USE OF CARTILAGE IN TYMPANOPLASTY
Introduction
The use of cartilage in tympanoplasty was presented as used in author’s otologic practice. It includes treatment and prevention of attic retraction, reconstruction of tympanic membrane (TM) perforation, especially revision cases and atelectatic TM reconstructions, placement over the ossicular prosthesis to prevent extrusion, and reduction of mastoid bowl size in canal wall down mastoidectomy. Illustrative cases were presented for the use of cartilage for these purposes.
Treatment and prevention of attic retraction
When there is attic retraction pocket without cholesteatoma, the tympanomeatal flap is developed to beyond the 12-o’clock position to 1 or 2 o’clock. The flap is extended to elevate the TM over the manubrium to the umbo (Fig. 1.1). The perichondrium/cartilage island flap is made either from tragal or conchal cartilage (Fig. 1.2) and grafted to the retraction defect. This procedure can prevent development of cholesteatoma.
Fig. 1.1. The retraction pocket is elevated with an extended tympanomeatal flap down to the manubrium.
Pitfalls of this procedure include: continuation of the Eustachian tube dysfunction ending up with atelectatic TM or recurrence of retraction pocket, or, even worse, covering up deeper cholesteatoma.
Fig. 1.2. Perichondrium/cartilage island flap from tragus to be grafted to the retraction pocket.
Reconstruction of TM perforation
Recently there have been many reports on the superior outcome of the use of cartilage for reconstruction of TM perforation. Cartilage is used as perichondrium/cartilage island flap1,2 or palisade.3 These studies revealed that cartilage with or without perichondrium is either superior or equal to a fascia graft.1,2
For posterior or central perforation, the edges of perforation are denuded of epithelial tissue (Fig. 2.1.1), a perichondrium/cartilage island flap is made (Fig. 2.1.2) and grafted as medial (underlay) graft (Figs. 2.1.3 and 2.1.4) with Gelfoam support under the graft. For anterior or subtotal TM perforation, a perichondrium/ cartilage island graft can be placed as a medio-lateral technique.4
The use of cartilage is the more important for revision tympanoplasty and reconstruction of atelectatic TM.
Fig. 2.1.1. Surgical steps to repair posterior or central TM perforation with medial graft tympanoplasty. First, the edges of perforation are denuded.
Fig. 2.1.2. The perichondrium/cartilage island graft is prepared.
Fig. 2.1.3. The tympanomeatal flap is elevated.
Fig. 2.1.4. The graft is placed medial to the TM perforation.
Placement over the ossicular prosthesis to prevent extrusion
When ossiculoplasty is performed using a titanium or hydroxyapatite partial ossicular replacement prosthesis (PORP) or a total ossicular replacement prosthesis (TORP), the cartilage graft is essential to prevent extrusion (Figs. 3.1 and 3.2).
Fig. 3.1. The titanium total ossicular replacement prosthesis is in place.
Fig. 3.2. The cartilage is grafted over the prosthesis to prevent extrusion.
Reduction of mastoid bowl size in canal wall down mastoidectomy
At the time of canal-wall-down mastoidectomy, cartilage removed from the concha to perform wide me-atoplasty is cut and packed into the mastoid bowel reducing the size of the bowel. This is in effect partial reconstruction of the posterior canal wall.5
1.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 33(4):586–590, 2012
2.Mohamad SH, Khan I, Hussain SS. Is cartilage tympanoplasty more effective than fascia tympanoplasty? A systematic review. Otol Neurotol. 33(5):699–705, 2012
3.Velepic M, Starcevic R, Ticac R, Kujundzic M, Velepic M. Cartilage palisade tympanoplasty in children and adults: long term results. Int J Pediatr Otorhinolaryngol 76(5):663–666, 2012
4.Jung, T, Kim Youhyun, Kim Yoonhwan, Park, S, Martin D. Medial or medio-lateral graft tympanoplasty for repair of tympanic membrane perforation. International J Ped Otorhinolaryngo 73:941–943, 2009
5.Maniu A, Cosgarea M. Mastoid obliteration with concha cartilage graft and temporal muscle fascia. ORL J Otorhinolaryngol Relat Spec 74(3):141–145, 2012
Address for correspondence: Timothy T. K. Jung , 11790 Pecan Way, Loma Linda, CA 92354, USA. ttkjung@gmail.com
Cholesteatoma and Ear Surgery – An Update, pp. 97–101
Edited by Haruo Takahashi
2013 © Kugler Publications, Amsterdam, The Netherlands