Tympanoplasty: Manal Al Quaimi 207000989 2011

Tympanoplasty
Manal Al Quaimi
207000989
2011
• Definition
• History
• Anatomy
• Etiology
• Types
• Techniques
• Tympanoplasty in children
• Complications
• Conclusion
• References
Myringoplasty Vs. Tympanoplasty
Myringoplasty
- reconstruction of perforated Tympanic Membrane (TM)
 Assumes – normal middle ear (ME) mucosa and ossicles
 TM is not elevated from its sulcus
Tympanoplasty
- reconstruction of the Tympanic Membrane and evaluation
of Middle Ear
o Cholesteatoma, adhesions
o Ossicular chain problems
o Usually involves elevating the TM from its sulcus
Tympanoplasty can be accompanied with or without mastoidectomy

When was the 1st Tympanoplasty !!
1640 – Banzer
+
Anatomy :
TM is oval in shape
8 mm X 10 mm
55 degrees to the floor of the
meatus
3 layers – 130 microns thick
Outer epithelial – keratinizing
squamous
Middle fibrous – superficial radial,
deep circular
Inner – mucosa
Epithelial migratory pattern
Centrifugal growth for the umbo
outward
Consists of three layers:
1. Outer epithelial layer
2. Middle fibrous layer
3. Inner mucosal layer
The drum direction is oblique so that the anterior and

inferior walls of the External Auditory Meatus are
longer than the roof and the posterior walls
7
• Blood supply
– Inner surface
• Ant. Tymp a.
– Outer surface
• Deep
auricular a.
Tympanic membrane perforation :
• Infection is the principal cause of tympanic membrane
perforation (TMP).
• Trauma :
1. Blunt
2. Penetrating
3. Thermal
patients usually complain of hearing loss

Tympanoplasty
Tympanoplasty
- reconstruction of the Tympanic Membrane and evaluation
of Middle Ear
• The surgeon takes a graft from the tissues under the
skin around the ear and uses it to reconstruct the
eardrum.
• One of the most common graft sites is from the tragus.
• It is done under local or general anesthesia.
• It is done on an outpatient basis and is successful 85-

90% of the time.
Indication of surgery :
• Conductive hearing loss due to TM perforation or
ossicular dysfunction.
• Chronic or recurrent otitis media Progressive hearing
loss due to chronic middle ear pathology .
• Perforation or hearing loss persistent > 3 months due to
trauma, infection, or surgery
• Inability to bath or participate in water sports safely
Goals of Surgery :
• Establish an intact TM
• Eradicate middle ear disease and create an air-
containing middle ear space
• Restore hearing by building a secure connection
between the ear drum and the cochlea
Classification of Tympanoplasty :
• Wullstein (1956)
• Type I tympanoplasty ( myringoplasty

)
• TM is grafted to an intact ossicular
chain
• Type II tympanoplasty
• Malleus is partially eroded
• TM +/- malleus remnant is grafted to
the incus
• Type III tympanoplasty
• Malleus and incus are eroded
• TM is grafted to the stapes suprastructure
• Type IV tympanoplasty
• Stapes suprastructure is eroded but foot
plate is mobile
• TM is grafted to a mobile foot plate
• Type V: Used when the footplate the stapes is fixed.

Techniques
- Overlay technique (lateral grafting)
- Underlay technique (medial grafting)

