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Tympanoplasty for sinus tympani retraction may result in delayed recurrence of the original problem. This is especially true in children with marginal eustachian tube function. Autogenous tragal cartilage, scored on one surface with perichondrium attached on the other, produces a "natural bend" in the cartilage. When placed in the middle ear, with the scored convex surface facing the promontory, retraction into the sinus tympani can be prevented. This simple, yet effective, surgical technique is outlined. (Arch Otolaryngol Head Neck Surg. 1994;120:1395-1396)

Ten cases of large nasal septal perforation were repaired with a tragal cartilage inferior turbinate mucoperiosteal sandwich graft technique with 70 per cent success rate over a follow-up period of up to 24 months. The technique is described in detail. The results are comparable to other techniques.

Extrusion of plastic or ceramic implants is a significant cause of failure in ossiculoplasty for chronic ear disease. This paper reports the use of a composite tragal cartilage and perichondrial autograft compared to cartilage or bone paste between the graft and tympanic membrane. At 2 years, there were no extrusions in the group with the composite graft (n = 18) and 5 extrusions in the cartilage/bone paste group (n = 18) (P = 0.02). The mean average air-bone gap was significantly better for the composite grafts at 2 years (15 dB vs 24 dB) (P less than 0.05). Extrusions were eliminated and hearing results better at 2 years using the composite graft.

We reviewed 564 tympanoplasties operated upon over an eight year period at the Otologic Medical Group in which tragal cartilage was used to re-establish the sound pressure transfer mechanism. Eighty-six percent of the cases were revisions, and half of these were planned second stage procedures. In the majority of cases the stapes crural arch was missing. The conductive deficit in these cases was reduced to 20 db or less in 67% and 10 db or less in 40%. The commonest single cause of failure was a short prosthesis. There were no instances of cartilage resorption. Extrusion occurred in one case. Tragal cartilage has been more satisfactory than ossicular tissue in many situations. Recently we have been using plastic prostheses (TORP and PORP) in combination with tragal cartilage and believe that the results will be even better.

Reconstruction of old radical cavities The methods as well as the primary and late results of 74 partial and 93 total reconstructions of old radical cavities were described. In partial reconstructions the tympanic cavity was reconstructed, but the cavity was not eliminated, as it was dry or could be kept dry. In total reconstructions the tympanic cavity and auditory canal were reconstructed, and in most cases the cavity was obliterated, either by muscle or by combined grafts of muscle, tragal cartilage, and homologous septal cartilage. On the basis of the late results, functionally 10–20% poorer than the primary ones, the indications for reconstruction of old radical cavities were discussed. If there is chronic aural discharge, and if the cavity is lined with granulations, the ear can be rendered dry by total reconstruction in 90% of the cases.

The results of cholesteatoma surgery performed from 1965 to 1980 and the surgical methods most frequently employed are presented. By canal down technique, a conservative radical operation with obliteration with muscle or combined transplants, we have obtained almost similar results as with a modified intact wall technique, whereby a small cortical mastoidectomy was performed together with atticotomy. It is concluded that no single method is optimal in all cases of cholesteatoma, and that the surgical approach must be individualized in relation to the pathology in the tympanic cavity and the tubal function.

Following Palva's1 original description of the technique, the “swinging door” tympanoplasty was modified and reported by several otologic surgeons, including Glass-Cock,2,3 Fisch,4 Smyth,6 Pennington.6 The basic technique involves the elevation of superiorly based and inferiorly based canal skin flaps, or “swinging doors.” After dividing the posterior anulus, the flaps are rotated anteriorly, a maneuver that provides ample exposure of the middle ear and greatly simplifies underlay fascia grafting. The purpose of this article is to review this basic technique and to describe additional modifications that further simplify tympanoplasty grafting. These modifications include (1) canal flap advancement, (2) the use of multiple fascia grafts, (3) techniques for securing the graft to the malleus handle, and (4) the use of tragal cartilage in grafting. With this technique, a 95% take rate was observed at 3 months, and the graft was firmly attached to the malleus handle in all cases.

A method is described for closure of perforations of the tympanic membrane, utilizing pedicled meatal skin grafts supported on tragal cartilage. The method has minimal limitations and an encouraging success rate.

Correction of ossicular defects in tympanoplasty most commonly involves the use of commercially available prostheses or preserved allograft ossicles. Incus autografts and tragal cartilage autografts are also used by many surgeons. Presculptured preserved allograft ossicles have not been used widely, but are used almost exclusively by our clinic. The fate of ossicular grafts has been reported by a number of in investigators with evidence obtained at revision surgery. In this paper we will be able to trace the fate of a presculptured preserved autograft ossicle clinically and pathologically. The unique aspect of this study is the demonstration of the ossicular status in post mortem temporal bone dissection followed by histopathological serial section studies.

