The invention of microsurgical repair of chronic tympanic membrane perforation was one of the great contributions of 20th century otology. With success rates in experienced hands well over 90%, it is also among the most successful of all ear surgeries. As autologous material is readily available (e.g., temporalis fascia, tragal perichondrium), there is little rationale to employ artificial graft material. The recent trend has shown an increasing use of autologous cartilage (e.g., tragal, conchal) both to prepare for ossiculoplasty and because the resulting neomembrane better resists reperforation. Small islands of myringosclerosis may be left in place, but larger areas of calcification are best removed as they may impair vibration of the drum. As a general rule, perforations posterior to the malleus can be handled transcanal, whereas those anterior to the malleus are best approached postauricularly for the superior visualization of the anterior tympanum it affords. Anteriorly situated perforations which extend to the annulus require special techniques lest perforation persist.
While some surgeons routinely rim the margin of the perforation, others (including the author) never do as graft take results are equivalent without rimming. Scratching the mucosa on the medial side of the tympanic membrane remnant is routine to expose subepithelial tissue and to stimulate bleeding which both helps graft adhesion and provides the initial substrates for healing. Today, most surgeons use the technique of placing the graft medial to the tympanic membrane remnant. The lateral graft technique has more complications such as epithelial pearl formation, anterior blunting, and lateralization. The push through or butterfly technique is gaining in popularity, especially for smaller perforations. In the coming years, autologous growth factors may well allow a biologically based, nonsurgical approach to healing tympanic membrane perforations.
Alain H, Esmat NH, Ohad H, Yona V, Nageris BI. Butterfly myringoplasty for total, subtotal, and annular perforations. Laryngoscope 2016;126(11):2565–2568 PubMed
Anzola JF, Nogueira JF. Endoscopic techniques in tympanoplasty. Otolaryngol Clin North Am 2016;49(5):1253–1264 PubMed
Hardman J, Muzaffar J, Nankivell P, Coulson C. Tympanoplasty for chronic tympanic membrane perforation in children: systematic review and meta-analysis. Otol Neurotol 2015;36(5):796–804 PubMed
Hsu YC, Kuo CL, Huang TC. A retrospective comparative study of endoscopic and microscopic tympanoplasty. J Otolaryngol Head Neck Surg 2018;47(1):44 PubMed
Jalali MM, Motasaddi M, Kouhi A, Dabiri S, Soleimani R. Comparison of cartilage with temporalis fascia tympanoplasty: a meta-analysis of comparative studies. Laryngoscope 2017;127(9):2139–2148 PubMed
Jumaily M, Franco J, Gallogly JA, et al. Butterfly cartilage tympanoplasty outcomes: a single-institution experience and literature review. Am J Otolaryngol 2018;39(4):396–400 PubMed
Luukkainen V, Kivekäs I, Silvola J, Jero J, Sinkkonen ST. Balloon eustachian tuboplasty: systematic review of long-term outcomes and proposed indications. J Int Adv Otol 2018;14(1):112–126 PubMed
Mudry A. History of myringoplasty and tympanoplasty type I. Otolaryngol Head Neck Surg 2008;139(5):613–614 PubMed
Neudert M, Zahnert T. Tympanoplasty – news and new perspectives. GMS Curr Top Otorhinolaryngol Head Neck Surg 2017;16:Doc07 PubMed
Randrup TS, Ovesen T. Balloon eustachian tuboplasty: a systematic review. Otolaryngol Head Neck Surg 2015;152(3):383–392 PubMed
Silvola J, Kivekäs I, Poe DS. Balloon dilation of the cartilaginous portion of the eustachian tube. Otolaryngol Head Neck Surg 2014;151(1):125–130 PubMed
Visvanathan V, Vallamkondu V, Bhimrao SK. Achieving a successful closure of an anterior tympanic membrane perforation: evidence-based systematic review. Otolaryngol Head Neck Surg 2018;158(6):1011–1015 PubMed
Yang T, Wu X, Peng X, Zhang Y, Xie S, Sun H. Comparison of cartilage graft and fascia in type 1 tympanoplasty: systematic review and meta-analysis. Acta Otolaryngol 2016;136(11):1085–1090 PubMed
5.2 Tympanic Membrane Perforations
Fig. 5.1 Pars tensa and pars flaccida of the tympanic membrane. The pars tensa has three layers: lateral stratified squamous epithelium, central fibrous layer, and medial low cuboidal mucosal epithelium. The pars flaccida is deficient in its fibrous layer.
