Tympanoplasty is a surgical procedure to repair the eardrum and the ossicles in the middle ear. It is often performed to treat chronic middle ear infections, a perforated eardrum, or following the removal of a cholesteatoma. The goal of the procedure is to improve hearing and restore sound transmission.
Depending on the extent of the damage, different types of tympanoplasty according to Wullstein are used. This may involve reconstructing the eardrum or restoring the incus, stapes, or the entire ossicular chain. The surgery is usually performed under general anesthesia using an operating microscope. Modern middle ear surgeries often yield very good functional results.
When is tympanoplasty necessary?
A non-healing perforation of the eardrum and damaged ossicles result in impaired sound transmission. In addition, recurrent middle ear infections may occur.
The ossicles consist of
- the malleus,
- an incus, and
- stapes.
These are the smallest bones in the human body. Together, they form what is known as the ossicular chain.
Recurrent inflammation can cause permanent damage to the ossicles or even destroy them completely. In addition, a cholesteatoma—a specific type of chronic middle ear infection—can lead to significant complications.
To resolve these problems, surgical repair of the eardrum defect is required. During this procedure, the ossicular chain is reconstructed. This procedure is called tympanoplasty.
Medical professionals distinguish between various forms of tympanoplasty. These range from simple eardrum repair to complete replacement of the ossicles. Today, Type I and Type III tympanoplasty are among the most commonly used surgical techniques.
Preliminary Examinations Before Tympanoplasty
During the diagnostic consultation, the ENT specialist asks the patient about
- their symptoms,
- their medical history, and
- whether there are any underlying medical conditions.
This allows the doctor to gain initial insight into the causes of the condition and assess the severity of the symptoms. This is followed by a preliminary hearing test using a tuning fork.
The affected ear is usually examined using a microscope. This allows the doctor to assess the size and location of the defect and rule out any current inflammation. Next, a hearing test is performed to assess the degree of hearing loss.
A computed tomography (CT) scan may be performed to determine the extent of the condition, for example, in cases of
- suspected cholesteatoma or
- inflammation of the mastoid bone (mastoiditis).
Procedure for Tympanoplasty
Tympanoplasty can be performed under local or general anesthesia. The doctor should take the patient’s preferences and pain tolerance into account when making this decision. If local anesthesia is used, the patient must be able to lie still for an extended period during the procedure.
The incision for access can be made
- in the ear canal,
- in front of the ear, or
- behind the auricle
. The decision depends primarily on the patient’s anatomical characteristics and the location of the eardrum defect.
After the incision, the skin of the ear canal is peeled back from the bone toward the eardrum until the edge of the eardrum becomes visible. The surgeon then detaches this edge from the bone and folds the eardrum upward. The edges of the tympanic membrane defect are trimmed to avoid removing vital tissue and to improve the healing process.
Closure of the Tympanic Membrane Defect
The surgeon can choose from various autologous tissues to close the defect. The following are available:
- connective tissue from muscle (fascia),
- perichondrium, and
- cartilage.
The surgeon harvests the tissue from the exposed surgical site without making any additional incisions. For very small defects and a tympanic membrane with adequate blood supply, adipose tissue can also be used.
Replacement of Damaged Ossicles
The surgeon can either reconstruct the existing ossicles or implant prostheses (usually made of titanium). To close the eardrum, the surgeon places the graft behind the eardrum (underlay technique). It usually adheres to the back of the eardrum on its own through adhesive forces.
At the end of the surgery, silicone sheets are inserted into the ear canal and applied to the skin of the ear canal. The ear canal is then packed with a tamponade (cellulose or gel). The tamponade presses the skin of the ear canal against the bony ear canal, thereby promoting healing. The surgery is concluded with skin sutures and a wound dressing.
Postoperative Care Following Tympanoplasty
In addition to regular wound checks, a hearing test should be performed after surgery to assess hearing function.
The skin sutures are removed after 8 to 10 days.
The external auditory canal tamponade and the silicone sheets can be left in place, depending on
- the material used for the tamponade,
- the surgery, and
- the surgeon’s assessment
between the 5th and 21st day after surgery.
Complications and Risks of Tympanoplasty
Complications and risks of tympanoplasty include
- graft rejection,
- recurrence of symptoms,
- inflammation,
- severe scarring,
- pain,
- dizziness,
- taste disturbances, and
- hearing loss, up to and including complete deafness.
In addition, hearing improvement may be limited. Facial nerve paralysis is a very rare complication.
Conclusion on Tympanoplasty
Tympanoplasty is a safe method for closing a perforation in the eardrum and reconstructing the ossicular chain. When performed by an experienced surgeon, the risks of complications from the procedure are very manageable. Complications occur only in very rare cases.
FAQ
What is tympanoplasty?
Tympanoplasty is a middle ear surgery performed to reconstruct the eardrum and the ossicles. The goal of the surgery is to close a hole in the eardrum, improve sound transmission, and restore hearing. Depending on the extent of the damage, different types of tympanoplasty are used.
What types of tympanoplasty are there?
The classification is based on Wullstein’s typology. There are Type I tympanoplasty (myringoplasty), Type II tympanoplasty, Type III tympanoplasty, and Type IV tympanoplasty. While Type I involves only the reconstruction of the eardrum, higher types also include the reconstruction of the ossicles—such as the malleus and stapes—or the use of a prosthesis, specifically a titanium prosthesis (PORP or TORP).
When is tympanoplasty performed?
Tympanoplasty is performed in cases of chronic middle ear infection, a perforated eardrum, or following the removal of a cholesteatoma. Other indications include hearing loss, osteomyelitis, or defects in the ossicular chain. The ENT specialist determines the appropriate surgical method based on the examination and imaging results.
How is the surgery performed?
The surgery is usually performed under general anesthesia. An incision is often made behind the auricle or through the external auditory canal. Autologous material, such as cartilage or perichondrium, is used to reconstruct the eardrum. After the procedure is complete, the ear is packed with a tamponade, which is later removed.
What are the risks and chances of success associated with tympanoplasty?
Like any surgery, tympanoplasty can be associated with complications. Possible complications include infections, recurrent eardrum perforations, or a decline in hearing. In most cases, however, the procedure improves sound transmission and restores hearing. After surgery, air travel and significant changes in air pressure should be avoided until complete healing has occurred.
