International Journal of Pediatric Otorhinolaryngology 127 (2019) 109684

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International Journal of Pediatric Otorhinolaryngology

journal homepage: www.elsevier.com/locate/ijporl

Evaluating butterfly inlay tympanoplasty T

a,1,∗ a,1 b b
Leonard James A. , Ryan S. Ference , Michael S. Weinstock , John P. Bent
a
Albert Einstein College of Medicine, Montefiore Medical Center, 1300 Morris Park Avenue, Bronx, NY, 10461, USA
b
Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center / Children's Hospital of Montefiore, 3400 Bainbridge Avenue 3rd Floor, Bronx,
NY, 10467, USA

A R T I C LE I N FO A B S T R A C T

Keywords: Objective: To compare closure rate, reduction in air-bone-gap, and operative time of butterfly tympanoplasty
Pediatrics (BT) to underlay tympanoplasty (UT).
Otology Methods: Retrospective cohort study of children (age < 18y) undergoing Type I tympanoplasty between 2009
Hearing loss and 2017. Patients were excluded if they had < 6 months of follow up, mastoidectomy, fat graft or cholestea-
Tympanoplasty
toma.
Results: Twenty-one patients (mean age 13.4) underwent BT while forty-one patients (mean age 13.5) under-
went UT. The mean size of perforation in 30.6% in BT patients and 43.6% in UT patients (p = 0.01).
Preoperative audiogram showed a similar air-bone-gap between the two groups of 31.7, 22.7, and 17.9 dB in BT
vs 29.6, 24.8, and 17.6 dB in UT at 500, 1000, and 2000 Hz, respectively (p = 0.65, 0.63, and 0.94). Operative
time was reduced in BT as compared to UT (94.0 min vs. 150.9, p = 0.01). Closure rate was similar at 85.7% in
BT vs 75.6% in UT patients (p = 0.40). Average reductions in air-bone gap were similar with 19.2, 11.7, and
13.2 dB for BT vs 16.6, 12.1, and 10.3 dB for UT at 500, 1000, and 2000 hz, respectively (p = 0.66, 0.93, 0.40).
Conclusion: BT has become a reliable tool for the pediatric otolaryngologist. This retrospective study shows that
pediatric BT results in similar outcomes with reduced operative time.

1. Introduction 2. Methods

Tympanoplasty was first described by Zollner and Wullstein in the
1950s [1,2]. Traditional techniques often involve raising a tympano-
meatal flap and repairing the perforation with an underlay graft. Ma-
terials used may include adipose tissue, perichondrium, cartilage, and
temporoparietal or temporalis fascia [3]. In 1998, Eavey published
early findings using a novel, tragal cartilage graft with butterfly shaped
cartilage for selected type I tympanoplasty patients. It offered increased
patient comfort postoperatively, a better chance at avoiding intubation,
and decreased operative time [4]. While the technique was originally
described for small, nonmarginal perforations, Ghanem, Monroy et al.
[5] and others [6] have shown success with closure of large perfora-
tions. The present study compared the perforation sizes, perforation
closure rate, air-bone gap closure rate, and operative time in pediatric
patients managed with butterfly inlay tympanoplasty (BT) vs underlay
tympanoplasty (UT).
This cohort study of pediatric BT included an Institutional Review
Board approved retrospective review that examined patient records at a
tertiary care center in an urban setting from 2009 to 2017. Inclusion
criteria included age less than 18 years and current procedural termi-
nology code for tympanoplasty. Patients were excluded for preoperative
cholesteatoma, mastoidectomy, use of fat graft or less than 6 months of
postoperative follow-up. Patient's managed with fat grafts were ex-
cluded because of the often much smaller perforation size which would
not be comparable to perforations managed with fascial or cartilage
grafts. Charts were reviewed for location and size of perforation, sur-
gical approach and technique, graft material, operative length, and air-
bone gaps via pre and postoperative audiograms. For dichotomous
outcomes, Pearson chi square tests were used to test the null hypothesis
of equal occurrence probabilities in the two groups. For comparison of
means, two-tailed, equal variance t tests were used.

