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"contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1130 "Ancho" => 1505 "Tamanyo" => 157236 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Surgical protocol. 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These defects require to be repaired not only to attain relief from intermittent otorrhoea but also to prevent retraction pockets and sequential cholesteatoma.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The repair often tends to fall in the external auditory canal (EAC) or into the mastoid cavity and is unstable.</p><p id="par0015" class="elsevierStylePara elsevierViewall">We have exploited the curling property of the cartilage graft, which can be used effectively for providing a robust reconstruction of the canal wall defects.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Materials and methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">We performed a retrospective review of 5 cases managed at our centre using the below described method of repair for small focal canal wall defects. These surgeries had been performed between January 2017 and December 2017. Strict inclusion criteria were 1. No active squamosal or mucosal chronic otitis media or any active ear disease 2. Defect size less than or equal to 10<span class="elsevierStyleHsp" style=""></span>mm. Details of these cases are mentioned in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Technique</span><p id="par0025" class="elsevierStylePara elsevierViewall">Our patients were scanned by high resolution computed tomography (HRCT) of the temporal bones. Imaging is useful to know 1. The location of the defect 2. Size of the fistula 3. Absence of active pathology in the middle ear or mastoid.</p><p id="par0030" class="elsevierStylePara elsevierViewall">We examined these patients with a zero-degree endoscope for performing aural toilet and visualising the mastoid cavity beyond the fistula. A pure tone audiogram was performed to note the hearing level of these patients. An informed consent was taken from the patients.</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Defining the bony canal wall defect</span><p id="par0035" class="elsevierStylePara elsevierViewall">The canal wall defects were re-examined intra-operatively with a ball probe, to identify the margins and note the absence of any in-growing squamous epithelium. The tympanomeatal skin flap was raised till the annulus, there was no need to enter the middle ear. The bony canal wall defect must be well-defined (preferably circular) with sharp margins. Three of the patients had a well-defined idiopathic canal wall defect (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Two of the cases had an irregular defect, following an intact canal wall mastoidectomy done at some other centre for chronic otitis media, 8 months ago. The margins of the fistula in these 2 cases had to be delineated by drilling. These patients had a wide canal and endomeatal drilling could be performed easily. One may need to do a cortical mastoidectomy and thin the posterior canal wall, to demarcate the canal wall defect.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Harvest and fashioning of the butterfly graft</span><p id="par0040" class="elsevierStylePara elsevierViewall">An inverted U-shaped incision was made over the meatal aspect of the tragus and an appropriately sized full-thickness tragal cartilage with intact perichondrium on both the sides, was harvested. The dome of the tragus (1<span class="elsevierStyleHsp" style=""></span>mm) was preserved for cosmetic reasons.</p><p id="par0045" class="elsevierStylePara elsevierViewall">An 11 number blade was used to make a circumferential 1<span class="elsevierStyleHsp" style=""></span>mm incision all along the edge of the cartilage graft. The cartilage curls towards the perichondrium on both sides, creating a butterfly like graft (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Repair of the canal wall defect</span><p id="par0050" class="elsevierStylePara elsevierViewall">The designed butterfly tragal cartilage (about 1<span class="elsevierStyleHsp" style=""></span>mm larger than the defect) was then snugly fitted into the defect (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). The bony edge of the fistula gets sandwiched between the curled margins of the butterfly graft. The assembly was then reinforced by perichondrium, on which the tympanomeatal flap was reposited. No packing of the ear canal or the mastoid cavity was done in these cases. They were examined at 10 days, 20 days, 1 month and 6months, 2years (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>) post-operatively.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results</span><p id="par0055" class="elsevierStylePara elsevierViewall">All the 5 cases had a successful repair of the fistula. A successful result was assessed on basis of the following points:</p><p id="par0060" class="elsevierStylePara elsevierViewall">1. Viability of the graft, 2. Relief from intermittent otorrhoea, 3. No migration of the cartilage used for repair, 4. Epithelialization of the bony canal wall over the repair site.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discussion</span><p id="par0065" class="elsevierStylePara elsevierViewall">Meato-mastoid fistula (MMF) is a connection between the external auditory canal and the mastoid cavity. It may be iatrogenic and could occur during procedures which require thinning of the posterior canal wall, especially when the canal wall is curved posteriorly. These surgeries would include: Intact canal wall mastoidectomy, posterior tympanotomy for facial nerve decompression or cochlear implant procedure. Removal of exostosis in the EAC could also cause a canal wall defect.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Canal wall defects may occur in cases of EAC cholesteatoma (EACC) or aggressive keratosis obturans. Very often the differentiation between keratosis and EACC maybe difficult.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Aggressive keratosis obturans can also cause bony erosion and lead to a MMF. Though keratosis is generally a relatively benign condition, it may present with complex patterns of bone erosion.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> However according to Persaud et al.,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> osteonecrosis or bony sequestra and focal loss of epithelium are typical of EACC. Trauma or neoplastic disease can also lead to defects in the EAC. Many times inspite of thorough clinical examination and history, the cause of these defects maybe idiopathic.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Failure of fusion of the foramen of Huschke is a rare cause of dehiscence in the tympanic plate. This defect in the anterior wall of the external auditory canal allows herniation of retrodiscal soft tissues of the temporomandibular joint into the ear canal.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> The incidence of patent foramen of Huschke has been reported as 7.7 per cent in a cadaver study.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> The foramen is usually located in the medial half of the anterior tympanic plate and within 0.5<span class="elsevierStyleHsp" style=""></span>mm of the tympanic annulus in over 90 per cent of cases. None of the 5 cases in our series had an anterior canal wall defect. The butterfly tragal graft may be tailored and used for repair of anterior canal wall defects.