What is Tympanoplasty?
Tympanoplasty, myringoplasty, ossiculoplasty, mastoidectomy
These words are sometimes used loosely and are interchangeably by doctors, which can add to a degree of confusion. A myringoplasty means a repair or refashioning of the eardrum, an ossuculoplasty involves removal of replacement or refashioning of the three little bones of the ear and a mastoidectomy implies drilling away the bones over the mastoid air cells to improve aeration or remove cholesteatoma. A tympanoplasty can mean combining one or more of the above previously mentioned operations. The purpose of a tympanomplasty/mastoid operation is first and foremost to remove disease from the mastoid air cells; this is usually cholesteatoma or other infective material. The first aim of the operation therefore is to render the ear “safe”.
Unfortunately the price to be paid for making the ear “safe” may be either the creation of a mastoid cavity which requires long term care or become infected or indeed a reduction in the level of hearing. For this reason over the years many methods have been sort to try and get the best of both worlds, i.e. a safe ear and a dry ear, which hears normally. This is not always achievable and depends entirely on the original anatomy and also on the skill and training of the individual surgeon. There is debate within the medical profession as to the optimum treatment for various conditions affecting the ear and you would be advised to read some of the following links and to discuss cases with a surgeon with an interest in ear disease.
Eardrum repair is a procedure to correct a tear in the eardrum (tympanic membrane) or the small bones in the middle ear. Ruptured or perforated eardrums are usually caused by middle ear infections or trauma, such as an object in the ear, a slap on the ear, or an explosion. Tympanoplasty is a microsurgical procedure that uses a patient’s own tissues (autologous grafts), to reconstruct the tympanic membrane. Grafts may be taken from different areas, including (in order of most frequent use) loose connective tissue, temporalis fascia, tragal perichondrum, and the periosteum (COULD YOU DESCRIBE EACH OF THESE IN A WORD OR 2?). Veins are rarely used as they weaken over time. Alloderm grafts (from synthetic materials) may be used if patients have had multiple previous surgeries and have limited graft availability. Results are about equal as those with autologous tissue. Homografts (tissue taken from other humans) or xenografts (from animals) are sometimes available, but in general they are less successful and less frequently used.
Effects of Tympanoplasty
Results of tympanoplasty with ossicular reconstruction vary with the degree of prior damage to the bones of hearing. With an intact, normally mobile chain of ear bones, the restored hearing is generally very good once the hole is closed. Erosion of the incus is usually the msot common bony problem and the easiest ossicular problem to repair. Good hearing results are obtained in a high percentage of operations.
Candidates for Tympanoplasty
If antibiotics or other nonoperative treatment do not heal chronic ear infections, surgical eardrum repair may be necessary.
Chronic middle ear infections are described as:
- Seven or more ear infections in a year
- Five or more ear infections per year for 2 years
Signs of chronic ear infections include persistent ear pain, ear drainage, or hearing loss(over a 3-month period). period).
Tympanoplasty surgery has been refined to the point of offering the possibility of an intact eardrum and improved hearing in most individuals with perforations and hearing loss. Prolonged medical treatment and the clearing of sinus, nasal and allergy problems are necessary prior to recommending ear surgery.
In a few individuals, other medical problems such as poorly controlled diabetes or heart disease may exclude them as tympanoplasty candidates. However, a great majority of individuals with perforations and hearing loss find improvement with microsurgical tympanoplasty
The Tympanoplasty Procedure
Using general anesthesia, an ear/nose/throat (ENT) specialist grafts a small patch from a vein or fascia (muscly sheath) onto the eardrum to repair the tear.
For problems with the small bones (ossicles), the surgeon will use an operating microscope to view and repair this chain of small bones using plastic devices or ossicles from a donor.
The patient is usually placed under general anesthesia, although it may also be done under local anesthesia. The surgeon reconstructs the membrane either through the ear canal alone, or through the ear canal and through an incision behind the ear. The surgeon may use a laser to carefully remove any scarring in the middle ear. If the ossicles (small bones in the inner ear) have been damaged, the surgeon may also repair these, using either donor bones or prosthetic devices (ossiculoplasty).
