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Tympanoplasty—conchal cavum approach Man, S. C; Nunez, Desmond A Jan 6, 2016

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HOW I DO IT ARTICLE Open AccessTympanoplasty—conchal cavum approachS. Christopher Man1* and Desmond A. Nunez2AbstractThe three well recognized tympanoplasty approaches: permeatal, postaural, and endaural, each have advantages anddisadvantages. The permeatal approach is suitable only for ears with adequate canal size. The postaural approach limitsvisualization of the posterior eardrum margin. The endaural approach limits the view of the eardrum's anterior margin.This study describes a modified endaural approach, developed to overcome these limitations. A retrospective caseseries review and collection of a prospective cohort of patient reported outcome data were undertaken to assess thetechnique.Method: Standard incisions as used in an endaural approach are placed within the ear canal. The novel incisionextends from the superior canal incision into the conchal cavum. This allows a flap of the thick, hairbearing skin fromboth the bony and cartilaginous portions of the canal to be raised, and everted, to provide an excellent view of theentire drum. Perichondrium can be harvested for grafting from the conchal cavum.The clinical charts of all patients operated on by the first author using this technique from 2010–2012 wereretrospectively reviewed. The size and position of the perforation, size of the canal, whether primary orrevision surgery, graft take rate, hearing results and the occurrence of chondritis/perichondritis were recorded.To investigate the morbidities and the acceptance by the patients of the incision/scar in the conchal cavum,all patients undergoing the procedure in the 8 months up to the end of August 2013 were prospectivelyrecruited to complete a self-assessment Likert scale questionnaire recording postoperative pain, andsatisfaction with the cosmesis of the operative site. The clinician recorded if there was any evidence of chondritis/perichondritis.Results: A 100 % graft take rate was achieved in the 75 adults treated by the first author from 2010 to 2012 regardlessof the size and position of the perforation, configuration of the canal, primary or revision surgery.Preoperative Pure Tone Audiometric (PTA) Air Bone Gap (ABG) averaged over 3 frequencies (0.5, 1 and 2 K Hz) was19.4dB (standard deviation = 9.6, range 2 to 50). Postoperative PTA ABG average was 6.2 dB (standard deviation = 8.3,range -7 to 37), demonstrating a statistically significant post-surgery mean improvement of 13.2 dB (paired T-test,p < 0.001).Twenty-one patients who underwent the procedure in 2013, reported minimal postoperative analgesic use, and scoredthe acceptability of the incision scar highly (4.8 out of a maximum of 5). There was no case of chondritis/perichondritisin the 96 cases.Conclusion: Whilst it is the surgeon’s decision to use a permeatal, postaural or endaural approach, the endauralapproach with the conchal cavum modification is an excellent alternative to the traditionally described approaches.Trial Registration: Clinical trial number: NCT02000843 at ClinicalTrials.gov* Correspondence: man2183@aol.com1Clinical Instructor, Division of Otolaryngology, Department of Surgery,University of British Columbia, 102-2620 Commercial Drive, Vancouver, BC,CanadaFull list of author information is available at the end of the article© 2016 Man and Nunez. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Man and Nunez Journal of Otolaryngology - Head and Neck Surgery  (2016) 45:1 DOI 10.1186/s40463-015-0113-3IntroductionThere are three well recognised approaches utilized bysurgeons when undertaking middle ear surgery namelythe permeatal, postauricular, and endaural. These ap-proaches are used in a range of operations where accessto the ear drum and middle ear contents is necessarysuch as myringoplasty, tympanoplasty and stapedectomy.Each approach has advantages and disadvantages thatcombined with the individual surgeon’s preference forone technique over the others determines the approachused in any particular case. The permeatal approach re-stricts access to the tympanic membrane margins in pa-tients with narrow ear canals. The post auricularapproach requires a fair amount of soft tissue dissectionwith associated morbidity but provides favourable accessto the eardrum’s anterior margin. The endaural approachlimits access to the anterior eardrum margin.ObjectiveAn improvement of the endaural approach is reported.An incision into the conchal cavum releases thick, hairbearing skin of posterior canal, allowing it to be movedout of