Fig. 5.2 Relationship of the tympanic membrane to the tympanic ring and ossicles.
Fig. 5.3 Quadrants of the tympanic membrane.
Fig. 5.4 The vascular strip in the posterior-superior ear canal provides blood supply to the central portion of the tympanic membrane.
Fig. 5.5 Anterior tympanic membrane perforation with a remaining rim. Note the Eustachian tube orifice in the depth.
Fig. 5.6 Anterior tympanic membrane perforation without a remaining rim. This type of perforation has a higher reperforation rate unless specialized techniques are used.
Fig. 5.7 Posttympanostomy tube residual perforation. Often such residual small anterior perforations have little effect on hearing and provide ventilation in the face of Eustachian tube dysfunction.
Fig. 5.8 Posterior central tympanic membrane perforation. Perforations such as this one, which lie posterior to the malleus, can be addressed with a transcanal approach to tympanoplasty.
Fig. 5.9 Posterior marginal tympanic membrane perforation. The location over the round window leads to a greater conductive hearing loss due to phase cancellation.
Fig. 5.10 Typical “kidney bean shaped” central tympanic membrane perforation.
Fig. 5.11 Near-total tympanic membrane perforation with a small remaining rim at the annulus.
Fig. 5.12 Total tympanic membrane perforation.
5.3 Fascia Harvesting
Fig. 5.13 Harvesting fascia for tympanoplasty. An incision is made above the linea temporalis leaving about 1 cm of intact fascia to facilitate closure of the postauricular incision.
Fig. 5.14 Elevating the fascia off of the underlying temporalis muscle. Getting in the proper plane minimizes bleeding and obtains a cleaner piece of fascia.
Fig. 5.15 The superior incision is made easier by curved scissors such as Fomon upper lateral cartilage scissors.
Fig. 5.16 Extra tissue on the fascia can be trimmed on a Teflon block where the fascia is cut to the desired shape.
5.4 Tragal Cartilage Harvesting
Fig. 5.17 In cartilage and/or perichondrium harvesting, the incision is hidden on the canal side of the tragus.
Fig. 5.18 Scissor dissection establishes the plane.
Fig. 5.19 Dissection is carried down the posterior surface of the tragus.
Fig. 5.20 Incision is made through the ipsilateral perichondrium and partial thickness into the cartilage.
Fig. 5.21 Scissors complete the cartilage incision and establish the plane on the anterior surface.
Fig. 5.22 Cuts are made superiorly and inferiorly.
Fig. 5.23 Pulling laterally with Brown-Adson forceps while making the medial cut. Handling cartilage with standard toothed Adson forceps should be avoided, as they tend to lacerate the cartilage.
Fig. 5.24 Dissection of perichondrium from the cartilage with a stapes knife.
Fig. 5.25 Perichondrial graft is separated.
Fig. 5.26 Cartilage disc is shaped for use in tympanic membrane reconstruction, to overlie an ossicular prosthesis, and/or to repair an epitympanic defect. Note the beveling of the cartilage on the surface facing the tympanic membrane.
Fig. 5.27 If only perichondrium is needed, the cartilage can be replaced.
Fig. 5.28 The wound is closed loosely with two absorbable sutures.
5.5 Medial Graft Tympanoplasty
Fig. 5.29 Typical central tympanic membrane perforation. Most microsurgical tympanic membrane perforations are managed via medial grafting.
Fig. 5.30 Many surgeons rim the perforation by removing the squamous margin under the theory that an intact margin may inhibit graft healing. Others believe this step is unnecessary. The author stopped doing this maneuver decades ago with equivalent results.
Fig. 5.31 A classical technique of rimming is to create a “pie crust” edge with a needle and then stripping the rimming with a hook or cup forceps.