John L. Domhoffer Michael B.

Gluth

Seeking knowledge and expertise in the art of tympano- TYPES OF TYMPANOPLASTY

plasty and ossiculoplasty can be a difficult task, in part due AND OSSICULAR RECONSTRUCTION
to the overwhelming number of techniques that have been
described, but also because of the plethora of dogma and Tympanoplasty techniques were classically outlined by
surgical tradition that circulates throughout the otologic Zollner (1) and Wullstein (2). Subsequent modifica-
surgery community. In the following chapter, the authors tions of Wullstein's classification have been based on the
seek not to champion a particular set of techniques, but to underlying properties of acoustic mechanics associated
provide a broad overview of this topic with a focus on fun- with each tympanoplasty type as opposed to classification
damental principles that apply globally. This information based on underlying tympanic and ossicular pathology.
is delivered under the assertion that it is wise for otologists Understanding this classification system is helpful not only
to acquire a working mastery of several techniques that for purposes of grasping a global and historical view of
may be applied in a customized manner based on pathol- tympanic membrane and ossicular chain reconstruction,
ogy and conditions at hand. but also for understanding basic principles of middle ear
acoustic mechanics.
DEFINITION OF TERMS
Type I Tympanoplasty
Canalplasty refers to surgical modification of the bony
external auditory canal. This is often used as an adju- This procedure involves repair of the tympanic membrane
vant procedure in tympanoplasty to improve surgical in the setting of an intact native ossicular chain. At most
access. manipulation of the ossicular chain is limited to interven-
Meatoplasty refers to surgical modification of the cartilag- tions aimed at improving mobility. such as lysis of tym-
inous external auditory canal and external auditory panic adhesions or removal of tympanosderotic foci.
meatus. This is often used as an adjuvant procedure
in tympanoplasty to provide improved postoperative
Type II Tympanoplasty
access or to attain consistent lateral-to-medial ear
canal size matching following canalplasty. This procedure involves repair of the tympanic membrane
Myringoplasty refers to surgical repair of the tympanic in combination with any type of ossiculoplasty proce-
membrane that involves work confined to the dure that preserves the integrity of the malleoincudal lever
drumhead only. mechanism. The most common example of this is repair
Ossiculoplasty refers to surgical modification of the ossicu- of a dysfunctional (eroded) incudostapedial articulation.
lar chain, including reconstruction and mobilization. Tympanoplasty with delayed staged ossiculoplasty consist-
Tympanoplasty refers to surgical repair of the tympanic ing of an incus-grip stapedotomy could also be considered
membrane in combination with work within the tym- a subgroup within this category. It is perhaps worth noting
panic deft, such as ossiculoplasty, middle ear explo- that these modem depictions of type II tympanoplasty dif-
ration, or lysis of tympanic adhesions. Traditionally. fer somewhat from the classic description that was devised
elevation of the annulus within a tympanomeatal to deal with the uncommon scenario of isolated malleus
flap has served as a practical boundary that differen- erosion, wherein tympanic membrane grafting is applied
tiates tympanoplasty from myringoplasty. directly upon the intact long process of the incus.
2465
2466 Section IX: Otology

