comparison of the anatomic and hearing outcomes of cartilage type 1 tympanoplasty in pediatric and...

OTOLOGY

Comparison of the anatomic and hearing outcomes of cartilagetype 1 tympanoplasty in pediatric and adult patients

Mahmut Sinan Yilmaz • Mehmet Guven •

Gurkan Kayabasoglu • Ali Fuat Varli

Received: 16 September 2013 / Accepted: 17 December 2013

� Springer-Verlag Berlin Heidelberg 2013

Abstract As a graft material cartilage produces an

excellent anatomical result with a low risk of re-perfora-

tion. However, there is a controversy among surgeons

regarding its sound conduction properties, due to the

thickness and stiffness of the cartilage. The aim of this

study was to evaluate results of cartilage type I tympano-

plasty and to compare anatomic and audiologic results in

pediatric and adult patients. Patients with chronic otitis

media who underwent cartilage type I tympanoplasty were

evaluated retrospectively. Patient age, gender, pre and

postoperative hearing levels, surgical technique and post-

operative complications were recorded. Hearing outcomes

of the patients were measured with tonal audiometry by

comparing the pre and postoperative hearing threshold

calculated at 0.5, 1, 2, and 4 kHz. Graft success rates and

hearing outcomes of the pediatric and adult patients were

compared. Of the 136 patients included in the study, 58

were male and 78 were female. The average age was 25.03.

Forty-five patients were B16-year old and 91 patients were

[16-year old. Intact graft was determined in 41 of 45

pediatric patients and 85 of 91 adult patients at the last

follow-up visit. The overall graft success rate was 92.6 %.

The mean pre and postoperative pure-tone average was

34.8 ± 8.5 and 23.4 ± 9.1 dB in adult patients, and

30.6 ± 7.7 and 17.8 ± 7.8 dB in pediatric patients. Carti-

lage graft provides a quite satisfactory anatomical result

and perfect stability. Hearing outcomes of cartilage

tympanoplasty are also acceptable in both children and

adult patients.

Keywords Tympanoplasty � Cartilage � Hearing �Pediatric � Adult

Introduction

Tympanoplasty is a surgical procedure used for eradicating

chronic middle ear infections and for reconstruction of

hearing in infected ears. It is widely performed in otolar-

yngology clinics all over the world. Tympanoplasty aims to

reconstruct the tympanic membrane and create a well

aerated, healthy, and hearing middle ear. Since the intro-

duction of tympanoplasty, numerous surgical techniques

have been developed and numerous graft materials used for

the closure of tympanic membrane perforations, including

skin, fascia lata, temporalis fascia, fat, vein, and peri-

chondrium. Among these, temporalis fascia grafts have

been most frequently used for many years for the recon-

struction of ear drum perforations [1]. Recently, many

surgeons have preferred to use cartilage as a graft material

in cases of high risk of failure, such as total perforation, re-

perforation, atelectasis or retraction, due to its higher sta-

bility and resistance to negative middle ear pressure [2].

Although cartilage can provide an excellent anatomical

result as a graft material, with a low risk of re-perforation,

there is still a controversy among surgeons regarding its

sound conduction properties, due to the thickness and

stiffness of the cartilage. Some authors believe that carti-

lage can be good for graft stabilization but the hearing

result is not as good as the anatomic result. However, there

is no evidence in the literature to support the thought that

cartilage is associated with a negative effect on hearing [3].

M. S. Yilmaz � M. Guven � G. Kayabasoglu � A. F. Varli

Department of Otorhinolaryngology, Sakarya University Faculty

of Medicine Training and Research Hospital, Adapazari,

Sakarya, Turkey

M. S. Yilmaz (&)

Seker Mah. 884. Sok. No:15/4, Adapazari, Sakarya, Turkey

e-mail: [email protected]

123

Eur Arch Otorhinolaryngol

DOI 10.1007/s00405-013-2869-2

There is still a debate among surgeons regarding the

surgical treatment of chronic otitis media (COM) in chil-

dren. Some authors think that tympanoplasty in children

has a greater risk of surgical failure compared with that in

adults and therefore they advocate for not performing

tympanoplasty in children [4, 5]. There are some differ-

ences between children and adults that make tympano-

plasty in children a controversial issue. The increased

frequency of upper respiratory tract infections, otitis media,

and eustachian tube dysfunction can cause surgical failure

in children following tympanoplasty [6, 7]. Different

techniques of cartilage tympanoplasty have been proposed

for surgical treatment of COM, but there is a lack of data

on their use in children. There were a few studies com-

paring anatomic and audiologic results of the children and

adults following cartilage tympanoplasty. Therefore, we

aimed to evaluate the results of cartilage type I tympano-

plasty in both children and adult, and to compare anatomic

and audiologic results of pediatric and adult patients.

