Tympanoplasty is a procedure that can be performed in a variety of ways, with considerations, subtleties, and preferences that differ according to the surgeon and the patient. Expert physician panelists shared their thoughts on the procedure at a session during the 2022 Triological Society Combined Sections Meeting, with the goal of helping others make their procedures more successful.
Explore This IssueMay 2022
“As much as any otologic procedure we do, tympanoplasty is something that has a very personal quality to it,” said Kevin Brown, MD, PhD, chief of otology and neurotology at the University of North Carolina at Chapel Hill. “How each of us do it is going to be different, and being different doesn’t mean that it’s less effective. It just means that through trial and error, it’s what you have figured out to be the most efficient way to operate.”
The panelists offered these tips:
Remove mucosa and sclerosis from the membrane. “You need to be prepared to sacrifice part or all of the eardrum in the interest of removing mucosalized or sclerotic tympanic membrane, because otherwise that will interfere with your healing,” Dr. Brown said.
Recognize skin ingrowth. “If it isn’t identified at the time of surgery, the skin can actually grow under the remnant of the tympanic membrane; if you try to do a medial graft and don’t recognize that, it’s definitely going to fail,” said Joni Doherty, MD, PhD, an associate professor of clinical otolaryngology–head and neck surgery at the University of Southern California in Los Angeles.
A cartilage graft can be a helpful option. “Sometimes the fascia and perichondrium can undergo atrophy,” Dr. Doherty said. “Cartilage is more resistant to resorption, it’s more rigid, it has good long-term survival, and it’s nourished largely by imbibement from perichondrium or from the vascularized mucosa that grow underneath it.”
Situations in which cartilage should be considered are when there is atelectasis, a retraction pocket or cholesteatoma, or a high-risk of perforation or risk of procedure failure. These cases can include revision procedures, anterior perforations, or otorrhea at the time of the surgery, she said.
How each of us do it is going to be different, and being different doesn’t mean that it’s less effective. It just means that through trial and error, it’s what you have figured out to be the most efficient way to operate. —Kevin Brown, MD, PhD
Studies have found a 92% closure rate for cartilage tympanoplasty, with hearing results that are comparable to procedures using fascia and perichondrium grafts, said Dr. Doherty. But a systematic review and meta-analysis found that further study is needed to assess cartilage grafts in cases of larger perforations (Ear Nose Throat J. doi:10.1177/01455613211015439).
Consider an endaural approach in certain situations. Surgeons should be comfortable using an endaural approach, which incorporates the endaural incision to the traditional transcanal flap incision, allowing for improved visualization and access, said Rick Nelson, MD, PhD, an associate professor of otolaryngology–head and neck surgery at the Indiana University School of Medicine in Indianapolis.
An endaural approach should be considered with large perforations when there is a need for canalplasty to improve visualization of the entire perforation, in the case of attic disorders such as malleus fixation or small cholesteatoma, and when circumstances dictate during surgery that it would be necessary or helpful to transition from a transcanal to endaural procedure, he said.
This is especially true when there are problems completely visualizing the tympanic membrane perforation, which has been the case in revisions that he has handled when it’s apparent that a poor view led to technical issues with the procedure. “Some of these are technical [mistakes] that I’ve seen on revision tympanoplasties, particularly when there’s a large canal hump,” said Dr. Nelson. “It was clear to me that the surgeon may not have been able to even see the perforation in its entirety.”
Closure of the perforation alone can be a success in some cases. “Closure of the perforation without having a significant improvement in hearing can still be considered a success because there are circumstances that one encounters where the degree of tympanosclerosis is so significant and severe that you may not be able to improve their hearing,” said Dr. Brown.
Don’t overlook the importance of the injection. “The injection really is a critical component of the operation,” Dr. Brown said. “It’s something that you should do slowly and very carefully because it makes everything easier thereafter.”
Be extra careful with packing in cases of lateral tympanoplasty. This is the preference of Michael Hoffer, MD, a professor of otolaryngology at the University of Miami in Coral Gables, for near-total perforations. “We place a very big emphasis on how we pack the canal after the lateral technique,” he said. “It’s much more critical than when you’re packing after a medial technique. If you pack wrong, then anterior blunting [blunting of the anterior tympanomeatal angle, which can interfere with hearing] is going to occur.”
Be diligent with the graft specimen you use in lateral procedures. “Don’t get lazy on your tympanoplasty material,” Dr. Hoffer said. “Get a good piece of fascia.”
Thomas R. Collins is a freelance medical writer based in Florida.