Tympanoplasty

What is Tympanoplasty?

Tympanoplasty is a microsurgical operation aimed at reconstructing the eardrum to fix perforation, sometimes combined with reconstruction of the tiny bones in the middle ear (ossicles) to improve hearing. The eardrum vibrates in response to sound waves, so repairing it helps restore hearing and prevents recurrent infections by sealing the middle ear from outside contaminants.

Indications for Tympanoplasty

Tympanoplasty is recommended for:

• Chronic perforations of the eardrum that do not heal on their own.

• Prevention of water entry into the middle ear and future infections.

• Repeated middle ear infections (otitis media) causing persistent discharge.

• Tympanic membrane retraction pockets that risk developing cholesteatoma (a destructive growth).

• Cholesteatoma itself, to remove the disease and reconstruct the ear (the tympanoplasty would generally be combined to a mastoidectomy in those cases).

• Ossicular chain damage or discontinuity leading to hearing loss.

• Prevention of complications such as meningitis, facial paralysis, or brain abscess related to chronic ear disease (also generally combined to a mastoidectomy).

Both adults and children with hearing loss or chronic ear problems can be candidates for tympanoplasty, sometimes even before symptoms become severe, to prevent future complications.

Surgical Approaches: Post-Auricular vs. Trans-Canal

Two main approaches are used to access the eardrum during tympanoplasty:

• Post-Auricular Approach (behind the ear): A skin incision is made behind the ear (hidden behind the ear, follows the curve of the ear), allowing wide view of the ear canal and middle ear. This approach is preferred for large or complex perforations, cases requiring a lot of dissection in the middle ear (very infected or inflamed ear), or when the ear canal is narrow or deformed.

  • Pros: It provides excellent visualization and for more room to work for the surgeon.

  • Cons: Because of the skin incision, the surgery is longer, it is generally performed under general anesthesia, and recovery time is longer. 

Courtesy of the Stanford Otolaryngology Atlas. For more images of the surgical steps, please visit: https://otosurgeryatlas.stanford.edu/otologic-surgery-atlas/tympanoplasty/

• Trans-Canal Approach (through the ear canal): Surgery is performed entirely through the ear canal (through an instrument called a speculum inserted in the ear).  This minimally invasive technique is perfect for patients with a well-formed ear canal and when the entire perforation is visible through the speculum. This is a critical point to consider.

  • Pros: It avoids an external incision, resulting in less pain and faster recovery. The surgery is also quicker and can be done under local anesthesia (or mild sedation), therefore avoid a general anesthesia.

  • Cons: The surgery is entirely performed through the ear canal through a small speculum. 

    This approach provides limited space for the surgeon, making it more technically challenging. It can only be done for well selected cases.

Courtesy of the Stanford Otolaryngology Atlas. For more images of the surgical steps, please visit: https://otosurgeryatlas.stanford.edu/otologic-surgery-atlas/tympanoplasty/

Factors determining the choice of approach include the size and location of the perforation, the anatomy of the ear canal, the need for ossicular reconstruction, surgeon expertise, and patient preference.

Steps of Tympanoplasty

1. Preparation: The ear canal and surrounding area are cleaned and anesthetized.

2. Incision: Depending on the approach, an incision is made either behind the ear or within the ear canal.

3. Harvesting Graft: A graft material, often from the temporalis fascia (a thin fibrous tissue that is harvested from the under the skin, just over the temple area) or cartilage from the tragus (structure just in from the of the ear canal), is taken. See section below for more information on the graft types.

4. Elevation of Tympanomeatal Skin Flap: The eardrum and ear canal skin are gently lifted together to expose the middle ear.

5. Removal of Diseased Tissue: Any infected or abnormal tissue, such as cholesteatoma and inflammation, are removed. The diseased eardrum is also removed (we leave a rim of normal eardrum to help in the healing). We inspect the middle ear and inner structures to make sure other important structures are healthy and functional.

6. Packing of the Middle Ear: Since there are no sutures to hold the graft in place, we use a "sandwich" of packing material to stabilize it. The first layer of that sandwich is the placement of resorbable packing (usually "gelfoam") in the middle ear, just before we place the graft. 
   
   

7. Graft Placement: The graft is carefully positioned over the packing to reconstruct the eardrum and close the perforation, usually under the remaining eardrum and skin flap. The skin flap is then replaced in its natural position, over the new eardrum graft. This will help the skin grow over the graft to make the new eardrum.

8. Ossicular Reconstruction: If needed, damaged middle ear bones are repaired or replaced with prostheses. Read this article here to learn more about this topic.

9. Packing of the Ear Canal: Once the reconstruction is in place, we cover it with a layer of packing (again gelfaom) and antibiotic ointment. This is the outer layer of the sandwich described earlier, ensuring the reconstruction stays secure.
   