Type Ill Tympanoplasty is generally performed in a staged manner once active

infectious disease is controlled. Historically, fenestration
This procedure involves repair of the tympanic membrane of the lateral semicircular canal was described as part of
in combination with any type of ossiculoplasty procedure this procedure to counteract stapes fixation; however, total
that does not preserve the integrity of the malleoincudal footplate removal and a soft tissue seal have generally
lever mechanism. Type III tympanoplasty includes the replaced fenestration.
vast majority of techniques described for routine ossicular
chain reconstruction. Accordingly, type III tympanoplasty
classification has been further subdivided according to
PHYSIOLOGY: MECHANISMS OF GAIN
ossiculoplasty technique. The modern view of middle ear acoustic science involves
two basic pathways by which sound is able to stimulate the
Stapes Columella Subtype
inner ear (3,4). The first involves transmission of sound
This type III tympanoplasty involves placement of a tym-
pressure through the tympanic membrane and ossicu-
panic membrane graft directly onto the superstructure of
lar chain via the oval window. This is known as ossicular
the stapes without the use of a prosthesis or any other sub-
coupling. This mechanism is the primary means by which
stantial interpositional material.
the state of impedance mismatch that exists between the
air in the ear canal (low impedance) and the fluid within
Minor Columella Subtype
the cochlea (high impedance) is overcome. In such a state,
This involves the use of an interpositional graft or pros-
sound pressure is deflected during passage through the air-
thesis to establish continuity between the tympanic mem-
fluid interface, resulting in a loss of gain in the realm of
brane and the superstructure of the stapes. Examples of this
30 dB. The coupling effect of the tympanic membrane and
include the use of a synthetic partial ossicular replacement
ossicles almost overcomes this loss.
prosthesis (PORP) or sculpted ossicular (incus or malleus
Ossicular coupling has been attributed to the col-
head) autograft. Interpositional ossiculoplasty techniques
lective effect of three characteristics of the tympano-
that employ a lateral contact point with the malleus manu-
ossicular mechanism traditionally known as the acoustic
brium also fall within this subtype.
transformer theory (5). The first and most significant of
Major Columella Subtype these characteristics is the hydraulic lever effect that results
from the difference between the surface area of the tym-
This procedure is exactly the same as the minor columella
panic membrane relative to that of the oval window
subtype except that the stapes superstructure is absent; thus,
with a major columella subtype the interpositional graft or (usually a ratio of nearly 21:1). This effect results in
prosthesis is set upon the stapes footplate. An example of compression of sound energy and increase in force at
this is use of a synthetic total ossicular replacement pros- the oval window, equating to a theoretic approximate
thesis (IDRP). Tympanoplasty with delayed staged ossicu- increase in gain of 26 dB. The second characteristic is
loplasty that consists of a malleus-grip stapedotomy could the malleoincudal lever effect that results from the differ-
ence in length between the malleus manubrium relative
also be considered to fall within this subtype.
to that of the long process of the incus along the axis of
ossicular rotation (a ratio of 1.3:1). However, this effect
Type IV Tympanoplasty only accounts for an additional 2 dB theoretical increase
This procedure involves repair of the tympanic membrane in gain. The final factor is the so-called catenary lever
in such a manner that the boundary between the mucosal- effect that is generated by the elastic stretching of the
ized middle ear space and the epithelialized lateral com- tympanic membrane from the annulus to the malleus
partment (external auditory canal, open mastoid cavity, manubrium-somewhat akin to the stretched strings
epitympanum) is shifted in a way that renders the stapes across a tennis racquet. The specific degree of acous-
footplate externalized as part of the latter. As a result, the tic benefit derived from the catenary effect is not well
tympanic cavity is divided into a smaller-than-normal aer- understood but probably lies within a range similar to
ated space in continuity with the eustachian tube, termed that of the malleoincudal lever.
the cavum minor, in which the round window is acous- It is important to recognize that, in reality, ossicular
tically shielded, and an external component in which the coupling is a much more complex phenomenon than what
mobile stapes footplate is covered by a thin epithelial layer is suggested by these simplified traditional models as they
and is directly exposed to incoming sound energy. do not account for factors such as variation in efficiency
with changes in frequency or inefficiencies in sound trans-
mission through the tympanic membrane and ossicular
Type V Tympanoplasty
chain attributed to the inherent tension or laxity of the
This procedure is the same as the type N tympano- ossicular ligaments. Thus, it is perhaps not surprising that
plasty, except that it also includes the need to address the 25 to 30 dB of gain that is predicted by the acoustic
an underlying immobile stapes footplate and, therefore, transformer theory does not equate well with experimental
 Chapter 153: Reconstruction of the Tympanic Membrane and Ossicular Chain 2467

