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.

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.

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.

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.