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Irrespective of the location, MMF needs closure to restore the normal anatomic conditions in the ear. The materials used for repair often tend to migrate and are unstable. They may either get displaced into the EAC or into the mastoid cavity. Depending on the graft used for the repair, there maybe a significant donor site morbidity. Various alloplastic implants have been mentioned in literature. Solid implants do not allow vascular growth hence capsule formation, suppuration and extrusion are frequent. Silastic has 50 percent extrusion rate at five years.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> Porous high density polyethylene allows fibrous and bony tissue ingrowth within the implant material, which improves tissue tolerance and allows the material to behave more like native tissues and less like a foreign body. Use of titanium sheets or porous implants like polypropylene has been described.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6,7</span></a> Hydroxylapatite is bulky, brittle and lacks tensile strength. There is a potential risk of biofilm formation and tissue reaction in repairs with alloplastic implants. These materials are expensive and may not be easily available too. Compared to these materials, tragal cartilage is an autologous graft material with no significant donor site morbidity. This composite tragal cartilage graft is easy to harvest, relatively rigid, adequate and can be shaped according to the need.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Roland D. Eavey designed the butterfly tragal cartilage graft in 1998.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> The cartilage grafts tend to curl towards the side with intact perichondrium. The butterfly graft design is based on this curling property of the composite cartilage. The butterfly tragal cartilage graft has been successfully used for tympanoplasties but the literature regarding use of this graft for effective closure of focal canal wall defects, is scant. This technique has been described with successful results in 3 patients undergoing combined approach tympanoplasty by Farboud A,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> but they have not used endoscopes in any of their cases.</p><p id="par0090" class="elsevierStylePara elsevierViewall">It is worth doing a HRCT for these cases, imaging helps us to document the size and location of the defects. It reveals any anatomical variations and the aeration of the middle ear and the mastoid cavity. We preferred to use endoscopes for surgical repair in our cases. They provide a panoramic view and good magnification. Angled endoscopes can be used to examine the mastoid cavity, beyond the canal wall defect. Sometimes a narrow meatus or the curvature of the bony canal may hide a laterally located MMF, such defects can be identified and examined with endoscopes.</p><p id="par0095" class="elsevierStylePara elsevierViewall">The size of the MMF can be measured intra-operatively too using a bone-wax template. Sung Il Cho has described the use of bone wax template to determine the correct size and shape of the cortical mastoid bony plate which they used for reconstruction.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">For our technique of repair, the MMF must be small (10<span class="elsevierStyleHsp" style=""></span>mm or less), preferably circular and with well-defined bony edges. In iatrogenic cases of small MMF, this can be accomplished intra-operatively itself. A cortical mastoidectomy can be done to define the circumferential bony edge of the MMF. The butterfly graft snugly fits into the MMF very similar to the placement of ventilation tubes into the tympanic membrane. This technique has many advantages: 1. The circumferential bony edge of the MMF is sandwiched between the curled margins of the butterfly graft, which prevents its migration or displacement. 2. The curled cartilage maintains the curvature of the bony canal wall. 3. This reconstruction doesn’t require support, the ear canal and mastoid cavity don’t need to be packed post-operatively. 4. The graft becomes instantly stable. 5. The procedure has a short learning curve and can be performed quickly under local anaesthesia 6. It has good patient comfort and is less expensive because of the diminished operative and recovery room time.</p><p id="par0105" class="elsevierStylePara elsevierViewall">However, it may not be adequate for larger defects (more than 10<span class="elsevierStyleHsp" style=""></span>mm), for which bony plate over the sigmoid sinus can be used. The bone over the sigmoid sinus is thin and has a natural curvature which is more physiological for a MMF repair. But this procedure is more invasive, requires mastoidectomy and entails the risk of injury to the sigmoid sinus itself. It should be attempted by a more experienced ear surgeon. For very large canal wall defects, repair may not be possible and these patients require a formal canal wall down mastoidectomy.</p><p id="par0110" class="elsevierStylePara elsevierViewall">The limitations of the technique are: 1. It can be used for repair of small focal defects only. 2. The results of this technique over a long duration and in a larger group of patients require to be assessed. It is known that the cartilage grafts used for tympanoplasty become homogenous over a period of many years. The long-term fate of cartilage grafts used for MMF repair has not been studied yet.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conclusion</span><p id="par0115" class="elsevierStylePara elsevierViewall">Our technique describes an effective and innovative use of the butterfly tragal cartilage graft for repair of focal posterior canal wall defects. This technique is recommended for repair of small, circular, well-defined bony canal wall defects. It is a minimally invasive, suture-less, cosmetic and cost-effective technique.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Funding source</span><p id="par0120" class="elsevierStylePara elsevierViewall">None.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflict of interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">None.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres1323810" "titulo" => "Abstract" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Aim/objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Material and methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusion and significance" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1220684" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1323809" "titulo" => "Resumen" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Material y métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1220685" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials and methods" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Technique" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Defining the bony canal wall defect" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Harvest and fashioning of the butterfly graft" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Repair of the canal wall defect" ] ] ] 7 => array:2 [ "identificador" => "sec0035" "titulo" => "Results" ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conclusion" ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Funding source" ] 11 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflict of interest" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-10-08" "fechaAceptado" => "2019-03-31" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1220684" "palabras" => array:5 [ 0 => "Ear canal" 1 => "Endoscopic" 2 => "Repair" 3 => "Cartilage" 4 => "Fistula" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1220685" "palabras" => array:5 [ 0 => "Canal auditivo" 1 => "Endoscópico" 2 => "Reparar" 3 => "Cartílago" 4 => "Fístula" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Meato-mastoid fistula is a connection between the external auditory canal and the mastoid cavity. It may be iatrogenic or pathological. The repair of these focal canal wall defects is necessary to prevent retraction pockets or sequential cholesteatoma and attain relief from otorrhoea.