Overlay Technique :
1. Temporal fascia or perichondrial graft is harvested.
2. Endaural or postaural incision
2. Incision is made in the meatus as shown and meatal skin raised along
with all epithelium from the outer surface of tympanic membrane remnant.
3. Graft placed on the outer surface of TM. A slit is made in the graft to tuck
it under the handle of malleus.
4. Meatal skin removed earlier is now replaced, covering the periphery of
the graft. Ear canal packed with gelfoam
and then with a small antibiotic pack.
A modification of the overlay technique is to place
the anterior edge of fascia graft under the annulus after removing the
epithelium. This prevents blunting of anterior canal which is seen as a
complication of overlay technique .
5. Closure of endaural or postaural incision.
Tympanic Membrane grafts:
1. Cartilage
2. Fool’s fascia
(loose areolar fascia over temporalis fascia)
3. Temporalis fascia
• Underlay Technique
• 1. Harvesting the graft of temporalis fascia or perichondrium from
the tragus.
• 2. Preparing the T.M. for grafting. An incision is made along the
edge of perforation and the ring of epithelium removed. Remove
also a strip of mucosal layer from the inner side of perforation.
• 3. Inspecting the middle ear. A stapes-type incision is made and the
tympanomeatal flap raised to see the integrity and mobility of the
ossicular chain and to ensure that no squamous epithelium has
grown into the middle ear.
• 4. Placing the graft. Middle ear is packed with gelfoam soaked with
an antibiotic. A proper sized graft is placed so that its edges extend
under the margins of perforation all round and a small part also
extends over the posterior canal wall. Tympanomeatal flap is
replaced. An underlay technique has the advantage that the
squamous epithelium is not buried in the middle ear.
Cartilage graft :
 Fascia and perichondrium undergo atrophy
 Skin graft: Infection
 Cartilage
More rigid and resist resorption
Good long-term survival
Nourished largely by diffusion
Techniques of cartilage Tympanoplasty
• Techniques of cartilage tympanoplasty
• Four techniques have been described for cartilage tympanoplasty, namely the inlay butterfly graft, Perichondrium/cartilage
island flap, palisade flap, and cartilage shield tympanoplasty. The choice of technique is dictated by surgeon’s preference,
size of the perforation, integrity of the ossicular chain, and the presence of cholesteatoma.
• Inlay butterfly graft
• This technique was originally described for small TM perforation myringoplasty. The tragal cartilage graft is harvested with
intact perichondrium on both sides. Using a beaver blade, a 2 mm circumferential incision can be made on the cartilage to
create a groove with an appearance similar to the wings of a butterfly. After the perforation rim is freshened, the cartilage
graft can then be anchored onto the perforation similar to a tympanostomy tube. A split thickness skin graft can be placed
over the graft if the perforation is large. For perforation greater than 1/3 of TM or close to the annulus, the graft can be
anchored onto the bony annulus, as described by Ghanem et al in 2006.
• Perichondrium/ cartilage island flap
• Tragal cartilage graft is harvested because it is flat, thin (~ 1mm) and abundant. Perichondrium from the side away from the
external auditory canal is removed. A flap of perichondrium is produced posteriorly that will eventually drape over the
posterior canal wall. Next, a complete strip of cartilage 2 mm in width is removed vertically from the center of the cartilage to
accommodate the entire malleus handle. The entire graft is placed in an underlay fashion, with the malleus fitting in the
groove.
• Palisade technique
• Cartilage graft can be harvested from either the tragus or concha cymba. The latter is used when a post-auricular incision is
planned, as in the case of mastoidectomy. For conchal cartilage graft, perichondrium is removed from the post-auricular
side. Cartilage graft is cut into several slices or strips, which are subsequently pieced together medial to the malleus to
reconstruct the TM. This technique is favored when ossicular chain reconstruction is performed because it provides a better
visualization of the prosthesis and precise placement of graft onto the prosthesis. In cases of posterior perforation, the
anterior half of the TM can be left alone to allow postoperative surveillance and future myringotomy tube placement.
• Cartilage shield technique
• A vascular strip incision is made in the ear canal, followed by a post-auricular incision. Areolar tissue overlying temporalis
fascia is harvested. A round piece of conchal cartilage is harvested and perichondrium on both sides is removed. A small
wedge of cartilage is removed to accommodate the handle of the malleus. The graft is then placed medial to the malleus
and the remnants of the TM. The areolar graft is then placed in between the cartilage graft and the remnants of the TM.
The choice of technique is dictated by
surgeon’s preference, size of the
perforation, integrity of the ossicular
chain, and the presence of
cholesteatoma.
• Postoperative Care
- Mastoid dressing removed postoperative day one
- Incisions cleaned bid with H2O2 and topical abx
- Patient instructions
 Avoid nose blowing
 Sneeze with mouth open
 Avoid heavy lifting (>10 lbs) or straining
 Dry ear precautions
- One week ear drops are started
- Three weeks, gelfoam is removed from the External Auditory Canal
- 2-3 months, postoperative audiogram is performed

Complications
• Infection
• Poor aseptic technique
• Prior contamination
• Graft failure is associated with postop infection
• Graft failure
• Infection
• Inadequate packing (anterior mesotympanum)
• Inadequate overlay of graft with TM remnant
(underlay)
• Chondritis
• Injury to the chorda tympani nerve
• SNHL and vertigo
• Excessive manipulation of the ossicles
• Increased conductive hearing loss
• Unrecognized eroded ISJ
• Blunting
• Thick graft extending onto the anterior canal wall in lateral
grafting
• Lateralization of the TM from the malleus handle
• External auditory canal stenosis
• Lateral grafting
Pediatric patients
Considered less successful than adults
Wide range of success rates
35% to 93%
Avoid Tympanoplasty < 3 years

Repair at age 4
If contralateral ear is perforated, perform
adenoidectomy and defer until age 7
Cartilage tympanoplasty in the worst ear
Conclusion
 Hearing results after cartilage tympanoplasty is
comparable to temporalis fascia graft
 Tympanoplasty in the pediatric

age group is controversial
 Both underlay and overlay techniques for grafting are

effective, however, the surgeon should do what he is most
experienced and successful with.
 Choice of techniques depend on surgeon’s preference,

status of ossicular chain, Eutstachian tube, presence of
cholesteatoma, etc.
Refferances
• http://www.pedsent.com
• http://emedicine.medscape.com/article/858684-overview
• http://orl.zclub.fr/
• Grand Rounds Presentation, UTMB, Dept. of Otolaryngology,
January 15, 2003,Christopher Muller, Arun Gadre, M.D.
• Diseases of Ear, Nose and Throat PL Dhingra
• CURRENT Diagnosis and Treatment in Otolaryngology Head
and Neck Surgery Second Edition LANGE CURRENT Series
• Tympanoplasty ,Christopher Muller, M.D.Arun Gadre, M.D.
University of Texas Medical Branch Galveston, TX

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Tympanoplasty

Tympanoplasty can be accompanied with or without mastoidectomy

The drum direction is oblique so that the anterior and

patients usually complain of hearing loss

• One of the most common graft sites is from the tragus.

• It is done under local or general anesthesia.

• It is done on an outpatient basis and is successful 85-

• Type I tympanoplasty ( myringoplasty

• Type V: Used when the footplate the stapes is fixed.

- Underlay technique (medial grafting)

 Skin graft: Infection

- Incisions cleaned bid with H2O2 and topical abx

- Three weeks, gelfoam is removed from the External Auditory Canal

- 2-3 months, postoperative audiogram is performed

Avoid Tympanoplasty < 3 years

 Tympanoplasty in the pediatric

 Both underlay and overlay techniques for grafting are

 Choice of techniques depend on surgeon’s preference,

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