Three groups of nine patients each were analyzed. The first two groups consisted of
those that underwent tympanoplastic due to chronic inflammation of middle ear. Two
different standard auditory canal skin incisions were applied, i.e. tympanomeatal flap
(TMF) or vascular strip (VS). The third control group consisted of non-operated patients.
All the operated patients were subjected to a quantitative analysis of the auditory
canal revascularization by means of the Weibel stereological test method, i.e. the B 100
double network system. The density of capillaries, arterioles, venulolymphatic spaces
and a total volume density of all vascular elements of the auditory canal skin were measured.
The obtained results of vascularization were compared with those of the target
control group. It was found out that there were no significant differences in vascularization
of auditory canal skin between TMF and VS patients from one side and the control
group on the other side

Dejan Komljenović

Gordana Žauhar

Marko M. Velepič

Mitja S. Velepič

Niko Cvjetković

Hrčak - Portal of scientific journals of Croatia

Coll. Antropol. 27 (2003) 1: 279–284UDC 616.288-089.84Original scientific paperThe Quantitative Analysis of theVascularization Following Two BasicAuditory Canal Skin IncisionsNiko Cvjetkovi}¹, Mitja S. Velepi~¹, Marko M. Velepi~¹, Dejan Komljenovi}¹and Gordana @auhar²1 Department of Otorhinolaryngology, School of Medicine, University of Rijeka, Rijeka, Croatia2 Department of Physics, School of Medicine, University of Rijeka, Rijeka, CroatiaA B S T R A C TThree groups of nine patients each were analyzed. The first two groups consisted ofthose that underwent tympanoplastic due to chronic inflammation of middle ear. Twodifferent standard auditory canal skin incisions were applied, i.e. tympanomeatal flap(TMF) or vascular strip (VS). The third control group consisted of non-operated pa-tients. All the operated patients were subjected to a quantitative analysis of the auditorycanal revascularization by means of the Weibel stereological test method, i.e. the B 100double network system. The density of capillaries, arterioles, venulolymphatic spacesand a total volume density of all vascular elements of the auditory canal skin were mea-sured. The obtained results of vascularization were compared with those of the targetcontrol group. It was found out that there were no significant differences in vascula-rization of auditory canal skin between TMF and VS patients from one side and the con-trol group on the other side.Key words: auditory canal, skin vascularization, tympanomeatal flap, vascular stripIntroductionVarious incisions have been describedfor the purpose of access to the middle earwhen undergoing tympanoplasty1–3. Mostof them origin from two standard inci-sions: the one forming tympanomeatalflap (TMF), and the other vascular strip(VS). TMF is formed by means of two lon-gitudinal auditory canal incisions. Theupper one runs along the tympanosqua-mous suture line (approximately in posi-tion 12 o’clock), and the lower one at ap-proximately 6 o’clock. The incisions com-mence close to the annulus and extendabout 8 mm towards the auditory canalexit where they are joined with a trans-versal incision.279Received for publication September 2, 2001The VS differs from TMF in two fea-tures. The VS is exclusively applied inretroauricle approach. Its basis is locatedlaterally from the tympanic membrane,in the level of bony cartilaginous junc-tion. Longitudinal incisions run towardsthe edge of the tympanic membrane wherethey are joined with a transversal inci-sion. The upper one runs along the tym-panosquamous suture line, whereas thelower one follows the tympanomastoidsuture line (in left ear at position of 3o’clock, in the right ear at 9 o’clock)4–7.The objective of the paper is to assessthe revascularization of auditory canalskin of patients to whom TMF or VS wasformed following a tympanoplasty. Theobjective was carried out by means of thestereology method in quantitative analy-sis of vascular elements (capillaries, arte-rioles, venulolymphatic spaces).Material and MethodsIn this brief study, three groups ofnine patients each were analyzed. Thefirst group was made of 5 males and 4 fe-males in the age of 20–45 (average agebeing 36.9). The second group consisted of4 males and 5 females in the age of 19–43(average age being 32.3). The third groupincluded 6 males and 3 females in the ageof 23–52 (average age being 34.8). Boththe first and the second group of patientswere chosen among those who had al-ready been