ENT

1. Techniques Of Harvesting
Cartilage Graft For
Cartilage Tympanoplasty
Dr. Erami M.D.
ENT Resident
Department Of ENT
Shahid Sadoghi Hospital
Yazd Iran

2. •Cummings 2015 (141 | TYMPANOPLASTY AND OSSICULOPLASTY)
• The tissue rigidity of cartilage and its resistance to retraction, even
in the setting of ongoing eustachian tube dysfunction, has led to
the growing acceptance of its use in middle ear reconstruction.
• Some of indications:
1. Cartilage grafts placed between the TM and an ossicular
prosthesis decrease extrusion risk and can augment the
prosthesis-tissue interface, which allows for better long-term
hearing results.

3. •Cummings 2015 (141 | TYMPANOPLASTY AND OSSICULOPLASTY)
2. If a second-stage ossiculoplasty with an allograft is anticipated:
• a cartilage graft may be placed beneath the central portion of the
membrane at the time of tympanoplasty.
3. In addition to the more common uses of cartilage:
• provide structural support to attic defects and posterosuperior
retraction pockets

4. •Cummings 2015 (141 | TYMPANOPLASTY AND OSSICULOPLASTY)
• more recent literature supports the use of cartilage for:
• the atelectatic ear and other conditions associated with increased
failure rates with traditional techniques :
 revision surgery
 perforation >50%
 drainage at time of surgery
 bilateral perforations
 reconstruction after cholesteatoma
(although more controversial)

5. •Cummings 2015 (141 | TYMPANOPLASTY AND OSSICULOPLASTY)
• Numerous techniques and types of cartilage grafting have
been described, the most common of which include:
either placement of composite cartilage/perichondrial grafts of
varying sizes and shapes or creation of cartilage palisade arrays.

6. •Cummings 2015 (141 | TYMPANOPLASTY AND OSSICULOPLASTY)
• Cartilage may be harvested with its attached perichondrium
from the tragus or the concha.
• Tragal cartilage than conchal cartilage:
• Thicker
• flatter
• Tragal cartilage may be :
• more suitable for larger perforations

7. •Cummings 2015 (141 | TYMPANOPLASTY AND OSSICULOPLASTY)
• The cartilaginous graft can be made quite thin and of a small
enough diameter to bolster only the weakened portion of the
involved TM, or it may be shaped to fill a pantympanic
perforation.
• Reducing cartilage thickness optimizes:
• the acoustic-transfer properties
• with thicknesses of 500 μm or less resulting in a highly favorable
vibratory transfer.

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

9. • All three approaches can be applied
in Cartilage tympanoplasty
Transmeatal or
transcanal
endaural retroauricular

10. •In mastoidectomy, antrotomy, and atticotomy:
• most surgeons will employ a retroauricular approach.

11. •Plester Technique
After a retroauricular fold incision
At the level of 4-5 mm medially
to the suprameatal spine, a
circumferential incision of the
meatal skin from the
12-o’clock to the 6-o’clock
Position

12. After a superior vertical incision
and an inferior vertical incision,
a large tympanomeatal flap
is elevated together with the
fibrous annulus and eardrum

13. •Palva’s Swing-Door
Technique
After a retroauricular fold incision
performed a radial incision at the:
9-o’clock position
elevated a large superior and
inferior tympanomeatal flap
provides an excellent view of the
anterior part of the:
• tympanic cavity
• fibrous annulus

14. •Wullstein—KIey technique
• retroauricular fold incision
• the bony ear canal is
widened by drilling for 2-3 mm
• circumferential incision is made
about 10 mm medial to the spine
• A small lateral radial incision at
the 1 2 & 6-o’clock position
• skin flap is pulled outward
• A superior incision of the skin
is continued outward.

15. Transmeatal Approach through Fixed Ear Speculum

17. Cartilage may be harvested from the tragus or the concha.

18. • Sites for harvesting
the cartilage in the right
auricle seen on the front
side.
• C: concha
• CY: cymba
• TE: triangular
eminence
• S: scapha
• T: tragus
• A: antitragus
• CH: crus of the helix

19. • Lines 1 and 2:
• Resection of the most anterior 3-4
mm and 4-5 mm, used after
canal wall down mastoidectomy
to prevent stenosis.
Lines 1and 2 do not involve the crus of the
helix.
• Lines 3 and 4:
• used when treating stenosis after
previous canal wall down
mastoidectomy. Considerable areas
of cartilage are removed, including
part of the crus of the helix.
• Lines 5a and 5b:
• involve the entire concha, taken as
graft material.

20. •Harvesting of Tragal Cartilage:
•Tragal cartilage seems to be used more often than conchal
cartilage, mainly because :
•it is harvested along the same route as that of the
transcanal and the endaural approaches.
•tragal cartilage is less convex than conchal cartilage.
•For cosmetic reasons, the incision is most often made:
• 2-3 mm medial to the tragal dome

21. •In cartilage Tympanoplasty
•A small or medium-sized tragus graft:
•can be harvested during the endaural approach by
exposing the superior edge of the tragus or the inferior
edge of the concha.
•For the removal of a large piece of tragal cartilage:
•the incision is 15mm long.
•Using a pair of scissors
•the extraperichondrial plane is created on both sides
and the cartilage graft is excised.

22. Harvesting a large tragal
cartilage graft with a 15 mm
incision 2 mm medial to the
dome.
The large incision is made
in one sweep through the
skin and the cartilage with
the perichondrium

23. Using a pair of scissors,
the extra perichondrial
tissue is elevated on both
sides of the tragus

24. First :
The tragus is cut
along the superior border
Then:
The tragus is cut
along the the inferior

25. Using pincers the tragus is
pulled outward and cut
along the medial border

26. • Harvesting the tragus cartilage:
• Heermann endaural approach
(through the intercartilaginous
incision)
• The superior edge of the tragus
is first separated from the
fibrous tissue of the
intercartilaginous region
• tragus is grasped and pulled in
superior direction
• subcutaneous tissue is elevated
from the dome anteriorly and
posteriorly

27. •The cartilage is cut
along the medial
border using a pair of
scissors.

