What is
Tympanoplasty?
Tympanoplasty,
myringoplasty, ossiculoplasty, mastoidectomy
These words are sometimes used loosely and
are interchangeably by doctors, which can
add to a degree of confusion. A
myringoplasty means a repair or refashioning
of the eardrum, an ossuculoplasty involves
removal of replacement or refashioning of
the three little bones of the ear and a
mastoidectomy implies drilling away the
bones over the mastoid air cells to improve
aeration or remove cholesteatoma. A
tympanoplasty can mean combining one or more
of the above previously mentioned
operations. The purpose of a tympanomplasty/mastoid
operation is first and foremost to remove
disease from the mastoid air cells; this is
usually cholesteatoma or other infective
material. The first aim of the operation
therefore is to render the ear "safe".
Unfortunately the price to be paid for
making the ear "safe" may be either the
creation of a mastoid cavity which requires
long term care or become infected or indeed
a reduction in the level of hearing. For
this reason over the years many methods have
been sort to try and get the best of both
worlds, i.e. a safe ear and a dry ear, which
hears normally. This is not always
achievable and depends entirely on the
original anatomy and also on the skill and
training of the individual surgeon. There is
debate within the medical profession as to
the optimum treatment for various conditions
affecting the ear and you would be advised
to read some of the following links and to
discuss cases with a surgeon with an
interest in ear disease.
Eardrum repair is a procedure to correct a
tear in the eardrum (tympanic membrane) or
the small bones in the middle ear.
Ruptured or perforated eardrums
are usually caused by
middle ear
infections or trauma, such as an
object in the ear, a slap on the ear, or an
explosion.
Tympanoplasty
is a microsurgical procedure that uses a
patient's own tissues (autologous grafts),
to reconstruct the tympanic membrane. Grafts
may be taken from different areas, including
(in order of most frequent use) loose
connective tissue, temporalis fascia, tragal
perichondrum, and the periosteum (COULD YOU
DESCRIBE EACH OF THESE IN A WORD OR 2?).
Veins are rarely used as they weaken over
time. Alloderm grafts (from synthetic
materials) may be used if patients have had
multiple previous surgeries and have limited
graft availability. Results are about equal
as those with autologous tissue. Homografts
(tissue taken from other humans) or
xenografts (from animals) are sometimes
available, but in general they are less
successful and less frequently used.
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Effects
of Tympanoplasty
Results of tympanoplasty with ossicular
reconstruction vary with the degree of prior
damage to the bones of hearing. With an
intact, normally mobile chain of ear bones,
the restored hearing is generally very good
once the hole is closed. Erosion of the
incus is usually the msot common bony
problem and the easiest ossicular problem to
repair. Good hearing results are obtained in
a high percentage of operations.
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Candidates
for Tympanoplasty
If antibiotics or other nonoperative
treatment do not heal chronic ear
infections, surgical eardrum repair may be
necessary.
Chronic
middle
ear infections
are described as:
·
Seven or more ear infections in a year
·
Five or more ear infections per year for 2 years
Signs of
chronic ear
infections include persistent
ear pain,
ear drainage,
or
hearing loss
(over a 3-month period).
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Your
Consultation
Tympanoplasty surgery has been refined to
the point of offering the possibility of an
intact eardrum and improved hearing in most
individuals with perforations and hearing
loss. Prolonged medical treatment and the
clearing of sinus, nasal and allergy
problems are necessary prior to recommending
ear surgery.
In a few individuals, other medical problems
such as poorly controlled diabetes or heart
disease may exclude them as tympanoplasty
candidates. However, a great majority of
individuals with perforations and hearing
loss find improvement with microsurgical
tympanoplasty
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The Tympanoplasty
Procedure
using general anesthesia, an ear/nose/throat
(ENT) specialist grafts a small patch from a
vein or fascia (muscly sheath) onto the
eardrum to repair the tear.
For problems with the small bones (ossicles),
the
surgeon
will use an operating microscope to view and
repair this chain of small bones using
plastic devices or ossicles from a donor.
The patient is usually placed under general
anesthesia, although it may also be done
under local anesthesia. The surgeon
reconstructs the membrane either through the
ear canal alone, or through the ear canal
and through an incision behind the ear. The
surgeon may use a laser to carefully remove
any scarring in the middle ear. If the
ossicles (small bones in the inner ear) have
been damaged, the surgeon may also repair
these, using either donor bones or
prosthetic devices (ossiculoplasty).
