How to: An Innovative Tympanoplasty—Sleeve and Tongue Technique

by Yichen Wan, MD, Danheng Zhao, MM, and Jianjun Sun, MD, PhD •

INTRODUCTION

Since Wullstein and Zollner first introduced the classical methods of tympanoplasty in the 1950s, numerous alternatives have been explored, many of which have proven even more promising. Methods of tympanic membrane (TM) perforation restoration can be generally categorized into two patterns: the overlay and the underlay, with their respective merits and flaws (Laryngoscope. 1997;107:25–29). Numerous techniques used today are evolved versions of these original approaches, such as LMUT (lateral-to-malleus underlay tympanoplasty), double layer tympanoplasty, loop underlay or overlay technique, butterfly myringoplasty, swing-door tympanoplasty, circumferential sub-annular tympanoplasty, and three-point fix tympanoplasty. All these techniques need to make an incision in the external canal. For patients who merely need perforation repair, our method spares a canal incision, which favors blood supply to the TM and simplifies wound dressing. Besides this advantage, by innovatively combining the “sleeve” canalplasty together with a tongue-shaped fascia covering the perforation in the over-underlay pattern, we have successfully obtained a desirable outcome even for the relatively difficult large and/or anterior perforations.

METHOD

First, a postauricular incision was made to harvest the temporalis fascia graft with a diameter of about 1.0–1.5 cm. A “U”-shaped myoperiosteal flap was created, and its pedicle was connected to the subcutaneous tissue posterior to the external meatus.

Second, approaching the myoperiosteal flap, the external canal skin was separated from the bony canal in an encircled manner and headed forward until it reached the tympanic annulus. It is noteworthy that there were no incisions in the skin of the external auditory canal, and caution was taken to reduce tension during the procedure to form a complete “sleeve” of the skin of the external auditory canal. We used a diamond bur and kept enough safety space to avoid a canal skin tear. Therefore, a 270°–360° canalplasty was conducted to ensure a wide operative vision. If a bulging anterior bony canal limits the exposure of the front edge of the perforation, 360° canalplasty should be performed.

Third, there was still no incision, starting from the annulus, and the epithelial layer of remnant TM was elevated toward the edge of the perforation, except at the 2–5 o’clock position (right ear), which was left intact for subsequent process. In case of a posterior perforation, the epithelial layer can also be elevated 360° around the perforation. After de-epithelization of the perforation edge, the ossicular chain was inspected and the lesions were treated accordingly.

Afterward, the end of the manubrium of the malleus was excised approximately 0.5–1.0 mm in patients with remarkable inward malleus. If left untreated, it is likely that the adducted umbo of the malleus will press the fasci against the promontory, resulting in adhesions and even atelectasis.