| Last Updated on 16 October 2007.
Extended Tympanometal Flap Tympanplasty
An Easy and Reproducible technique with very high positive results
Dr. Prahlada N.B
Karnataka ENT Hospital & Research Center
Opp. S.P Office, turuvanur Road, Kelagote,
Chitradurga - 577501,
Karnataka,
India.
Introduction:
So far many techniques of tympanoplasty have been described for total/subtotal perforations. However, none of this techniques report good results. Primrose and Kee used an anterior tunnel created under the annulus to improve graft tension. Gristwood and Venables described an underlay myringoplasty creating two anterior tunnels for graft stablilization. Sauvage et al presented a surgical technique that included the creation of a large anterior flap for stabilizing the fascia. However, all these procedures are techniqualy difficult and demanding. Hereby I do tympanoplasty using extended tympanomeatal flap as described below.
Step I : End-aural incisions:
First endaural incision is made starting from at 6 ‘o’ clock position on the inferior meatal wall, 5 mm away from the annulus, extending in the same horizontal plane over the posterior and superiormeatal wall and then on to anterior meatal wall up to 3 ‘o’ clock position (RIGHT SIDE) (Fig 1 & 2). Second endaural vertical incision is made beginning again at the 12 ‘o’ clock position on the superior meatal wall from the level of first incision. The second incision extends outwards for about 5 mm (Fig.8). The third incision is made at the 4 ‘o’ clock position where the first incision ends. The third incision also extended outwards for about 5 mm (Fig.9). The incisions are deepened to the periosteum and modified Korner’s flap is raised outwards using a canal knife (Fig. 10) . The inner flap (endomeatal flap) is not disturbed at this moment.
Step II : Post-approach, Harvesting TM fascia:
A post-auricular sulcus incision with 1 centimeter superior extension is made (Fig. 1). A large Temporalis fascia graft is harvested using technique described earlier. Post aural soft tissue and periosteum are incised in a T-shaped manner with horizontal limb lying parallel and corresponding to linea temporalis and vertical limb over the mastoid cortex and parallel to the posterior wall of the external auditory canal (Fig. 11). The pinna and periostium are retracted using self retaining mastoid retractors (Fig. 12).
Step III : Elevating inner tympanomeatal flap:
The inner tympanomeatal flap is now elevated from posterior, superior and anterior canal wall in the regions corresponding to earlier first end-aural incision (Fig. 13). While elevating it from superior canal wall, the attachments to malleus are also released, if any. After having done this, now the flaps is based only at the floor region from 4 to 7 ‘o’ clock position (Fig. 14).
Step IV : Type of inner endo-meatal flap:
If the perforation is subtotal and adequate tympanic membrane remnant is present in the inferior quadrant, flap described earlier is adequate.
If the perforation is subtotal and adequate tympanic membrane remnant is absent in the inferior quadrant, flap described earlier is adequate. However, if the perforation is total and there is no tympanic membrane remnant is present, the fibrous annulus and skin flap is also elevated for about 3-4 mm, from the 4 to 7 ‘o’ clock position also. This helps to anchor the graft in the inferior quadrant.
Step V : Additional routine steps:
Canalplasty is done. Ossicular mobility and round window reflex are checked. If required, cortical mastoidectomy and ossiculoplasty are done.
Step VI : Grafting:
Next in case of subtotal perofration with adequate tympanic membrane remnant in the floor, the dried temporalis fascia is grafted in such a way that it is underneath the bony annulus at the inferior quadrant and lies over the bony external auditory canal in the remaining quadrants (Fig. 14 ). If there is no adequate tympanic membrane remnant, the graft itucked below the annulus which is elevated as described earlier. The graft is split at the malleus, to tuck below the manubrium of the malleus. The split ends taken around the malleus and placed over the superior meatal wall (Fig. 15).
The middle ear is filled with small gelfoam pieces and tympanomeatal flap is reposited which now lies over the temporalis fascia graft which is lying over bony canal wall (Fig. 16). Next Korner’s flap is reposiied over the remaining part of the temporalis fascia and external auditory canal is filled with gelfoam pieces and a ointment soaked pack. Wound is closed.
Advantages:
1. Technically easy and less time consuming.
2. Avoids anterior blunting of the graft
3. Anchors the graft well all around in subtotal as well as total perforations.
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prahladnb@gmail.com
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