A technique of surgical reconstruction of the middle ear, subjected previously to a radical mastoidectomy, using only autogenous grafts, is presented. Missing bony canal walls are reconstructed with tragal cartilage and its skin lining-by using the epidermal lining of the mastoid bowl. All squamous epithelium is removed from the middle ear spaces, great care being taken to preserve the mucoperiosteum. No attempt is made to obliterate or diminish the mastoid cavity which should remain in communication with the reconstructed tympanic cavity, no retroauricular drainage then being necessary. Suitable ossiculoplasty, usually of the columellar type, utilizing any ossicular remnants, autogenous bone or cartilage, is performed. For total or subtotal myringoplasty a large fascial graft is used. In all 22 patients thus operated on a completely healed middle ear, with integrity of all grafts, was obtained. In 6 cases with a follow-up of 16 months to 4 years slightly enlarged reconstructed ear canal and a restored, s...

ONE OF THE most difficult problems in the surgical treatment of chronic otitis media is reconstruction of the ossicular chain. It is the purpose of this paper to describe a technique of ossicular reconstruction using autogenous tragal cartilage. In the past, the main consideration in the surgical treatment of otitis media was the control of disease. With the development of tympanoplasty techniques, equal attention was given to reconstruction of the soundconducting mechanism. 1,2 The goal of tympanoplasty today is to control disease, retain normal anatomy whenever possible, and restore hearing. 3 Hearing restoration depends upon effective transmission of sound through the middle ear. When healthy ossicular remnants are present this may be accomplished by careful repositioning. 4-6 Many different types of prostheses have been advocated as ossicular substitutes. 3,5,7-9 In the earlier years of tympanoplasty we frequently used a polyethylene or Teflon strut between the handle of the malleus and

Recurrent cholesteatoma following atticotomy or combined-approach tympanoplasty remains a significant problem. The importance of closing defects created by surgery or disease in the posterosuperior bony canal is recognized, and numerous materials and techniques have been advocated. Our experience with a composite autograft of tragal cartilage and perichondrium in 40 ears is presented after 1 to 6 years follow-up. The composite autograft performed satisfactorily in 38 cases. In no case did recurrent cholesteatoma develop at the site of a defect that had been obliterated by the autograft.

TORPs and PORPs in tympanoplasty In an attempt to improve results in ossicular reconstruction, a newly introduced material, Plasti Pore, has been evaluated over a short term. The techniques employed are described in detail and the use of a lateral covering material such as tragal cartilage is advocated as a means of preventing extension of this foreign material. The results in over 100 ears are better than those obtained with previous methods.

Indications for repair of nasal septum perforations include excessive crusting, recurrent bleeding, whistling, and pain. Large subtotal perforations usually are less symptomatic, but smaller defects (less than 1 cm) may need repair. Tragal cartilage with perichondrium autograft was used to repair these perforations. After the septal defect was debrided, this free graft was harvested and used to fill the defect. This technique was attempted in ten patients with septal perforations, none secondary to systemic illnesses. Nine of these patients had successful closure of their perforations.

A surgical technique for reconstruction of a well-ventilated middle ear space using tragal cartilage has been developed. Our technique was designed so as to secure an atticoantrum cavity and a complement of posterior tympanic annulus with a cartilage. This technique can be utilized in a radical mastoidectomy cavity at an original surgery and at a revision.

MANY materials have been used successfully for the reconstruction of the middle ear. Ossicular remnants are the most widely used material for this purpose. These autografts are well tolerated and even retain some viability. 1 When no remnants are available, other types of grafts have been incorporated with varying degrees of success. These include homografts, 2 autogenous tragal cartilage, 3 soft tissue, 4 polyethylene, wire, and other materials. 5 In certain situations there is still a need for a substance that is packaged, sterile, nonantigenic, and readily available. Raymond-Jones 6 reported on the use of deproteinized, lyophilized calf bone as a stapedectomy prosthesis in humans. His initial results were encouraging, but there have been no further reports and no animal studies have been done. The purpose of this study was to examine the response of the monkey middle ear to this material. Since autogenous bone has such proven value

THE ADVANTAGES of preservation of the bony posterior wall of the external auditory canal during surgery for chronic infection have been stressed by many authors. 1-4 Unfortunately this part of the external canal is often partially destroyed by infection or cholesteatoma or must necessarily be removed to ensure adequate control of attic or mastoid pathology. Attempts to repair the resultant defect have been frustrated by numerous problems. Muscle flaps or muscle-periosteal flaps placed in the mastoid cavity were inevitably found to shrink and retract, producing secondary retraction of the canal wall. Some surgeons have reported success in preventing the formation of a mastoid cavity by filling the cavity with autografts, homografts, and even alloplastic implants. An excellent review of the materials used to obliterate the mastoid cavity has been compiled by Merifield. 5 He found that autograft cartilage survived very well in the cavity and stated: "Cartilage apparently possesses

• A method was developed for the use of tragal cartilage and perichondrium with the total ossicular replacement prosthesis. The method involves securing the flat base of the prosthesis in a perichondrial tunnel on the cartilage to stabilize the prosthesis, prevent extrusion, and promote vascularization. ( Arch Otolaryngol 104:213, 1978)