Patients Info: Surgical Information: Tympanoplasty

TYMPANOPLASTY – REPAIR OF THE EARDRUM

Myringoplasty is an operation to repair a perforation (hole) in the eardrum. This results in a sealed, water-resistant ear and greatly reduces the chance of infections following swimming and showering. It may also improve hearing. A perforation occurs most commonly after:

  • a severe middle ear infection, often in childhood
  • self-cleaning of the ear canal
  • sporting injuries, such as a blow to the ear
  • work-related injuries, for example, a burn from a welder’s spark
  • some fungal infections of the external ear canal
  • insertion of a grommet in the eardrum, or other operations of the middle ear.

Recurrent infection is likely if water enters the middle ear through a perforated eardrum or as the result of nasal congestion or sinus infection. In some patients, recurrent middle ear infection is associated with a cholesteotoma (a cyst-like mass) that must be surgically removed. All but very small perforations cause some degree of hearing loss.

Surgery should be considered if:

  • the ear discharges frequently
  • infection occurs despite precautions to keep water out of the ear
  • hearing loss is a problem
  • the perforation is part of a deeper process of disease, such as cholesteotoma.

However surgery may not be needed if:

  • water is kept out of the ear to prevent infection
  • the perforation is small and does not cause a problem; a very small perforation may eventually heal
  • infection is frequent and easily controlled by antibiotic eardrops
  • hearing loss is mild.

TALK TO YOUR SURGEON

This transcript provides general information about myringoplasty. It is not a substitute for advice from your surgeon. Read it carefully. Some terms may require further explanation by your surgeon. Write down questions you want to ask.
Although patients should be as informed as possible about the surgery, every aspect cannot be covered in this transcript. With your surgeon, discuss diagnosis, non-surgical treatment options, and the benefits, risks and limitations of surgery.
If you are uncertain about the advice you are given, you are encouraged to seek the opinion of another specialist. This transcript should only be used in consultation with your surgeon.

DIAGNOSIS

Most perforations can be diagnosed by examination of the eardrum. Further investigations may include:

  • a hearing test
  • tympanometry, which may be done to help detect a very small hole; a small, soft probe is used to pressure test the eardrum.
  • a CT scan to detect suspected underlying mastoid or middle ear problems.

 

YOUR MEDICAL HISTORY

The surgeon needs to know your medical history to plan the best treatment. Disclose all health problems you have had. Some may interfere with surgery, anaesthesia and aftercare.
Your surgeon needs to know about:

  • any prior ear surgery
  • any allergy or bad reaction to antibiotics, anaesthetic drugs or other medicines
  • recent illness, including recent infections
  • any bleeding disorder or easy bruising
  • recent or long-term illness
  • any personal or family history of deep vein thrombosis (DVT)
  • thick, raised scarring (keloid) or poor healing of scars after previous surgery.

Give the surgeon a list of ALL medicines you take or have recently taken. Include medicines prescribed by your family doctor and those bought “over the counter” without prescription. Include medicines such as insulin, warfarin and contraceptive pills.
You may be advised not to take aspirin, medicines containing aspirin (such as cough syrups), large amounts of vitamins (particularly vitamin E), anti-inflammatory medicines or over the counter preparations for at least ten days before surgery. These may increase the risk of excessive bleeding during and after surgery, and interfere with a successful result.

Smoking
Stop smoking at least 3 weeks before surgery, and do not smoke for several weeks after surgery. It is best to quit because smoking increases surgical and anaesthetic risk, impairs healing, and interferes with Eustachian tube function.

BEFORE SURGERY

Notify your surgeon in the weeks before surgery if the ear is discharging or feels wet inside. You may be advised to apply antibiotic eardrops to clear any infection. Some eardrops can harm the inner ear if not used as directed by your surgeon.
Consent form
If you decide to have treatment, your surgeon will ask you to sign a consent form. If you have any questions about it, ask your surgeon.

ANAESTHESIA

Most myringoplasty procedures are performed under a general anaesthetic. Modern anaesthetic is safe and effective, but it does have some risks. Rarely side effects from an anaesthetic can be life threatening. Ask your anaesthetist for more information. Give your anaesthetist a list of all the medications you are taking or have taken. Inform your anaesthetist about any allergies, heart disease, respiratory disease, diabetes or any other medical condition.

