INTRODUCTIONWullsteinandZollnerintoducedtheconceptoftympanoplastyinthefieldofchroniceardiseases.Lempertoriginallydesignedtympanomeatalflapforhistympanosympathectomyoperation.LateradoptedbyRosenforoperationonthestapes.TheconceptofplacingthegraftunderthedrumremnantwassetforthbySheaandTabbin1960’s.Theirprocedurewereidenticalbuttheyemployedveinasagraftmaterial.Thetechniquewassameasinstapedectomytoraisetheendomeatalflapandplacethegraftunderit.MauriceSourdilleinnovationofusingtympanomeatalflapfortympanoplastywasthestartingpointofneweraofmoderntympanoplasty.SincethentympanomeatalflapshavebeenusefulinunderlaytympanoplastyandotherOtologicsurgery.TheelevatedtympanomeatalflapallowsaccessforanumberofmiddleearprocedureslikerepairofTMorperilymphfistula,ossiculoplasty,

removegrowthssuchascholesteatomaandglomustumour.Differenttypesoftympanomeatalflaparenamedasperthebaseoftheflap:1.SuperiorFlap.(Plester,SheehyandGlasscock)2.AnteriorFlap.(Shambaugh,Singhetal)3.InferiorFlap.(SeifiAE)4.AnteriorandposteriorFlap.(GibbandChang)5.3Flaptechnique(RoyChaudri)6.Vascualarstripwasanothernamegiventothesuperiorlybasedflap.Balkanetalin2003namedtheseflapswithsomeminorvariations

1.StandardFlaps2.StapedectomyFlap3.CongenitalCholeateatomaFlap4.GlomustympanicumFlap

Standardflaphasmanyusesandprovidesmaximumexposuretotheposteriormesotympanum.Theincisionextendsto12o’clockand6o’clockpositionsandiskept1mmawayfromthetympanicmembrane

Stapedectomyorossicularreconstructionflap.IntheMinorvariationofthestandardflap,anasymmetricalincisionismadeWiththesuperiorportionoftheflapbeing8mmlongtocompensateforcurettageofthescutum.

Congenitalcholesteatomaflap.Theflapextendstothestandardflaptoprovidebetteraccesstotheanteriorandsuperiormesotympanum(A).Themostcommonlocationofsmallcongenitalcholesteatomasisshown(B).

Anteriorcanalwallflap.Alimitedanteriorflapmaybeusedtopullagraftthrough,tostabilizeitforanteriormar-ginalperforations(A).Theflapmaybeextendedontheanteriorwalltoremovecanalwallbulge,osteoma,orexostosis(B)TearsinT-flapdooccurwhileelevatingtheflap.MostcommonlytearsoccurinthehandofinexperiencedOtologicsurgeonsbutcanalsooccurinexperiencedhands.Withtheabovereference,wedesignedaprospectivestudytoseewhetherthetearwhichusuallyoccursduringelevationoftheflapreallymattersornot?Thisstudyisfirstofitskindintheliterature.

MaterialandMethods:Patientdataincluded:1. Age2. Sex3. Audiogram4. Significantmedicalproblems

Allearsweredry3-4weekspriorsurgery.Agerangefrom15-55years.AllcasesunderwentaudiologicalandevaluationbeforesurgeryApproach:Allcasesunderwentpostauralapproachwithunderlaytechnique.AProspectivestudyforaperiodof18monthsfromJuly2014tillDecember2015.DoneinBuraidahCentralHospital.70casesofCSOMwhounderwenttypeItympanoplastybyunderlaytechniquewerestudiedduringthisperiod.

Inclusioncriteria:CSOMofsafetypewithmediumsize;kidneyshape,subtotalortotalperforation.Exclusioncriteria:1. CSOMwithcholesteatoma/polyp/granulation

