84
GELATIN FILM SANDWICH IN TYMPANOPLASTY MARC S. KARlAN, MD GAINESVillE, flORIDA
A technique is presented that utilizes two sheets of gelatin film as a sandwich to provide a scaffold for medial support and lateral cover to fascia grafts while permiUing visual inspection of both fascia and tympanic membrane.
GELATIN film has been employed for both the prevention of adhesions in the middle ear cleft'·] and the induction of a neotympanic rnernbrane.s We present a technique that utilizes two sheets of gelatin film as a sandwich to provide a scaffold for support of, and a windowpane through which to view, the fascia graft. The gelatin film provides medial support and lateral cover to the grafts while permitting visualization of both fascia and tympanic membrane. This has been successful for teaching surgeons accurate placement of fascia and in allowing exacting examination of this technique.
stored to its original position, and the gelatin film window is then introduced lateral to the tympanic membrane and the fascia graft. Inspection through, and suction over, the film can now be performed. The ear canal is packed as usual (Fig 1 through 6).
Fig 1.-Raising tympanomeatal flap after "rimming" perforation.
METHOD Immediately preceding insertion of the fascia graft in standard tympanoplasty, gelatin film is placed medial to the tympanic membrane remnants and lateral to the gelatin sponge. The temporalis fascia is slipped on the film into position medial to the remaining tympanic membrane. By lifting one edge of the film, gelatin sponge may be inserted beneath it to secure effective contact with the covering tissues. The tympanomeatal flap is reFig 2.-Flap reflected anteriorly. Scattered Gelfoam in mesotympanum. Submitted for publication July 20, 1978. From the University of Florida, College of Medicine, Gainesville.
MATERIALS AND RESULTS
Presented as a Scientific Poster Presentation at the 1978 Annual Meeting of the American Academy of Otolaryngology, las Vegas, Sept 10-13.
Forty-five consecutive tympanoplasties were performed using this technique (20
Otolaryngol Head Neck Surg 87:84-86 (Jan-Feb) 1979 Downloaded from oto.sagepub.com at CAMBRIDGE UNIV LIBRARY on June 5, 2016
GElFILM IN TYMPANOPLASTY
Fig 3.-Gelfilm scaffold in place over Gelfoam.
85
Fig 5.-Flap reflected; gelfilm window over tympanic membrane a.nd graft. Inspection through this is easy even after lime delay caused by change in chairs between surgeon and first assistant.
GELFILM SANDWICH
.. • •
..
...
GELFOAM GELF IlM TM FLAP FASCIA GElFILM
Fig 4.-Fascia slid onto gelfilm under perforation.
GElFOAM type I, 22 type II, 3 type III). All surgical procedures were performed in a teaching setting. Retrospective analysis of graft status recorded at between three and six months postoperatively showed a total of three perforations in the series (one patient was on corticosteroids at the time of procedure), six thin atrophic grafts, 28 normal or good grafts, and eight grafts obscurely recorded as "intact." None of the grafts were lateralized or recorded as thick. Audiograms at six months were available for 34 patients. Of the patients with type I tympanoplasties, 2 had perforations, 1 had a 10-dB air-bone gap at the pure-tone average, and 15 had closure at 5 dB or better. Of the patients with
Fig G.-Exploded view of layers of repair.
type II tympanoplasties, 8 had 10-dB gaps or better, 2 had 15-dB gaps, and 3 had 30-dB gaps. Of those with type III tympanoplasties, one had a 25-dB gap and one had a perforation. The patient
OtoJaryngoJ Head Neck Surg 87:84-86 (jan-Feb) 1979 Downloaded from oto.sagepub.com at CAMBRIDGE UNIV LIBRARY on June 5, 2016
MARC S. KARLAN
86
with a type IV tympanoplasty had a 40-dB gap. These results are comparable to tympanoplastic procedures performed without gelfilm sandwich technique.
spection of graft position through the film windowpane is unhampered by late bleeding; and (6) the ear canal can be packed without risk of graft displacement.
DISCUSSION The advantages of this technique are multiple: (1) even with a blood-clouded field, the gelatin may be quickly placed and accurately positioned because of its stiffness; (2) fascia may be placed by sliding on a smooth surface rather than by manipulation on an insecure foundation of resilient sponges; (3) the lateral contact of fascia with the medial aspect of the tympanic membrane is improved by lifting and working under the scaffold of gelatin film; (4) suction to maintain visualization is facilitated by the gelatin film, which precludes inadvertent aspiration of gelatin foam or temporalis fascia; (5) in-
REFERENCES
1. Holzer F: The fate of gelatin film in the middle ear. Arch Oto/aryngo/98:319-321, 1973. 2. Falbe-Hansen J Jr. Tos M: Silastic and gelatin film sheeting in tympanoplasty. Ann Otol Rhinol Laryngol 84:315-317, 1975. 3. Kitchens GG, Gross CW: Investigation of the mesotympanum's reaction to Silastic and gelatin film. Arch Oto/aryngol 102:547-551, 1976. 4. Harris I, Barton S, Gussen R, et al: Gelfilm-induced neotympanic membrane in tympanoplasty. Laryngoscope 81:1826-1837, 1971.