measurements, which suggest an actual more modest a conductive hearing loss between 5 and 40 dB depending
increase in the realm of just over 20 dB (6-8). on its characteristics (9). Controversy exists as to whether
The second pathway of sound stimulation of the or not the location of a perforation impacts the degree of
inner ear involves direct passage of sound pressure via hearing loss, yet perforation size and underlying middle
the oval and round windows without involvement of the ear volume do matter (an ear with a smaller volume tends
tympanic membrane or ossicular chain. This is known to have worse hearing than one with a larger volume, even
as acoustic coupling (4). Given an intact tympanic mem- given identical perforations) .
brane and functional ossicular chain, this pathway is of When the tympanic membrane is intact, a conductive
only minor importance. However, in the various condi- hearing loss greater than 35 to 40 dB strongly suggests the
tions of a diseased ear, acoustic coupling can be impor- possibility of ossicular chain dysfunction. Furthermore,
tant. This is why, for example, a conductive hearing loss the pattern of hearing loss may be typical of particular
will be greater in the case of ossicular discontinuity and scenarios; for example. ossicular fixation generally causes
an intact tympanic membrane (60 dB) compared with a low-tone conductive hearing loss, the degree of which
ossicular discontinuity and an absent tympanic mem- is related to the extent and location of the fixation. With
brane (40 to 50 dB). With the former, the intact tym- malleus head fixation, the low-tone air-bone gap gener-
panic membrane restricts the acoustic coupling pathway ally closes at the higher frequencies, whereas stapes fixa-
by blocking direct access of sound pressure to the oval tion tends to affect the middle and high frequencies to a
and round window membranes. relatively greater degree (10).
A final relevant consideration in middle ear acoustic The status of the eustachian tube will impact surgical
mechanics is that of phase. A sound stimulus to the inner outcomes, yet there is no consensus on the optimal way
ear is detected as the net difference in sound pressures to reliably assess its function (11). Auto-inflation using the
applied to the round and oval windows that results in Valsalva or Toyenbee maneuver is helpful, albeit a non-
movement of intracochlear fluids. If these sound pressures physiologic test of tubal patency. The clinical status of the
are simultaneously applied to the round and oval windows contralateral ear likewise can provide insight into tubal
with equal amplitude and phase, they will counteract each maturity and function in the diseased ear ( 12). As part of
other and no resultant intracochlear fluid displacement the eustachian tube evaluation. the nose should be exam-
will occur. In the normal situation, this does not occur ined so that allergy, adenoiditis, and rhinosinusitis can
due to the unbalanced selective effect of ossicular coupling be treated in an effort to promote optimized tubal func-
upon the oval window, the acoustic shielding effect of the tion (13). Furthermore, aggressive medical treatment of
tympanic membrane upon the round window, and the infection involving the ear itself should be undertaken
uneven anatomical positioning of the round window ver- prior to surgery, including aural toilet and ototopical agent
sus the oval widow relative to incoming sound. However, application. When an ear will not dry with medical ther-
when the tympana-ossicular mechanism is absent and apy, culture acquisition may be useful in helping to iden-
acoustic coupling is primarily relied upon (as in the case of tify antimicrobial-resistant pathogens.
a type N or V tympanoplasty), an unshielded round win- Once patient assessment is complete, a few general rules
dow can yield significant negative acoustic consequences should be applied to surgical candidacy. First, one should
due to phase cancellation (4 ). avoid elective surgery on an only-hearing ear as much as is
A simplified chart depicting the theoretic ideal acoustic reasonably possible. Exceptions to this would be situations
effects of various tympana-ossicular scenarios is shown in where surgery is primarily confined to the tympanic mem-
Table 153.1. brane, and drilling or significant ossicular manipulation is
unlikely, or when a perforation is contributing to difficulty
PREOPERATIVE EVALUATION with hearing aid usage. Also, cases that involve disease pro-
cesses that impart risk of hearing loss, such as cholestea-
When a patient is considered for tympanoplasty or ossi- toma, will generally warrant intervention. Second, when
culoplasty, a thorough history, examination, and audio- bilateral disease is present, surgery should be undertaken
metric evaluation should be performed on both ears. on the worse-hearing ear in the absence of any other com-
Otoscopy and pneumatic insufflation under the binocular pelling reason to do otherwise on account of underlying
microscope, following careful removal of debris, provide a disease. Finally, special consideration should be given to
wealth of information. The results of the audiogram should the timing of surgery in the pediatric patient.
always be correlated with the physical exam, including Age as a prognostic factor in tympanoplasty is contro-
Weber and Rinne tuning fork tests, especially when a mask- versial, with contradicting reports present in the litera-
ing dilemma is present. If the audiogram and tuning fork ture (14,15). The authors' approach to pediatric patients
exam do not agree. surgery should not be performed until is to avoid repairing the tympanic membrane during the
this is reconciled. otitis-prone years (:S:3 years). If the contralateral ear is
A preoperative audiogram can be helpful in suggesting normal, routine tympanoplasty is considered at age 4 for
underlying pathology. Generally, a perforation will cause an ear that is dry or only occasionally drains with water
I

