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Cartilage Tympanoplasty John Dornhoffer & Edward Gardner

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Cartilage Tympanoplasty John Dornhoffer & Edward Gardner Chapter 6 Cartilage Tympanoplasty John Dornhoffer & Edward Gardner Generally speaking, there are two distinct techni- the use of less compliant, more rigid grafting ques utilized for cartilage reconstruction of the materials for TM reconstruction, such as the cartilage tympanic membrane (TM): the perichondrium/car- graft. Although one might anticipate a significant tilage island flap, which uses tragal cartilage, and the conductive hearing loss with cartilage, due to its palisade technique, which uses cartilage from the rigidity, it is this quality that tends to resist resorp- tragus or cymba, depending on the surgical ap- tion and retraction, even in the milieu of continuous proach. Either technique can be used to reconstruct eustachian tube dysfunction. It has been shown in the TM; however, the choice of technique is typically both experimental and clinical studies that cartilage dictated by the specific middle ear pathology or, in is well-tolerated by the middle ear, and long-term cases where the TM reconstruction is in conjunction survival is the norm.15 Á 18 It appears that cartilage with ossiculoplasty, the status of the ossicular chain. grafts are nourished largely by diffusion and become The palisade technique is preferred in cases of well incorporated in the TM.19 Human and animal cholesteatoma and when ossicular reconstruction is studies20,21 have shown that although some soft- needed in the malleus-present situation. The peri- ening occurs with time, the matrix of the cartilage chondrium/cartilage island flap is preferred for remains intact, but with empty lacunae, demonstrat- management of the atelectatic ear and the high-risk ing degeneration of the chondrocytes. perforation. This chapter describes the two techni- The use of cartilage in middle ear surgery is not a ques in detail, followed by descriptions of the new concept, but the last decade has shown a modifications that should be taken in response to renewed interest in this material as an alternative specific surgical indications. to more traditional grafting materials for TM recon- Tympanoplasty, or repair of the TM, was first struction. Cartilage has been recommended on a introduced by Zoellner1 and Wullstein2 in 1952. limited basis to manage retraction pockets by ad- Since that time, numerous graft materials and vocates such as Sheehy,22 Glasscock and Hart,23 methods of placement have been described to Levinson19,Eviatar,24 and Adkins,25 all of whom reconstruct the TM. Skin, fascia, vein, and dura have reported excellent anatomic results. Cartilage mater have all been described as grafting materials also has been described for use in cases of recurrent for the TM.3 Á9 Temporalis fascia and perichondrium perforation and revision tympanoplasty with en- remain the most commonly employed materials for couraging results.14,26,27 closure of TM perforations, and successful recon- Given the good anatomic results, more attention struction is anticipated in approximately 90% of also has been given to the acoustic properties of primary tympanoplasties.10 cartilage compared with more traditional grafting In certain situations such as the atelectatic ear, materials. In a retrospective comparison between cholesteatoma, and revision tympanoplasty, how- perichondrium and cartilage in type I tympanoplas- ever, the results have not been as gratifying. In these ties, we reported no significant difference in hearing situations fascia and perichondrium have been between groups.28 Graft take was 100% in the shown to undergo atrophy and subsequent failure cartilage group and 85% in the perichondrium in the postoperative period, regardless of placement group. These results were supported by other technique.11 The recurrent perforation and dischar- researchers who have shown excellent closure of ging ear are likewise associated with less than the air/bone gap with cartilage tympanoplasty optimal results.12 Á 14 These observations have led to techniques.14,26,27,29 1 2 . MIDDLE EAR AND MASTOID SURGERY TECHNIQUES FOR RECONSTRUCTION measuring 15 x 10 mm in children and somewhat larger in adults. The perichondrium from the side of the cartilage furthest from the ear canal is dissected off, leaving HARvEST OF THE CARTILAGE GRAFT the thinner perichondrium on the reverse side. A Cartilage for TM reconstruction is typically har- perichondrium/cartilage island flap is constructed 28 vested from two areas, the tragus and the cymba, as described previously. Using a round knife, depending on the type of reconstruction to be cartilage is removed to produce an eccentrically performed. The perichondrium/cartilage island located disk of cartilage about 7 to 9 mm in diameter flap is nearly always constructed with cartilage for total TM reconstruction. A flap of perichondrium harvested from the tragus. This cartilage is ideal is produced posteriorly that will eventually drape because it is thin, flat, and