The Palisade Technique

In the palisade technique, the cartilage is cut into several slices that are subsequently pieced together, like the pieces of a jigsaw puzzle, to reconstruct the TM (Fig. 6-5). Because of the nature of the reconstruction, it is not necessary to have one large, flat piece of cartilage, and the more curved cymba cartilage, which is harvested from the postauricular incision, is suitable (Fig. 6-6). A large area of conchal eminence can be exposed by elevating the subcutaneous tissue and postauricular muscle from the conchal perichondrium. The cymba cartilage is the prominent bulge at the superior aspect of the concha (Fig. 6-7). A circumferential cut the size of the anticipated graft is made through the perichondrium and cartilage, but not through the anterior skin. The perichondrium is removed from the postauricular side, and the cartilage, with the perichondrium on the anterior aspect, is dissected from the skin. This technique is also used for harvesting cartilage for canal wall reconstruction when the retrograde mas-toidectomy technique is used for cholesteatoma surgery.

The technique described here differs somewhat from the palisade tympanoplasty of Heermann et

TM flap

Cartilage

TM flap

Cartilage Palisade Tympanoplasty

FIGURE 6-5 Schematic of palisade technique (right ear).

Harvest

FIGURE 6-5 Schematic of palisade technique (right ear).

al.3 Instead of placing rectangular strips of cartilage side to side, an attempt is made to cut one major piece of cartilage in a semi-lunar fashion, which is placed directly against the malleus on top of the prosthesis (Fig. 6-8A,B). This acts to reconstruct a major portion of the posterior half of the TM and serves as a foundation for the rest of the cartilage pieces. A second semi-lunar piece is placed between this first piece and the canal wall to reconstruct the scutum precisely (Fig. 6-8C). Any spaces that result between this cartilage and the canal wall or scutum are filled in with small slivers of cartilage to prevent prosthesis extrusion and recurrent retraction (Fig. 6-8D). The reconstruction is then covered with the

Helix Anti helix

Cymba concha

Cavum concha Tragus

Helix Anti helix

Cymba concha

Cavum concha Tragus

Tragus Graft Tympanoplasty Procedure

FIGURE 6-6 Schematic illustrating location of cymba cartilage (left ear).

Harvest

Cymbal cartilage

Overlay Tympanoplasty Technique

Perichondrium

FIGURE 6-7 Harvesting of cymba cartilage with postauricular incision (right ear).

Cymbal cartilage

FIGURE 6-6 Schematic illustrating location of cymba cartilage (left ear).

Perichondrium

FIGURE 6-7 Harvesting of cymba cartilage with postauricular incision (right ear).

previously harvested perichondrium draped over the posterior canal wall (Fig. 6-9).

Although this technique can be used for TM reconstruction without ossicular reconstruction, it is favored when ossiculoplasty is performed in a malleus-present situation and is especially suitable for cholesteatoma surgery. Because the prosthesis is placed prior to the cartilage reconstruction, this technique allows direct visualization and contact of the notched prosthesis to the manubrium handle, which has been shown to provide superior hearing results.32 The prosthesis acts as a scaffolding on which the cartilage is placed, which serves to reconstruct the TM as well as prevent prosthesis extrusion. It likewise allows a precise and watertight fit between the reconstructed TM and the canal wall in the posterior area, where recurrent cholesteatoma most frequently occurs. Typically, in these situations, the anterior half of the TM is not altered or is grafted with conventional materials to allow cholesteatoma surveillance and possible intubation in the postoperative period if necessary.

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Responses

  • selina
    What is cymbal cartilage?
    5 years ago

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