Harvesting cartilage for cartilage tympanoplasty

HARVESTING CARTILAGE FOR CARTILAGE TYMPANOPLASTY

Dr. Anusha S ShettyJunior Consultant

Karnataka ENT Hospital and Research Centre

Hands on Workshop on Cartilage TympanoplastySeptember 6th and 7th 2014

EYES CAN’T SEE WHAT MIND DOES NOT KNOW

• Muscle • Cortical bone• Fascia • Cartilage• Perichondrium Otological surgeries being so challenging yet has a boon of abundant graft material present in and around the ears. When used in the right manner can fetch us outstanding results

Courtesy rcsullivan.com

1. Subtotal perforation

2. Anterior perforation

3. Atelectactic TM4. Reperforation5. ETD

SUCCESS RATE WITH TEMPORALIS FASCIA

ONLY 60-75%

REASONS

– Poor adaptation of graft– Medial displacement of graft– Lateralization of graft– Shrinkage of graft– Graft atrophy– Perforation

BIOMECHANICS OF CARTILAGE- Thickness, mass effect

Thick graftMore stableGreater reflectionLess acoustic sensitivity

Thin graftLess stableLesser reflection Greater acoustic sensitivity

BIOMECHANICS- Elastic ModulusGRAFT MATERIALS AND TYMPANIC MEMBRANE

ELASTIC MODULUS

TYMPANIC MEMBRANE- Pars Tensa- Pars Flaccida

3.3× 107 N/m2

1.1 × 107 N/m2

TEMPORALIS FASCIA 1.5 × 107 N/m2

PERICHONDRIUM 2.0 × 107 N/m2

CONCHAL CARTILAGE 0.6 × 107 N/m2

TRAGAL CARTILAGE O.3 × 107 N/m2

DONOR SITES

1. Tragus2. Anterior crus of helix3. Cavum4. Cymba5. Triangular fossa6. Costal cartilage7. Septal cartilage

APPROACHES

ENDAURAL APPROACH

RETROAURAL APPROACH

HARVESTING CARTILAGE THROUGH ENDAURAL APPROACH

• TRAGAL CARTILAGE– Heermann’s approach

• CONCHAL CARTILAGE – Shambaugh’s/ Lempert’s approach– Farrior approach

HEERMANN’S APPROACH- Tragal cartilage

• Commonly preferred • INCISIONS:

1. Circumferential incision2. Vertical incision, 15mm

upwards3. Extending into postaural

groove• Preservation of tragal dome

SHAMBAUGH’S & LEMPERT’S APPROACHES- Conchal cartilage

INCISION1. Lateral

circmferential 2. Intercartilagenous 3. Lateral radial

incision toward concha

FARRIOR APPROACH- Conchal cartilage

• INCISION:1. Ant circumferential incision at 4

o clock2. Post circumferential incision3. Vertical4. Ant vertical5. Post vertical6. Lateral incision

• Lateral radial incision allows further elevation of skin

• Larger cartilage

RETROAURICULAR APPROACH

1. Cymba Cartilage2. Fossa triangularis 3. Scapha cartilage

RETROAURICULAR APPROACH- Cymbaconcha cartilage

• INCISION: slightly superior to eminence of concha

• Circular incision – convex part cut• 1.5 cm × 1 cm can be harvested

RETROAURICULAR APPROACH- Fossa Triangularis cartilage

1. Thinner than tragal cartilage2. Mobile neotympanic membrane3. 1 cm cartilage can be harvested

RETROAURICULAR APPROACH- Scapha cartilage

1. 20 × 5mm size cartilage can be harvested2. Cut into palisades

THICKNESS OF GRAFT

• IDEAL THICKNESS- 500-600 µm– Stiffness same as tympanic membrane

• IMPENDING EUSTACHIAN TUBE DYSFUNCTION:– High chances of graft retraction– Thicker cartilage >500 µm- stable reconstruction

METHODS OF THINNING THE GRAFT

1. Scalpel 2. Hildman cartilage clamp3. Kurz precise cartilage knife4. Huttenbink cartilage guide5. Groningen cartilage cutting device

SCALPEL1. Held between two fingers

2. Held against wooden tongue depressor

3. Held between surgical forceps

HILDMAN CARTILAGE SLICING CLAMP- ISLAND GRAFTS

a) Open clamp

b) Clamp holds the graft

c) Cartilage sliced from above

d) Cartilage sliced from below

KURZ PRECISE CARTILAGE KNIFE1. Cartilage placed

between Upper part positioned at right angled to lower part

2. Razor blade fixed3. Tightened nut

between the upper and lower blade

4. Sawing movements of the blade

HUTTENBRINK CARTILAGE GUIDE1. 2 cylinders, one

inserted into another2. Press the upper

cylinder3. Thin cartilage plate

obtained 2.5mm×3.5 mm, 0.3 mm thick, central 0.8 mm hole for titanium prosthesis

GRONINGEN CARTILAGE CUTTING DEVICE

1. Place cartilage in depression b

2. Depression has diameter 4 mm and 0.5 mm deep

3. No 11 blade used to cut off the upper part

CONCLUSION1. Cartilage provides good support to

temporalis fascia2. Effective anterior margin increases (narrow

anterior rim)3. Prevents graft from sinking into middle ear4. Appropiate thickness of graft doesn’t hamper

the mobility of neotympanic membrane5. Normal eustachian tube function preserved.6. Good closure and hearing improvement

TAKE HOME MESSAGE

THINGS WORK OUT BEST FOR THOSE WHO MAKE THE BEST OF HOW THINGS WORK OUT

Convenient approach

Right technique of harvesting

Appropriate size and thickness

SUCCESS RATE 100%

THANK YOU