tympanoplasty operated morethan a year before (average before 2 yearsand 9 months). The first group was sub-jected to a skin incision leading to the ofTMF formation in the auditory canal,whereas the second one underwent VSformation. The third group of patientswas chosen among those having chronicear inflammation and going to have tym-panoplasty for the first time. All the pa-tients had a normally wide auditory ca-nal, without pathological changes andanatomical anomalies. Their ears werefully dry.Three pieces of auditory canal skinwere taken from each patient for analy-sis, one from upper, one from posteriorand one from lower canal wall, at a dis-tance of 1–2 mm from the tympanic mem-brane (Figure 1). The skin was taken inits full thickness, starting from epithe-lium to the near bone tissue. Then theskin was dipped into 10% formalin solu-tion (pH = 7.0) for unlimited fixation at60 °C. This was followed by a routine em-bedding into paraffin (70% alcohol – 6hours, 96% alcohol – 18 hours, 100% alco-hol – 4 hours, toluol – 2 hours, paraffin 18hours).The skin was embedded into paraffincubes, thus enabling to obtain slices of 6mm in depth throughout the skin thick-ness. Each biotic sample was cut into5–15 slices referred to in the language ofstereology as 5 – 15 cross sectional views,or referential systems (referential spacesmeasured by the test system). The inci-sions were treated at a water tempera-280N. Cvjetkovi} et al.: Auditory Canal Revascularization, Coll. Antropol. 27 (2003) 1: 279–284Fig. 1. The auditory canal segments where fromthe tissue was taken for the quantitative analy-sis of vascularisation: 1 = upper wall; 2 = poste-rior wall; 3 = lower wall. Schematic diagramsof two different canal incisions: (……) = tympa-nomeatal flap; (------) = vascular strip.ture of 38–40°C. The incision stainingwas carried out by a standard method(hemalaun-eosin) in a Stainette (RechertWien) for 1 hour.The quantitative analysis of the audi-tory canal skin vascularization of thethree above quoted groups of patientswas carried out by means of the stereo-logical method. In the histological skin,the volume density of individual vascularelements – vascular phases (Vp), was de-termined. The volume density Vp, as arelative stereological variable, shouldshow the percentage of the analyzed unitvolume in the total skin volume. The vol-ume density of capillaries (c), arterioles(a) and venulolymphatic spaces (vl) wasanalyzed. Since the subject matter ele-ments are of a different volume (capillar-ies are much smaller than arterioles andvenulolymphatic spaces), a double B 100network system was used (Weibel). Themicroscopic magnification was 10 (objec-tive)  1.6 (intermediate lens)  6.3 (eye-piece lens). The double network test sys-tem is made up of two kinds of test points,thick line intersections (Pt) and all lineintersections (Pt’). When magnified, thecapillaries were found to be present intest points corresponding to all line inter-sections (Pt’), whereas the arterioles andvenulolymphatic spaces were identifiedat one to two thick line intersections. Therelation between Pt and Pt’ was estab-lished by formula: Pt’= Pt  q2. The testwas performed starting from epitheliumto the near bone tissue and, in parallel,backwards. In order to obtain the volumedensity of each analyzed Vp, the follow-ing formulae were used8:VVc = Pc/Pt’, VVa = Pa/Pt and VVvl = Pvl/ PtVVc = Volume density c; Pc = number ofidentified test points per c; Pt’= 400VVa = Volume density a; Pa = number ofidentified test points per a; Pt = 100VVvl = Volume density vl; Pvl = number ofidentified test points per vl; Pt = 100The average volume density of eachVp for each group of patients was calcu-lated by means of arithmetic averages ofindividual patients’ Vp. The arithmeticaverage of the total volume density of allpatients’ Vp within the group was used todetermine the total volume density of allVp (vascularization) of each group of pa-tients. The average of volume density ofeach Vp and the total volume density ofall Vp were calculated separately for up-per, posterior and lower walls of the audi-tory canal9.The significant differences of the totalvolume density of all Vp were defined bythe t-test for each of the above quoted au-ditory canal segments (software packageSTATISTICA 6.0, StatSoft, Inc.).ResultsThe numeric variables of stereologicalvariables obtained by the skin tested (av-erage volume density of individual Vpand total volume density of upper, poste-rior and lower Vp walls) were contrasted.Contrasting the numeric values referringto upper, posterior