How to: An Innovative Tympanoplasty—Sleeve and Tongue Technique

Subsequently, three slits were prepared onto the fascia (Figure 1). Two of them formed a “tongue” in the front, which was about to fit into the space beneath the anterior 2–5 o’clock annulus (right ear). The third one was carved posteriorly near the malleus handle, so as to better accommodate the fascia medial to the manubrium of the malleus, while covering the neck and head of the malleus laterally. Gelfoams were stuffed into the tympanic cavity to provide support.

Then, the graft was put into place. The “tongue” was tucked under the anterior margin of the remnant TM, and the remaining fascia was distributed over the fibrous layer of TM, covering the annulus and bony canal if little of the TM remained.

Afterward, the “sleeve” flap with the epithelial layer of remnant TM in the center was re-positioned and overlapped with the brim of the fascia. As is demonstrated by the above steps, this method is particularly suitable for anterior perforation, as it is much easier to tuck the fascia tongue under the anterior annulus when the perforation edge locates anteriorly. As for large perforations, because there is a less epithelial layer to separate from the remnant TM in large perforations, this method can actually be simplified when dealing with such lesions as long as a sufficiently large fascia is procured.

Ultimately, tightly rolled iodoform rosebuds were firmly stuffed in the ear canal, so as to press the canal skin onto the enlarged wall of the bony canal.

RESULTS

Complete medical records were collected from 86 patients, including 37 males and 49 females. The average follow-up period was 16.21 ± 13.06 months. Graft taken rate was 94.2% (81/86), three cases were reperforated due to infection, one case was reperforated due to poor ventilation, and one case might be related to some particularly thin area of fascia. No anterior blunting, lateralization, or fascia falling off was witnessed. There were 61 cases of anterior large/subtotal perforations, and 59 (96.72%) cases showed complete closure.

The sleeve and tongue tympanoplasty can be a trustworthy alternative for TM perforation repair, especially for large anterior perforations. According to our experience, it’s rarely essential to make an auxiliary intra-canal incision with this technique, as it has already provided sufficient exposure. Additionally, the sleeve flap ensures favorable blood supply in the external meatus, and tongue-shaped fascia not only seals the perforation solidly but also maintains the anterior acute angle and maximizes the physiological appearance of the TM.