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Aim/objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To study the effectiveness of an innovative technique for repair of meato-mastoid fistula (less than or equal to 10<span class="elsevierStyleHsp" style=""></span>mm in size) in the bony external auditory canal.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Material and methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We performed a retrospective review of 5 surgeries performed in our hospital between January 2017 and December 2017 for the repair of posterior bony canal wall defects. Active ear disease was ruled out before the repair. We used full-thickness butterfly tragal cartilage graft for the repair of these fistulae. All our surgeries were endoscopic and sutureless.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The butterfly tragal cartilage graft was in situ at the repair site and viable on examination at 2 years follow-up, in all our cases.</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusion and significance</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Small posterior canal wall defects can be successfully repaired using this technique. The method is minimally invasive and cosmetic, with good patient compliance. The curling property of the cartilage graft is exploited effectively in this method of repair.</p></span>" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Aim/objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Material and methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusion and significance" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducción</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La fístula meato-mastoidea es una conexión entre el canal auditivo externo y la cavidad mastoidea. Puede ser iatrogénica o patológica. La reparación de estos defectos focales de la pared del canal es necesaria para evitar las bolsas de retracción o el colesteatoma secuencial, y aliviar la otorrea.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Estudiar la eficacia de una técnica innovadora para reparación de fístula meato-mastoidea (inferior o igual a 10<span class="elsevierStyleHsp" style=""></span>mm de tamaño) en el hueso del canal auditivo externo.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Material y métodos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">se realizó una revisión retrospectiva de 5 cirugías en nuestro hospital de atención terciaria entre enero y diciembre de 2017 para la reparación de defectos de la pared ósea del canal posterior. Se descartó la enfermedad activa del oído antes de la reparación. Utilizamos injerto de cartílago tragal en mariposa de espesor completo para la reparación de estas fístulas. Todas las cirugías fueron endoscópicas y sin sutura.</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">El injerto de cartílago tragal en mariposa se realizó in situ en el sitio de reparación, siendo viable durante el examen de seguimiento a los 6 meses, en todos nuestros casos.</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusión</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Los defectos de la pared del canal posterior pequeños pueden repararse exitosamente con esta técnica. El método es mínimamente invasivo y cosmético, con buena aceptación del paciente. La propiedad ondulada del injerto de cartílago se aprovecha eficazmente en este método de reparación.</p></span>" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Material y métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusión" ] ] ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 663 "Ancho" => 756 "Tamanyo" => 88299 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Right sided well-defined meato-mastoid fistula.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 653 "Ancho" => 1253 "Tamanyo" => 109088 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Butterfly tragal cartilage graft with intact perichondrium on both sides.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 603 "Ancho" => 756 "Tamanyo" => 100875 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Butterfly tragal cartilage graft snugly fitted in the MMF.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 726 "Ancho" => 752 "Tamanyo" => 114495 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">2 years post-operative view after the MMF repair.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">No. \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Age/sex \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Side \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Size of MMF in the posterior canal wall \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Etiology \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Significant history \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Drilling to demarcate MMF \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60/F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5MM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Idiopathic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">H/O Otorrhoea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Not done \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Left \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.5MM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Idiopathic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Not done \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45/F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Left \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4MM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Iatrogenic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Post-mastoid surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Done \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Left \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.5MM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Iatrogenic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Post-mastoid surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Done \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">65/F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6MM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Idiopathic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">H/O OtorrhoeaKoch's 20 years ago. Treatment completed. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Not done \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2268939.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Details of the patients with focal posterior canal wall defects.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Keratosis obturans and external auditory canal cholesteatoma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J.C. Piepergedes" 1 => "E.E. 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Butterfly tragal cartilage for repair of focal canal wall defects
Cartílago tragal en mariposa para reparar los defectos focales de la pared del conducto auditivo externo