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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