Ia I

I
II I
~
I I
1
I
 Chapter 153: Reconstruction of the Tympanic Membrane and Ossicular Chain 2469

contamination (16). Ho~ if the contralateral ear is quite dissimilar to the native drumhead in rigidity and thick-
abnormal at this time,. adenoidectomy is considered and ness, yet excellent acoustic outcomes have been attained.
tympanoplasty is deferred until the contralateral ear reaches For example, reconstruction with large cartilage grafts has
stable quiescence or the patient reaches age 7. If contralat- been reported to result in hearing outcomes equal to those
eral disease is still present at this time, a more aggressive with more pliable temporalis fascia (15,19-21 ), including
technique, such as cartilage tympanoplasty, is performed occurrences of complete air-bone gap closure in the speech
on the worse-hearing ear. The second ear is repaired several frequencies. Further complicating the situation is uncertainty
months later, but only after the first ear is documented to regarding the interplay between an aphysiologic recon-
have a stable satisfactory outcome and is not expected to structed tympanic membrane and the underlying aphysi-
require further surgery. ologic reconstructed ossicular chain in collectively providing
acoustic gain (22). Gaps between observed clinical outcomes
TYMPANOPLASTY and predicted tympanoplasty outcomes based on tympanic
membrane acoustic models highlight the fact that there is
General Principles still much to be learned.
Modern tympanoplasty techniques all have common
ground in that they endeavor to reconstruct the deficient Surgical Exposure
middle fibrous layer of a tympanic membrane perforation
The importance of assuring proper visualization and expo-
with graft materials that then act as a scaffold for lateral
sure in order to surgically manipulate the tympanic mem-
epithelial growth. Although simplified myringoplasty tech-
brane and middle ear may seem obvious, but if taken for
niques that utilize non-grafted temporary scaffold mate-
granted, surgical results can be compromised. Line-of-sight
rials, such as a thin paper patch, can be used for small
visualization in itself does not always signify adequate
perforations, they are relatively limited in application and
exposure. The surgeon must assure that instruments are
simple to learn. Thus, patch myringoplasty techniques are
allowed to enter the microscopic field at a sufficiently
not a focus of this discussion.
open lateral angle so as not to impede binocular vision or
The common goals of tympanic membrane repair are to
require awkward manipulation. Although minimally inva-
Create a barrier between the dry lateral epithelialized sive approaches can be desirable, these should only be uti-
compartment (drumhead, external auditory canal, open lized if they provide equally sufficient access and exposure
mastoid cavity) and the moist medial mucosalized com- to the surgical target. The morbidity associated with even
partment (middle ear, eustachian tube) the widest tympanoplasty access route (postauricular with
Provide reinforcement to correct tympanic membrane canalplasty) is generally not high. Table 153.2 provides a
wealmesses in order to resist future disease processes suggested guide for choosing appropriate access for tym-
(atelectasis, perforation) panic membrane repair. One noteworthy consideration is
Create an optimized sound-conducting platform for that when a perforation involves the anterior drumhead,
ossicular coupling or a round window shield for acous- wide exposure via a postauricular incision and, when
tic coupling depending on tympanoplasty type needed, a canalplasty may be helpful.
Create a contour favorable for outward keratin debris
migration
Canal Incisions
Numerous sites for canal incisions have been described to
Applied Tympanic Membrane Mechanics
raise a tympanomeatal flap, and generally these are chosen
The tympanic membrane is the major element of the according to the anticipated surgical plan. Many surgeons
middle ear transformer mechanism and acts as a barrier have traditionally insisted upon preservation of the poste-
between the sound pressure of the ear canal and middle rior-superior vascular strip of canal skin or avoidance of
ear. Its motion, which has been studied with laservibrome- transecting the tympanic annulus. However, many of these
try and stroboscopic holography. is both complex and vari- dictums seem to be routinely ignored by accomplished otol-
able depending on the frequency of stimulation (17,18). ogists with little if any apparent negative consequence. In
At frequencies up to 1,000 Hz, the tympanic membrane reality, quality surgical execution and careful atraumatic han-
tends to vibrate in one consolidated phase, but as fre- dling of canal skin are probably the key factors to a success-
quency rises further, its vibration splits into a state of phase ful outcome regardless of how this is done (see Fig. 153.1).
subdivision, with overall diminished efficiency.
While it is intellectually satisfying to assert that recon-
Preparing the Drumhead
struction of the tympanic membrane must endeavor to
exactly recreate these native vibratoiY patterns, in truth it is Prior to graft placement, the tympanic membrane
unknown if this is possible or even necessaey. Numerous should be prepared to maximize the chances of graft
tympanic membrane graft materials have been used that are take and rapid epithelialization. This typically involves
2470 Section IX: Otology

