1. A simple technique to close subtotal perforations of the tympanic membrane Sylvester Valentine Fernandes BSc(Hons),MB,BS,MCPS,FRCSEd,FRACS,FACS,LLB Senior Surgeon & Senior Clinical Lecturer Newcastle University, Australia Email: mdsfe@yahoo.com.au

2. Temporalis fascia technique Disadvantages Lifting of tympanomeatal flap Bleeding may impair visualisation Flap tears may occur Packing may cause displacement of graft, unbeknown to surgeon Postoperative care Not suitable for very young children

3. Composite graft Advantages Available very locally Minimal non visible scar Has all the advantages of temporalis graft Cartilage easy to handle, provides firm scaffolding and resistance from infection Good fixation ensured Occurrence of retraction pockets and chances of recurrent perforation reduced No packing Postoperative care minimal Both ears can be done at the same time

4. CRITERIA Small to medium sized perforation (maximum one-half of tympanic membrane) Nonmarginal perforation with clear view of margins Dry ear and no granular myringitis Conductive loss no greater than 35dB in any frequency Atleast 12 months of clinical observation for non healing

5. Typical perforation

6. Tragal cartilage – Donor site

8. Circumperipheral separation of perichondrium from cartilage

9. In larger perforations use reflected perichondrim from other side

10. (inside

12. Tragal composite graft

15. Reflected perichondrium on one side

21. Perforation

22. De-epithelisation of perforation (postage stamp technique)

23. Composite graft laid with cartilage in middle ear

24. Flattened gellfoam laid on graft

25. Catgut stitch to donor site

26. Antibiotic ointment into external canal

27. 6 month postoperative

28. 18 month postoperative

29. RESULTS Average Preop A/B gap Average Postop A/B gap 500 Hz 13.7 dB 8.3 dB 1 kHz 12.3 dB 5.7 dB 2 kHz 5.3 dB 2.7 dB 4 kHz 19.7 dB 9.0 dB Average gain 500 Hz 5.3 dB 1 kHz 6.7 dB 2 kHz 2.7 dB 4 kHz 10.7 dB

32. Follow this sequence: 1. Inject tragus with vasoconstrictor/anaesthetic 2. Freshen perforation and prepare site 3. Take and prepare graft (cartilage can be thinned if required). Use ophthalmic instruments (if available) to separate the periphery of cartilage and perichondrium. 4. Place graft ( at this time the site of graft placement has stopped bleeding) Place cartilage in middle ear and perchondrium on to remnant tympanic membrane and place flattened gelfoam on graft 5. Place ointment in ear canal 6. Close donor site with (one) catgut stitch (no need for removal by doctor later as it falls off by itself) This way there is almost no bleeding to obscure vision!

33. Patient must be told of cartilage use and must be told to inform future health providers

34. Technique favourable in …… Children Revision surgery Bilateral cases Costs concerns and follow up difficult (missionary work) Time concerns (takes < 30 minutes) Neophyte surgeon (registrar training) Infact …in all myringoplasty cases fulfilling criteria

35. REFERENCES Fernandes SV. Composite chondroperichondrial clip tympanoplasty: The triple “C” technique. Otolaryngol Head Neck Surg 2003;128: 267-72 Tos M. “Cartilage Tympanoplasty” 2009 George Thieme Verlag. Stuttgart.Chapter 26