The rate of reperforations is significantly lower with PCI graft.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Duckert LG, Müller J, Makielski KH, Helms J. Composite autograft “shield” reconstruction of remnant tympanic membranes. Am J Otol 1995;16:21-6.  Back to cited text no. 1
Dornhoffer J. Cartilage tympanoplasty: Indications, techniques, and outcomes in a 1,000-patient series. Laryngoscope 2003;113:1844-56.  Back to cited text no. 2
Dornhoffer JL. The chronic ear. Round table on TM reconstruction. In: Dornhoffer JL, Gluth MB, editors. The Chronic Ear. Edition-1. New York, United States of America: Thieme; 2016. p. 167.  Back to cited text no. 3
Beutner D, Huttenbrink KB, Stumpf R, Beleites T, Zahnert T, Luers JC, et al. Cartilage plate tympanoplasty. Otol Neurotol 2010;31:105-10.  Back to cited text no. 4
Cabra J, Moñux A. Efficacy of cartilage palisade tympanoplasty: Randomized controlled trial. Otol Neurotol 2010;31:589-95.  Back to cited text no. 5
Onal K, Arslanoglu S, Songu M, Demiray U, Demirpehlivan IA. Functional results of temporalis fascia versus cartilage tympanoplasty in patients with bilateral chronic otitis media. J Laryngol Otol 2012;126:22-5.  Back to cited text no. 6
Heo KW. Outcomes of type I tympanoplasty using a cartilage shield graft in patients with poor prognostic factors. Auris Nasus Larynx 2017;44:517-21.  Back to cited text no. 7
Altuna X, Navarro JJ, Algaba J. Island cartilage tympanoplasty in revision cases: Anatomic and functional results. Eur Arch Otorhinolaryngol 2012;269:2169-72.  Back to cited text no. 8
Durán-Padilla CL, Martínez-Chávez J, Amador-Licona N, Pereyra-Nobara TA. Cartilage Island versus temporalis fascia in high-risk tympanic perforation. Rev Med Inst Mex Seguro Soc 2017;55 Suppl 1:S58-63.  Back to cited text no. 9
Gozeler MS, Sahin A. Comparison of temporalis fascia and transcanal composite chondroperichondrial tympanoplasty techniques. Ear Nose Throat J 2021;100:192-5.  Back to cited text no. 10
Ciğer E, Balcı MK, İşlek A, Önal K. The wheel-shaped composite cartilage graft (WsCCG) and temporalis fascia for type 1 tympanoplasty: A prospective, randomized study. Eur Arch Otorhinolaryngol 2018;275:2975-81.  Back to cited text no. 11
Moore GF. Candidate's thesis: Revision tympanoplasty utilizing fossa triangularis cartilage. Laryngoscope 2002;112:1543-54.  Back to cited text no. 12
Tos M. Cartilage tympanoplasty methods: Proposal of a classification. Otolaryngol Head Neck Surg 2008;139:747-58.  Back to cited text no. 13
Glasscock ME 3rd, Hart MJ. Surgical treatment of the atelectatic ear. In: Friedman M, editor. Operative Techniques in Otolaryngology – Head and Neck Surgery. Philadelphia: WB Saunders; 1992. p. 15-20.  Back to cited text no. 14
Ozbek C, Ciftçi O, Ozdem C. Long-term anatomic and functional results of cartilage tympanoplasty in atelectatic ears. Eur Arch Otorhinolaryngol 2010;267:507-13.  Back to cited text no. 15
Iacovou E, Kyrodimos E, Sismanis A. Cartilage “Shield” tympanoplasty: An effective and practical technique. Eur Arch Otorhinolaryngol 2014;271:1903-8.  Back to cited text no. 16
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Yang T, Wu X, Peng X, Zhang Y, Xie S, Sun H. Comparison of cartilage graft and fascia in type 1 tympanoplasty: Systematic review and meta-analysis. Acta Otolaryngol 2016;136:1085-90.  Back to cited text no. 18
Andersen J, Cayé-Thomasen P, Tos M. Cartilage palisade tympanoplasty in sinus and tensa retraction cholesteatoma. Otol Neurotol 2002;23:825.  Back to cited text no. 19
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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3], [Table 4]


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