Description: A lateral graft tympanoplasty is performed to demonstrate the utility of this technically challenging approach. The technical pearls that contribute to the high success rate of this graft are highlighted.
Learning Points: The lateral graft tympanoplasty was popularized by Sheehy in the 1960s. Although technically more demanding than underlay graft techniques, the lateral graft is an essential method for Otologists to have in their armamentarium. The lateral graft is especially useful in cases of total perforation or anterior marginal perforation as well as revision tympanoplasty. Potential disadvantages of this technique include graft lateralization and anterior blunting as well as keratin pearl formation. When performed by an experienced surgeon, the results of lateral grafting are excellent. The technical considerations that promote successful lateral grafting are highlighted in this video.
Lateral Graft Tympanoplasty
Lateral graft tympanoplasty is a potent technique in Otolaryngology that can be used to address the full range of tympanic membrane perforations. It is commonly employed for large tympanic membrane perforations, anterior marginal perforations and revision tympanoplasty.
Contraindications to the lateral graft technique are similar to those of the medial graft technique and include active middle ear infection.
Setup should include a standard tympanoplasty tray as well as a balanced, sterile microscope.
Pre-operative workup includes a thorough history and physical examination. A formal audiogram should be obtained on all patients to document pre-operative hearing prior to surgery.
Pertinent anatomy includes the anatomy of the tympanic membrane, which is composed of an outer keratinizing squamous layer, middle fibrous and inner mucosal layer. The blood supply to the inner surface of the tympanic membrane is from the anterior tympanic artery and the outer surface is from the deep auricular artery.
The lateral graft technique has the advantage of being applicable to any size and location of tympanic membrane perforation. In experience hands, the lateral graft technique offers excellent and reliable results. The primary disadvantage of this technique is that it is technically more challenging and more time consuming than a medial graft.
Potential risks of the operation include graft failure with persistent perforation, blunting at the anterior sulcus, lateralization of the graft, facial nerve injury, iatrogenic cholesteatoma, vertigo and dysgeusia,
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House, W. F., & Sheehy, J. L. (1961). Myringoplasty: use of ear canal skin compared with other techniques. Archives of Otolaryngology, 73(4), 407-415.
House, H. P. (1953). XCIII Surgical Repair of the Perforated Ear Drum. Annals of Otology, Rhinology & Laryngology, 62(4), 1072-1082.
This video shows a transotic approach for a cochlear schwannoma in a 59-year-old female who presented with sudden sensorineural hearing loss in her left three years prior. She was found to have subsequent growth of her tumor on imaging and elected to undergo surgery. The transotic approach is a valuable approach within the armamentarium of a skull base team and differs from the transcochlear approach in the handling of the facial nerve. Techniques for ear canal overclosure, eustachian tube packing and mastoid obliteration are also highlighted.
Here, we have a 39 yrs old female with complaints of noisy breathing for last two years post thyroidectomy. Flexible laryngoscopy confirmed bilateral vocal cord paralysis. She was planned for coblation assisted cordectomy.
Patient was taken up for procedure under general anaesthesia. She also started having stridor after induction. Nasopharyngeal intubation with spontaneous breathing technique was used. Entropy leads were placed over forehead to monitor the depth of anaesthesia. Tube position was confirmed with endoscopic view and Benjamin lindohlm laryngoscope was suspended. As the patient was spontaneously breathing, the stridor became more prominent, with stable vitals and the procedure was continued. The vocal cord retractor was fixed and coblation wand was then used with 7:3 settings for ablation and coagulation respectively. The surgical limits were-anteriorly the junction between ant 2/3 and post 1/3 of the vocal cord, posteriorly just anterior to the vocal process of arytenoid to prevent cartilage exposure and post operative granulations. Superely till the ventricle and inferioly till the medial most surface of the subglottis. Laterally approx. 5 mm depth was defined to prevent injury to the superior laryngeal artery branch and further bleeding. Once the final airway was achieved , the topical lignocaine was used to prevent laryngeal spasm post extubation.
The patient was shifted to the ward without oxygen, the voice was assessed on post op day 2.
Patient was called for follow up on post op day 14th and good voice outcomes were achieved.
So lets have a look on some tips & tricks for the safe procedure—–
Nasopharyngeal insufflation technique with entropy monitor will give adequate and safe surgical field
2. Appropriate exposure will help you to delineate the surgical margins
3. Topical anaesthesia before and after the procedure will prevent sudden laryngeal spasm
4. Firm holding of coblation device will help to prevent injury to surrounding structures like anterior 2/3 vocal cord, opposite side vocal cord, medial surface of vocal cord or aryteroid posteriorly
5. Do not ablate more laterally to prevent bleeding, if at all it happens, use patties or coagulation switch for hemostasis.
6. And at the end of the procedure ,use catheter suction to suck out blood clots or saline from the airway if any….
To Conclude-Coblation Assisted Cordectomy( CAC) can be performed safely with good outcomes in case of bilateral vocal cord paralysis using tubeless anesthesia technique without tracheostomy !
We present the harvest of a osteocutaneous fibula free flap for head and neck reconstruction performed at the University of Cincinnati. This reconstructive technique has a wide variety of implications but has found greatest utility in the reconstruction of mandibular defects.
Review Lateral Graft Tympanoplasty.