the operative field, and brings the anterior ear-drum margin into full view. Conchal perichondriumand/ or cartilage can be harvested by extending the con-chal cavum incision. The details of the technique are de-scribed. The tympanoplasty graft take rate, hearingresults, complications and patient satisfaction with thepost-operative scar achieved in a series of patients usingthis modified approach are assessed and reported.Description of techniqueSkin incisionsInside the canalStandard incisions are used [1]. A 180 to 270° circumfer-ential incision (incision c), starting just medial to thehairline of the external canal, extending from the 12O’clock position posterior-inferiorly to the 6 O’clockposition (180°) and when clinically indicated, continuinganteriorly to the 9 O’clock in a left ear (270°) divides thethick, hair-bearing skin from the thin, squamous epithe-lial lining of the canal (Fig. 1).At 6 and 12 O’clock, two lateral radial incisions, lowerincision a1 and upper incision a2, are made (Fig. 2).Outside the canalThe novel incision, incision b, extends posteriorly fromthe superficial end of the upper radial incision (incisiona2) into the conchal cavum inferior and parallel to thehelix crus, for a total length of about 5 mm (Fig. 3).The first author makes incisions a1, a2 first, followedby incision b and then incision c. However, the order isa matter of surgical preference.Fig. 1 Circumferential in the ear canal incision. Legend- Thisillustrates the circumferential incision c. It is a half circle, 180°,on the posterior bony wall, which can be extended to 270° ifindicated. It separates the thick hair bearing canal from the thinsquamous epithelial liningFig. 2 Radial ear canal incisions. Legend- The lower radial incision a1and the upper radial incision a 2 are illustratedMan and Nunez Journal of Otolaryngology - Head and Neck Surgery  (2016) 45:1 Page 2 of 5Dissection of the canal skin/squamous epitheliumThe thick hairbearing skin from the both bony and car-tilaginous portions of the canal posteriorly is dissectedand elevated in a retrograde fashion.The skin is turned inside out, exposing the poster-ior bony canal. With self-retaining retractor(s) inplace, the canal skin is held away from the surgicalfield, fully exposing the bony ear canal (Fig. 4).The cuff shape tympanomeatal flap of thin epitheliallining is elevated from the deep bony canal wall, and dis-placed medially (Fig. 5).Any bony obstruction can be removed until the annu-lus is visualized, and elevated as required for underlaygrafting.Harvesting of the graftThe conchal cavum incision is extended the full lengthof the upper border of the conchal cavum. The conchalcavum cartilage is dissected and harvested (Fig. 6). Theperichondrium on the posterior surface is removedfrom the cartilage and used as grafting material. Thecartilage, if not used, is returned to the conchal cavum.Patients and methodApproval for the research was granted by UBC-Providence Health Care Research ethics board. (H13-03261) Part A- The medical records of all patients whounderwent conchal cavum approach tympanoplasty bythe first author between 2010 and 2012 were reviewedto identify patients, who were followed up for a minimumof one year. No patient undergoing the procedure duringthe study period was excluded or lost to follow up. Thereview of records was undertaken in January 2014.Data collected included the size and position of theperforations, size of the ear canal, if the procedure wasprimary or revision surgery, evidence of postoperativechondritis/perichondritis, pre- and post-operative PureTone Audiometric (PTA) Air and Bone Conductionhearing thresholds at 0.5, 1 and 2 KHz. The adequacy ofthe lumen of the external ear canal for surgical accessFig. 3 Conchal incision. Legend- The novel incision b, made at thesuperficial end of upper radial incision a2, extends into the conchalcavum, which allows eversion of the posterior canal skinFig. 4 Bony ear canal exposure. Legend: The bony canal is exposedby everting the skin flap which consists of canal skin from both thebony and cartilaginous portions of the canalFig. 