Tympanoplasty Techniques

Tympanoplasty: Introduction & Goals - Drumming Up Repairs

• Definition: Surgical reconstruction of the tympanic membrane (TM) ± ossicular chain.
• Goals:
  • Restore TM integrity (watertight seal).
  • Improve hearing by re-establishing sound conduction.
  • Create a dry, safe, self-cleaning middle ear.
• Indications: TM perforations, ossicular discontinuity, chronic otitis media with perforation.
• Basic Classification (Wullstein): Types I-V (details follow).

⭐ The primary aims are to achieve a waterproof seal of the middle ear and to restore or improve hearing function if compromised by the perforation or ossicular damage.

Tympanoplasty: Pre-Op Assessment - Ears to Success

• History: Ear discharge (duration, type), hearing loss, tinnitus, vertigo, prior surgeries, comorbidities.
• Examination:
  • Otomicroscopy/Otoscopy: TM perforation (site, size), middle ear status (dry/wet), ossicular chain integrity.
  • Tuning Fork Tests: Rinne, Weber (assess hearing type).
  • Nasal & PNS exam: Rule out contributing factors.
• Investigations:
  • Pure Tone Audiometry (PTA): Quantify hearing loss, Air-Bone (A-B) gap.
  • X-ray Mastoids/HRCT temporal bone (if cholesteatoma/complications suspected).
  • Ear swab for culture/sensitivity (if active discharge).
• Anaesthesia fitness.

⭐ A dry ear for at least 6 weeks is generally preferred before tympanoplasty to maximize graft success rates and reduce infection risk.

Tympanoplasty: Grafts & Types - Perfect Patchwork

• Common Grafts:
  • Temporalis Fascia (most common)
  • Perichondrium (tragal, conchal)
  • Cartilage (tragal, conchal)
  • Vein grafts
  • Fat (small perforations)
• Wullstein Classification (Types):
  • Type I (Myringoplasty): Repair of TM perforation. Ossicles intact & mobile.
  • Type II: TM defect + malleus erosion. Graft to incus or malleus remnant.
  • Type III: Malleus & incus eroded. Graft to stapes head (columella effect).
  • Type IV: Ossicular chain destroyed (except stapes footplate). Graft to mobile footplate, shields round window.
  • Type V: Stapes fixed. Fenestration of horizontal SCC (historical).

⭐ Temporalis fascia is the most popular graft material due to its low metabolic rate, good vascularity, and structural similarity to the tympanic membrane.

Tympanoplasty: Surgical Techniques - Ear's Inner Workings

• Surgical Approaches: Chosen by perforation (site/size) & EAC anatomy.
  • Transcanal: Direct speculum view; for small, uncomplicated posterior perforations.
  • Endaural: Incisions within meatus (e.g., Lempert's); for anterior perforations, minor canalplasty.
  • Postauricular (Wilde's): Incision behind ear; widest exposure for all perforations, revisions, mastoidectomy.
• Graft Placement Techniques:
  • Overlay (Lateral): Graft lateral to de-epithelialized annulus/TM remnant. Risk: blunting, lateralization, delayed healing.
  • Underlay (Medial): Graft medial to annulus & TM remnant/malleus. Preferred; better vascularity, lower complication risk.

    ⭐ Underlay technique preferred: success >90%, less blunting/lateralization.

Tympanoplasty: Post-Op & Complications - Healing Harmonies

• Post-Op Care:
  • Ear canal pack; keep dry.
  • Systemic antibiotics, analgesics.
  • Avoid: straining, nose blowing, water entry, air travel.
  • Pack removal: 1-3 weeks.
• Healing & Follow-up:
  • Graft status check: pink, intact.
  • Audiometry: 6-8 weeks post-op to assess hearing gain.
• Complications:
  • Early: Infection, hematoma, graft displacement, pain, dizziness.
  • Late: Graft failure, reperforation, cholesteatoma, persistent conductive/sensorineural hearing loss.
  • Rare: Facial nerve injury, taste disturbance (chorda tympani).

⭐ Graft failure is the most common complication following tympanoplasty, often due to infection or poor eustachian tube function.

High‑Yield Points - ⚡ Biggest Takeaways

• Wullstein classification (Types I-V) guides tympanoplasty approach.
• Temporalis fascia is the most common autologous graft.
• Underlay technique: Medial placement, good for anterior perforations, better vascularity.
• Overlay technique: Lateral placement, risks anterior blunting & graft lateralization.
• Cartilage grafts offer stability in atelectatic ears & revisions.
• Ossiculoplasty (PORP/TORP) may be combined for hearing restoration.
• Pre-requisites: Dry ear, good Eustachian tube function.