∗
Corresponding author. 1300 Morris Park Ave, Bronx, NY, 10461, USA.
E-mail address: jleonard@mail.einstein.yu.edu (J.A. Leonard).
1
These authors should be considered joint first author.

https://doi.org/10.1016/j.ijporl.2019.109684
Received 19 June 2019; Received in revised form 6 September 2019; Accepted 12 September 2019
Available online 15 September 2019
0165-5876/ © 2019 Elsevier B.V. All rights reserved.
J.A. Leonard, et al. International Journal of Pediatric Otorhinolaryngology 127 (2019) 109684

Table 1 Table 3
Patient demographics including age, tympanic membrane perforation size and Comparison of pre and postoperative air bone gaps for UT and BT.
location as well as preoperative air bone gap.
Preoperative Air Bone Gap Postoperative Air Bone Gap P value
Underlay Butterfly Tympanoplasty P value (db) (db)
Tympanoplasty
Underlay Tympanoplasty
Number of patients 41 21 500 hz 29.6 15.2 < 0.01
(n) 1000 hz 24.8 15.0 0.02
Average age at time 13.5 13.4 0.97 2000 hz 17.6 8.5 < 0.01
of surgery Butterfly Tympanoplasty
(years) 500 hz 31.7 10.6 < 0.01
Average perforation 43.6 30.6 0.01 1000 hz 22.7 8.8 < 0.01
size (%) 2000 hz 17.9 4.7 < 0.01
Perforation Location (n)
anterior inferior 1 6
anterior superior 2 2 Table 4
anterior central 3 0
Comparison of perforation closure rate, operative time, and reduction in air
anterior 7 5
bone gap between tympanoplasty groups.
posterior inferior 1 1
posterior superior 1 1 Underlay Butterfly p value
posterior 5 0 Tympanoplasty Tympanoplasty
central 3 0
inferior 5 5 Perforation Closure 75.6 85.7 0.40
Preoperative Air-Bone Gap Rate (%)
500 hz 29.6 31.7 0.65 Operative Time 150.9 94.0 0.01
1000 hz 24.8 22.7 0.63 (minutes)
2000 hz 17.6 17.9 0.94 Change in Air-Bone Conduction Gap (db)
500 hz 16.6 19.2 0.66
1000 hz 12.1 11.7 0.93
3. Results 2000 hz 10.3 13.2 0.40

Sixty-two patients remained after exclusion criteria, twenty-one of

whom underwent BT (Table 1). No significant difference existed in
average patient age (13.4 years in BT versus 13.5 years UT). There was
a significant difference in average tympanic membrane (TM) perfora-
tion estimate size: 30.6% in BT versus 43.6% in the UT group (p < .05).
When comparing preoperative audiograms, there were no significant
differences between the two groups at varied frequencies including 500,
1000, and 2000 Hz.
There were several differences between the two groups with regard
to approach, technique, and graft materials (Table 2). All 21 patients
who underwent BT had tragal cartilage harvested. Meanwhile, patients
treated with traditional tympanoplasty used a variety of materials in-
cluding 36 with temporalis fascia and 3 with tragal cartilage, among
others. Unlike BT in which all grafts are placed in an inlay fashion, in
the traditional tympanoplasty group, grafts were placed in an underlay
fashion.
When comparing preoperative and postoperative air-bone gap, both
Fig. 1. Left tympanic membrane 3 weeks status post butterfly tympanoplasty
groups showed statistically significant reductions at 500, 1000, and
for perforation of anterior inferior quadrant.
2000 hz (Table 3). The average reduction in air-bone gap was not
significantly different between the two groups (Table 4). The difference
in perforation closure rate between the two groups was also not sig- patient and costs to the hospital and healthcare system. There was a
nificant but greater at 85.7% closure in the butterfly group versus significant decrease in operative time between the two groups with an
75.6% closure in traditional tympanoplasty (Fig. 1). An analysis of average of 94.0 min for BT and 150.9 min for traditional tympanoplasty
operative time was also completed because of the associated risk to the (p < 0.01).

