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HARVESTING CARTILAGE FOR
CARTILAGE TYMPANOPLASTY
Dr. Anusha S Shetty
Junior Consultant
Karnataka ENT Hospital and Research...
EYES CAN’T SEE WHAT MIND DOES
NOT KNOW
• Muscle
• Cortical bone
• Fascia
• Cartilage
• Perichondrium
Otological surgeries ...
Courtesy rcsullivan.com
1. Subtotal
perforation
2. Anterior
perforation
3. Atelectactic TM
4. Reperforation
5. ETD
SUCCESS RATE WITH
TEMPORALIS FASCIA
ONLY 60-75%
REASONS
– Poor adaptation of graft
– Medial displacement of graft
– Lateralization of graft
– Shrinkage of graft
– Graft a...
BIOMECHANICS OF CARTILAGE-
Thickness, mass effect
Thick graft
More stable
Greater reflection
Less acoustic sensitivity
Thi...
BIOMECHANICS- Elastic Modulus
GRAFT MATERIALS AND TYMPANIC
MEMBRANE
ELASTIC MODULUS
TYMPANIC MEMBRANE
- Pars Tensa
- Pars ...
DONOR SITES
1. Tragus
2. Anterior crus of helix
3. Cavum
4. Cymba
5. Triangular fossa
6. Costal cartilage
7. Septal cartil...
APPROACHES
ENDAURAL APPROACH RETROAURAL APPROACH
HARVESTING CARTILAGE THROUGH
ENDAURAL APPROACH
• TRAGAL CARTILAGE
– Heermann’s approach
• CONCHAL CARTILAGE
– Shambaugh’s/...
HEERMANN’S APPROACH- Tragal
cartilage
• Commonly preferred
• INCISIONS:
1. Circumferential incision
2. Vertical incision, ...
SHAMBAUGH’S & LEMPERT’S
APPROACHES- Conchal cartilage
INCISION
1. Lateral
circmferential
2. Intercartilagenous
3. Lateral ...
FARRIOR APPROACH- Conchal cartilage
• INCISION:
1. Ant circumferential incision
at 4 o clock
2. Post circumferential incis...
RETROAURICULAR APPROACH
1. Cymba Cartilage
2. Fossa triangularis
3. Scapha cartilage
RETROAURICULAR APPROACH- Cymba
concha cartilage
• INCISION: slightly superior to eminence of
concha
• Circular incision – ...
RETROAURICULAR APPROACH- Fossa
Triangularis cartilage
1. Thinner than tragal cartilage
2. Mobile neotympanic membrane
3. 1...
RETROAURICULAR APPROACH- Scapha
cartilage
1. 20 × 5mm size cartilage can be harvested
2. Cut into palisades
THICKNESS OF GRAFT
• IDEAL THICKNESS- 500-600 µm
– Stiffness same as tympanic membrane
• IMPENDING EUSTACHIAN TUBE
DYSFUNC...
METHODS OF THINNING THE GRAFT
1. Scalpel
2. Hildman cartilage clamp
3. Kurz precise cartilage knife
4. Huttenbink cartilag...
SCALPEL
1. Held between two fingers
2. Held against wooden
tongue depressor
3. Held between surgical
forceps
HILDMAN CARTILAGE SLICING CLAMP-
ISLAND GRAFTS
a) Open clamp
b) Clamp holds the
graft
c) Cartilage sliced
from above
d) Ca...
KURZ PRECISE CARTILAGE KNIFE
1. Cartilage placed
between Upper
part positioned at
right angled to
lower part
2. Razor blad...
HUTTENBRINK CARTILAGE GUIDE
1. 2 cylinders, one
inserted into
another
2. Press the upper
cylinder
3. Thin cartilage plate
...
GRONINGEN CARTILAGE CUTTING
DEVICE
1. Place cartilage in
depression b
2. Depression has
diameter 4 mm and
0.5 mm deep
3. N...
CONCLUSION
1. Cartilage provides good support to
temporalis fascia
2. Effective anterior margin increases (narrow
anterior...
TAKE HOME MESSAGE
THINGS WORK OUT BEST FOR THOSE WHO MAKE THE
BEST OF HOW THINGS WORK OUT
Convenient approach
Right techni...
THANK YOU
Harvesting cartilage for cartilage tympanoplasty
Harvesting cartilage for cartilage tympanoplasty
Harvesting cartilage for cartilage tympanoplasty
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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.

