The tympanic membrane remnant is prepared as previously described.
The cartilage graft
is then used to reconstruct the entire surface area of the tympanic membrane, rotating it into
position until the groove is aligned with the malleus handle (Fig. 2.17A,B). If the graft is of
proper size, the edge of the cartilage will snap up against the posterior bony annulus and fit
snugly like a manhole cover (the use of Gelfoam in the middle ear is optional with this
technique). The free perichondrium is then laid against the bony canal. The tympanomeatal flap
is then draped over the composite graft (Fig. 2.18A,B). If the perforation is large, the flap can be
incised at its narrowest point, usually inferiorly, and its edges advanced and rotated over the area
of the perforation, to provide maximal epithelial coverage (this maneuver borrows skin from the
ear canal to cover the tympanic membrane defect, which rarely poses a problem in healing).
The cartilage graft with or without perichondrium is most frequently used in the patient
with a scutum defect from cholesteatoma disease (Fig. 2.19). It should be noted that when
cartilage is used, an intact canal wall mastoidectomy has been performed either at this operation
or previously. Cartilage-perichondrial grafts are also selectively used in canal wall down
procedures. We advise the use of perichondrium attached to the cartilage as the graft of choice.
The cartilage is then trimmed from the perichondrium as needed to repair the particular defect.
The tragus is an alternative place for harvesting cartilage, with or without perichondrium,
with over 1 cm of cartilage available. The surgeon may harvest the cartilage with perichondrium
on both sides of the cartilage if tissue is needed. This series of photos is incision, identification of
perichondrium, then incision through the cartilage with preservation of the anterior
perichondrium in its anatomical position (Figs. 2.20, 2.21, and 2.23). Removal of cartilage from
the perichondrium is then accomplished, with the necessary size determined by the pathology.
The perichondrium is then draped over the malleus with the cartilage to fit the defect of the
tympanic membrane and scutum if necessary, then the remaining perichondrium is laid onto the
posterior bony canal wall (Figs. 2.23 and 2.24).
Fig. 2.17 (A) The cartilage graft is inserted into the ear and used to reconstruct the
tympanic membrane (TM) in an underlay fashion, rotating into position until it is cinched against
the bony annulus. (B) Cartilage graft rotated into position, with cartilage tucked under the
anterior TM remnant (arrowheads), and the free edge of the perichondrium draped over the bony
canal (arrow).
Fig. 2.18 (A) Tympanomeatal flap advanced and rotated over the composite graft to
cover the entire tympanic membrane (TM) defect. (B) The tympanomeatal skin is then advanced
and rotated over the TM defect to completely reepithelialize the TM.
Fig. 2.19 Cartilage graft reconstruction of scutum, as well as posterosuperior tympanic
membrane.
Fig. 2.20 Scissor dissection of the anterior perichondrium from the tragus cartilage.
Fig. 2.21 Scissors dissection of the posterior tragal soft tissue from the tragus
perichondrium and cartilage.
Fig. 2.22 Trimmed cartilage block attached to the perichondrial tissue.
♦ Laser-Assisted Myringoplasty
Laser-assisted myringoplasty is a minimally invasive surgical technique for a select
group of patients, using the CO2 laser to reduce or eliminate tympanic membrane atelectasis. Our
study revealed a significant reduction in the redundant tympanic membrane. Tympanic
membrane atelectasis is the loss of normal contour and elasticity of the tympanic membrane as a
result of persistent negative middle ear pressure. Atelectasis occurs in advanced chronic otitis
media with or without effusion and often with chronic otorrhea. Atelectasis predisposes the
patient to adhesive otitis, tympanic membrane atrophy, cholesteatoma formation, ossicular
erosion, hearing loss, dizziness, and perforation. Atelectasis is one of the most difficult problems
encountered with the tympanic membrane due to its chronicity and progression of severity over
time. If identified in the early stages of retraction, atelectasis can be halted or even reversed by
placing ventilation tubes to eliminate negative pressure in the middle ear. We have observed that
even after placement of middle ear ventilation tubes to alleviate the effect of eustachian tube
dysfunction, the tympanic membrane will often remain atelectatic or “floppy,” with persistence
of a retraction pocket (Fig. 2.25).
Fig. 2.23 Perichondrial cartilage graft in place to repair the scutum and the tympanic
membrane defect.
Fig. 2.24 Perichondrial cartilage graft in place to repair the scutum and the tympanic
membrane defect.
