tplasty-cartilage-slides-080319 - Cartilage Tympanoplasty...

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Unformatted text preview: Cartilage Tympanoplasty Cartilage K. Kevin Ho, MD Tomoko Makishima, MD PhD Univ. of Texas Medical Branch, Dept. of Otolaryngology – Grand Rounds Presentation March 19, 2008 History of Tympanoplasty History Banzer (1640): repair TM w/ pig’s bladder. Toynbee (1853): rubber disk. Blake (1877): paper patch. Zoellner and Wullstein in 1952, using STSG 1958 – Jansen 1958 First reported use of cartilage in OCR 1963 – Salen and Jansen 1963 Salen First reported use of cartilage for reconstruction of the First TM TM Tympanic Membrane Tympanic Oval shape. 8x10 mm. 55° angle w/ respect angle to floor of meatus. to 130 µm thick. 3 layers: • Outer epithelial – Outer keratinizing squamous keratinizing • Middle fibrous – superficial Middle radial, deep circular radial, • Inner – mucosa Tympanic Membrane Perforations Perforations Etiology: Middle ear infections. EAC infections. Blunt Trauma. Iatrogenic. Risk factors for ReRisk perforation Large perforation (Lee P 2002) (Lee Large • 56% success vs. 74% in small perf Anterior location Anterior (Bhat NA 2000) (Bhat • 67% success vs. 90% in posterior perf Disease in contralateral ear (Ophir D 1987) (Ophir Disease Otorrhea during surgery (Lau T 1986) (Lau Otorrhea Middle ear mucosa status (Albu S 1998) (Albu Middle Smoking (Becvaroski Z 2001) Smoking (Becvaroski Age and Success of Cartilage Tympanoplasty Tympanoplasty Albera et al, 2006 EBM III Graft Materials Graft Fascia Perichondrium Vein Dura Skin Cartilage Why Cartilage? Why Fascia and perichondrium undergo Fascia atrophy atrophy Skin graft: Infection Cartilage Cartilage More rigid and resist resorption Good long-term survival Nourished largely by diffusion Nourished Mucosal Traction Theory Mucosal Mucosal layers of TM and middle ear linings Mucosal undergo constant migration undergo ETD creates the initial retraction and contact ETD between mucosa of TM and ossicles between If mucosa of TM and ossicles are coupled by If mucous or fibrous adhesions, migratory forces pull mucosa towards the incus forces Mucosal traction plays a stronger role than Mucosal Eustachian tube dysfunction in forming cholesteatoma cholesteatoma Jackler Otology Update 2006: EBM V Indications for Cartilage Tympanoplasty Cartilage Atelectatic ear Retraction pocket/ Cholesteatoma High Risk Perforation Revision Revision Anterior perforation > 50% Otorrhea at the time of surgery Bilateral Techniques Techniques Perichondrium/ Cartilage island flap Cartilage shield technique Conchal cartilage Palisade technique Tragal cartilage Tragal cartilage Concha cymba Inlay Butterfly graft Tragal cartilage Inlay Butterfly Graft Originally designed for small perforation Originally (< 1/3 TM diameter) myringoplasty without cholesteatoma cholesteatoma Inlay technique without elevation of Inlay tympanomeatal flap tympanomeatal Quick office procedure Expanded recently to repair larger Expanded perforations in conjunction with mastoidectomy mastoidectomy Split thickness skin graft over perichondrium Split for large perforation for Inlay Butterfly Graft Inlay Eavey RD 1998 Placement of Butterfly graft Placement Eavey RD 1998 Postop Inlay Butterfly graft Postop Eavey RD 1998 Inlay graft for large perforation Inlay Ghanem MA 2006 Tragal Cartilage Harvest Tragal Cut on medial side of tragus Leave 2 mm tragal cartilage Leave for cosmesis for Abundance: 15 x 10 mm Abundance: Flat ~ 1 mm thickness Perichondrium from the side Perichondrium away from the EAC is removed removed Dornhoffer 2003 Perichondrium/ Cartilage Graft Perichondrium/ Dornhoffer 2003 Medial Grafting Medial Dornhoffer 2003 Postop Perichondrium/ Cartilage Island Graft Island Dornhoffer 2003 Cartilage Shield Aidonis I 2005 Cartilage Shield Cartilage Palisade technique Palisade This technique is This favored when OCR is performed in malleus-present situation situation Cartilage from either Cartilage tragus or cymba tragus Post-auricular: Post-auricular: Cymba Cymba Transcanal: Tragus Dornhoffer 2003 Conchal Cartilage Graft Conchal Palisade techniques Palisade Preparation of Cartilage Strips Preparation Kazikdas KC 2007 Palisade technique Palisade Anderson J et al. Otol Neurotol. 