Surgery to reconstruct the tympanic membrane (eardrum) can be performed either under local or general anesthesia. Many patients prefer to be completely asleep. In small perforations, the operation can be easily performed under local anesthesia with intravenous sedation. An incision is made into the ear canal and the remaining eardrum is elevated away from the bony ear canal and lifted forward.
The operating microscope helps to enlarge the view of the ear structures, giving a more detailed image to the ear surgeon. If the perforation is very large or the hole is far forward and away from the view of the surgeon, it may be necessary to perform an incision behind the ear. This elevates the entire outer ear forward, gaining access to the perforation. Once the hole is exposed fully, the perforated remnant is rotated forward, and the bones of hearing are inspected. There may be scar tissue and bands surrounding the bones of hearing. These can be removed either with micro hooks or laser.
Having identified the bones of hearing, the ossicular chain is pressed to determine if the chain is mobile and functioning. If the chain is mobile, then the remaining surgery concentrates on repairing the drum defect.
Tissue is taken either from the back of the ear or from the small cartilaginous lobe of skin in front the ear called the tragus. The tissues are thinned and dried. An absorbable gelatin sponge is placed under the drum to allow for support of the graft. The graft is then inserted underneath the remaining drum remnant and the drum remnant is folded back onto the perforation to provide closure.
Very thin silastic sheeting is generally placed against the top of the graft to prevent it from sliding out of the ear, when the patient blows his nose or sneezes. A small amount of Gelfoam is also placed on the outside of the silastic to hold it into position in a so-called sandwich type layer (drawing).
If opened from behind, the ear is then stitched together. Usually, the stitches are buried in the skin and do not have to be removed later. A sterile patch is placed on the outside of the ear canal and the patient returns to the recovery room. Generally, the patient can return home within two to three hours. Antibiotics are given along with a mild pain reliever such as Tylenol or Tylenol with Codeine.
After about ten days, the packing is removed and a good evaluation can then be obtained as to whether the graft was successful. Water is kept away from the ear and blowing of the nose is discouraged. If there are allegies or a cold, further antibiotics and decongestant should be given. Most individuals can return to work after five or six days unless they perform heavy physical labor, in which case the patient can return after two or three weeks.
After three weeks, all packing is completely removed under the operating microscope in the office. It can then be determined whether the graft has fully taken. In over 90 percent of cases, the tympanoplasty procedure is successful and a hearing test is performed at four to six weeks after the operation.
Patients usually leave the hospital the same day as the surgery. It is important to avoid water in the ear. Your health care provider may recommend the use of a hair cap when showering for a few weeks after the procedure.
After surgery, patients may often leave the hospital the same day. They must keep the operated ear dry while bathing for two to three weeks, as directed. Any hearing loss or tinnitus usually resolves in a few days. Occasionally patients may lose the sense of taste on the operated side of the tongue; this also resolves within weeks.
In most cases, the operation relieves pain and infection symptoms completely. Hearing loss is minor. The operation can have a less optimistic outcome if the bones in the middle ear need reconstruction along with the eardrum.
Eardrum Repair: Risks
Risks for any anesthesia are:
- Reactions to medications
- Problems breathing
Risks for any surgery are:
Additional risks include:
- Incomplete healing of the hole in the eardrum
- Damage to the small bones in the middle ear, causing hearing loss
- Need for further surgery
Tympanoplasty is usually a highly successful procedure, with over 90% of patients recovering without any complications. In the hands of Columbia’s highly trained surgeons, over 94% of patients’ grafts take successfully. If subsequent operations are required, these also are highly successful. Bleeding and infection are very small risks, as are chances of incomplete healing of the eardrum. Development of cholesteatoma is another very small risk and requires special treatment if it occurs. If the ossicles have been damaged by injury or disease, hearing loss may be sustained despite surgery. Approximately 2 to 4 patients out of 1000 will experience sustained hearing loss after tympanoplasty, according to research. As with any surgery, the risks of anesthesia, such as reactions to the drugs and breathing difficulties, must be discussed with your physician.