  

THE TYMPANOPLASTY PROCEDURE

A tissue graft is used to close the perforation. Most commonly, the graft is a piece of the lining (facia) of the temporalis muscle located beneath the skin just above the ear. Sometimes a small piece of ear cartilage is used.
The surgeon makes an incision behind the ear or within the ear canal opening. Using an operating microscope, the surgeon lifts up the eardrum remnant and lays the graft on the underside of the eardrum (underlay graft, also called a medial graft).
Sometimes the graft is laid directly on top of the eardrum (overlay graft, also called a lateral graft). Your surgeon will decide whether an underlay or overlay graft is best for your condition.
To affix the graft in place during healing, a special soluble sponge is used adjacent to the graft. It is slowly resorbed by the body over several weeks.
The eardrum is put back in position and the ear incision is closed with stitches. Packing is placed in the ear canal to protect the eardrum as it heals.
Myringoplasty is often combined with canalplasty (removal of bone from the external ear canal). This procedure widens the ear canal, allowing the surgeon to have better access to the perforation.
During the procedure, the surgeon will check the health of the middle ear to determine whether a cholesteotoma (sac of skin tissue), infection or other condition may be present.
If one of the small bones (ossicles) of the middle ear is found to be deficient or eroded, an attempt may be made during the procedure to reconstruct the ossicular chain using a prosthesis. However, this may be often delayed and then done at a second operation.
Small perforations:  These can sometimes be closed using fat tissue taken from the earlobe and placed into the perforation without any external incision.
A recent development is the use of a cartilage graft placed into the perforation without any external incision.
To harvest the fat tissue or cartilage graft, a small external excision is necessary.

RECOVERY AFTER SURGERY

Most patients stay in hospital overnight, although some may go home the same day. A dressing over the ear is held in place by a bandage. Nursing staff will check the dressing and advice about dressing changes. The ear may have some blood- stained discharge for several days. A prescription painkiller is provided if necessary.
At a postoperative visit, your surgeon removes the external canal packing. Stitches, if not dissolvable, are removed one to two weeks after surgery.
During the healing period avoid getting water in your ear. Your surgeon will discuss with you how best to care for your ear.
Most patients can return to work in about one week. Healing should be complete in about 3 months.
Another hearing test may be given to determine the amount of hearing recovery.
In many cases, myringoplasty can restore close to normal hearing. However, in patients with large or longstanding perforations, only limited improvement of hearing may occur.
You should not undertake air travel for one to two months after the operation or as advised by your surgeon.

THE POSSIBLE COMPLICATIONS OF SURGERY

All surgical procedures are associated with some risk. Despite the highest standards of surgical practice, complications are possible.
It is not usual for a doctor to dwell at length on every possible side effect or rare but serious complication of any surgical procedure. However it is important that you have enough information to weigh up the benefits and risks of myringoplasty.
Most patients will not have complications, but if you have concerns about possible side effects, discuss them with your surgeon. The following list of possible complications is intended to inform you, not to alarm you. There may be others that are not listed.

General risks of surgery

Possible complications include:

  • wound infection (treatment with antibiotics may be needed)
  • pain and discomfort that may persist
  • nausea (typically from the anaesthetic; this usually settles down quickly)
  • allergies to anaesthetic agents, antiseptic solution, suture material or dressings
  • slow healing ( most likely in smokers and people with diabetes)
  • side effects associated with general anaesthesia, that may include stroke, heart attack or deep venous thrombosis. Any of these may be life threatening.

Specific risks of myringoplasty

Graft failure: In about 10 to 15 out of every 100 operations, the tissue graft to close the hole may not “take”. This may require further surgery.

Tinnitus: A ringing or other noise in the ear may occur after surgery, but the noise usually stops after a few weeks. Rarely, it may persist or become permanent. If present before surgery, it may rarely become permanently louder after surgery.

Hearing loss and balance disturbance: These may persist for days or weeks but generally resolve spontaneously. Rarely, total deafness can occur in the operated ear (less than 1 patient in 1000).

Numbness: Due to the incision, numbness of the top half of the ear may persist, but generally settles after a few months.

Taste disturbance and dry mouth: The nerve of taste passes through the middle ear and may be injured during surgery. Some patients experience a taste disturbance on that side of the tongue for a few months and dryness of the mouth. Occasionally these are permanent.

Facial paralysis: As the facial nerve is close to the site of surgery, paralysis of facial muscles on that side of the face may uncommonly occur. It usually recovers in a few days or weeks. Rarely, paralysis may be permanent (less than 1 patient in 1000).

Keloid or hypertrophic scar: The incision behind the ear may heal as a thick, raised (keloid) scar or hypertrophic scar. There may be hair loss around the scar, which sometimes is permanent.

Blunting: After canalplasty, excessive scar tissue may form, partially blocking the deep ear canal and leading to some hearing loss. Such “blunting” of the angle between the front of the eardrum and the ear canal can be difficult to correct.

Inadequate hearing: Despite a successful surgical outcome, a hearing aid may still have to be worn.

Cholesteotoma: Sometimes, skin may grow from the edges of the perforation into the middle ear. If this skin is not removed completely at the time of operation, a skin cyst can develop deep to the grafted eardrum. This cyst, or cholesteotoma, must be removed surgically to prevent further damage to the middle ear and other complications. A cholesteotoma may be detected by the surgeon at a routine six-month or 12 month postoperative visit.

REPORT TO YOUR SURGEON

Tell your surgeon at once if you develop any of the following:

  • Temperature higher than 38 degrees Celsius or chills.
  • Persistent pain, redness, pus or swelling around the wound
  • Nausea or vomiting
  • Extensive discharge from the operation area
  • Any troublesome ear symptoms
  • Any concerns you have regarding your surgery