1. Myringoplasty Tympanoplasty
Department of Otorhinolaryngoglogy
the 2nd Hospital affliatted to Medical college
Zhejiang University
Xu Yaping

2. overview Define terms History Anatomy Preoperative evaluation
Techniques
Complications
Results

3. Definition
Myringoplasty and tympanoplasty are descriptive terms defining surgical procedures that address pathology of the tympanic membrane (TM) and middle ear.

4. Tympanoplasty – reconstruction of the TM
Myringoplasty - reconstruction of a perforation of the tympanic membrane (TM)
Assumes – normal middle ear (ME) mucosa and ossicles
TM is not elevated from its sulcus
Tympanoplasty – reconstruction of the TM
Also includes addressing middle ear pathology
Cholesteatoma, adhesions
Ossicular chain problems
Usually involves elevating the TM from its sulcus

5. Classification of Tympanoplasty Wullstein (1956)
Type I: Hearing is achieved via an anatomically and functionally intact lever mechanism of the ossicular.
an intact ossicular chain
Type II: Hearing is achieved via an abnormal but recontructed lever mechanism of the sound-conducting ossicular.
Malleus is partially eroded
TM +/- malleus remnant is grafted to the incus
Type III: Hearing is achieved without a lever mechanism but with sound pressure transformation of the tympanic membrane.
Malleus and incus are eroded
TM is grafted to the stapes suprastructure

6. Types with sound protection
Type IV: Hearing is achieved by sound protaction of one of the windows ( usually the round window) through the lower aeration pathway.
Stapes suprastructure is eroded but foot plate is mobile
TM is grafted to a mobile foot plate
Type V Tympanoplasty
TM is grafted to a fenestration in the horizontal semicircular canal

7. History of Tympanoplasty
1640 – Banzer
First attempt at repair of a TM perforation
Used pigs bladder as a lateral graft
1853 – Toynbee
Placed a rubber disk attached to a silver wire over the TM
Reported significant hearing improvement
1863 – Yearsley
placed a cotton ball over a perforation
1877 – Blake
Paper patch
First reported use of cartilage for reconstruction of the TM

8. 1876 – Roosa 1878 – Berthold Treated TM perf. with chemical cautery
Coined the term myringoplasty
Placed cork plaster against TM to remove epithelium
Applied a FTSG

9. Anatomy

10. Preoperative Evaluation
History
Hearing loss
Tinnitus
Vertigo
Otalgia
Otorrhea
Facial paralysis
Prior otologic procedures
Medical history – DM, heart, lung, kidney, liver

11. Physical exam – complete H/N exam
Facial nerve
External ear
Tullio’s Phenomenon
Otomicroscopy
Ear canal TM
Perforation – location, size
Retraction pockets, granulation tissue
Status of middle ear through perforation
Audiometry – preferable with a dry ear >2 weeks
Air and bone lines, acoustic reflexes
Tympanometry: eustachian tube
+/- CT temporal bone

12. Indications for Surgery
Conductive hearing loss due to TM perforation or ossicular dysfunction
Chronic or recurrent otitis media secondary to contamination
Progressive hearing loss due to chronic middle ear pathology
Perforation or hearing loss persistent > 3 months due to trauma, infection, or surgery
Inability to bathe or participate in water sports safely

13. Goals of Surgery Establish an intact TM
Eradicate middle ear disease and create an air-containing middle ear space
Restore hearing by building a secure connection between the ear drum and the cochlea

14. Myringoplasty

15. Techniques Overlay technique (lateral grafting)
Underlay technique (medial grafting)

16. Medial Grafting

17. Debride the edges of the perforations
Purpose
Separates the continuity
of the inner mucosa with
the outer epithelium
Disrupts the fistulous tract

18. Elevation of the tympanomeatal flap
Inspect the undersurface of the TM for squam
Inspect the middle ear
Ossicles
Erosion
mobility
Round window reflex
Eustachian tube

19. Pack middle ear with gelfoam

20. Placing medial fascia graft

21. Replacing the tympanomeatal flap

22. Lateral Grafting

23. Tympanic Membrane Oval shape. 8x10 mm.
55° angle w/ respect to floor of meatus.
130 µm thick.
3 layers:
Outer epithelial – keratinizing squamous
Middle fibrous – superficial radial, deep circular
Inner – mucosa

24. Graft Materials Fascia Perichondrium: tragal cartilage Vein Dura Skin
Cartilage: tragal cartilage

25. Inlay Butterfly Graft
Eavey RD 1998

26. Placement of Butterfly graft

27. Postop Inlay Butterfly graft

28. Inlay graft for large perforation

29. Tragal perichondrium Harvest
Cut on medial side of tragus
Leave 2 mm tragal cartilage for cosmesis
Abundance: 15 x 10 mm
Flat
~ 1 mm thickness
Perichondrium is removed
Dornhoffer 2003

30. Perichondrium/ Cartilage Graft
Dornhoffer 2003

31. Medial Grafting
Dornhoffer 2003

32. Postop Perichondrium/ Cartilage Island Graft
Dornhoffer 2003

33. Postop care 2 weeks postop: Gelfoam completely suctioned from EAC
Start topical antibiotics x 2 weeks
Adult: Start valsalva
Children: Otovent TID
3-4 months: Audiogram
Air bone gap
Tympanogram no longer reliable. Type B tymp despite normal hearing

34. Cartilage T-plasty with TORP

35. Type III tympanoplasty

36. TORP using cartilage stiffener

37. Type IV Tympanopasty

38. Complications Infection Graft failure Poor aseptic technique
Prior contamination
Graft failure is associated with postop infection
Graft failure
Inadequate packing (anterior mesotympanum)
Inadequate overlay of graft with TM remnant (underlay)

39. Injury to the chorda tympani nerve SNHL and vertigo
Chondritis
Injury to the chorda tympani nerve
SNHL and vertigo
Excessive manipulation of the ossicles
Increased conductive hearing loss
Unrecognized eroded ISJ
Blunting
Thick graft extending onto the anterior canal wall in lateral grafting
Lateralization of the TM from the malleus handle
External auditory canal stenosis
Lateral grafting

40. Conclusion
A high rate of success in closing tympanic membrane perforations and improving hearing
Patients should be chosen carefully based on the indications for a dry ear prior to surgery
Patients should be thoroughly counseled preoperatively about the expectations and goals of the surgery
Tympanoplasty in the pediatric age group is controversial
(less successful than adults,higher incidence of ETD --eustachian tube dysfunction and otitis media)
Both underlay and overlay techniques for grafting are effective, however, the surgeon should do what he/she is most experienced and successful