Oto/aryngol Head Neck Surg 87:84-86 (Jan-Feb) 1979 Downloaded from oto.sagepub.com at CAMBRIDGE UNIV LIBRARY on June 5, 2016
GELATIN FILM SANDWICH IN TYMPANOPLASTY MARC S. KARlAN, MD GAINESVillE, flORIDA
A technique is presented that utilizes two sheets of gelatin film as a sandwich to provide a scaffold for medial support and lateral cover to fascia grafts while permiUing visual inspection of both fascia and tympanic membrane.
GELATIN film has been employed for both the prevention of adhesions in the middle ear cleft'·] and the induction of a neotympanic rnernbrane.s We present a technique that utilizes two sheets of gelatin film as a sandwich to provide a scaffold for support of, and a windowpane through which to view, the fascia graft. The gelatin film provides medial support and lateral cover to the grafts while permitting visualization of both fascia and tympanic membrane. This has been successful for teaching surgeons accurate placement of fascia and in allowing exacting examination of this technique.
stored to its original position, and the gelatin film window is then introduced lateral to the tympanic membrane and the fascia graft. Inspection through, and suction over, the film can now be performed. The ear canal is packed as usual (Fig 1 through 6).
Fig 1.-Raising tympanomeatal flap after "rimming" perforation.
METHOD Immediately preceding insertion of the fascia graft in standard tympanoplasty, gelatin film is placed medial to the tympanic membrane remnants and lateral to the gelatin sponge. The temporalis fascia is slipped on the film into position medial to the remaining tympanic membrane. By lifting one edge of the film, gelatin sponge may be inserted beneath it to secure effective contact with the covering tissues. The tympanomeatal flap is reFig 2.-Flap reflected anteriorly. Scattered Gelfoam in mesotympanum. Submitted for publication July 20, 1978. From the University of Florida, College of Medicine, Gainesville.
MATERIALS AND RESULTS
Presented as a Scientific Poster Presentation at the 1978 Annual Meeting of the American Academy of Otolaryngology, las Vegas, Sept 10-13.
Forty-five consecutive tympanoplasties were performed using this technique (20
Otolaryngol Head Neck Surg 87:84-86 (Jan-Feb) 1979 Downloaded from oto.sagepub.com at CAMBRIDGE UNIV LIBRARY on June 5, 2016
GElFILM IN TYMPANOPLASTY
Fig 3.-Gelfilm scaffold in place over Gelfoam.
85
Fig 5.-Flap reflected; gelfilm window over tympanic membrane a.nd graft. Inspection through this is easy even after lime delay caused by change in chairs between surgeon and first assistant.
GELFILM SANDWICH
.. • •
..
...
GELFOAM GELF IlM TM FLAP FASCIA GElFILM
Fig 4.-Fascia slid onto gelfilm under perforation.
GElFOAM type I, 22 type II, 3 type III). All surgical procedures were performed in a teaching setting. Retrospective analysis of graft status recorded at between three and six months postoperatively showed a total of three perforations in the series (one patient was on corticosteroids at the time of procedure), six thin atrophic grafts, 28 normal or good grafts, and eight grafts obscurely recorded as "intact." None of the grafts were lateralized or recorded as thick. Audiograms at six months were available for 34 patients. Of the patients with type I tympanoplasties, 2 had perforations, 1 had a 10-dB air-bone gap at the pure-tone average, and 15 had closure at 5 dB or better. Of the patients with
Fig G.-Exploded view of layers of repair.
type II tympanoplasties, 8 had 10-dB gaps or better, 2 had 15-dB gaps, and 3 had 30-dB gaps. Of those with type III tympanoplasties, one had a 25-dB gap and one had a perforation. The patient
OtoJaryngoJ Head Neck Surg 87:84-86 (jan-Feb) 1979 Downloaded from oto.sagepub.com at CAMBRIDGE UNIV LIBRARY on June 5, 2016
MARC S. KARLAN
86
with a type IV tympanoplasty had a 40-dB gap. These results are comparable to tympanoplastic procedures performed without gelfilm sandwich technique.
spection of graft position through the film windowpane is unhampered by late bleeding; and (6) the ear canal can be packed without risk of graft displacement.
DISCUSSION The advantages of this technique are multiple: (1) even with a blood-clouded field, the gelatin may be quickly placed and accurately positioned because of its stiffness; (2) fascia may be placed by sliding on a smooth surface rather than by manipulation on an insecure foundation of resilient sponges; (3) the lateral contact of fascia with the medial aspect of the tympanic membrane is improved by lifting and working under the scaffold of gelatin film; (4) suction to maintain visualization is facilitated by the gelatin film, which precludes inadvertent aspiration of gelatin foam or temporalis fascia; (5) in-
REFERENCES
1. Holzer F: The fate of gelatin film in the middle ear. Arch Oto/aryngo/98:319-321, 1973. 2. Falbe-Hansen J Jr. Tos M: Silastic and gelatin film sheeting in tympanoplasty. Ann Otol Rhinol Laryngol 84:315-317, 1975. 3. Kitchens GG, Gross CW: Investigation of the mesotympanum's reaction to Silastic and gelatin film. Arch Oto/aryngol 102:547-551, 1976. 4. Harris I, Barton S, Gussen R, et al: Gelfilm-induced neotympanic membrane in tympanoplasty. Laryngoscope 81:1826-1837, 1971.
Oto/aryngol Head Neck Surg 87:84-86 (Jan-Feb) 1979 Downloaded from oto.sagepub.com at CAMBRIDGE UNIV LIBRARY on June 5, 2016