Materials and methods

Patients with COM who underwent type I tympanoplasty

using cartilage as a grafting material in the Sakarya Uni-

versity Training and Research Hospital Department of

Otorhinolaryngology between June 2009 and January 2013

were included in the study. The study protocol was

approved by the ethical committee of the Sakarya

University Medical Faculty. Charts of the patients were

evaluated retrospectively. Patients with cholesteatoma,

\6 months duration perforation, middle ear discharge

within the last 3 months prior to surgery and patients who

underwent mastoidectomy were not included in the study.

Recurrent cases were also excluded. Patient age, gender,

pre and postoperative hearing levels, surgical technique

and postoperative complications were recorded. Informed

consent was obtained from all of the patients.

Surgeries were performed under general anesthesia with

an operation microscope using a postauricular approach.

All patients had a mobile, intact ossicular chain at the time

of surgery, and none required ossicular chain reconstruc-

tion. Cartilage island graft harvested from the tragus or

concha cymba was used as a graft material for all patients.

The graft was placed in an underlay fashion. Graft success

was defined as full healing of the grafted tympanic mem-

brane, without evidence of perforation, retraction and lat-

eralization at the last follow-up examination with a

minimum of 6 months. Evaluation of the grafted tympanic

membrane was done with an otologic microscope in con-

trol examination.

Hearing outcomes of the patients were measured with

tonal audiometry by comparing the pre and postoperative

hearing threshold calculated at 0.5, 1, 2, and 4 kHz. Pure-

tone averages (PTA) and air-bone gaps (ABG) were based

on the means of these four frequencies. Functional success

was defined as a postoperative ABG of no greater than

20 dB at the last audiometric evaluation at least 6 months

after the operation. Graft success rates and hearing out-

comes of the pediatric and adult patients were compared.

Kolmogorov–Smirnov test was used to evaluate whether

the distribution of variables was normal. Two independent

sample t test was used to compare the parametric contin-

uous data between pediatric and adult patients groups.

Mann–Whitney U test was used to compare the non-para-

metric continuous data between pediatric and adult patients

groups. Two related sample t tests were used to compare

the parametric continuous data between pre- and post-op

periods. Wicoxon rank sum test was used to compare the

non-parametric continuous data between pre- and post-op

periods. The continuous data were presented as the mean ±

standard deviation. Categorical data were compared with

Pearson’s or Fisher’s exact Chi-square tests. Categorical

data were presented as the count (n) and percentage (%).

A p value\0.05 was considered significant. Analyses were

performed using commercial software (IBM SPSS Statis-

tics 20, SPSS inc., an IBM Co., Somers, NY).

Results

One hundred thirty-six patients with a mean age of

25.03 ± 11.50 (7–51) were included in the study. There

were 58 male and 78 female patients. Forty-five patients

(33.1 %) were B16-year old (group 1) and 91 patients

(66.9 %) were [16-year old (group 2). Of the 45 pediatric

patients, 24 were male and 21 were female, and the average

age was 13.1 ± 2.6 [7–16] in group 1. There were 91 adult

patients with a mean age of 30.9 ± 9.4 (17–51). Thirty-

four patients were male and 57 patients were female in

group 2. Intact graft was determined in 41 of 45 pediatric

patients and 85 of 91 adult patients at the last follow-up

visit, which was done at least 6 months postoperatively.

The mean follow-up time was 18.17 ± 7.24 (7–36) months

for children and 24.59 ± 11.25 (8–40) months for adults.

There was no statistically significant difference between

two groups according to follow-up time. The overall graft

success rate was 92.6 % (126/136). The overall functional

success rate, defined as a postoperative ABG of no greater

than 20 dB, was 77.9 % (106/136). We observed 6 pedi-

atric cases and 17 adult cases that achieved anatomical

success without functional success. Surgical success,

including intact graft and postoperative ABG\20 dB, was

obtained in 103 (75.7 %) patients. According to the groups,

the surgical success rate was 77.8 % (35/45) in group 1 and

74.7 % (68/91) in group 2 (Table 1).


