TYMPANOPLASTY
DEFINITION: It is an operation in which reconstruction of the tympanic
membrane and the ossicular chain is done after removing active disease, if
any, from the middle ear cleft.
INDICATIONS:
1. Benign perforations of the tympanic membrane.
2. Dry perforations of the tympanic membrane free of active infection.
CONTRAINDICATIONS:
1. Dangerous perforation of the tympanic membrane.
2. Wet perforation of the tympanic membrane with otorrhoea.
3. Septic foci.
4. Eustachian tube dysfunction.
5. Sensorineural deafness.
6. Fixation of stapes to the oval window.
7. Conditions making the patient temporarily unfit for surgery: uncontrolled
diabetic mellitus, hypertension, etc.
8. Coagulopathy.
TYPES:
TYPE - I: Only the tympanic membrane is repaired.
TYPE – II: The tympanic membrane is repaired along with transposition
or ossicular grafting.
TYPE – III: Incus and malleus are absent. The grafted tympanic
membrane is placed in contact with the head of stapes (Columella
effect).
TYPE – IV: Superstructure of stapes is absent. The oval window is
exposed to the exterior, while the round window and the Eustachian
tube opening are protected by the grafted tympanic membrane (Baffle
effect).
TYPE – V: Foot plate of stapes is fixed. Hence fenestration operation is
done in which a window is made in the lateral semicircular
TECHNIQUE:
1. Anaesthesia: local or general.
2. Poition: supine, with the head turned to the opposite side, and the neck
extended with a pillow under the shoulder on the same side.
3. A postaural incision is made 0.5 cm behind the retroauricular sulcus.
Alternatively an enaurl incision may be made.
4. An operating microscope is used for subsequent steps.
5. The edges of the perforation are made raw. The onlay technique is
used, in which the outer layer of the tympanic membrane is reflected
from the middle fibrous layer along with some portion of the skin of the
external auditory meatus.
6. The ossicular chain is inspeted by lifting up the remaining layers of the
tympanic membrane from its attachment to the annulus.
7. Any discontinuity of the chain is corrected by transposition of the
ossicles or by using ossicular autografts or homografts (see table). Bio
materials are available as total ossicular replacement prosthesis
(TORP) or partial ossicular replacement prosthesis (PORP).
Simple mastoidectomy is done if any disease is suspected to be
present in the mastoid.
8. The perfortion is repaired by laying temporalis fascia on the fibrous
middle layer of the tympanic membrane. The ear canal skin and the
outer layer of the tympanic membrane are replaced back on the
temporalis fascia (onlay technique).
9. Alternatively one may use the inlay yechnique in which the graft is
place medial to the fibrous layer of the tympanic membraneby
elevating the tympanic membrane from its annulus in its posterior
aspect.
10. Pressure is maintained on the grafted tympanic membrane by
gelatine sponge pieces and a cotton plug placed over it in the external
auditory canal.
11. A mastoid bandage is applied.
COMPLICATIONS:
Immediate
1. Haemorrhage.
2. Damage to the inner ear if stapes is removed accidentally.
3. Injury to the facial nerve.
4. Damege to meninges and CSF otorrhoea.
5. Injury to sigmoid sinus.
Delayed
1. Infection of the external auditory canal.
2. Acute perichondritis of the pinna: with an endaural ncision.
3. Sensorineural deafness due to damage to the labyrinth.
4. Facial paralysis: due to injury to the fcial nerve.
5. Conductive hearring loss.
6. Failure of the graft: 5% cases.
