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INTRODUCTION Wullstein and Zollner intoduced the concept ... … · Glasscock) 2. Anterior Flap.(...
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INTRODUCTION Wullstein and Zollner intoduced the concept of tympanoplasty in the field of chronic ear diseases.Lempert originally designed tympanomeatal flap for his tympanosympathectomy operation. Later adopted by Rosen for operation on the stapes.The concept of placing the graft under the drum remnant was set forth by Shea and Tabb in 1960’s. Their procedure were identical but they employed vein as a graft material.The technique was same as in stapedectomy to raise the endomeatal flap and place the graft under it. Maurice Sourdille innovation of using tympanomeatal flap for tympanoplasty was the starting point of new era of modern tympanoplasty. Since then tympanomeatal flaps have been useful in underlay tympanoplasty and other Otologic surgery. The elevated tympanomeatal flap allows access for a number of middle ear procedures like repair of TM or perilymph fistula, ossiculoplasty,
Transcript of INTRODUCTION Wullstein and Zollner intoduced the concept ... … · Glasscock) 2. Anterior Flap.(...
INTRODUCTIONWullsteinandZollnerintoducedtheconceptoftympanoplastyinthefieldofchroniceardiseases.Lempertoriginallydesignedtympanomeatalflapforhistympanosympathectomyoperation.LateradoptedbyRosenforoperationonthestapes.TheconceptofplacingthegraftunderthedrumremnantwassetforthbySheaandTabbin1960’s.Theirprocedurewereidenticalbuttheyemployedveinasagraftmaterial.Thetechniquewassameasinstapedectomytoraisetheendomeatalflapandplacethegraftunderit.MauriceSourdilleinnovationofusingtympanomeatalflapfortympanoplastywasthestartingpointofneweraofmoderntympanoplasty.SincethentympanomeatalflapshavebeenusefulinunderlaytympanoplastyandotherOtologicsurgery.TheelevatedtympanomeatalflapallowsaccessforanumberofmiddleearprocedureslikerepairofTMorperilymphfistula,ossiculoplasty,
removegrowthssuchascholesteatomaandglomustumour.Differenttypesoftympanomeatalflaparenamedasperthebaseoftheflap:1.SuperiorFlap.(Plester,SheehyandGlasscock)2.AnteriorFlap.(Shambaugh,Singhetal)3.InferiorFlap.(SeifiAE)4.AnteriorandposteriorFlap.(GibbandChang)5.3Flaptechnique(RoyChaudri)6.Vascualarstripwasanothernamegiventothesuperiorlybasedflap.Balkanetalin2003namedtheseflapswithsomeminorvariations
1.StandardFlaps2.StapedectomyFlap3.CongenitalCholeateatomaFlap4.GlomustympanicumFlap
Standardflaphasmanyusesandprovidesmaximumexposuretotheposteriormesotympanum.Theincisionextendsto12o’clockand6o’clockpositionsandiskept1mmawayfromthetympanicmembrane
Stapedectomyorossicularreconstructionflap.IntheMinorvariationofthestandardflap,anasymmetricalincisionismadeWiththesuperiorportionoftheflapbeing8mmlongtocompensateforcurettageofthescutum.
Congenitalcholesteatomaflap.Theflapextendstothestandardflaptoprovidebetteraccesstotheanteriorandsuperiormesotympanum(A).Themostcommonlocationofsmallcongenitalcholesteatomasisshown(B).
Anteriorcanalwallflap.Alimitedanteriorflapmaybeusedtopullagraftthrough,tostabilizeitforanteriormar-ginalperforations(A).Theflapmaybeextendedontheanteriorwalltoremovecanalwallbulge,osteoma,orexostosis(B)TearsinT-flapdooccurwhileelevatingtheflap.MostcommonlytearsoccurinthehandofinexperiencedOtologicsurgeonsbutcanalsooccurinexperiencedhands.Withtheabovereference,wedesignedaprospectivestudytoseewhetherthetearwhichusuallyoccursduringelevationoftheflapreallymattersornot?Thisstudyisfirstofitskindintheliterature.
MaterialandMethods:Patientdataincluded:1. Age2. Sex3. Audiogram4. Significantmedicalproblems
Allearsweredry3-4weekspriorsurgery.Agerangefrom15-55years.AllcasesunderwentaudiologicalandevaluationbeforesurgeryApproach:Allcasesunderwentpostauralapproachwithunderlaytechnique.AProspectivestudyforaperiodof18monthsfromJuly2014tillDecember2015.DoneinBuraidahCentralHospital.70casesofCSOMwhounderwenttypeItympanoplastybyunderlaytechniquewerestudiedduringthisperiod.