123

The mean pre and postoperative PTA was 33.4 ± 8.4

and 21.6 ± 9 dB, with a statistically significant difference.

Regarding the PTA, the mean audiological improvement

was 11.8 ± 8.7 dB. According to the groups, the mean pre

and postoperative PTA was 30.6 ± 7.7 and 17.8 ± 7.8 dB

in group 1, and 34.8 ± 8.5 and 23.4 ± 9.1 dB in group 2

(Table 2). The overall mean pre and postoperative ABG

was 26.7 ± 7.1 and 16.2 ± 6.9 dB, respectively. The dif-

ference between mean pre and postoperative ABG was

statistically significant. The improvement of the mean

ABG was 10.5 ± 7 dB in all patients. The pre and post-

operative average ABG was 27.9 ± 5.7 and 16.3 ± 6.2 dB

in group 1, and 26.1 ± 7.7 and 16.2 ± 7.2 dB in group 2,

respectively. The detailed audiologic results of the patients

were shown at Tables 3 and 4.

Discussion

The success of tympanoplasty depends on the eradication

of the disease and restoration of a healthy and aerated

middle ear. To date, various graft materials and perforation

closure techniques have been described. Among them,

cartilage has been successfully used in middle ear surgeries

since first used by Jansen [8] and Salen [9]. Recently, many

otologic surgeons have believed that cartilage is a reliable

graft material since it is resistant to re-perforation and

placing cartilage under the manubrium is easier than other

graft materials. It can also be harvested easily from the

surgery site. In the literature, clinical and experimental

studies have shown that cartilage is well tolerated with

minimal resorption time and survives for a long period with

good hearing results [10, 11].

Closure of a tympanic membrane perforation with car-

tilage compares favorably with other graft materials [12].

Reported success rates for cartilage tympanoplasty in the

literature are quite satisfactory. Kazikdas et al. [13] found a

95 % graft success rate for palisade cartilage grafts, com-

pared with 75 % for fascia grafts. Amedee et al. [14]

reported a 100 % success rate in short-term follow-up for

cartilage tympanoplasty. Callioglu et al. [15] found a

Table 1 Characteristics of the patients

Adult Children p

Number 91 45

Age 30.9 ± 9.4 13.1 ± 2.6 \0.001

Sex

Male 34 24 0.077

Female 57 21

Graft success

Yes 85 41 0.730

No 6 4

Functional success

Yes 71 35 1.000

No 20 10

Surgical success

Yes 68 35 0.930

No 17 10

Table 2 The mean pre and postoperative pure-tone average (PTA)

and air-bone gap (ABG) of the patients

Pediatric (n = 45) Adult (n = 91) p1

PTA (dB)

Pre-op 30.6 ± 7.7 34.8 ± 8.5 0.006

Post-op 17.8 ± 7.8 23.4 ± 9.1 0.001

p2 \0.001 \0.001

Decreasing 12.8 ± 7.6 11.4 ± 8.4 0.402

ABG (dB)

Pre-op 27.9 ± 5.7 26.1 ± 7.7 0.179

Post-op 16.3 ± 6.2 16.2 ± 7.2 0.928

p2 \0.001 \0.001

Decreasing 11.6 ± 6.7 9.9 ± 7.6 0.241

Data were shown as mean ± standard deviation1 p values of the comparisons between pediatric and adult patients2 p values of the comparisons between pre and post op periods

