Volume 03 Issue 04-2023
88
International Journal of Medical Sciences And Clinical Research
(ISSN
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2771-2265)
VOLUME
03
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1121105677
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ABSTRACT
To date, there is no consensus on the question of which tissues are more appropriate to use for tympanic membrane
plastic surgery. We decided to study the use of xenograft from sheep pericardium in myringoplasty in rabbits in the
experiment, and in patients with chronic dry mesotympanitis. Experimental morphological studies using a xenograft
were carried out in 28 rabbits. In the experiment, a positive result was obtained in 25 (89.3%) rabbits. In addition, 77
patients with dry perforation of the tympanic membrane were examined. To compare the results of the study, these
patients underwent myringoplasty: 54 patients with the use of a xenograft from the sheep pericardium, 23 patients
with the use of the fascia of the temporal muscle. Reliable engraftment of a xenograft from sheep pericardium after
surgery was observed in 48 patients (88.9%), and with the use of temporal muscle fascia in 20 patients (86.9%).
KEYWORDS
Research Article
MYRINGOPLASTY WITH APPLICATION XENOGRAFT FROM SHEEP
PERICARDIA
Submission Date:
April 14, 2023,
Accepted Date:
April 19, 2023,
Published Date:
April 24, 2023
Crossref doi:
https://doi.org/10.37547/ijmscr/Volume03Issue04-13
Matkuliev K.M.
Researcher Tashkent Medical Academy, Uzbekistan
Khasanov U.S.
Researcher Tashkent Medical Academy, Uzbekistan
Rakhimjonova G.A.
Researcher Tashkent Medical Academy, Uzbekistan
Bakieva Sh.K.
Researcher Tashkent Medical Academy, Uzbekistan
Abdullaeva N.N.
Researcher Tashkent Medical Academy, Uzbekistan
Journal
Website:
https://theusajournals.
com/index.php/ijmscr
Copyright:
Original
content from this work
may be used under the
terms of the creative
commons
attributes
4.0 licence.
Volume 03 Issue 04-2023
89
International Journal of Medical Sciences And Clinical Research
(ISSN
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VOLUME
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ISSUE
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1121105677
Publisher:
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Servi
Xenograft, myringoplasty, temporal muscle fascia, flap.
INTRODUCTION
Despite the significant progress made in reconstructive
and restorative surgery of the middle ear over the past
two to three decades, the problem of surgical
restoration of the integrity of the tympanic membrane
is still relevant. No less important is the problem of
choosing an effective plastic material for the formation
of the neotympanic membrane.
Most otosurgeons prefer the autofascia of the
temporal muscle, which is similar in nature to the
tympanic membrane and convenient to use [5,8].
However, it, like all soft tissue grafts, often atrophies,
which causes a recurrence of perforation or turns into
a flabby scar, which significantly reduces the functional
effect of the operation [2]. For this reason, in recent
years, more rigid, usually multi-layered grafts have
been used, which provide better morphological
results.
However, due to the use of several heterogeneous
tissues, the formed neotympanic membrane differs
from the natural one in its physical and acoustic
properties, which inevitably affects the functional
result of myringoplasty.
Thus, the current state of the problem of
reconstructive and restorative surgery of the middle
ear, in particular the plastics of tympanic membrane
defects, dictates the urgent need for further search for
both more adequate transplants and improvement of
methods of surgical interventions.
Achievements in reconstructive surgery and tissue
conservation have found their expression in the use of
flaps - homotransplants, mainly from connective tissue
[11] (pericardium, aortic valve, dura mater, sclera,
cornea, etc.). The most popular is the preserved dura
mater,
which
has
low
antigenicity,
good
revascularization, resistance to infections, and quickly
interacts with the receptive bed [3,7].
So V.I. Rodin et al.[4] using a preserved dura mater,
they achieved tympanic membrane defect closure in
93% of patients, but according to M. Tos [1], the dura
mater is quite rigid, dense and thick material, and this
is one of its main drawbacks. Allografts were also used
for myringoplasty: the dura mater of an adult and fetus
[6], the tympanic membrane of an adult and fetus.
Allografts can be transmitters of such dangerous
infections as AIDS, hepatitis, syphilis, as well as genetic
diseases.
Many years of clinical experience with the use of these
grafts in surgical interventions on the middle ear
revealed a number of disadvantages: rejection of the
plastic material, recurrence of perforation in the
neotympanic membrane, the need for additional
operations to collect the graft, which negatively
affects the anatomical and functional results of
surgical treatment of patients . Therefore, in modern
otosurgery, the development of new highly effective
grafts for tympanic membrane defect repair is an
urgent and important problem.
Recently, many foreign authors have used xenografts
for myringoplasty [9,10]. In our republic, R.O.
