Surgical Procedures
(1) Anesthesia: all patients were subjected to both general anesthesia
and local infiltration anesthesia. . (2) Preparation of graft: an arc
incision was made on the tragus 3 mm from the free margin. The
subcutaneous tissue was dissected to cut a piece of tragus
cartilage-perichondrium complex of suitable size. (3) Preparation of
graft bed: annulus fibrocartilagineus in the vicinity of the perforation
was removed using a cachet hook. (4) Elevation of tympanomeatal flap: an
arc-shaped incision (3/4 circle of the EAC) was made from 6 o’clock to 2
o’clock position clockwise on the right ear (or 10 o’clock to 6 o’clock
position clockwise on the left ear) at the junction of the skin and
mucosa, and then tympanomeatal flap was dissected and elevated up to the
annulus. (5) Exploration: the ossicular chain was confirmed to be intact
and mobile, and the orifice of the eustachian tube was unobstructed. (6)
Placement of grafts: perichondrium on the parotid side was harvested for
later use (Step 7). The cartilage-perichondrium complex was trimmed to
an appropriate size, with the perichondrium slightly wider than the
cartilage, and a wedge-shaped notch to accommodate the malleus handle.
The graft was then placed on the inner side of the
residual
tympanic membrane. The
tympanomeatal flap was repositioned back once the graft tightly fit the
tympanic membrane. (7) Extra patching: if the graft did not tightly fit
the residual tympanic membrane or if the marginal perforation had no
tympanic remnant to support the graft, an extra perichondrium patch was
used to strengthen the anterior-inferior tympanic membrane. We trimmed
the perichondrium (prepared in Step 6) into a wide and long strip, laid
it at the fissure with a crochet hook and folded it inward to make it in
good contact with both the residual tympanic membrane /annulus and the
graft. After that, we confirmed that the extra patch was firmly
stabilized and tucked (Figure 1 and 2 for the extra patch). (8)
Filling of the external auditory
canal with gelatin sponge. (9) Suture of the tragus incision.