Surgery to reconstruct the tympanic membrane (eardrum)
can be performed either under local or
general anesthesia. Many patients prefer to
be completely asleep. In small perforations,
the operation can be easily performed under
local anesthesia with intravenous sedation.
An incision is made into the ear canal and
the remaining eardrum is elevated away from
the bony ear canal and lifted forward.
The operating microscope helps to enlarge the view of
the ear structures, giving a more detailed
image to the ear surgeon. If the perforation
is very large or the hole is far forward and
away from the view of the surgeon, it may be
necessary to perform an incision behind the
ear. This elevates the entire outer ear
forward, gaining access to the perforation.
Once the hole is exposed fully, the
perforated remnant is rotated forward, and
the bones of hearing are inspected. There
may be scar tissue and bands surrounding the
bones of hearing. These can be removed
either with micro hooks or laser.
Having identified the bones of hearing, the ossicular
chain is pressed to determine if the chain
is mobile and functioning. If the chain is
mobile, then the remaining surgery
concentrates on repairing the drum defect.
Tissue is taken either from the back of the ear or from
the small cartilaginous lobe of skin in
front the ear called the tragus. The tissues
are thinned and dried. An absorbable gelatin
sponge is placed under the drum to allow for
support of the graft. The graft is then
inserted underneath the remaining drum
remnant and the drum remnant is folded back
onto the perforation to provide closure.
Very thin silastic sheeting is generally placed against
the top of the graft to prevent it from
sliding out of the ear, when the patient
blows his nose or sneezes. A small amount of
Gelfoam is also placed on the outside of the
silastic to hold it into position in a
so-called sandwich type layer (drawing).
If opened from behind, the ear is then stitched
together. usually, the stitches are buried
in the skin and do not have to be removed
later. A sterile patch is placed on the
outside of the ear canal and the patient
returns to the recovery room. Generally, the
patient can return home within two to three
hours. Antibiotics are given along with a
mild pain reliever such as Tylenol or
Tylenol with Codeine.
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Recovery
After about ten days, the packing is removed and a good
evaluation can then be obtained as to
whether the graft was successful. Water is
kept away from the ear and blowing of the
nose is discouraged. If there are allegies
or a cold, further antibiotics and
decongestant should be given. Most
individuals can return to work after five or
six days unless they perform heavy physical
labor, in which case the patient can return
after two or three weeks.
After three weeks, all packing is completely removed
under the operating microscope in the
office. It can then be determined whether
the graft has fully taken. In over 90
percent of cases, the tympanoplasty
procedure is successful and a hearing test
is performed at four to six weeks after the
operation.
Patients usually leave the hospital the same
day as the surgery. It is important to avoid
water in the ear. Your health care provider
may recommend the use of a hair cap when
showering for a few weeks after the
procedure.
After surgery, patients may often leave the
hospital the same day. They must keep the
operated ear dry while bathing for two to
three weeks, as directed. Any hearing loss
or tinnitus usually resolves in a few days.
Occasionally patients may lose the sense of
taste on the operated side of the tongue;
this also resolves within weeks.
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Risks
In most cases, the
operation relieves pain and infection
symptoms completely.
Hearing loss
is minor. The operation can have a less
optimistic outcome if the bones in the
middle ear need reconstruction along with
the eardrum.
Eardrum Repair: Risks
Risks for any anesthesia are:
·
Reactions to medications
·
Problems breathing
Risks for any surgery are:
·
Bleeding
·
Infection
Additional risks include:
·
Incomplete healing of the hole in the eardrum
·
Damage to the small bones in the middle ear, causing
hearing loss
·
Need for further surgery
Tympanoplasty is usually a highly successful
procedure, with over 90% of patients
recovering without any complications. In the
hands of Columbia's highly trained surgeons,
over 94% of patients' grafts take
successfully. If subsequent operations are
required, these also are highly successful.
Bleeding and infection are very small risks,
as are chances of incomplete healing of the
eardrum. Development of
cholesteatoma is another very small risk
and requires special treatment if it occurs.
If the ossicles have been damaged by injury
or disease, hearing loss may be sustained
despite surgery. Approximately 2 to 4
patients out of 1000 will experience
sustained hearing loss after tympanoplasty,
according to research. As with any surgery,
the risks of anesthesia, such as reactions
to the drugs and breathing difficulties,
must be discussed with your physician.
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Frequently Asked
Questions
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