and lower auditory ca-nal regions, following results were ob-tained:¿ The numeric value of individual Vp vol-ume density averages is the highest inthe upper region, somewhat lower inthe posterior, and the lowest in the lowwall region in all three groups of pa-tients tested (Table 1);¿ The numeric value of the total volumedensity of all Vp is also highest in theupper region, somewhat lower in theposterior, and the lowest in the lowwall region, in all three groups of pa-tients tested;Such results correspond to the exist-ing data of the qualitative histologicalanalyses of the auditory canal.The primary purpose of the study wasto analyze the revascularization after TMF281N. Cvjetkovi} et al.: Auditory Canal Revascularization, Coll. Antropol. 27 (2003) 1: 279–284and VS tympanoplasty operation. There-fore, the total values of the volume den-sity of all Vp of individual auditory canalswere compared. The following was de-duced:¿ The numeric value of the total volumedensity of all Vp, and in all three re-gions of the auditory canal was statisti-cally significant highest (p<0.05) withnon-operated patients (Tables 2 and 3).282N. Cvjetkovi} et al.: Auditory Canal Revascularization, Coll. Antropol. 27 (2003) 1: 279–284TABLE 1AVERAGE VOLUME DENSITY OF VASCULAR PHASES (CAPILLARIES, ARTERIOLES ANDVENULOLYMPHATIC SPACES) OF UPPER, POSTERIOR AND LOWER AUDITORY CANAL WALLIN THREE GROUPS OF PATIENTSAuditory canalwallTMF VS Non-operatedUpperVVcVVaVVl0.23010.01560.00440.10870.02320.01060.44000.16000.0840PosteriorVVcVVaVVl0.11000.02890.01330.09130.01110.00230.34950.07210.0863LowerVVcVVaVVl0.14370.01890.00560.07830.00000.00000.19760.01780.0267VVc – volume density of capillaries; VVa – volume density of arterioles; VVl – volume density ofvenulolymphatic spacesTABLE 2TOTAL VOLUME DENSITY COMPARISON OF ALL VASCULAR PHASES OF THE UPPER,POSTERIOR AND LOWER CANAL WALLS IN BOTH THE OPERATED (FORMED TYMPANOMEATALFLAP) AND NON-OPERATED PATIENTSAuditory canalwallTMFVP SDNon-operatedVP SDt pUpper 0.0834 0.0361 0.2280 0.0536 6.71 0.000005Posterior 0.0507 0.0464 0.1693 0.0327 6.27 0.000011Lower 0.0560 0.0284 0.0807 0.0477 1.33 0.202VP – mean total volume density of all vascular phases (capillaries, arterioles and venulolymphaticspaces)TABLE 3TOTAL VOLUME DENSITY COMPARISON OF ALL VASCULAR PHASES OF THE UPPER,POSTERIOR AND LOWER CANAL WALLS IN BOTH THE OPERATED (FORMED VASCULAR STRIP)AND NON-OPERATED PATIENTSAuditory canalwallVSVP SDNon-operatedVP SDt pUpper 0.0475 0.0524 0.2280 0.0536 7.22 0.000002Posterior 0.0349 0.0358 0.1693 0.0327 8.31 0.0000003Lower 0.0261 0.0336 0.0807 0.0477 2.80 0.0127VP – mean total volume density of all vascular phases (capillaries, arterioles and venulolymphaticspaces)¿ Further statistical analysis could notprove any statistically significant dif-ference (p>0.05) in total volume den-sity of all Vp, for each of the analyzedauditory canal segments, between theTMF patients and patients with VS(Table 4).DiscussionThe differences of internal body struc-ture between the experimental and con-trol target groups are often small and un-clear due to their particular structure. Insuch cases, a reliable establishment ofdistinctions, based only upon the qualita-tive methods seems to be very hard, unre-liable or completely impossible. Stereo-logy offers a multidisciplinary methodologyon the basis of which it is viable to esti-mate quantitatively the three-dimensio-nal internal body structure taking intoconsideration two dimensional cross-sec-tions and geometrical probability. Suchminor differences can be quantitativelydescribed and analyzed by means of ste-reological methods10,11.The auditory canal skin does not haveonly a protective task. Its physiologicalactivity is demanding and logically de-pendent upon the vascular network con-dition. The vascular elements of the audi-tory canal take part in irrigation of themiddle ear conductive structures and inparticular of the tympanic membrane12–13.The auditory canal functions may belowered down by a middle ear surgery op-eration.The idea of different incisions has notoriginated only from the necessity to havean easier surgery access to the ear, butalso because of a more complete and qui-cker auditory canal recovery, and in par-ticular of its revascularization.A successful revascularization of theauditory canal should take place most in-tensively in the first month following theoperation, bringing about an enhancedvascularization of the transplanted tym-panic membrane. In this way a conditionis met for a successful result of tympa-noplasty.For several decades various