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. Anusha S Shetty
Junior Consultant
Karnataka ENT Hospital and Research Centre
Hands on Workshop on Cartilage Tympanoplasty
September 6th and 7th 2014

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

4. SUCCESS RATE WITH
TEMPORALIS FASCIA
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
- 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. DONOR SITES
1. Tragus
2. Anterior crus of helix
3. Cavum
4. Cymba
5. Triangular fossa
6. Costal cartilage
7. Septal cartilage

9. APPROACHES
ENDAURAL APPROACH RETROAURAL APPROACH

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

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

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

15. 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

17. RETROAURICULAR APPROACH
1. Cymba Cartilage
2. Fossa triangularis
3. Scapha cartilage

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
Triangularis cartilage
1. Thinner than tragal cartilage
2. Mobile neotympanic membrane
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. Hildman cartilage clamp
3. Kurz precise cartilage knife
4. Huttenbink cartilage 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. Appropiate thickness of graft doesn’t hamper
the mobility of neotympanic membrane
5. Normal eustachian tube 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
Convenient approach
Right technique of harvesting
Appropriate size and thickness
SUCCESS RATE
100%

30. THANK YOU