in sufficient quantities to over the posterior canal wall. A complete strip of permit reconstruction of the entire TM. The cartilage cartilage 2 mm in width is then removed vertically is used as a full-thickness graft and is typically from the center of the cartilage to accommodate the slightly less than 1 mm thick in most cases. Although entire malleus handle (Fig. 6Á/2). The creation of two Zahnert et al30 suggested a slight acoustical benefit cartilage islands in this manner is essential to enable could be obtained by thinning the cartilage to 0.5 the reconstructed TM to bend and conform to the mm, this advantage is offset by the unacceptable normal conical shape of the TM. When the ossicular curling of the graft that occurs when the cartilage is chain is intact, an additional triangular piece of cartilage is removed from the posterior-superior thinned and perichondrium is left attached to one quadrant to accommodate the incus. This excision side. prevents the lateral displacement of the posterior When the palisade technique is used for recon- portion of the cartilage graft that sometimes occurs struction of the TM, cartilage can be harvested from because of insufficient space between the malleus either the tragus or the cymba. Cartilage from the and incus. cymba area of the conchal bowl is used if the The entire graft is placed in an underlay fashion, surgical approach involves a postauricular incision. with the malleus fitting in the groove and actually Tragal cartilage is used if the approach is transcanal pressing down into and conforming to the perichon- or endaural. The cartilage of the cymba is similar to drium, as shown in Figure 6Á/3. The cartilage is the tragus in that it has an acceptable thickness of placed toward the promontory, with the perichon- about 1 mm compared to other areas of the concha, drium immediately adjacent to the TM remnant, which are thicker and irregular. It is different, both of which are medial to the malleus. Failure to v v howe er, in that it is cur ed, making it difficult to remove enough cartilage from the center strip will create a perichondrium/cartilage island flap suitable cause the graft to fold up at the center instead of for reconstruction of the entire TM. lying flat in the desired position. Likewise, if the strip is insufficient, the cartilage may be displaced medially instead of assuming a more lateral position PERICHONDRIUM/CARTILAGE ISLAND FLAP in the same plane as the malleus. Gelfoam (Upjohn Laboratories, Kalamazoo, MI) is The general technique of reconstruction using the packed in the middle ear space underneath the perichondrium/cartilage island flap begins with anterior annulus to support the graft in this area, harvest of the cartilage from the tragal area.28 An and the posterior flap of perichondrium is draped initial cut through skin and cartilage is made on the over the posterior canal wall. Middle ear packing is v medial side of the tragus, lea ing a 2-mm strip of avoided on the promontory and in the vicinity of the cartilage in the dome of the tragus for cosmesis (Fig. ossicular chain. One piece of Gelfoam is placed 6Á/1). The cartilage, with attached perichondrium, is lateral to the reconstructed TM, and antibiotic dissected medially from the overlying skin and soft ointment is placed in the ear canal (Fig. 6Á/4). tissue by spreading a pair of sharp scissors in a plane that is easily developed superficial to the perichon- drium on both sides. At this point, it is necessary to THE PALISADE TECHNIQUE make an inferior cut as low as possible to maximize In the palisade technique, the cartilage is cut into the length of harvested cartilage. The cartilage is several slices that are subsequently pieced together, then grasped and retracted inferiorly, which delivers like the pieces of a jigsaw puzzle, to reconstruct the the superior portion from the incisura area. The TM (Fig. 6Á/5). Because of the nature of the recon- superior portion is then dissected out while retract- struction, it is not necessary to have one large, flat ing, which produces a piece of cartilage typically piece of cartilage, and the more curved cymba CHAPTER 6CARTILAGE TYMPANOPLASTY . 3 Figure 6 /1 Harvest of cartilage, leaving small rim of cartilage in dome for cosmesisÁ (right ear). Figure 6 /2 Prepared perichondrium/cartilage island graft, showingÁ strip of cartilage removed to facilitate malleus. Figure 6 /3 Lateral line drawing demonstrating proper placementÁ of graft. 4 . MIDDLE EAR AND MASTOID SURGERY Figure 6 /4 Postoperative ear with peri- chondrium/cartilageÁ island graft (left ear). Figure 6 /5 Schematic of palisade techniqueÁ (right ear). Figure 6 /6 Schematic illustrating location ofÁ cymba cartilage (left ear). Figure 6 /7 Harvesting of cymba cartilage with postauricularÁ incision (right ear). Figure 6 /8 Series demonstrating sequence of palisade reconstructionÁ (left ear). (A) Total ossicular replacement prosthesis (TORP) in place. (B) Initial cartilage placement. (C) Reconstruction of the scutum. (D) Reconstruction of remainder of posterior tympanic membrane.
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