Table 2 4. Discussion
Details of operative approach, tympanoplasty technique and graft materials
compared between tympanoplasty groups. In this study, we compared BT using inlay tragal cartilage grafts
Underlay Tympanoplasty Butterfly Tympanoplasty with traditional underlay grafts of temporalis fascia among other ma-
terials. Our cohort of patients demonstrated similar characteristics be-
Approach tween groups with an average age of 13 years and commonly anterior
Endaural (n) 19 19
location of their perforations. While the mean estimated perforation
Posterior auricular (n) 22 2
Technique size differed between the two groups, 30.6% in BT patients and 43.6%
Underlay (n) 41 0 in UT, the median perforation size varied little between the two groups,
Inlay (n) 0 21 30% in BT and 32.5% in UT, and the modes were equal, 30%. TM
Graft Material perforation rates for BT vary in the literature. In 2005, Couloigner et al.
Conchal Cartilage (n) 2 0
reported a TM perforation closure rate of 71% with BT while Jumaily
Tragal cartilage (n) 3 21
Temporalis fascia (n) 36 0 et al. reported a closure rate of 67.7% in 2018 [3,7]. However, several
other recent studies have reported BT TM perforation closure rates

2
J.A. Leonard, et al.
above 85% [8–10]. Our closure rate of 85.7% when using BT was
consistent with these findings. The results for reduction in air-bone gap
were also similar to those reported in the literature. In parallel with Kim
et al. we found a significant decrease in the gap with both techniques
and no significant difference in gap reductions between the two groups
[6]. We also found significantly reduced operative time when using BT
which Kim et al. postulated may be related to eliminating the need for a
tympanomeatal flap or packing of the external auditory canal [6]. This
is one of the clear advantages to the technique.
It has previously been asserted that BT is better suited for smaller
sized perforations. However, Ghanem et al. found that BT could be used
for perforations greater than 50% of the TM [11]. In our cohort, pa-
tients had primarily small perforations less than half the size of the TM,
but this was consistent in both BT and UT groups. The preference for
smaller perforations was a result of patient characteristics, but may
have been influenced by surgeon preference.
Preoperatively, average air bone gap varies dramatically in the lit-
erature. In our BT cohort the air-bone gap was on the larger end of the
spectrum, 17.9–31.7 db, but comparable to studies like that of Kaya
et al., 22.1 ± 7.1 12. Successful closure of the air bone gap in the
majority of our patients demonstrates that BT is effective for patients
with dramatic conductive hearing deficits. This is another useful metric
for determining which patients may benefit from BT.
When considering how anatomic differences between BT and UT
contribute to successful outcomes, it has been suggested that the graft
in BT has the advantage of rigid fixation avoiding medial migration
during the post-operative healing phase [13]. This decreases the like-
lihood of graft migration into the middle ear, better avoiding iatrogenic
cholesteatoma and TM retraction with persistent Eustachian dysfunc-
tion conditions [12,13]. Our study did not have any cases of iatrogenic
cholesteatoma in the BT group, consistent with other studies [3,12]. In
theory, graft medialization is more likely in UT because the graft does
not have the same anchoring tension forces provided by the TM com-
pared to BT. Furthermore, it has been suggested that the cartilage grafts
stripped of perichondrium are more resistant to adhesion formation
compared to fascial grafts. Additional analysis of complications, graft
failure and cholesteatoma rates may provide statistical support for these
assertions.
Limitations of this paper include the sample size and retrospective
nature. Additionally, perforation size was estimated by the surgeon and
not measured. While a cohort of 62 patients is of modest size, a greater
n would have allowed for a more powerful study. Retrospective chart
reviews provide some insight into best practices but have inherent
limitations. The type of tympanoplasty performed for particular per-
foration sizes and locations is a reflection of surgeon preference and
presenting patients in need of tympanoplasty. Another limitation of this
paper is that the majority of postoperative audiograms were obtained
within 6 months of surgery. Ideally additional audiograms and clinical
exams would be completed several years out. However, in a retro-
spective study, these exams are typically unavailable in clinically
asymptomatic patients. Future studies could include a randomized,
prospective trial enrolling patients of varied ages, perforation sizes and
International Journal of Pediatric Otorhinolaryngology 127 (2019) 109684
locations with increased follow-up. It would also be interesting to col-
lect data on speech recognition post operatively.
5. Conclusion
Our study showed that BT is an effective alternative to traditional
UT. BT reduced operative time while yielding similar results as the
traditional methods.
Conflicts of interest
All authors report no conflicts of interest.
Acknowledgments
None.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://
doi.org/10.1016/j.ijporl.2019.109684.
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