Table 3 Comparison of the pre and postoperative PTA at 500,

1,000, 2,000 and 4,000 Hz of the children and adults


500 Hz

Pre-op 32.1 ± 8.2 39.2 ± 10.7 \0.001

Post-op 19 ± 7.4 26.1 ± 11.9 \0.001

p2 \0.001 \0.001

Decreasing 13.1 ± 7.5 13.1 ± 10.8 0.213

1,000 Hz

Pre-op 31.1 ± 8.8 32.8 ± 8 0.316

Post-op 17.9 ± 6.9 21.8 ± 10.9 0.207

p2 \0.001 \0.001

Decreasing 13.2 ± 7.7 11 ± 8.2 0.217

2,000 Hz

Pre-op 28.8 ± 8.7 30.3 ± 9.9 0.391

Post-op 16.8 ± 8.4 19.7 ± 11 0.092

p2 \0.001 \0.001

Decreasing 12 ± 8.3 10.6 ± 9.9 0.765

4,000 Hz

Pre-op 31.4 ± 7.4 37.3 ± 13.8 0.009

Post-op 20.3 ± 11.7 30.3 ± 14.3 \0.001

p2 \0.001 \0.001

Decreasing 11.1 ± 8.5 7 ± 13.7 0.006



123

significantly higher success rate for cartilage tympano-

plasty, with a 95.2 % success rate, compared to a rate of

80 % for fascia tympanoplasty. They also reported that

their success rate was not significantly associated with age,

sex, and mastoidectomy. But their follow-up time was

short with a mean almost 12 months like Amedee et al.’s

study. Limited data are available on the long-term out-

comes of cartilage tympanoplasty, especially in children in

the literature. Demirpehlivan et al. [16] evaluated 120 cases

of type 1 tympanoplasty and found a 97.7 % success rate

for perichondrium cartilage island flap, a 80.6 % success

rate for temporalis fascia, and a 79 % success rate for

palisade cartilage graft. Their follow-up time is quite

longer than other studies with a mean 27.5 months. This

study showed that cartilage has low re-perforation rates on

long-term follow-up with no negative effect on hearing.

We found a 92.6 % overall graft success rate on long-term

follow-up as well. Our findings support the results of

Demirpehlivan’s study.

In addition to age, many other factors including otor-

rhea, eustachian tube function in the contralateral ear, site

and size of the perforation and surgical technique have

been examined in several studies as a possible factor that

may impact the success of tympanoplasty in children.

Among these factors, age was thought to be the most

important potential prognostic factor. Koch et al. [5]

reported that patient age affected the surgical outcome and

recommended that tympanoplasty must be performed on

children 8 years of age and older. Shih et al. [17] and Raine

and Singh [18] recommended postponing tympanoplasty in

children until age 10 and age 12, respectively. Tos et al.

[19] reported that tympanoplasty was more successful in

children over 6 years of age. Like age, regarding other

factors, literature is also mixed. There is no consensus on

other prognostic factors among surgeons. We think that,

success of tympanoplasty in children is likely dependent on

the surgeons selecting patients well and use of appropriate

surgical technique.

Different techniques of cartilage tympanoplasty have

been proposed for many years in otologic surgery, but

there is a lack of data on their use in children in the

literature. Traditionally, children are believed to be more

prone to graft failure than adults. But in recent studies,

anatomical success rates range from 71 to 100 % for

pediatric cartilage tympanoplasty in the literature [20].

Eavey [21] examined an inlay butterfly cartilage tympa-

noplasty technique in 11 patients aged 6–19 years and had

a graft closure rate of 100 %. Albirmawy [22] followed 82

children who underwent tympanoplasty for 1 year and

reported a 95 % success rate for the cartilage group and a

76.2 % success rate for the fascia group. Gaslin et al. [23]

reported their results of a new method of cartilage inter-

leave tympanoplasty with a long-term success rate of

83.3 %. The technique of cartilage interleave tympano-

plasty can be performed in a minimally invasive way. A

tympanomeatal flap does not need to be elevated, and the

procedure can be performed transcanally. In our study, the

anatomic success rate was 91.1 % (41/45) in children and

93.4 % (85/91) in adults. There were no statistically sig-

nificant differences between adults and children in graft

success rate. The definition of success following tympa-

noplasty may be variable. Some authors may use achiev-

ing postoperative intact tympanic membrane without

evidence of a perforation as a success criterion (anatom-

ical success) while other authors may use the improvement

of hearing (functional success). Therefore, reported suc-

cess rates of tympanoplasty were variable in the literature.

We investigated both anatomical and functional success

rate of two groups and obtained a higher success rate for

anatomical results in comparison with functional results in

both children and adults, as expected. Intact tympanic

membrane without hearing improvement was achieved in

6 children and 17 adults. The difference between two

groups was not statistically significant.