SUGGES'I15D ROUTES OF ACCESS FOR TYMPANIC

MEMBRANE REPAIR

(
Transcanal J Small myringoplasty
Patch procedures)
(office
posterior underlay tympanoplasty

;::::::=======::::::::

( &mn }=.----
( -~~ }u--
Postaurlcular Underlay tympanoplasty with large anterior component
with Canalplasty Overlay tympanoplasty

freshening the maigins of the perforation with cold knife that have been stripped of perichondrium on the medial
rim resection or laser application in order to encourage surface but have adherent perichondrium or overlying
sprouting of new microvasculature. AJ a general rule, it is fascia on the lateral surface (26). In the authoD' experi-
better to be aggressive in completely removing unhealthy ence, such grafts tend to be much more resistant to involve-
portions of the tympanic membrane than to attempt ment with postoperative middle ear adhesions than either
incorporation of them into the reconstruction process. fascia or perichondrium.
This includes myringitis (particularly important), tympa-
nosclerotic plaque, scat and old graft material. Pathologic
adhesions between the drumhead and middle ear should
also be released.

Choosing, Preparing, and Shaping the Graft

The most commonly used tympanic membrane grafting
material is temporalis fascia, which is desired for its pli-
ability. This is harvested, via either an endaural or post-
auricular incision, as the glistening whitish layer of fascia
immediately overlying the temporalis muscle fibers. After
harvest. this is generally pressed thin and set aside for dJ:y-
ing, which may promote ease of trimming and placement
Readily available alternatives to tempomlis fascia that are
also thin and pliable include pressed perichondrium, peri-
osteum, and muscle. Cadaveric acellular dermal matri.x
(AlloDerm, LifeCell Corp, Branchburg, NJ) (23) has also
been used with Succe8S and may be particularly useful for
simple in-office tympanoplasty procedures where harvest
of a tissue graft is not desired.
Auricular cartilage grafts are very useful in tympano-
plasty (24,25) and may be harvested from various sites, but
are typically harvested from the tragus and the cymba with A
the overlying perichondrium intact These can be applied
Figur. 153.1 Canal incisions. A:. The dassic vascular strip inci-
with or without perichondrium or the concurrent use of sion involves preservation of the posterior canal skin to within a
fascia; howeve~;. the authoiS' bias is to apply cartilage grafts few millimeters of the annulus.
 Chapter 153: Reconstruction of the Tympanic Membrane and Ossicular Chain 2471

c D
Figure 153.1 (Continued) B: A "book page" flap provides particularly good access for graft plae
ment by dividing the annulus \'\lith an Incision through the c:.anal skin and tympanic membrane Into
the perforlrtlon. C: A "ship sail" ftap Is larger at the superior aspect and Is particularly uSQf'ul when
wide curettage of scutum bone results In the need for extra tympanomeatal Rap length for cover
age. D: Modified canal lndslons for underlay tympanoplasty can Incorporate both a standard tym
panomelrtal Rap as v-.11 as a separate anterior canal lndslon to elevate the annulus and anchor the
graft. (Continued on next page)
2472 Section IX: Otology

;
/

Figure 153.1 (Continued) E: Overlay tympano-

......... __ _, .;'
/

plasty naqulres Incisions thllt afford removal of the

anterior canal wall skin to allow ac:aw for canalplasty.
F: Overlay tympanoplasty lndsions can be modified
to allow wider removal of canal skin If deslnad. F