5 Cuff shape tympanomeatal flap. Legend: A cuff shape medialtympanomeatal flap is raised. The middle ear cavity can then beentered by lifting of the annulus from the tympanic ringMan and Nunez Journal of Otolaryngology - Head and Neck Surgery  (2016) 45:1 Page 3 of 5was subjectively assessed at the time of surgery. A re-stricted ear canal was defined as one which precluded afull view of the ear drum margin using the operatingmicroscope with the largest comfortable ear canalspeculum in situ. The graft take rate at 12 months(complete closure of the perforation) was tabulated.AnalysisAveraged pre and post-operative Air Conduction (AC) andBone Conduction (BC) were calculated. Individual patient'spre and post-operative Air Bone Gap (ABG) was calculatedby substracting the averaged 3 frequency (BC from AC)thresholds recorded at the same sitting. Changes in con-ductive hearing loss were calculated according to the guide-lines of the American Academy of Otolaryngology Headand Neck Surgery Committee on Hearing and Equilibrium(2), the only exception due to the retrospective nature ofthe data collection being the replacement of the 4 frequencywith a 3 frequency average (0.5, 1, and 2K Hz).The Statis-tical Program for the Social Sciences (SPSS) version 23 wasused to determine sample means, standard deviations andundertake a paried T test comparison of pre- and post-operative ABG for statistically significant differeence.Part B - Patients undergoing the procedure betweenJanuary and August 2013 were assessed at three weeksand three months postoperatively, recording postoperativeanalgesic use, conchal bowl appearance and numbness,occurrence of chondritis/perichondritis, and the patient’ssatisfaction with the appearance of the conchal bowl andscar determined by a Likert scale questionnaire.ResultsPart ASeventy-five patients (44 women and 31 men) treatedfrom 2010 to 2012 meet the study inclusion criteria.Their ages ranged from 23 to 75 years at the time ofsurgery. The age distribution by decade in this adultseries was 3 aged 20–29, 10 aged 30–39, 19 aged 40–49,28 aged 50–59, 13 aged 60–69, and 2 aged 70–79.There were 29 subtotal or total perforations. 13 smallerperforations were anteriorly placed. The canal size was smallor restrictive in 13 cases, 68 cases were primary, and 7 revi-sion cases. All the perforations were completely healed onfollow-up. There was no case of chondritis or perichondritis.Preoperative PTA ABG averaged over 0.5, 1 and 2 Kwas 19.4dB (standard deviation = 9.6, range 2 to 50), andthe Postoperative PTA ABG average was 6.2 dB (standarddeviation = 8.3, range -7 to 37). There was a statisticallysignificant mean 13.2 (standard deviation= 8.5, range -3 to33) dB closure of the ABG with surgery (paired T-test,p < 0.001). 51, 16, 1, and 4 patients demonstrated a 0-10dB, 11-20 dB, 21-30 dB, and >30 dB change in AB gap sec-ondary to surgery respectively. In 4 patients the AB gapincreased post surgery, in 2 by 2 dB and in 2 by 3 dB.Part BTwenty-one patients who underwent a conchal approachtympanoplasty in 2013 were studied.All patients were prescribed 1 to 2 tablets of Acet-aminophen every 4 to 6 hourly as required for postoper-ative analgesia. 14 patients used Acetaminophen dailyfor one or two days. One patient used Acetaminophenfor three days. One patient used 200 mg of Ibuprofen onthe first post-operative day only. It is noteworthy that 5patients did not use any postoperative analgesics.No patients complained of numbness of the conchalbowl. The conchal bowl was well healed and retained itsnormal shape in all cases. There was no case of chondri-tis or perichondritis. On the Likert scale questionnaire, 5patients agreed and 16 strongly agreed that the cosmesisof the conchal bowl and scar was excellent.DiscussionGood exposure of the annulus is important in underlaytympanoplasty. Obstruction of exposure by the cartil-aginous and bony canal must be adequately addressed.The skin of the cartilaginous canal and outer portion ofbony canal is often thick and hair bearing. The bony canalis frequently curved, and narrow particularly at the isthmus.With this conchal cavum approach, the thick hairbearingcanal skin is mobilized and kept out of the way. The entirebony canal becomes easily accessible. Any bony obstruc-tion interfering with the dissection of the annulus from thesulcus of the tympanic ring can be easily removed.In the standard endaural approach, in order to gainmore exposure, an incision is made between the tragusand helix, extending superiorly anterior to the crus ofthe helix [3]. A fair amount of dissection is needed. Theexposure of the drum anteriorly is limited. Perichondritisfrom the pressure exerted by a retractor on the helicalcartilage has been reported [4]. Also the scar in front ofthe helix is at times very visible.Fig. 6 Conchal cartilage harvest. Legend: The harvesting of theconchal cartilage for grafting is shownMan and Nunez Journal of Otolaryngology - Head and Neck Surgery  (2016) 45:1 Page 4 of 5In the conchal cavum approach, the incision in theconchal cavum releases soft tissues to be retracted with-out undue pressure and keeps it out of the way. It canbe extended as far back as necessary to achieve a similarlevel of visualization