28. •A vertical incision
made with a scalpel
in the inferior part
of the tragus
completely
mobilizes the tragal
graft.

29. Heermann’s approachHarvesting of Tragal Cartilage

30. • Harvesting of Cartilage from the Auricle Cartilage :
• can be harvested from various sites of the
posterior side of the auricle :
• Eminence of the concha
• Eminence of the cymba concha
• Eminence of the triangular fossa
• Eminence of the scapha
• From the anterior side of the auricle:
large parts of the conchal cartilage
can be removed ¡n various endaural approaches.

31. •Harvesting of Conchal Cartilage:
•Conchal cartilage than tragal cartilage is :
•slightly thicker
•more convex
but it is always
• large enough for any composite graft

32. • Harvesting of conchal cartilage
via a retroauricular approach:
• Both sides are covered with perichondrium.

33. • Harvesting of the cymba cartilage and the fossa triangularis
cartilage:
• Incision of the skin is:
slightly superior to the
eminence of the concha.
• Subcutaneous tissue:
is elevated
• The perichondrium is exposed
( of the superior part of the
eminence of the concha and
of the cymba cartilage).
• With a circular incision:
The most convex part—the cymba cartilage—is cut and removed.

34. • The dashed line:
• the eminence of the
triangular fossa (FT).
• The dotted line:
• the eminence of the
scapha (S).

35. •Harvesting of Fossa Triangularis (FT) Cartilage:
•The eminence of the FT
•is positioned superiorly
to the cymba.
•It starts at the anterior crus
of the antihelix
•It ends at the posterior crus
•of the antihelix.

36. •Harvesting of cartilage from the eminence of the scapha:
• After a 20 mm long skin incision:
on the eminence of the scapha
• skin and subcutaneous tissue
are elevated
• exposing an area
of 20 mm x 5 mm to allow
cutting and removal
of a 20 mm x5 mm piece of cartilage.

37. • fossa triangularis cartilage than tragal cartilage is:
• thinner and has less mass.
• In the paper, Moore et al. reported good anatomical and
functional results ¡n tympanoplasty of 83 patients with fossa
triangularis cartilage ¡n total perforations
• cartilage palisade arrays:

38. •HARVESTING CARTILAGE THROUGH ENDAURAL APPROACH
• TRAGAL CARTILAGE
• Heermann’s approach
• CONCHAL CARTILAGE
• Heermann’s approach
• Shambaugh’s/ Lempert’s approach
• Farrior approach

39. • Endaural Approach with Intercartilaginous Incision
Lempert incision

40. • Endaural Approach with Intercartilaginous Incision
The Farrior incision The Shambaugh incision

41. •Harvesting conchal cartilage in the endaural approach with
the Heermann incision.
• The ear canal skin is elevated
outward exposing conchal
Cartilage which is removed
With the perichondrium.

42. •HarvestIng conchal cartilage ¡n the Shambaugh endaural
approach.
• The skin is elevated outward
from the helixand the
conchal cartilage.
• The lateral radial incision
of the conchal skin allows
resection of a large piece
of the conchal cartilage.

43. •Harvesting conchal cartilage in the Farrior endaural
approach.
• A relatively long lateral
radial skin incision and
elevation of the lateral
ear canal skin allow
easy exposure and
removal of the
conchal cartilage.

44. •Thinning the Cartilage
•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

45. •Methods of thinning the graft:
1. Scalpel
2. Hildmann cartilage clamp
3. Kurz precise cartilage knife
4. Hüttenbrink cartilage guide
5. Groningen cartilage cutting device

46. •Scalpel:
• Held between two fingers
• Held between surgical forceps

47. • The Hildmann cartilage slicing clamp.
• a Open clamp
• b The clamp holds the cartilage
with the perichondrium to be
sliced from above with a scalpel
• c A cartilage island graft with
a perichondrium flap is sliced
from above.
• d The island graft is sliced from
below

48. • Kurz Precise Cartilage Knife:
• The upper part of the
two-piece cutting block is
positioned at right angles
to the lower part
to illustrate the location
of the recess of the cutting
block into which the
cartilage is placed(thick arrow)
• The guiding slits (thin arrow)
where the razor plate will be placed.
• After placement of the cartilage, the upper cutting block is turned in
the direction of the curved arrow.

49. •The razor blade is fixed
¡n the blade holder with a screw.

50. • First
the lower and the upper
cutting blocks are aligned
• Then
the blade holder with the
blade is placed into the slits
of the cutting block.
• With sawing movements of the blade
in directions of the horizontal arrows the cartilage is sliced.

51. •Distance plates.
• Metal plates of the same shape
and area as the recess of the
lower cutting block and of
thickness 0.1, 0.2, and 0.3 mm
compared with the cartilage
of 0.7 mm cut without
the use of distance plates.

52. •The 0.6 mm thick cartilage
and a 0.1 mm thick
distance plate(arrow)
are removed from the
recess of the cutting block,
after completion of cutting
with the distance plate.

53. •The Hüttenbrink Cartilage Guide
a. 2 cylinders, one
inserted into another
b. Press the upper cylinder
c-d. Thin cartilage plate
obtained 2.5mm×3.5 mm,
0.3 mm thick, central 0.8
mm hole for titanium
prosthesis

54. •The Groningen Cartilage Cutting Device
• Place cartilage in depression b
• Depression has diameter
4 mm and 0.5 mm deep
• No 11 blade used to
cut off the upper part