When the use of a composite perichondrium-cartilage a cartilage graft thickness of 0.7 mm or less is preferable;
island graft is desired, perichondrium is usually stripped hoM!Vel;. ifshaved too thin, undesirable curling of the graft
off of one side, and the remaining au'lilage is cut to the mayoCOJr.
desired shape as an "island upon the preserved opposite lhe choice of graft material is made based on the com-
side (see Fig. 153.2). If used for repair of a large perfora- plexity of the reconsttuction and the activity of any under-
tion, a composite island graft is shaped into a thin circu- lying chronic ear disease. In higher risk situatiom, cartilage
lar disk 8 to 9 mm in diameter, with a notch cut to cradle tympanoplasty techniques may provide more durable
the malleus manubrium and tails of perichondrium on results (27,28). A high-risk perforation might be consid-
the periphecy that can be anchored on the atemal audi- ered one that is huger than 50%, an anterior perforation,
toty canal wall under the annulus. For optimized acoustics, a perforation draining at the time of surgery, a recurrent
 Chapter 153: Reconstruction of the Tympanic Membrane and Ossicular Chain 2473

External Auditory
Canal Skin _ _ _ __..,

A 6
Figure 153.2 Composite perichondrium-cartilage i'land graft. A:. A compo'ite perichondrium-
cartilage island graft is formed by stripping perichondrium off a 'ingle side of the graft. The carti-
lage i' then cut to the desired 'hape and size without violating the remaining perichondrium. For
total tympanic membrane reconsu-uc1ion, the preferred diameter of the graft i' 8 to 9 mm. A 1-mm
cemral su-ip of cartilage i' removed to accommodate the malleu' handle and to allow posterior graft
elevation for ossiculoplany. The remaining peripheral perichondrial "apron" i' 'et over the canal
wall bone. B: Cross 'action of a perichondriurn-c:artilage island used as an underlay graft.

perforation (29,30), or a perforation in the setting of per- First. medial support is obtained via absorbable middle
manent absent eustachian tube function. Other situations ear packing material. Second, adhesion occun between the
where cartilage is useful are the atelectatic eat; retraction graft and the Wldersurface of the adjacent native drumhead
pockets, and cholesteatoma as re-attophy and perforation and between the graft and lateral packing material through
are common over the long term when fascia is used solely the perforation. Finally, the peripheral aspect of the graft
in the reconstruction (31). is anchored in place between the tympanic annulus/
Mini split-thiclmess skin grafts may also be used as an canal skin and the Wlderlying bone of the external audi-
adjuvant in tympanoplasty. Although it is generally not tory canal. Anchoring almost always involves the posterior
advisable to graft the entire reconstructed drumhead due canal wall and tympanomeatal flap but has also been
to the potential for dysfunctional postoperative epithelial described at various anterior points (32,33).
migration, small grafts (4 mm or less in any dimension) 1he advantages of underlay grafting include simplicity,
tend to inco~porate well with adjacent native epithelium. rapid exeaJtion, and a high rate ofreponed success. Howevet
When utilized,. these grafts are best rendered very thin and failures do occw;. and these are most often related to avm'eli-
positioned partially upon the intended tympanic graft anre on middle ear packing mate:rials. If peripheral annulus
target and at least partially upon adjacent healthy canal anchoring is insufficient, packing may fail to prevent medial
bone. Instances where mini split-thiclmess skin grafts (inwan:l) graft displarement and point separation of the graft
may be particularly useful include correction of tympanic from the perfomtion edge This seems to be a particular risk
membrane blunting, repair of total tympanic membrane when repairing an anterior or near-total perforation. In the
defects, removal of chronic granular myringitis, and treat- autho:rs' experience, lalge rigid cartilage grafts are less likely
ment of tympanic slag injury. than fascia or perichondrium to displace medially.
Another theoretic negative consequence of underlay
grafting relates to development of postoperative middle
Underlay Repair
ear adhesions and ffmpanosclerosis. When middle ear
Underlay tympanoplasty is the most widely used tympanic mucosa is denuded, the large volume of middle ear pack-
membrane repair technique and is suitable for perfora- ing required for underlay graft support harbors the poten-
tions of all sizes and locations (see Fig. 153.3). The concept tial to increase scar formation between the walls of the
of Wlderlay grafting involves placement of graft material middle ear cleft and the undersurface of the drumhead.
immediately Wlderneath the residual native drumhead in Additionally, redundant margins of underlay graft that lie
a manner that accounts for the entire defect and all per- in contact with the ossicular chain have the potential to
foration m;ugins. 'Ihree forces typically support this graft. adhere and negatively affect ossicular mobility.
2474 Section IX: Otology