ear sur-gery schools (European schools on the oneside and American on the other) havebeen in existence14. Their scientific re-search and extensive experience have en-abled them to use their specific tympano-plasty methods, i.e. specific incisions ofthe auditory canal skin. Ultimate resultsof the different tympanoplasty methodsdo not significantly differ. Therefore, dif-ferent auditory canal skin incisionsshould be more or less equally satisfac-tory. However, minor structural differen-ces in the auditory canal skin can be de-tected. This may be manifested in thedensity of vascular elements after apply-ing different types of incisions. Those dif-283N. Cvjetkovi} et al.: Auditory Canal Revascularization, Coll. Antropol. 27 (2003) 1: 279–284TABLE 4TOTAL VOLUME DENSITY COMPARISON OF ALL VASCULAR PHASES OF THE UPPER,POSTERIOR AND LOWER CANAL WALLS IN THE PATIENTS UNDERGONE TWO DIFFERENTCANAL INCISIONS (FORMED TYMPANOMEATAL FLAP AND VASCULAR STRIP)Auditory canalwallTMFVP SDVSVP SDt pUpper 0.0834 0.0361 0.0475 0.0525 1.69 0.111Posterior 0.0507 0.0464 0.0349 0.0358 0.81 0.429Lower 0.0560 0.0284 0.0261 0.0336 2.04 0.058VP – mean total volume density of all vascular phases (capillaries, arterioles and venulolymphaticspaces)ferences should have a practical value inthe reconstructive surgery of the middleear.ConclusionSince no statistical differences in theskin revascularization following the twoauditory canal incisions (TMF, VS) wereestablished, it could be concluded thatboth of them can be equally applied in earsurgery. No papers dealing with revas-cularization of auditory canal applyingquantitative histology were found. There-fore, no analysis comparison could bemade. The number of tested persons is in-sufficient for drawing ultimate conclu-sion, but it is assumed that the quantita-tive analysis applied in the above testcould be successively applied in furtheranalyses of this and similar otologicalmatters.R E F E R E N C E S1. LEGENT, F., Ann. Otolaryngol. Chir. Cervico-fac., 117 (2000) 215. — 2. LEGENT, F., Ann. Otola-ryngol. Chir. Cervicofac., 117 (2000) 220. — 3. SOOY,F. A., Laryngoscope, 74 (1964) 979. — 4. HOUSE, W.F., J. L. SHEEHY, Arch. Otolaryngol. Head. Neck.Surg., 73 (1961) 407. — 5. PLESTER, D., H. HILD-MANN, E. STEINBACH: Atlas der Ohrchirurgie. (W.Kohlhammer GmbH, Stuttgart, Berlin, Köln, 1989).— 6. McCULLOUGH, D. W., J. Otolaryngol., 10 (1981)325. — 7. SAUVAGE, J. P., F. HEURTEBISE, S. PUY-RAUD, Rev. Laryngol. Otol. Rhinol., 117 (1996) 247.— 8. KALI[NIK, M., Acta. Stereol., 4 (1985) 1. — 9.CLIFF, S., A. J. BEDLOW, A. W. STANTON, P. S.MORTIMER, Br. J. Dermatol., 140 (1999) 61. — 10.WEIBEL, E. R.: Practical methods for biological mor-phometry. (San Francisco Academic Press, London,NewYork, Toronto, Sydney, 1979). — 11. WEIBEL, E.R., J. Microsc., 155 (1989) 393. — 12. PERRY, T. E.:The human ear canal. (C. C. Thomas, BannerstoneHouse, Springfield, 1957). — 13. APPLEBAUM, E.L., C. E. DEUTSCH, Ann. Otol. Rhinol. Laryngol., 95(1986) 439. — 14. PEGAN, B., Timpanoplastika. In:PADOVAN, I.: Otorinolaringologija. ([kolska knjiga,Zagreb, 1984).N. Cvjetkovi}Department of Otorhinolaryngology, School of Medicine, University of Rijeka,B. Branchetta 20, 51000 Rijeka, CroatiaKVANTITATIVNA ANALIZA VASKULARIZACIJE NAKON DVIJETEMELJNE INCIZIJE KO@E ZVUKOVODAS A @ E T A KU radu se prikazuju tri grupe od devet ispitanika. U prve dvije grupe su ispitanicikod kojih je prethodno, radi kroni~ne upale srednjeg uha, u~injena timpanoplastika.Prilikom timpanoplastike su kori{tene dvije standardne, ali u principu razli~ite inci-zije ko`e zvukovoda. Kod prve grupe je oblikovan timpanomeatalni re`anj (TMF), a koddruge vaskularni strip (VS). Tre}oj kontrolnoj grupi pripadaju neoperirani ispitanici.Kod svih ispitanika je u~injena kvantitativna analiza vaskularizacije ko`e zvukovodastereolo{kom metodom. Kori{ten je dvostruki mre`asti sistem B 100 (Weibel). Odre-|uje se volumna gusto}a kapilara, arteriola i venulolimfati~nih prostora te ukupna vo-lumna gusto}a svih vaskularnih elemenata. Statisti~ki zna~ajne razlike u vaskulariza-ciji ko`e zvukovoda izme|u dvije grupe operiranih ispitanika nisu primije}ene. Zna-~ajne razlike u vaskularizaciji nisu dokazane ni izme|u grupa operiranih bolesnika ikontrolne grupe ispitanika.284N. Cvjetkovi} et al.: Auditory Canal Revascularization, Coll. Antropol. 27 (2003) 1: 279–284

The Quantitative Analysis of the Vascularization Following Two Basic Auditory Canal Skin Incisions

Abstract

Similar works

Full text

Available Versions

Hrčak - Portal of scientific journals of Croatia