2004 Palisade Postop result Palisade Modified Palisade technique Modified Murbe D 2002 Postop care Postop 2 weeks postop: Gelfoam completely suctioned from EAC suctioned Start topical antibiotics x 2 weeks Adult: Start valsalva Adult: Children: Otovent TID 3-4 months: Audiogram Air bone gap Tympanogram no longer reliable. Type B tymp Tympanogram despite normal hearing despite Criticisms of Cartilage T-plasty Criticisms Time consuming to shape cartilage Opaque - Difficulty in surveillance Opaque Rigidity of cartilage raises concern Rigidity about audiologic outcome about Effect of TM perforation on Hearing Effect Diminished surface area on which sound Diminished pressure can exert Decreased area effect of TM: stapes footplate Decreased (normally 17:1) (normally dampening of lever action of the ossicular chain Sound reaching round window at same intensity Sound and phase as oval window cancelling fluid vibration in cochlear Sound pressure entering the perforation acts on Sound the medial surface of the TM against that on the lateral surface lateral Hearing Results: Dornhoffer et al. 95 patients who failed at least 1 temporalis 95 fascia graft tympanoplasty fascia 29 required OCR Avg f/u 12 months 90/95 (94.7%) with successful TM closure Pediatric group has similar success rate as Pediatric adults adults PTA (p < 0.001) Preop: Preop: Postop: Postop: 24.6 24.6 12.2 12.2 EBM III Hearing Results: Gerber 2000 Hearing 11 patients 2 groups: Cartilage vs. temporalis fascia Intact ossicular chain Size of graft: 1/3 – 2/3 of mesotympanum Tragal cartilage island graft (10), conchal (1) Primary indication: Retraction pocket Post-auricular or transcanal Average f/u: 12 months EBM III Hearing Results: Gerber 2000 Hearing Hearing Results: Gerber 2000 Hearing Thickness of Cartilage graft Thickness Murbe D 2002 Acoustic Properties Management of Middle ear effusion postop Management Appearance of TM Air-bone gap on audiogram CT temporal bone Initial treatment: Nasal steroids Valsalva 3 months Surgical treatment: Myringotomy (eg. CO2 laser) Tympanostomy tube (eg. soft Goode tube) Pediatric patients Pediatric Avoid T-plasty Avoid < 3 years Repair at age 4 If contralateral ear is perforated, perform If adenoidectomy and defer until age 7 adenoidectomy Cartilage tympanoplasty in the worst ear Cartilage High Risk perforation High Account for 1/3 cases of cartilage Account tympanoplasty tympanoplasty > 95% successful closure of TM after 95% cartilage t-plasty cartilage 5 % requires postop MT Hearing results comparable to fascia graft Ossicular Chain Reconstruction Ossicular Cartilage reinforces prosthesis to prevent Cartilage extrusion extrusion When malleus is present Palisade technique over island flap (obscure Palisade malleus and reconstruction) malleus When malleus is absent Tragal cartilage island flap Cartilage T-plasty with TORP Cartilage Cholesteatoma Cholesteatoma Palisade technique preferred Allow precise placement of Allow prosthesis against the malleus prosthesis Leave anterior TM without Leave cartilage to allow surveillance and future tube placement and Consider 2nd look if sac disrupted during initial cholesteatoma excision excision Pervasive Eustachian Tube Dysfunction Dysfunction Criteria for intraoperative tube placement Criteria Craniofacial abnormalities Nasopharyngeal carcinoma Recurrent otitis media with ETD Round knife used to create a window in Round the anterior graft the Goode tube placed prior to insetting the Goode graft graft Conclusions Conclusions Cartilage tympanoplasty is a reliable Cartilage technique in reconstruction of TM technique Hearing results after cartilage Hearing tympanoplasty is comparable to temporalis fascia graft temporalis Choice of techniques depend on surgeon’s Choice preference, status of ossicular chain, Eutstachian tube, presence of cholesteatoma, etc. Thank You! Thank ...
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This note was uploaded on 12/28/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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