c D
Figure 153.3 Underlay tympanoplasty. A:. The rlm of the perforation ls freshened. 1: The tympa
nomeatal flap ls raised and middle ear work completed as needed, lndudlng palpation of the os-
sicular chain. C: The graft ls set In an underlay fashion to account for all margins of the perforation.
D: Afwr application of middle ear packing to support the graft medially, the t:ympanomeatal ftap Is
returned to the anatomical posh:lon, wh:fl perforation closure assunad.

Overlay Repair in dealing with anterior and near total defects (34). They
have the advantage of being relatively resistant to graft fail-
The basic concept of overlay or "'ataal grafting.. involves ure due to inadequate medial support and inward graft
de-epithelialization of the tympanic membrane remnant migration during the healing phase sometimes seen with
while preserving what exists of the native middle :fibrous underlay techniques.
layer. This preserved middle layer remnant il!l then used as Most common overlay graft techniques are combined
partial medial support upon which grafting materiab are with canalplasty to remove the bulge of the anterior canal
set (see Fig. 153.4). Overlay techniques are robust and can wall. De-epithelialization of the tympanic membrane is
be applied to all perforations, but they are especially useful often Wldertaken as part of the process of exposing the
 Chapter 153: Reconstruction of the Tympanic Membrane and Ossicular Chain 2475

A B

c
Figure 153.4 Overlay tympanoplasty. A: With e~~pQ,ure of the canal wall for canalplany, all lateral
epithelial components of the remnant tympanic membrane are di,9&Cted free. B: The graft is shaped
with a notch for the malleus to account fer the entire surfaat of Ute tympanic membrane. C: The
graft is plaatd medial to the malleus handle to prevent lateralization and then draped over Ute canal
wall on the periphery, lateral to Ute fibrous tympanic membrane remnant. (CIJntinued on next page)
2476 Section IX: Otology

D Ledge drilled at anterior annulus E

Figure 153.4 (Continued) D: Cross section of overlay graft in

place. Of note, the anterior canal wall mun be drilled with a groove
to open the acute anterior tympanomeatal angle. This area is also
tiglnly pEtdc:ed. E: If epithelium is left on the remnant tympanic
membrane, an imratympanic keratin cyst may result. F: Inadequate
packing or drilling of the anterior canal wall can result in blunting.
Functionally, this becomes a problem when the malleus handle
becomes fixed to the anterior canal wall by scar tissue. F

bone of the anterior canal wall for drilling, wherein the surface area of the drumhead and ...pseudo-malleus fixa-
canal skin is elevated in continuum with the epithelial tion caused by adhesion between the manubrium and the
remnants of the drumhead. Usually, this canal wall skin anterior canal wall. This risk can be minimized not only by
is removed and reset near the end of the swge:ry as a free canalplasty, but also by strategically packing this area after
graft. Care should be taken that all epithelial remnants graft placement.
have been removed prior to graft overlay in order to pre-
vent development of intratympanic keratin inclusion cysts.
It is important to understand that canalplasty is per-
Unique Situations
formed with overlay grafting not only to provide adequate Atelectasis
exposure to the anterior tympanic ring, but also to open Tympanic membrane atelectasis may require augmenta-
the acute anterior tympanomeatal angle between the tion with an underlay graft (usually cartilage) or;. rarely,
anterior canal wall and drumhead in an effort to prevent drum replacement (14). As a general rule, when atelectasis
postoperative blunting of this area. Blunting can be fimc- is limited and has not resulted in the need for ossiculo-
tionally undentood as dense scarring of the anterior tym- plasty, medical management to promote eustachian tube
panic membrane that results in reduction of the functional function or tympanostomy tube placement is sufficient.