Mukhamadiev created a xenograft [12] from the
pericardium of sheep (author's certificate No. 002-
03/145 dated March 28, 2003), which was used by the
author extrasclerally for various pathologies of the
organ of vision. The xenograft attracts attention due to
the availability and almost unlimited supply of plastic
material..
Volume 03 Issue 04-2023
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International Journal of Medical Sciences And Clinical Research
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The aim of our study is a clinical and experimental
substantiation of the effectiveness of the use of a
xenograft
from
the
sheep
pericardium
in
myringoplasty.
Material
and
methods.
Experimental
and
morphological studies were carried out on 28 rabbits
using a xenograft from sheep pericardium with dry
mesotympanitis on the right ear (main group). The
control group consisted of the same rabbits (left ear),
in which dry mesotympanitis was modeled.
Morphological features of xenograft engraftment in
experimental animals we made on the 3rd, 7th, 14th,
21st days, 1 month and 3 months after the operation. In
the period from 3 days to 3 months after the operation,
the animals were euthanized by air embolism and
subjected to post-mortem examination. The extracted
xenograft was studied macro- and microscopically. The
pieces were fixed in 10% neutral formalin solution. After
washing in running water, dehydration was carried out
in alcohol and chloroform, and then they were filled
with paraffin and wax. Histological sections were
stained with hematoxylin-eosin. Collagen fibers were
detected by the Vann-Gieson method.
Results of the morphological study:
On the 3rd day after myringoplasty in the area and
circumference of the xenograft, dyscirculatory
changes were noted in the form of plethora of vessels
of the microcirculatory bed, diapedetic hemorrhage in
the perivascular zone, expansion of postcapillary
venules, and marginal location of white blood cells.
Directly in the circumference of the transplanted
pericardium, these changes were accompanied by
hemorrhages, loosening and fibrinoid necrosis of the
outer membrane of the pericardium. The fibrous
structures of the middle membranes of the
pericardium were subjected to edema, loosening and
moderate swelling. The above morphological and
functional changes in the soft tissues of the middle ear
indicate the development of acute discirculatory,
edematous-destructive changes in the surgical injury
and xenograft.
On the 7th day after myringoplasty in the zone and
circumference of the xenograft, dyscirculatory
changes turn into response inflammatory processes in
the form of hyperemia of the vessels of the
microcirculatory bed, thinning of their walls and
migration of both polynuclear and mononuclear
leukocytes
into
the
perivascular
zones.
An
inflammatory infiltrate is formed on the border of the
pericardium and the surrounding tissue. On the part of
the xenograft, loosening and destruction of its outer
shell in the form of fibrinoid necrosis, in which
activated lymphoid and macrophage cells appear, was
noted. In the middle membrane of the pericardium,
against
the
background
of
loosening
and
homogenization of fibrous structures, the appearance
of active cells, both of the proper pericardial and
reactive origin, was noted.
On the 14th day after myringoplasty, fusion of the
tissue structures of the pericardium with the
surrounding soft tissue and the bone base is noted
along the edges of the xenograft. At the same time, the
tissue structures of the pericardium are completely
destroyed and mixed with the surrounding structural
elements of both soft and bone tissue. From the side
of the skin of the external auditory canal, there was
also a complete fusion of the pericardium with the
structural elements of the skin. Only in the areas of the
surgical incision, the appearance of a small
proliferative infiltration, consisting of granulation
tissue and inflammatory cells, is observed.
21 days after myringoplasty. There was a decrease in
the volume of destructive changes in the composition
of the xenograft. Maturation and differentiation of
Volume 03 Issue 04-2023
91
International Journal of Medical Sciences And Clinical Research
(ISSN
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ISSUE
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Publisher:
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Servi
young histiocytic cells of inflamed pericardial foci into
mature histiocytes and fibrocytes were observed with
the development of fibrous structures, which, merging
with the fibrous elements of the pericardium, form
dense and thick fibrillar structures. On the part of the
bone tissue, the appearance of a thin layer similar to
the
periosteum,
consisting
of
cellular-fibrous
connective tissue, was determined. On the part of the
skin of the external auditory canal, the formation of a
mature connective tissue from the inflammatory-
granulation tissue and its fusion with the fibrous tissue
of the hypodermis and dermis was also noted.
One month after the experiment, the development of
regressive phenomena in the composition of
myringoplasty and surrounding tissues was noted in
the form of the disappearance of inflammatory cells,
maturation and differentiation of cambial histiocytic
cells into mature histiocytes and fibrocytes. Moreover,
such a regressive differentiation of connective tissue
cells was accompanied by a decrease in their number.
The number of thin-walled vessels also decreased with
stabilization of hemodynamic and edematous
phenomena. Fibrous structures in the composition of
the newly formed connective tissue and pericardium
also decreased in volume, turned into separate
bundles, which were tightly and closely connected on
one side with bone tissue, and on the other with the
dermis of the skin.