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Harvesting cartilage for cartilage tympanoplasty

  1. 1. HARVESTING CARTILAGE FOR CARTILAGE TYMPANOPLASTY Dr. Anusha S Shetty Junior Consultant Karnataka ENT Hospital and Research Centre Hands on Workshop on Cartilage Tympanoplasty September 6th and 7th 2014
  2. 2. 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
  3. 3. Courtesy rcsullivan.com 1. Subtotal perforation 2. Anterior perforation 3. Atelectactic TM 4. Reperforation 5. ETD
  4. 4. SUCCESS RATE WITH TEMPORALIS FASCIA ONLY 60-75%
  5. 5. REASONS – Poor adaptation of graft – Medial displacement of graft – Lateralization of graft – Shrinkage of graft – Graft atrophy – Perforation
  6. 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. 7. BIOMECHANICS- Elastic Modulus GRAFT 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
  8. 8. DONOR SITES 1. Tragus 2. Anterior crus of helix 3. Cavum 4. Cymba 5. Triangular fossa 6. Costal cartilage 7. Septal cartilage
  9. 9. APPROACHES ENDAURAL APPROACH RETROAURAL APPROACH
  10. 10. HARVESTING CARTILAGE THROUGH ENDAURAL APPROACH • TRAGAL CARTILAGE – Heermann’s approach • CONCHAL CARTILAGE – Shambaugh’s/ Lempert’s approach – Farrior approach
  11. 11. HEERMANN’S APPROACH- Tragal cartilage • Commonly preferred • INCISIONS: 1. Circumferential incision 2. Vertical incision, 15mm upwards 3. Extending into postaural groove • Preservation of tragal dome
  12. 12. SHAMBAUGH’S & LEMPERT’S APPROACHES- Conchal cartilage INCISION 1. Lateral circmferential 2. Intercartilagenous 3. Lateral radial incision toward concha
  13. 13. FARRIOR APPROACH- Conchal cartilage • 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
  14. 14. RETROAURICULAR APPROACH 1. Cymba Cartilage 2. Fossa triangularis 3. Scapha cartilage
  15. 15. 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
  16. 16. RETROAURICULAR APPROACH- Fossa Triangularis cartilage 1. Thinner than tragal cartilage 2. Mobile neotympanic membrane 3. 1 cm cartilage can be harvested
  17. 17. RETROAURICULAR APPROACH- Scapha cartilage 1. 20 × 5mm size cartilage can be harvested 2. Cut into palisades
  18. 18. 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
  19. 19. METHODS OF THINNING THE GRAFT 1. Scalpel 2. Hildman cartilage clamp 3. Kurz precise cartilage knife 4. Huttenbink cartilage guide 5. Groningen cartilage cutting device
  20. 20. SCALPEL 1. Held between two fingers 2. Held against wooden tongue depressor 3. Held between surgical forceps
  21. 21. HILDMAN CARTILAGE SLICING CLAMP- ISLAND GRAFTS a) Open clamp b) Clamp holds the graft c) Cartilage sliced from above d) Cartilage sliced from below
  22. 22. 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
  23. 23. 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
  24. 24. 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
  25. 25. 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. Appropiate thickness of graft doesn’t hamper the mobility of neotympanic membrane 5. Normal eustachian tube function preserved. 6. Good closure and hearing improvement
  26. 26. 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%
  27. 27. THANK YOU

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