Tympanoplasty: areolar tissue graft.
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A technique for closure of tympanic membrane perforation which preserves the normal anterior sulcus-tympanic membrane relationships is described. This underlay fixation technique provides a high graft take, good conization of the drum, prevention of lateralization of the reconstructed drum and elimination of tenting or blunting of the anterior sulcus. The reconstructed tympanic membrane presents a near normal appearance with good physiological and acoustic properties.
The bulge of the osseous anterior canal wall frequently prevents visualization not only of the margins of the perforation but also of the pathologic changes in the middle ear. In such instances, removal of this bone is absolutely necessary. In other instances, removal of the bulge facilitates both the surgical procedure and postoperative care. While the skin over the bulge may be sacrificed, it is preferable to preserve the skin by creating either a laterally or medially based flap. This provides access to the bone which is removed with motor driven burrs. The techniques are essentially the same whether the approach is through the canal or from behind the ear.
A description of ossicular reconstruction in problems with the stapes using autograft and/or homograft ossicles is given. The inverted stapes is employed for otosclerosis and tympanosclerosis. The two ossicle reconstruction is used in cases of a mobile footplate with absent crural arches. The reshaped incus is repositioned between the malleus handle and oval window when the stapes is fixed and there also exists a lateral ossicular chain defect. Loose connective tissue is an effective seal for the oval window and is a means of stabilizing ossicular functions.
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