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HARVESTING CARTILAGE FOR CARTILAGE TYMPANOPLASTY Dr. Anusha S Shetty Junior Consultant Karnataka ENT Hospital and Research Centre Hands on Workshop on Cartilage Tympanoplasty September 6 th and 7 th 2014

Harvesting cartilage for cartilage tympanoplasty

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Page 1: 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

Page 2: Harvesting cartilage for cartilage tympanoplasty

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

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Courtesy rcsullivan.com

1. Subtotal perforation

2. Anterior perforation

3. Atelectactic TM4. Reperforation5. ETD

Page 4: Harvesting cartilage for cartilage tympanoplasty

SUCCESS RATE WITH TEMPORALIS FASCIA

ONLY 60-75%

Page 5: Harvesting cartilage for cartilage tympanoplasty

REASONS

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

Page 6: Harvesting cartilage for cartilage tympanoplasty

BIOMECHANICS OF CARTILAGE- Thickness, mass effect

Thick graftMore stableGreater reflectionLess acoustic sensitivity

Thin graftLess stableLesser reflection Greater acoustic sensitivity

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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

Page 8: Harvesting cartilage for cartilage tympanoplasty

DONOR SITES

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

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APPROACHES

ENDAURAL APPROACH

RETROAURAL APPROACH

Page 10: Harvesting cartilage for cartilage tympanoplasty

HARVESTING CARTILAGE THROUGH ENDAURAL APPROACH

• TRAGAL CARTILAGE– Heermann’s approach

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

Page 11: Harvesting cartilage for cartilage tympanoplasty

HEERMANN’S APPROACH- Tragal cartilage

• Commonly preferred • INCISIONS:

1. Circumferential incision2. Vertical incision, 15mm

upwards3. Extending into postaural

groove• Preservation of tragal dome

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Page 13: Harvesting cartilage for cartilage tympanoplasty

SHAMBAUGH’S & LEMPERT’S APPROACHES- Conchal cartilage

INCISION1. Lateral

circmferential 2. Intercartilagenous 3. Lateral radial

incision toward concha

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Page 15: Harvesting cartilage for cartilage tympanoplasty

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

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Page 17: Harvesting cartilage for cartilage tympanoplasty

RETROAURICULAR APPROACH

1. Cymba Cartilage2. Fossa triangularis 3. Scapha cartilage

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RETROAURICULAR APPROACH- Cymbaconcha cartilage

• INCISION: slightly superior to eminence of concha

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

Page 19: Harvesting cartilage for cartilage tympanoplasty

RETROAURICULAR APPROACH- Fossa Triangularis cartilage

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

Page 20: Harvesting cartilage for cartilage tympanoplasty

RETROAURICULAR APPROACH- Scapha cartilage

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

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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

Page 22: Harvesting cartilage for cartilage tympanoplasty

METHODS OF THINNING THE GRAFT

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

Page 23: Harvesting cartilage for cartilage tympanoplasty

SCALPEL1. Held between two fingers

2. Held against wooden tongue depressor

3. Held between surgical forceps

Page 24: Harvesting cartilage for cartilage tympanoplasty

HILDMAN CARTILAGE SLICING CLAMP- ISLAND GRAFTS

a) Open clamp

b) Clamp holds the graft

c) Cartilage sliced from above

d) Cartilage sliced from below

Page 25: Harvesting cartilage for cartilage tympanoplasty

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

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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

Page 27: Harvesting cartilage for cartilage tympanoplasty

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

Page 28: Harvesting cartilage for cartilage tympanoplasty

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

Page 29: Harvesting cartilage for cartilage tympanoplasty

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%

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THANK YOU