Inclusioncriteria:CSOMofsafetypewithmediumsize;kidneyshape,subtotalortotalperforation.Exclusioncriteria:1. CSOMwithcholesteatoma/polyp/granulation
2. Marginalperforation3. Smallperforationwhichcanbedealtwithpermeatalapproach.
Allcaseswentundertheprocedurethroughpostauralapproach.Total14caseshadtearinthetympanomeatalflap,duringelevatingtheflap.6Caseshadsmalltearslinearorbuttonholetype,whichdidnotneedanyrepair.Onlygelfoampiecewaskeptoverthetear.8CaseshadlargetearsthatwererepairedbythehelpofTMFgraftcoveringtheperforationaswellasthetearbelowthetympanomeatalflap,Thetornflapwasapproximatedoverthegraftandgelfoamwaskeptoveritsoastostabilizeit.ONECasehadaverythintympanomeatalflapwhereelevationwasdifficultandnearly
hadtotaltearintheflap.ThiswascorrectedbylargeTMFcoveringthebareareaofthebonetotallyintheEAC.Results:6caseswithsmalllinearandbuttonholetearhealedwithoutanyrepair.7caseswithlargetearhealedwithdelayedprocess,outofwhich1casehadposteriorperforationinlongtermfollowup.1casewithnearlytotaltearhealedcompletelywiththeTMFgraft,ittooksomemoretimetohealascomparedtotheabovecases.Failureratewas7.2%outof14tears.Technique–usedwasUnderlay
PostauricularincisionHarvestgraftPerforationedgesElevationoftympanomeatalflapAnnulusGelfoamGraftplacementunderlay
POSTAURICULRINCISION
HARVESTINGTHETMFGRAFT
LINEARTEARINTHETMFLAP
FRESHNINGTHEMARGINS
LINEARTEARINTMFLAP
BUTTONHOLETEARINTHETMFLAP
TEARINTHEANNULUS
TEARINTHEANNULUS
GRAFTPLACEDINTHEUNDERLAYTECHNIQUE
UNDERLAYGRAFTINGCOVERINGTHETMDEFECTANDTHEDEFECTINTMFLAP
DISCUSSION:Elevationoftympanomeatalflap(T-flap)isanimportantstepinunderlaytympanoplasty.RaisingtheT-flapisthestateoftheartknowledge.ThegoalofelevationT-flapistoexposetheMEwithelevationTMandmobilisetheskinfromthegroovewithoutdamagingitsothatMEcanbeextraordinarilyexposedConceptofunderlaytympanoplastyafterelevationofT-flapwassetforthbySheaandFabbin1960.Innovationofusing
tympanomeatalflapintympanoplastybyMauriceSourdillegaveanewturntotympanoplasticprocedure.TearsinT-flapcanoccurwhileelevatingtheflapatdifferentsites:1.Obliquetympanomastoidsutureline2.Elevationattheofannuluswherethetearisverycommoninexperiencedhands.3.TearcanoccurwhiledrillingwithcuttingburrsinthecanalTearsinthetympanomeatalflapmayoccurinfollowingways:1.Alinearorbuttonperforationmayoccurintheskinflap2.Theskinflapmayseparatefromthetympanicannulus.ThisusuallyoccursininferiorlocationandisduetofailuretoelevatethetympanicannulusfromitssulcusTearsintheTM-flaporTMthatoccursduringelevationoftheflapanddrumshouldberepairedatthecompletionoftheprocedure.RepairofthetearsintheT-flapissimplebutmeticulous.
Linearandbuttonholetearsneednorepair,caremustbetakentoavoidunfoldingthemarginsoftearswhilereplacingtheflap.Smallertearneartheannulusrequirenorepairifitisapproximatedproperlywhilereplacingtheflap.TearsintheTM-flapcanberepairedbydifferentmaterialslikefat,vein,perichondriumandTMFgraft.Itdependsuponwhichmaterialisreadilyavailableforrepair.Duringstapedectomyfatandperchondriumareusedverycommonly.DuringtympanoplastyTMFgraftisusedverycommonlyasitsaccessisatthesameincisionalsite.TodayTMFhasbecomeverycommonintherepairoftearinTM-flapduringtympanoplasticprocedure.IthasbeenshownbyexperiencethatTM-flaptearcanbeavoidedbynevertakingtheknifeofthebonesurface.Ifonealwayskeepstheknifeonthebonesurfaceonecandeveloptheseparation/elevationonarelativelybroadfront.Secondlyneverallowsofttissuebeneaththeknife.Withthese
precautionsonecannotperforatetheT-flapCONCLUSIONWeconcludethattearsintheT-flaparenothazardousevents,theyshouldbehandledcarefullywithpatienceandrepairedbyapropertechniqueattheendoftheprocedure.Differentmaterialslikefat,vein,perichondriumandTMFgraftscanbeusedinrepairprocessThestudywasaimedtogivemessage,mainlytothelearnersandinexperiencedotologicalsurgeons:Atorntympanomeatalflapdoesnotneedabondoningtheprocedure,itcanberepairedbyapproximationorwiththehelpoftemporalisfasciagraft
placementoverthebareareaofthebonycanal.
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