2. Marginalperforation3. Smallperforationwhichcanbedealtwithpermeatalapproach.

Allcaseswentundertheprocedurethroughpostauralapproach.Total14caseshadtearinthetympanomeatalflap,duringelevatingtheflap.6Caseshadsmalltearslinearorbuttonholetype,whichdidnotneedanyrepair.Onlygelfoampiecewaskeptoverthetear.8CaseshadlargetearsthatwererepairedbythehelpofTMFgraftcoveringtheperforationaswellasthetearbelowthetympanomeatalflap,Thetornflapwasapproximatedoverthegraftandgelfoamwaskeptoveritsoastostabilizeit.ONECasehadaverythintympanomeatalflapwhereelevationwasdifficultandnearly

hadtotaltearintheflap.ThiswascorrectedbylargeTMFcoveringthebareareaofthebonetotallyintheEAC.Results:6caseswithsmalllinearandbuttonholetearhealedwithoutanyrepair.7caseswithlargetearhealedwithdelayedprocess,outofwhich1casehadposteriorperforationinlongtermfollowup.1casewithnearlytotaltearhealedcompletelywiththeTMFgraft,ittooksomemoretimetohealascomparedtotheabovecases.Failureratewas7.2%outof14tears.Technique–usedwasUnderlay

PostauricularincisionHarvestgraftPerforationedgesElevationoftympanomeatalflapAnnulusGelfoamGraftplacementunderlay

POSTAURICULRINCISION

HARVESTINGTHETMFGRAFT

LINEARTEARINTHETMFLAP

FRESHNINGTHEMARGINS

LINEARTEARINTMFLAP

BUTTONHOLETEARINTHETMFLAP

TEARINTHEANNULUS

TEARINTHEANNULUS

GRAFTPLACEDINTHEUNDERLAYTECHNIQUE

UNDERLAYGRAFTINGCOVERINGTHETMDEFECTANDTHEDEFECTINTMFLAP

DISCUSSION:Elevationoftympanomeatalflap(T-flap)isanimportantstepinunderlaytympanoplasty.RaisingtheT-flapisthestateoftheartknowledge.ThegoalofelevationT-flapistoexposetheMEwithelevationTMandmobilisetheskinfromthegroovewithoutdamagingitsothatMEcanbeextraordinarilyexposedConceptofunderlaytympanoplastyafterelevationofT-flapwassetforthbySheaandFabbin1960.Innovationofusing

tympanomeatalflapintympanoplastybyMauriceSourdillegaveanewturntotympanoplasticprocedure.TearsinT-flapcanoccurwhileelevatingtheflapatdifferentsites:1.Obliquetympanomastoidsutureline2.Elevationattheofannuluswherethetearisverycommoninexperiencedhands.3.TearcanoccurwhiledrillingwithcuttingburrsinthecanalTearsinthetympanomeatalflapmayoccurinfollowingways:1.Alinearorbuttonperforationmayoccurintheskinflap2.Theskinflapmayseparatefromthetympanicannulus.ThisusuallyoccursininferiorlocationandisduetofailuretoelevatethetympanicannulusfromitssulcusTearsintheTM-flaporTMthatoccursduringelevationoftheflapanddrumshouldberepairedatthecompletionoftheprocedure.RepairofthetearsintheT-flapissimplebutmeticulous.

Linearandbuttonholetearsneednorepair,caremustbetakentoavoidunfoldingthemarginsoftearswhilereplacingtheflap.Smallertearneartheannulusrequirenorepairifitisapproximatedproperlywhilereplacingtheflap.TearsintheTM-flapcanberepairedbydifferentmaterialslikefat,vein,perichondriumandTMFgraft.Itdependsuponwhichmaterialisreadilyavailableforrepair.Duringstapedectomyfatandperchondriumareusedverycommonly.DuringtympanoplastyTMFgraftisusedverycommonlyasitsaccessisatthesameincisionalsite.TodayTMFhasbecomeverycommonintherepairoftearinTM-flapduringtympanoplasticprocedure.IthasbeenshownbyexperiencethatTM-flaptearcanbeavoidedbynevertakingtheknifeofthebonesurface.Ifonealwayskeepstheknifeonthebonesurfaceonecandeveloptheseparation/elevationonarelativelybroadfront.Secondlyneverallowsofttissuebeneaththeknife.Withthese

precautionsonecannotperforatetheT-flapCONCLUSIONWeconcludethattearsintheT-flaparenothazardousevents,theyshouldbehandledcarefullywithpatienceandrepairedbyapropertechniqueattheendoftheprocedure.Differentmaterialslikefat,vein,perichondriumandTMFgraftscanbeusedinrepairprocessThestudywasaimedtogivemessage,mainlytothelearnersandinexperiencedotologicalsurgeons:Atorntympanomeatalflapdoesnotneedabondoningtheprocedure,itcanberepairedbyapproximationorwiththehelpoftemporalisfasciagraft

placementoverthebareareaofthebonycanal.