Tympanoplasty (ear drum repair)
What is a tympanoplasty?
This is an operation that is used to repair the ear drum. Tympano- means "ear drum" and -plasty means "to fix".
Why is it performed?
A tympanoplasty is performed for conditions that require a repair of the ear drum, such as:
Tympanic membrane perforation – a hole in the ear drum.
Retraction pocket of the ear drum.
Cholesteatoma – a skin cyst growing through a hole in the ear drum or within a retraction pocket; in cholesteatoma it is performed as part of a larger operation known as a mastoidectomy and the whole procedure is then called a tympanomastoidectomy.
How is a tympanoplasty performed?
Tympanoplasty is usually performed under a general anaesthetic. To get access to the ear drum, a cut is either made behind the ear (a post-auricular approach) or inside the ear canal (an endaural approach), depending on which approach gives the best access for that particular ear. Occasionally, in people with very wide ear canals, no cut is needed and the operation can be done directly down the ear canal (a permeatal or transcanal approach). A decision about which approach is best suited for you will often be made in the clinic but this decision can occasionally be changed at the time of surgery if the access to the ear drum is not as good as originally thought.
Once the ear drum is accessible, it is lifted up to expose the middle ear, including the hearing bones (the ossicles). The ossicles are assessed for mobility and good function as a rule. A small piece of cartilage is then harvested from around the ear, usually from the tragus, the small projection that lies in front of the ear canal, and which people sometimes pierce. Sometimes it is harvested from part of the the bowl of the ear known as the concha cymba.
This piece of cartilage is used as a graft and is shaped appropriately and used to reconstruct the ear drum. Taking cartilage from these sites does not change the shape of the ear and is unnoticable to anyone looking at the ear. If necessary, an ossiculoplasty will be performed at this stage.
Once the ear drum has been reconstructed, it is placed back into position. The ear canal is then packed with an ear wick (a non-dissolvable dressing) near the entrance. The wound is then stitched close using dissolvable sutures. A head bandage may or may not be applied.
The facial nerve, which passes through the ear on its way to supply the muscles of the face, is monitored in all cases with a facial nerve monitor. This helps to protect the facial nerve from injury. To do this, tiny needles are placed above the eye, at the corner of the mouth and on the chest. These are removed at the end of the operation and you may feel some short-lived discomfort or develop bruising in these areas. Mr Trinidade does not generally shave hair for this procedure.
The ear may stick out for a couple of weeks (especially if a post-auricular approach was used) but this will return to normal once the swelling subsides and a scar forms.
What are the risks of tympanoplasty?
Tympanoplasty is a common operation with minimal risks, but as with all operations, there are risks that you need to be aware of. These include:
Bleeding and infection
As with any operation, these are standard risks. Bleeding is usually in the form of an ooze, which settles within the first 24 hours. Sometimes, there is significant bleeding that collects under the skin forming a haematoma. This usually needs to be evacuated with a small procedure. Infection may cause redness and swelling around the wound site or show as drainage from the ear canal. Oral and topical antibiotics may be required.
The taste nerve runs along the back of the ear drum and may be bruised during surgery resulting in an abnormal taste in the mouth, usually salty or metallic, or may make certain foods taste strange. It is usually temporary and resolves after several weeks or months. The risk of this is about 1 to 2%.
Any ear operation has the risk of worsened hearing. This risk of this in tympanoplasty is about 0.5 to 1%. Often the hearing loss is due to fluid or blood collection within the middle ear during the healing phase and can take up to about 3 months to resolve. Rarely it is a permanent loss.
In less than 1% of cases, the facial nerve is injured. This may lead to a partial or full weakness of the face that very rarely is permanent. The use of a facial nerve monitor helps to avoid this risk.
About 2-3% of patients will experience some tinnitus (ringing in the ear) following surgery. This is usually temporary and resolves with time. In some people it is persistent, but the majority of people are able to ignore it without it becoming bothersome.
Cartilage tympanoplasty has a failure rate of about 1 to 2%. This may be as a result of infection or poor blood supply of the ear drum not allowing for taking of the graft. It may also occasionally be due to an issue with the technique, especially if the ear drum was difficult to access in the first place. In cases of failure, revision surgery can be undertaken and usually solves the issue.
What is the aftercare following tympanoplasty?
After surgery, you will have a wick within the ear and will therefore not be able to hear very well from that ear. If you have had a head bandage applied, this can be taken off at home the following morning. This will often be blood-stained and is normal. Take regular pain medicine for the first 2 to 3 days, or longer if needed. If you stopped aspirin before the operation, this can be restarted the day after surgery.
Do not wash your hair for 2 days, after which you may do so, but you must not get water inside the ear. The best way to protect the ear from getting wet is to place a cotton ball smeared in Vaseline into the bowl of the ear during showering/bathing (click here to see how). Apply antibiotic ointment to the wound twice daily for 1 week.
Your first follow up with Mr Trinidade will be in 1 to 2 weeks. Two days before your appointment, start applying ear drops to your ear (you will be supplied with this before leaving the hospital). This will help to soften the wick so that it can be easily removed in the clinic. If your wick has come out before this time, do not worry. Just start using the ear drops as prescribed and keep water out of it.
At the clinic, your wound will be inspected and the ear wick will be removed. This can sometimes be uncomfortable but is usually straightforward and takes less than a minute to do. Once the wick is out, you will be asked to continue ear drops for a further week. As the stitches are dissolvable, they will not need to be removed in the clinic.
You can start showering/bathing without cotton wool protection at 4 to 6 weeks after the operation. You are encouraged to start gently popping your ears by pinching your nose and blowing out (called a Valsalva manoeuvre; click here to see how to perform one) after 6 weeks. Your second visit to the ENT clinic will be in approximately 3 months after the operation when a hearing test will be performed.
Any signs of infection (pain, swelling, drainage, fever) should be reported to your GP or to the ENT clinic. Flying and diving should be avoided for 6 to 8 weeks after the operation. Mr Trinidade advises that you have your ear checked prior to resuming diving.
What is a myringoplasty?
A myringoplasty is a type of tympanoplasty, but instead of cartilage, a different tissue is used, usually a small bit of fascia (which is the tissue that covers muscle), or fat (usually taken from the ear lobe). Mr Trinidade mainly performs cartilage tympanoplasty, but may occasionally perform a myringoplasty if the hole in the ear drum is small. For larger holes, a myringoplasty has a higher failure rate than cartilage tympanoplasty (approximately 10 to 15%). Besides using a different tissue as a graft, myringoplasty is performed in the same way as tympanoplasty (see above) and has the same risks. Myringoplasty is not performed for retraction pockets or cholesteatoma. For these, a cartilage tympanoplasty is almost always used as cartilage is more robust than other tissues.
Read more about ossiculoplasty here.
A diagram showing an endaural (in the canal) incision
A diagram showing a postauricular (behind the ear) incision
A picture of the ear showing the tragus and the concha cymba (shaded area)
A diagram showing a cartilage graft (depicted as blue) being harvested from the back of the tragus through a well-camoflauged incision
This picture shows an example of a perforated ear drum that was reconstructed using the cartilage tympanoplasty method. On the left, most of the ear drum is missing. The malleus (hammer) can be seen suspended on its own in the middle. On the right, cartilage has been used to completely reconstruct the ear drum and close the hole.