Tympanoplasty: Its Overview,Indication,Process & Complications

Overview

Tympanoplasty is an eardrum repair surgery. The term ‘tympanic’ refers to the eardrum and ‘plasty’ means to repair.

Tympanoplasty is a surgical procedure to repair eardrum.

Tympanoplasty can be performed by an ENT (Ear, Nose, Throat) specialist.

Typically, the eardrum and the tiny bones of the middle ear can rupture due to ear infections or external injury. Damage to eardrum can occur due to water pressure or trauma on head or near ear.

Perforation of this membrane is often self healing but sometimes tympanoplasty may be required.

Holes in eardrum or failure of healing can lead to different degree of hearing loss and increased risk of otitis media i.e. inflammation of middle ear and cholesteatoma in middle ear i.e. cyst formation.

Tympanoplasty is an outpatient procedure requiring only a couple of hours and often no hospitalisation after the procedure is needed, it is still opted for only when other alternatives are not feasible.

The bones together with the eardrums are responsible for the function of hearing and a defect in any of these can lead to loss of hearing.

What is Tympanic Membrane?

Tympanic membrane also known as eardrum is a thin layer of tissue in ear. This membrane is shaped as a flattened cone with tip pointed inward.

It is well supplied with blood vessels and sensory nerves which makes it extremely sensitive to pain.

This membrane receives sound vibration from outer environment and transfer it to the auditory ossicles.

Auditory ossicles are small bones present in middle ear, named as incus, malleus and stapes.

Indications

Tympanoplasty is suggested only under these specific circumstances –

1. The perforation of the tympanic membrane is more than 20% of its total size.

2. The patient suffers from antibiotically incurable chronic infections of the ear.

3. High ear trauma due to piercing by a sharp object in the ear, loud explosive noises, head injury etc.

4. Poor blood supply to the middle ear causing eardrum hole.

5. Malfunctioning of the middle ear bones.

 

Process

Depending on the size and location of perforation, mainly three types of surgeries can be performed. These are:

  • Myringoplasty: This is used when the hole or tear is small. Perforation is patched with gel or paper like tissue. This is a simple procedure and can be performed in a doctor’s clinic using local anesthesia. It takes only 15 to 30 minutes.

  • Ossiculoplasty: This is performed when the auditory ossicles are damaged due to ear infection or trauma. This surgery is performed under general anesthesia. The damaged bone is replaced by bones from a donor or by prosthetic (artificial) device.

  • Tympanoplasty: This is used when the hole in eardrum is large or if there is chronic infection which cannot be cured by antibiotics. This surgery is performed under general anesthesia.

In this surgery first of all laser is used to remove any excess tissue or scar tissue from the middle ear. And tissue from a vein or muscle sheath is used to close the hole in eardrum.

Every procedure that lifts the tympanic membrane from its original position in the ear canal is included in tympanoplasty, thereby classifying it into 5 different types altogether.

  1. Type I: Type I tympanoplasty singularly repairs the eardrum while the middle ear is left untouched. It is the only type of tympanoplasty wherein just the tympanic membrane is handled and the ossicles are left untouched.

  2. Type II: In type II tympanoplasty, the eardrum, as well as the middle ear, is repaired because of the slight defects of the ossicles.

  3. Type III: Type III tympanoplasty is considered when there are major defects in the malleus and incus. In type III tympanoplasty, the ossicles of the malleolus and incus are removed and the tympanic membrane is connected directly to the stapes bone.

  4. Type IV: In type IV tympanoplasty, the movable footplate of the stapes is repaired. Post this procedure, the patient’s middle ear is formed only of the eustachian tube and the hypotympanum.

  5. Type V: Type V tympanoplasty includes work on the fixed footplate of the stapes. It is a rare case and this procedure is carried out only when the problem is very deep-rooted in the ear.

 

Irrespective of the type of tympanoplasty, the patient is administered general anaesthesia before the surgery.

The surgeon makes use of a laser and/or microscope to operate on the ear and a part of the patient’s skin is used as a graft to seal the eardrum perforations.

Graft consist of cartilage, fat or fascia.

There are two different approaches to tympanoplasty, depending on which part of the ear is used to gain access to the tympanic membrane.

  1. The first approach is the transcanal approach, wherein the entire procedure is carried out solely through the ear canal.

    To get the skin for the tympanic membrane grafting, just a small incision is made behind the ear.

    Since there is an extremely limited view of the anterior part of the tympanic membrane, this approach is only used when the perforations are comparatively smaller and are placed at the posterior part of the tympanic membrane.

  2. The other is the post-auricular approach where a curved incision is made at the auricle (crease behind the ear).

    This approach is used very often in tympanoplasty as it awards the surgeon with a brilliant view of the entire eardrum.

    Depending on the reason for tympanoplasty and its type, the surgeon decides to use either the underlay or the overlay technique to seal the eardrum perforations.

    These refer to the way in which the surgeon places the graft on the tears of the tympanic membrane.

 

After Surgery:

After the surgery, ear is packed with cotton ball which should not be removed for 5 to 7 days after surgery.

For weeks after surgery, patient may feel pain, popping and clicking sound, heaviness in ears etc. these problems will gradually fade and disappear.

Patient is instructed to take following precautions:

  • Ear drops are given to apply daily by slowly removing the packing and replacing it back after putting the ear drop. Patient is strictly instructed not to put anything else in ear.

  • Water should not enter in ear so, patient should avoid swimming and should wear a shower cap while bathing.

  • Pressure should not be applied on eardrums. To avoid pressure, patient should not blow nose and should sneeze with mouth open.

  • Patient should avoid going in crowded place to remain protected from any infection.

 

Complications

Though rare, a few of the involved risks include:

  • Narrowing of the ear canal: Temporary narrowing off ear canal is seen due to the swelling in ear after the surgery. It usually gets normal in a few days after surgery

  • Facial Nerve Paralysis: A nerve is runs through the middle ear and mastoid bone. Swelling or bruising of facial nerve can cause temporary paralysis.

  • Perforation: Inability of the graft to heal causing a relapse in tympanic membrane perforations. Tympanoplasty is a surgery to close the eardrum hole but sometimes it may not heal properly and new perforations may appear.

  • Taste Disturbance: The nerve responsible for taste runs through middle ear and it need to be push aside or cut while performing the surgery. Hence, there is temporary numbness of tongue or taste disturbance is possible. It usually lasts for a few months after surgery.

  • Hearing loss: Although patients experience improved hearing after the surgery but in rare cases it might get worse.

  • Worsening of Tinnitus: The echo-type noises in the ear.

  • Cholesteatoma: Abnormal growth of non cancerous skin in middle ear behind the eardrum.

 

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