Hearing outcomes of cartilage tympanoplasty is still a

debate among otologic surgeons. Although the anatomic

success rate of cartilage tympanoplasty is relatively higher

Table 4 Comparison of the pre and postoperative ABG at 500,

1,000, 2,000 and 4,000 Hz of the children and adults


500 Hz

Pre-op 28.5 ± 6.9 29.6 ± 10.8 0.274

Post-op 16.9 ± 6.8 17.3 ± 10.9 0.648

p2 \0.001 \0.001

Decreasing 11.6 ± 7 14.3 ± 10.7 0.158

1,000 Hz

Pre-op 28.6 ± 6.8 26.2 ± 9 0.122

Post-op 15.7 ± 6.4 17.6 ± 10.5 0.826

p2 \0.001 \0.001

Decreasing 12.9 ± 6.5 8.6 ± 10.1 0.085

2,000 Hz

Pre-op 26.4 ± 6.9 22.9 ± 8.4 0.002

Post-op 16.6 ± 7 14.8 ± 9.1 0.172

p2 \0.001 \0.001

Decreasing 9.8 ± 6.6 8.1 ± 8.8 0.107

4,000 Hz

Pre-op 29.4 ± 6.1 26.4 ± 11.1 0.435

Post-op 18.6 ± 6.8 19.9 ± 10.4 0.334

p2 \0.001 \0.001

Decreasing 10.8 ± 6.5 6.5 ± 10.6 0.082



123

than fascia, there is still a controversy regarding its use. It

is believed that using such a rigid and thick material in

tympanoplasty may have an adverse effect on postopera-

tive sound conduction. However, there are numerous

studies in the literature reporting good and acceptable

hearing outcomes with cartilage grafting. Kirazli et al. [11]

evaluated frequency-specific data for frequencies of 0.5, 1,

2, and 4 kHz and found no significant difference between

cartilage and fascia tympanoplasty groups. Gerber et al.

[2] reported similar results in which they compared hear-

ing results of cartilage and fascia tympanoplasty. Milewski

[24] reported a postoperative average ABG of \30 dB in

92.4 % and \10 dB in 43.6 % of 197 tympanoplasties

using cartilage. Karaman et al. [25] evaluated 74 patients

who underwent type 1 tympanoplasty with composite

cartilage island graft and found that the PTA ABG

improvement was 20.2 dB at 0.5 kHz, 23.6 dB at 1 kHz,

22.2 dB at 2 kHz, and 24.8 dB at 4 kHz. Dornhoffer [26],

who compared audiological results between patients who

underwent cartilage and fascia tympanoplasty, found that

the ABG gain was 6.8 dB in the cartilage group and

7.7 dB in the fascia group, with no statistically significant

difference. Callioglu et al. [15] did not find statistically

significant difference between cartilage and fascia graft

groups in terms of ABG gain. Because cartilage yields

equal hearing results with higher anatomical success, they

recommended to use cartilage, especially in patients with

low middle ear risk index. Friedman et al. [27] evaluated

119 pediatric patients who underwent cartilage type 1

tympanoplasty and found the average preoperative and

postoperative PTA ABG to be 20.7 and 8.5 dB with a

statistically significant difference. In a recent study, we

found that ABG gain was 11.6 dB in children and 9.9 dB

in adults. We also found that PTA improvement was

12.8 dB in children and 11.4 dB in adults. Our overall

surgical success rate, including intact graft and postoper-

ative ABG\20 dB, was 75.7 %. There were no significant

differences between the surgical success rates of adults

and children.

Conclusion

As a grafting material, cartilage can be safely used in the

reconstruction of tympanic membrane perforations in both

pediatric and adult patients. Cartilage graft provides a quite

satisfactory anatomical result and perfect stability. Hearing

outcomes of cartilage tympanoplasty are also acceptable in

both children and adult patients. Cartilage graft can also be

preferred in cases with a low risk of failure, not only in

cases with a high risk of failure such as total perforation,

re-perforation, atelectasis or retraction.

Conflict of interest The authors do not have any financial rela-

tionship with any organization and have no conflicts of interest to

disclose.

References

1. Sheehy JL, Anderson RG (1980) Myringoplasty. A review of 472

cases. Ann Otol Rhinol Laryngol 89:331–334

2. Gerber MJ, Mason JC, Lampert PR (2000) Hearing results after

primary cartilage tympanoplasty. Laryngoscope 110:1994–1999

3. Dornhoffer J (2003) Cartilage tympanoplasty: indications, tech-

niques, and outcomes in a 1000-patient series. Laryngoscope

113:1844–1856

4. Bluestone CD, Cantekin EI, Douglas GS (1979) Eustachian tube

function related to the results of tympanoplasty in children.

