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Tympanoplasty with tragal cartilage graft, postauricular approach

Tympanoplasty with tragal cartilage graft, postauricular approach

Blake Hollowoa, Michael Kubala, Gresham Richter.

Introduction

Tympanic membrane (TM) perforations arise from multiple conditions including acute otitis media, barotrauma, chronic eustachian tube dysfunction, or as a complication of pressure equalization (PE) tube insertion. Most perforations heal spontaneously or with conservative measures such as ototopical drops and dry ear precautions. Perforations that do not heal can lead to conductive hearing loss, chronic infection, or cholesteatoma. A 6-year-old patient with a persistent TM perforation presented with otalgia and otorrhea. A tympanoplasty with a tragal cartilage graft was performed to repair the patient’s TM perforation.

Methods

The patient was intubated and the operation carried out under general anesthesia. Facial electrodes were inserted for facial nerve monitoring. The patient was prepped and draped in sterile fashion. The external canal was suctioned and irrigated. A tragal incision was then made to harvest a 1 cm piece of cartilage for the TM graft. The tragal incision was closed with monocryl suture.  A postauricular incision was made in the natural skin crease to expose the posterior canal. Canal incisions were made to enter the external canal. A tympanomeatal flap was elevated until the middle ear was entered. The previously harvested tragal cartilage graft was inserted medial to the native TM perforation. Gel-Foam was inserted medial to the graft for support. Tragal perichondrium was inserted lateral to the tragal cartilage graft. Gel-Foam was then inserted lateral to the graft for support. The periosteum and postauricular incision were closed with vicryl suture. The external canal was inspected, then antibiotic ointment and an ear wick was inserted. The patient was dressed using a Glasscock dressing.

 

Results

The patient was discharged the same day and seen in clinic two weeks from his surgery. The incisions were healing well with no indications of infection or wound dehiscence. His pain was resolved and an appointment for formal audiology was scheduled for a 3-month follow-up visit.

Conclusion

Tympanoplasty with a tragal cartilage graft using a postauricular approach is a successful method to surgically correct persistent tympanic membrane perforations.

Tympanoplasty with tragal cartilage graft, postauricular approach
Tympanic membrane perforations that do not close spontaneously or fail treatment. Conditions such as acute/chronic otitis media, cholesteatoma, barotrauma, or as a complication of pressure equalization (PE) tube insertion can result in tympanic membrane perforations. Failed treatment options include dry ear precautions, ototopical drops, and myringoplasty.
Active otitis externa, active otitis media, total eustachian tube obstruction.
The operation was performed under general anesthesia with the patient in the supine position.
Detailed history. Head & neck exam including pneumatic otoscopy, otomicroscopy, and hearing assessment with tuning forks and/or formal audiometry. Treat any infections with antibiotics or antifungals (ototopical, oral, and/or intravenous) as indicated.
Identification of the chorda tympani when entering and working in the middle ear is critical (located between malleus and incus) to prevent taste disturbances.
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Tympanoplasty is generally well tolerated and outcomes are favorable. Complications include perforation recurrence with subsequent otorrhea, cholesteatoma, persistent conductive hearing loss, and taste disturbances (iatrogenic chorda tympani injury). Additional complications include failure of the graft. As with all surgeries, there is risk of bleeding and infection.
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