Technical Approach of ‘Butterfly’ Graft for Incisionless In-Office Endoscopic Tympanic Membrane Repair

By June 7, 2019

Kozin, Elliott1; Remenschneider, Aaron1
1 Massachusstes Eye and Ear Infirmary, Boston, MA, USA.

To minimize the morbidity of intraoperative surgical tympanic repair (TM), an in-office TM repair technique would apply the surgical principles of underlay graft using a ‘off the shelf graft’. Herein, we describe a novel design and use graft to facilitate closure of a TM perforations when placed in an office setting using transcanal endoscopic technique.

An 89-year-old female was placed in the supine position in the clinic setting. Using a Hopkins rod telescope to visualize the TM, a Rosen needle was used to rim the perforation. Under sterile conditions, a 4mm punch biopsy was used to fashion a circular biologic TM graft. Two pieces of porcine submucosa (Cook BioDesign) were utilized as the graft construct. Linear cuts were then made at the 12 o’clock and 6 o’clock potion, leaving a roughly 0.5mm gap. After creating two identical grafts, the grafts were then interdigitated, creating a “butterfly” graft, with four sets of flanges in two planes (medial and lateral). The butterfly graft was placed directly on the lateral surface of the tympanic membrane perforation. Using a Rosen needle, two flanges touching the TM are placed medial to the graft, while the lateral two flanges remain in position. Gelfoam soaked followed by bacitracin ointment are placed lateral to the graft.

There were no complications and the procedure took 20 minutes. Post-operatively, there was complete closure of the perforation and resolution of the air-bone-gap.

Novel ‘butterfly’ design of grafting material may allow for simple in-office TM repair.