Use of Platelet Rich Fibrin Membrane (PRF) reinforcement in Type 1 Tympanoplasty

Summary/Purpose

Tympanoplasty is the surgery performed in Chronic Otitis Media (COM) to improve the hearing function and prevent ear discharge. Platelet Rich Fibrin (PRF) is one of the materials that can be used to improve the graft uptake and hearing outcome. It is obtained by centrifugation of blood. The PRF contains leukocytes, cytokines, structural glycoproteins and growth factors which accelerates healing. It has been used in various surgical procedures to improve the outcome.

Platelet-rich fibrin (PRF) which is considered a second-generation platelet-rich plasma having a high content of growth factors could be implied as a sealant and adjuvant to grafting materials during tympanoplasty operation [1].

 Tympanoplasty has been treated with various materials since its initial technique described by Berthold in 1878 where the remnant tympanic membrane was deepithelialized and a skin graft was applied over the defect.[2]

Various modifications of the graft materials were done since then by Zollner (1954), Frenckner (1955), Shea (1960) Heermann (1960), and many other surgeons. The fundamental principles of the surgical procedure were first described by Wullstein in 1952, using a free skin graft, and Zoellner in 1955, using a pedicle graft.[3]

Since then, several types of materials have been used to reconstruct the tympanic membrane, temporalis fascia, fascia lata, periosteum, perichondrium, cartilage with and without perichondrium, veins, fatty tissue, and skin.[4] Other allografts mentioned in the literature include dura mater, pericardium, amniotic membrane, skin, cornea, peritoneum, veins, and aortic valve.[5]

Recently, alloplastic grafts such as paper, absorbable gelatin sponge, and acellular dermal matrix have also been used.[6]

Each of the techniques was associated with its own advantages and disadvantages. However, fascia temporalis is the most commonly used graft, with success rates between 93% and 97% in primary tympanoplasty, especially in well-aerated middle ears.[7,8]

Although the literature shows the type of graft material used for closure of tympanic membrane (TM) perforations has been shown to have an effect on the outcome of surgery, there are no consistent success rates for achieving an intact tympanic membrane after surgery using different surgical techniques.[9]

A study by Kütük et al. in 2019, with 91 patients randomized into two groups; temporalis fascia graft alone and temporalis fascia with PRP, found better graft survival rates in patients who had temporalis fascia with PRP therapy, especially in those with larger perforations. Reperforations were noted in those who had more than 50% perforation preoperatively. Although hearing gain was greater in those patients who received PRP therapy, it was not statistically significant between the two groups.[10]

A study by S. Yadav et al. reported 95% graft uptake and 18.62 dB hearing improvement in PRF group, while 85% graft uptake and 13.15dB hearing improvement in no PRF group.[11]

A similar study done in India by Shanmugam R et al. proved the superiority of using PRF, showing 100% graft uptake with usage of PRF and hearing improvement of 13.75 dB.[12]

Kaur reported that PRF aids in the initial stability of the grafted tissue at the recipient sites. PRF allows rapid vascularization of the healing tissue by delivering growth factors that induce regeneration. The regeneration occurred due to super-saturation of the wound with PRF, growth factors [13].

Habesoglu et al. [14] in their study on closure of acute tympanic perforations concluded that the use of platelet-rich fibrin accelerates the tympanic membrane closure.

Garin et al. [15] also observed good safety of platelet rich fibrin without any adverse effect in middle ear packing.

References:

Dohan DM, Choukroun J, Diss A, Dohan SL, Dohan AJ, Mouhyi J et al (2006) Platelet-rich fibrin (PRF): a second-generation platelet concentrate. Part I: technological concepts and evolution. Oral Surg Oral Med Oral Pathol Oral Radiol Endodontol 101(3):e37– e44

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Zollner F. The principles of plastic surgery of the sound-conducting apparatus. J Laryngol Otol 1955;69:637-52.

Lee JC, Lee SR, Nam JK, Lee TH, Kwon JK. Comparison of different grafting techniques in type I tympanoplasty in cases of significant middle ear granulation. Otol Neurotol 2012;33:586-90.

Van Rompaey V, Farr MR, Hamans E, Mudry A, Van de Heyning PH. Allograft tympanoplasty: A historical perspective. Otol Neurotol 2013;34:180-8.

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Malhotra M, Varshney S, Malhotra R, Joshi P. Indian perspectives on graft materials used for repair of tympanic membrane. J Clin Diagn Res 2017;11:ME01-6.

Kulkarni S, Kulkarni V, Burse K, Sancheti V, Roy G. Cartilage support for fascia graft in type I tympanoplasty. Indian J Otolaryngol Head Neck Surg 2014;66:291-6.

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Kütük SG, Özdaş T. Impact of platelet-rich fibrin therapy in tympanoplasty type 1 surgery on graft survival and frequency-specific hearing outcomes: A retrospective analysis in patients with tympanic membrane perforation due to chronic otitis media. J Laryngol Otol 2019;133:1068-73.

Yadav SP, Malik JS, Malik P, Sehgal PK, Gulia JS, Ranga RK. Studying the result of underlay myringoplasty using platelet-rich plasma. J Laryngol Otol. 2018;132(11):990-994. doi: 10.1017/S0022215118001846

Shanmugam R, Gnanavelu Y, Shanmugam VU, Swaminathan B, Nivas P, Bharath I. Myringoplasty with Autologous Platelet Rich Plasma - A prospective study. J Med Sci Clin Res. 2018;6(10):1170-1173. doi: 10.18535/ jmscr/v6i10.196

Kaur P (2011) Platelet-rich fibrin a novel bioengineering concept. Trends Biomater Artif Organs 25:86–90

Habesoglu M, Oysu C, Sahin S, Sahin-Yilmaz A, Korkmaz D, Tosun A, Karaaslan A. Platelet-rich fibrin plays a role on healing of acute-traumatic ear drum perforation. J Craniofac Surg. 2014;25(6):2056–2058. doi: 10.1097/SCS.0000000000001140. [PubMed] [CrossRef] [Google Scholar]

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