Harvesting cartilage for cartilage tympanoplasty

This presentation describes the various cartilage material that can be used for cartilage tympanoplasty and methods of harvesting the same.

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

2. EYES CAN’T SEE WHAT MIND DOES
NOT KNOW
•Muscle
•Cortical bone
•Fascia
•Cartilage
•Perichondrium
Otologicalsurgeries 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

3. Courtesy rcsullivan.com
1.Subtotal
perforation
2.Anterior
perforation
3.AtelectacticTM
4.Reperforation
5.ETD

4. SUCCESSRATEWITH
TEMPORALISFASCIA
ONLY 60-75%

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

6. BIOMECHANICS OF CARTILAGE-
Thickness, mass effect
Thick graft
More stable
Greater reflection
Less acoustic sensitivity
Thin graft
Less stable
Lesser reflection
Greater acoustic sensitivity

7. BIOMECHANICS-Elastic Modulus
GRAFT MATERIALS AND TYMPANIC
MEMBRANE
ELASTIC MODULUS
TYMPANIC MEMBRANE
-ParsTensa
-Pars Flaccida
3.3×10
7
N/m
2
1.1 ×10
7
N/m
2
TEMPORALIS FASCIA 1.5 ×10
7
N/m
2
PERICHONDRIUM 2.0 ×10
7
N/m
2
CONCHALCARTILAGE 0.6 ×10
7
N/m
2
TRAGAL CARTILAGE O.3 ×10
7
N/m
2

8. DONOR SITES
1.Tragus
2.Anterior crus of helix
3.Cavum
4.Cymba
5.Triangular fossa
6.Costal cartilage
7.Septalcartilage

9. APPROACHES
ENDAURAL APPROACH RETROAURAL APPROACH

10. HARVESTING CARTILAGE THROUGH
ENDAURAL APPROACH
•TRAGAL CARTILAGE
–Heermann’sapproach
•CONCHAL CARTILAGE
–Shambaugh’s/ Lempert’sapproach
–Farriorapproach

11. HEERMANN’S APPROACH-Tragal
cartilage
•Commonly preferred
•INCISIONS:
1.Circumferential incision
2.Vertical incision, 15mm
upwards
3.Extending into postaural
groove
•Preservation of tragaldome

13. SHAMBAUGH’S & LEMPERT’S
APPROACHES-Conchalcartilage
INCISION
1.Lateral
circmferential
2.Intercartilagenous
3.Lateral radial
incision toward
concha

15. FARRIOR APPROACH-Conchalcartilage
•INCISION:
1.Ant circumferential incision
at 4 o clock
2.Post circumferential incision
3.Vertical
4.Ant vertical
5.Post vertical
6.Lateral incision
•Lateral radial incision allows
further elevation of skin
•Larger cartilage

17. RETROAURICULAR APPROACH
1.CymbaCartilage
2.Fossa triangularis
3.Scaphacartilage

18. RETROAURICULAR APPROACH-Cymba
concha cartilage
•INCISION: slightly superior to eminence of
concha
•Circular incision –convex part cut
•1.5 cm ×1 cm
can be harvested

19. RETROAURICULAR APPROACH-Fossa
Triangulariscartilage
1.Thinner than tragalcartilage
2.Mobile neotympanicmembrane
3.1 cm cartilage can be harvested

20. RETROAURICULAR APPROACH-Scapha
cartilage
1.20 ×5mm size cartilage can be harvested
2.Cut into palisades

21. 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

22. METHODS OF THINNING THE GRAFT
1.Scalpel
2.Hildmancartilage clamp
3.Kurzprecise cartilage knife
4.Huttenbinkcartilage guide
5.Groningen cartilage cutting device

23. SCALPEL
1.Held between two fingers
2.Held against wooden
tongue depressor
3. Held between surgical
forceps

24. HILDMAN CARTILAGE SLICING CLAMP-
ISLAND GRAFTS
a)Open clamp
b)Clamp holds the
graft
c)Cartilage sliced
from above
d)Cartilage sliced
from below

25. KURZ PRECISE CARTILAGE KNIFE
1.Cartilage placed
between Upper
part positioned at
right angled to
lower part
2.Razor blade fixed
3.Tightened nut
between the upper
and lower blade
4.Sawing movements
of the blade

26. HUTTENBRINK CARTILAGE GUIDE
1.2 cylinders, one
inserted into
another
2.Press the upper
cylinder
3.Thin cartilage plate
obtained
2.5mm×3.5 mm, 0.3
mm thick, central
0.8 mm hole for
titanium prosthesis

27. 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

28. CONCLUSION
1.Cartilage provides good support to
temporalis fascia
2.Effective anterior margin increases (narrow
anterior rim)
3.Prevents graft from sinking into middle ear
4.Appropiatethickness of graft doesn’t hamper
the mobility of neotympanicmembrane
5.Normal eustachiantube function preserved.
6.Good closure and hearing improvement

29. TAKE HOME MESSAGE
THINGS WORK OUT BEST FOR THOSE WHO MAKE THE
BEST OF HOW THINGS WORK OUT
Convenientapproach
Righttechniqueofharvesting
Appropriatesizeandthickness
SUCCESSRATE
100%

30. THANK YOU