Composite chondroperichondrial clip tympanoplasty

Composite chondroperichondrial clip tympanoplasty, also known as triple-C tympanoplasty or triple-C myringoplasty, is a cartilage-graft surgical technique used to repair tympanic membrane perforations during tympanoplasty or myringoplasty. It uses a composite graft of cartilage and its perichondrium shaped into a "clip" that is seated across the edge of the perforation in a combined overlay–underlay fashion, and is performed through a transcanal (ear canal) approach. The technique was described by the Australian otolaryngologist Sylvester V. Fernandes in 2003.

History

The technique was introduced by Sylvester V. Fernandes, who reported it in a 2003 article in Otolaryngology–Head and Neck Surgery. In that original account, the method was applied to non-marginal perforations and evaluated in a retrospective series of 15 patients operated on by a single surgeon. The approach built on the broader use of cartilage and cartilage–perichondrium grafts in middle ear reconstruction, and has since been adapted by other authors into endoscopic and inlay variants.

Technique

The graft is a composite of cartilage and perichondrium, usually harvested from the tragal cartilage, and is fashioned into a clip. It is introduced through a transcanal approach and seated so that it grips the margins of the perforation in a combined overlay–underlay configuration, without requiring the ear canal skin to be incised or the middle ear to be packed with supporting material.

Cartilage-based grafts are used in tympanic membrane reconstruction because cartilage is generally more resistant to retraction and resorption than temporalis fascia, which has been more traditionally used for myringoplasty.

Variants

Later authors have described modifications of the original technique:

• an endoscopic approach, used for perforations in the anterior quadrant of the tympanic membrane that are difficult to visualise with a microscope; and
• an inlay variant applied to large or marginal perforations.

Outcomes

Reported outcomes for the technique and its variants come mainly from single-centre case series and retrospective studies, and results below are attributed to the individual studies rather than stated as established general findings.

In Fernandes' original 15-patient series, the technique was reported to provide low morbidity and favourable closure of non-marginal perforations in selected patients.

For the endoscopic variant, a 2018 case series of 25 patients with anterior-quadrant perforations reported a graft success rate of 92 per cent (23 of 25) at six months, with a mean follow-up of about 21.5 months and no observed intratympanic cholesteatoma. A later prospective study using an endoscopic clip technique reported complete healing in all patients with small perforations, 18 of 19 with medium perforations, and 11 of 12 with large perforations, together with a statistically significant improvement in the air–bone gap at six months.

For the inlay variant, a retrospective comparison of 183 patients (65 treated with inlay triple-C, 118 with conventional underlay cartilage island tympanoplasty) reported that the triple-C group had a shorter operative time, and the authors concluded that the technique was a viable option across perforation types, including large or marginal perforations.

See also

• Tympanoplasty
• Myringoplasty
• Perforated eardrum
• Cartilage