of the drum and annulus anteriorlyas achieved by the postaural approach. Usually, however,experience has shown only a short incision is necessary.Even though the number of cases in this report is rela-tively small, it demonstrates that the approach can han-dle a variety of cases of differing canal size, perforationsite and size. Revision cases were also successfullyrepaired with this technical modification.The graft take rate compared well with reported grafttake rates of 88 to 98.4 % [5, 6].However, with more cases, it is anticipated that thegraft take rate of 100 % will revert to the norm.The hearing results also appeared to be in line withthe literature of a range of 8 to 22 dB improvement[5, 6]. The use of this approach has not adversely af-fected the hearing results.Postoperative morbidity was minimal. Cosmesis of thescar and conchal bowl was graded as excellent by themajority of the patients surveyed in this small sample.Many factors determine this judgment, and surgeonsadopting this technique are advised to audit their ownpatients to ascertain their satisfaction with the cosmeticoutcome. Postoperative pain was assessed indirectlythrough reported analgesic consumption, and whilst it isreasonable to conclude that the patients studied experi-enced little if any troublesome postoperative pain thiswas not a comparative trial. It is therefore not possibleto determine if patients experienced less or more post-operative pain with this approach compared to othertechniques. There were no cases of chondritis/ perichon-dritis, consistent with the literature reports of safe har-vesting of cartilage and perichondrium from the concha[7-10].The technique is not recommended for patients inwhom keloid formation is a serious concern, thoughthere were no such patients in this series.ConclusionWhilst it is the surgeon’s decision to use a permeatal,postaural or endaural approach, the endaural approachwith the conchal cavum modification is an excellent al-ternative to the traditionally described approaches.AbbreviationsPTA: pure tone audiometric; ABG: air bone gap; dB: decibel; AC: airconduction; BC: bone conduction; SPSS: statistical program for the socialsciences.Competing interestThe authors declare that they have no competing interests.Authors’ contributionsSCM originated the procedure, co-designed the study, collected data, draftedthe manuscript, reviewed and approved the final manuscript with DN. DNco-designed the study, revised the drafted manuscript, analysed the data,reviewed and approved the final manuscript.AcknowledgmentsWe thank Ms. Vicky Earle for excellent illustrations.Author details1Clinical Instructor, Division of Otolaryngology, Department of Surgery,University of British Columbia, 102-2620 Commercial Drive, Vancouver, BC,Canada. 2Associate professor, Head / Division of Otolaryngology, Departmentof Surgery, University of British Columbia, Diamond Health Care Center, 2775Laurel Street, Vancouver, BC, Canada.Received: 6 August 2015 Accepted: 22 December 2015References1. Mirko Tos. Cartilage tympanoplasty Classification of methods—techniques—results.Publisher: Theime Ch. 3 Approaches. page 332. Gurgel RK, Jackler RK. A new standardized format for reporting hearingoutcome in clinical trials. Otolaryngol Head Neck Surg. 2012 Nov;147(5):803-73. Julianna Gulya. Glasscock-Shambaugh surgery of the ear 6th edition PeopleMedical Publishing House- USA. Page 4724. Tseng CC, Shiao AS. Postoperative auricular perichondritis after an endauralapproach tympanoplasty. J Chin Med Assoc. 2006;69(9):423–7.5. Phillips JS, Yung MN. Myringoplasty outcomes in the UK. Journal ofLaryngology & Otology. 2015;129:860–4.6. Emily I, Vlastarakos PV. Is cartilage better than temporalis muscle fascia intype 1 tympanoplasty? Eur Arch Otorhinolaryngol. 2013;270:2803–13.7. Inchingolo F, Tatullo M. Clinical case-study describing the use ofskin-perichondrium-cartilage graft from the auricular concha to cover largedefects of the nose. Head Face Med. 2012;8:10.8. Mowlavi A, Pham S. Anatomical characteristics of the conchal cartilage withsuggested clinical applications in rhinoplasty surgery. Aesthet Surg J.2010;30(4):522–6.9. Castellani A, Negrini S. Treatment of orbital floor blowout fractures withconchal auricular cartilage graft: a report on 14 cases. J Oral Maxillofac Surg.2002;60(12):1413–7.10. Marks NM, Argenta LC. Conchal cartilage and composite grafts forcorrection of lower lid retraction. Plast Reconstr Surg. 1989;83(4):629.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:Man and Nunez Journal of Otolaryngology - Head and Neck Surgery  (2016) 45:1 Page 5 of 5


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