   

10. Closure: The skin incision is closed (if the retro-auricular approach is used). A cotton ball is applied to the ear canal, and a bandage is used to cover the ear.

11. Recovery Room: Typanoplasties are same-day surgeries (ambulatory surgery), meaning you will go home the same day after a few hours of observations in the recovery room. 

Graft Materials and Their Selection

Common graft materials include:

• Temporalis Fascia: Most commonly used due to its thinness, flexibility, and good integration with the eardrum. The temporalis fascia is a thin fibrous layer that covers a muscle called "temporalis", which is a chewing muscle that covers the temple (area just over the ear).

• Tragal Cartilage and Perichondrium: Thicker and more rigid. It is preferred in cases with retraction pockets (collapsed eardrum) and eustachian tube dysfunction (learn more about this here) to resist retraction, as well as in cases where the hearing bones need to be reconstructed with a prosthesis (ossicular chain reconstruction). The perichondrium is the fibrous layer that covers the cartilage. This graft can be used alone (without the cartilage) in cases of small perforations.

• Other Materials: Less commonly used but may include vein grafts or synthetic materials.

The choice of the graft depends on:

• Size and location of the perforation.

• Condition of the middle ear and eustachian tube function.

• Presence of retraction or cholesteatoma.

• Surgeon experience and preference.

Risks and Benefits of Tympanoplasty

Benefits:

• The overall success of the surgery and graft is over 90%. This leads to improved hearing by restoring the eardrum and ossicular chain.
  
  
• Restores a water barrier to the ear, therefore allowing swimming and water sports without fear of infection.
  
  

• Prevention of recurrent ear infections and chronic discharge.

• Improved quality of life and reduced need for ongoing medical treatment.

Risks:

• Graft failure leading to persistent perforation (in less than 10% of cases).

• Infection or wound healing problems (rare, around 1%).
  
  

• Hearing loss (very rare, less than 1%).

• It's possible that hearing does not show much improvement after surgery. This occurs in patients who have undergone multiple ear surgeries (revision cases), those with significant damage to their hearing bones, and patients with severe Eustachian tube dysfunction, where fluid accumulates again under the eardrum.

• Taste disturbances due to chorda tympani nerve irritation (this is a nerve that travels in the ear exactly where the surgery is performed!). These disturbances are usually temporary, but can be permanent in 5-10% of individuals.

• Dizziness or tinnitus (ringing in the ears). These disturbances are usually temporary.

• Numbness of parts of the ear auricle. This is only in cases where there was a retro-auricular incision (not the trans-canal approach). The nerves giving sensation to the skin usually grow back and sensation returns, but we can see numbness in less than 5% of individuals.

Overall, success rates for graft take and hearing improvement are high, often exceeding 90%, especially with proper patient selection and surgical technique.

Post-Operative Care and What to Expect at Home

In the first week after tympanoplasty:

Tympanoplasty is not a very painful procedure. Patients can expect mild to moderate ear pain, which is usually manageable with over-the-counter pain medication or prescribed mild narcotics. Dizziness or a feeling of imbalance may occur during the first few days and typically improves gradually. The operated ear may feel blocked or clogged, and some bloody or pink watery drainage is normal as the ear heals. Hearing may be temporarily reduced because of ear packing placed during surgery, which will be removed or dissolve over 1 to 2 weeks. A pulsatile (beating) tinnitus may also be heard. The first follow-up visit is usually 1-2 weeks after the surgery. The external bandages will be removed, and the incision site (if one was made) will be examined. Part of the packing inside the ear will be removed, but not entirely, as the graft still needs to be protected. This cleaning will improve the feeling of pressure in the ear, but hearing will not significantly change at this stage of healing. Antibiotic ear drops are started after the first visit, and the remaining packing in the ear (including the part under the graft) will dissolve over the next 2-3 months.

After tympanoplasty, patients should:

• Keep the ear dry; avoid water exposure during bathing or swimming (usually for 6-8 weeks).

• Avoid nose blowing or heavy lifting (less than 15 lbs) for several weeks to prevent pressure changes (for at least 6-8 weeks).

• Take prescribed antibiotics and pain medications as directed.

• Avoid inserting anything into the ear canal.

• Attend follow-up visits for wound inspection and hearing tests.

• Temporary hearing changes may occur but usually improve as healing progresses.

• Regular activities (swimming, exercising, etc.) can usually be resumed 8 weeks after surgery.

Long-term expectations 

Full healing of the eardrum may take several weeks to months. Expect the hearing to gradually improve over at least 12 weeks. We usually obtain a first post-operative hearing test 4-6 months after surgery. During that time, you may hear the ear "crack" and "pop", indicating that ventilation is gradually coming back. Hearing may go up and down as this happens, do not worry. We obtain final hearing test at the 1-year anniversary of the surgery.