Three months after pericardial myringoplasty in the
surgical field, we saw the complete disappearance of
all types of general pathological, inflammatory and
regenerative changes. There was a complete fusion of
the pericardial tissue with the surrounding tissues and
microscopically, both in composition and in maturity,
did not differ from the local connective tissue. Only the
preservation of small areas with moderately
differentiated fibrocytic cells and signs of angiomatosis
was observed.
Macroscopic changes in the xenograft were assessed
using an otoscope and a microscope. According to the
results of experimental studies, it was noted: complete
rejection of the graft 1 (3.57%) 3-day, prolapse of the
graft in the tympanic cavity 1 (3.57%) 14-day, incomplete
healing of the graft 1 (3.57%) 21-day.
The clinical study was carried out on the basis of the
TMA clinic. The main group consisted of 54 patients
who underwent myringoplasty with a xenograft from
sheep pericardium. The control group consisted of 23
patients who underwent temporal muscle fascia
during myringoplasty. The distribution of patients by
gender was as follows: in the main group of 54
patients, there were 33 women and 21 men. In the
control group, out of 23 patients, 11 were women and
12 were men.
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Distribution of patients of the main and control age groups
Age
Main group (n=54)
Control group (n=23)
abs.
%
abs.
%
up to 19 years old
16
29,6
9
39,1
20-30 years old
25
46,3
6
26,1
31-40 years old
6
11,1
6
26,1
41-50 years old
5
9,3
-
-
51-60 years old
1
1,85
2
8,7
Over 60 years old
1
1,85
-
-
To determine the degree of hearing loss, patients with
dry mesotympanitis underwent the following clinical
and audiological studies: a study of hearing in
whispered and colloquial speech, tuning fork studies
using C128 and C2048 tuning forks. Tests were carried
out - Rinne, Weber, Schwabach, Jelly, Bing and the
Federici occlusion test. Audiometric studies were
performed on an MA-31 audiometer manufactured by
Klaman and Grahnert (Germany). The differential
threshold for the perception of sound intensity (TS)
was determined by the Luscher method at a frequency
of 2000 Hz and at a sound intensity of 40 dB above the
threshold, according to the generally accepted
method. The state of patency of the Eustachian tube
was also determined, which was crucial for achieving a
good functional result after the operation. When
performing myringoplasty, we were guided by the
following indicators: all patients had central
perforations, patency of the auditory tube of grade 0-
I, no morphological changes in the tympanic
membrane mucosa during otomicroscopy, and a
positive cotton test.
In patients, hearing loss I-II degree, assessed according
to the international classification, prevailed.
Audiometric indicators of auditory function were
performed at different times: before surgery, the
nearest period, after 6 months and after 1 year.
Before surgery, air conduction was 42.2±1.6 dB, bone-
air interval 29.1±1.1 dB. After the operation,
respectively, the air conduction was 25.1 ± 0.90 dB and
the bone-air interval was 13.0 ± 0.47 dB. After the
operation, the air conduction decreased by 17.1 dB and
the bone-air interval by 16.1 dB.
This table shows that before the operation, air
conduction was 41.2 ± 1.7 dB, bone-air interval 28.0 ± 1.1
dB. After the operation, respectively, the air
conduction was 27.3 ± 1.1 dB and the bone-air interval
was 14.0 ± 0.56 dB. After the operation, the air
conduction decreased by 13.9 dB and the air-bone
interval by 14.0 dB.
In the late period after myringoplasty, a positive result
was noted - in the main group 88.9% and in the control
group 86.95% of patients.
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Conclusion. A positive macroscopic result of the
healing of a xenograft from the pericardium of a sheep
during myringoplasty was obtained in 89.3% of rabbits.
When analyzing the above microscopic data, it can be
noted that in the early stages in the zone and
circumference
of
the
xenograft,
reactive
pathomorphological changes of a protective and
restorative nature develop in the form of
discirculation, edema, and loosening of tissue
structures. These changes in the nearest terms of the
experiment turn into an inflammatory-recovery
process in the form of the formation of inflammatory
granulation tissue at the border of the xenograft with
subsequent fusion with the tissue elements of the
pericardium, and from the side of the external auditory
canal it is covered with skin.
The final clinical and morphological outcomes of
myringoplasty in the main group of operated patients
show complete tympanic membrane closure in 88.9%
of patients, and in the control group of patients in
86.95% of cases. The audiometric parameters of
patients with the use of a xenograft during
myringoplasty are not inferior to the fascia of the
temporal muscle. Thus, the use of a xenograft from
sheep pericardium in myringoplasty is an alternative,
more effective method, which, at the same time, being
less traumatic, reduces the length of stay of patients in
the hospital.
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Volume 03 Issue 04-2023
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International Journal of Medical Sciences And Clinical Research
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SJIF
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5.
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Publisher:
Oscar Publishing Services
Servi
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