Laryngoscope 89:450–458

5. Koch WM, Friedman EM, McGill TJ, Healy GB (1990) Tym-

panoplasty in children. The Boston Children’s Hospital experi-

ence. Arch Otolaryngol Head Neck Surg 116:35–40

6. Caylan R, Titiz A, Falcioni M, De Donato G, Russo A, Taibah A,

Sanna M (1998) Myringoplasty in children: factors influencing

surgical outcome. Otolaryngol Head Neck Surg 118:709–713

7. Vrabec J, Deskin R, Grady J (1999) Meta-analysis of pediatric

tympanoplasty. Arch Otolaryngol Head Neck Surg 125:530–534

8. Jansen C (1963) Cartilaga-tympanoplasty. Laryngoscope

73:1288–1302

9. Salen B (1963) Myringoplasty using septum cartilage. Acta Ot-

olaryngol 188:82–91

10. Zahnert T, Huttenbrink K, Murbe D, Bornitz M (2000) Experi-

mental investigations of the use of cartilage in tympanic mem-

brane reconstruction. Am J Otol 21:322–328

11. Kirazli T, Bilgen C, Midilli R, Ogut F (2005) Hearing results

after primary cartilage tympanoplasty with island technique.

Otolaryngol Head Neck Surg 132:933–937

12. Hickx GW (1988) A review of 925 cases of tympanopla-

sties using formaldehyde-formed-fascia grafts. Laryngoscope 98:

150–153

13. Kazikdas KC, Onal K, Boyraz I, Karabulut E (2007) Palisade

cartilage tympanoplasty for management of subtotal perforations:

a comparison with the temporalis fascia technique. Eur Arch

Otorhinolaryngol 264:985–989

14. Amedee RGI, Mann WJ, Riechelmann H (1989) Cartilage pali-

sade tympanoplasty. Am J Otol 10:447–450

15. Callioglu EE, Ceylan BT, Kuran G, Demirci S, Tulaci KG,

Caylan R (2012) Cartilage graft or fascia in tympanoplasty in

patients with low middle ear risk index (anatomical and audio-

logical results). Eur Arch Otorhinolaryngol. doi:10.1007/s00405-

012-2238-6

16. Demirpehlivan IA, Onal K, Arslanoglu S, Songu M, Ciger E, Can

N (2011) Comparison of different tympanic membrane recon-

struction techniques in type 1 tympanoplasty. Eur Arch Otorhi-

nolaryngol 268:471–474

17. Shih L, de Tar T, Crabtree JA (1991) Myringoplasty in children.


18. Raine CH, Singh SD (1983) Tympanoplasty in children. A review

of 114 cases. J Laryngol Otol 97:217–221

19. Tos M, Orntoft S, Stangerup SE (2000) Results of tympanoplasty

in children after 15 to 27 years. Ann Otol Rhinol Laryngol

109:17–23

20. Nicholas BD, O’Reilly RC (2010) Is cartilage preferable to fascia

myringoplasty in children? Laryngoscope 120:2136–2137

21. Eavey R (1998) Inlay tympanoplasty cartilage butterfly tech-

nique. Laryngoscope 108:657–661


123

http://dx.doi.org/10.1007/s00405-012-2238-6

http://dx.doi.org/10.1007/s00405-012-2238-6

22. Albirmawy OA (2010) Comparison between cartilage–perichon-

drium composite ring graft and temporalis fascia in type one

tympanoplasty in children. J Laryngol Otol 124:967–974

23. Gaslin M, O’Reilly RC, Morlet T, McCormick M (2007) Pedi-

atric cartilage interleave tympanoplasty. Otolaryngol Head Neck

Surg 137:284–288

24. Milewski C (1993) Composite graft tympanoplasty in the treat-

ment of ears with advanced middle ear pathology. Laryngoscope

103:1352–1356

25. Karaman E, Duman C, Isildak H, Enver O (2010) Composite

cartilage island grafts in type 1 tympanoplasty: audiological and

otological outcomes. J Craniofac Surg 21:37–39

26. Dornhoffer JL (1997) Hearing results with cartilage tympano-

plasty. Laryngoscope 107:1094–1099

27. Friedman AB, Gluth MB, Moore PC, Dornhoffer JL (2013)

Outcomes of cartilage tympanoplasty in pediatric population.



123

comparison of the anatomic and hearing outcomes of cartilage type 1 tympanoplasty in pediatric and...

Documents