Tympanoplasty — Procedure Guide, Recovery & Risks | MyMedicPlus

Tympanoplasty is a microsurgical operation performed under magnification to repair a perforated tympanic membrane (eardrum) using a biological graft material, restoring the structural integrity and acoustic coupling function of the eardrum and eliminating the chronic risk of middle ear infection that a persistent perforation creates. Tympanic membrane perforations arise from acute otitis media with spontaneous perforation, barotrauma (sudden pressure change in flying or diving), direct trauma (cotton bud injury, slap to the ear, blast injury), or iatrogenic perforation after myringotomy. Perforations are classified by size (small under 25%, moderate 25-50%, large over 50% of the tympanic membrane surface area), by location (central perforations in the pars tensa — most amenable to repair; marginal perforations at the annulus; and attic perforations in the pars flaccida suggesting cholesteatoma), and by whether the ossicular chain is intact or damaged. The Wullstein classification system defines five types of tympanoplasty based on the status of the ossicular chain: Type I (myringoplasty — perforation repair with intact ossicular chain) is the most common; Types II-V involve progressively greater ossicular reconstruction. Graft materials include autologous temporalis fascia (gold standard), tragal perichondrium and cartilage, fat from the ear lobule for small perforations, and AlloDerm (acellular dermal matrix) as an alternative where autograft harvest is not feasible.

Tympanoplasty is indicated for persistent tympanic membrane perforations that have not healed spontaneously after an adequate observation period of 3–6 months, particularly when the perforation causes conductive hearing loss of 15–20 dB or greater on audiometry, recurrent ear discharge (otorrhoea) with exposure to water, or chronic discomfort and tinnitus. Patients with safe chronic otitis media (CSOM mucosal type) who wish to swim, bathe without ear protection, or are troubled by recurrent water-entry infections are good surgical candidates. Contraindications to surgery include the single hearing ear (relative contraindication requiring careful risk-benefit discussion), active purulent middle ear infection at the time of surgery (procedure should be deferred until the ear is dry), poorly controlled diabetes, and patients unable to comply with post-operative ear care restrictions. Pre-operative audiometry and tympanometry confirm the degree of hearing impairment. Imaging with CT of the temporal bone is performed when cholesteatoma is suspected.

Tympanoplasty is performed under general anaesthesia — or local anaesthesia with sedation in selected adult cases — using an operating microscope for high-magnification visualisation of the delicate middle ear structures. The graft material is harvested first: a small incision above and behind the ear (within the hairline) exposes the temporalis muscle, and a thin layer of temporalis fascia approximately 1.5 x 1.5 cm is harvested with scissors and electrocautery, pressed to remove moisture, and allowed to partially dry on a Teflon block. Tragal cartilage with its overlying perichondrium is an increasingly used alternative providing a stiffer, more robust graft with better results in revision cases or large perforations. Access to the tympanic membrane is achieved through the ear canal (transcanal approach for small posterior and inferior perforations) or via a retroauricular (post-auricular) incision behind the ear (for larger perforations, anterior perforations with limited visualisation, or combined mastoid surgery). The perforation edges are freshened (de-epithelialised) with a pick or microsurgical curette to create a raw vascular rim promoting graft ingrowth. The middle ear mucosa is inspected and the ossicular chain assessed for mobility and integrity. The graft is placed using the underlay technique (most widely used) — slid beneath the tympanic membrane remnant and onto the medial surface of the canal wall skin and fibrous annulus, providing circumferential support and allowing the native eardrum to grow over the graft surface. Alternatively, the overlay technique places the graft lateral to the remnant. Gelfoam or silicone sheeting is packed in the middle ear to support the graft. The ear canal is packed with antibiotic-impregnated gauze. Total operative time is 45-90 minutes.

Successful tympanoplasty eliminates the chronic pathway for bacterial contamination of the middle ear, ending the cycle of recurrent discharge and infection that affects quality of life and requires repeated antibiotic courses. Hearing improvement is a primary goal: graft take rates exceed 85–90% with temporalis fascia underlay technique in primary surgery, and audiometric improvement of 10 dB or more is achieved in 70–80% of patients with a successful graft. Normal or near-normal hearing is restored when the ossicular chain is intact and mobile. Patients who have undergone successful repair can bathe and swim without ear protection, eliminating a significant lifestyle restriction. The elimination of chronic otitis media also reduces the risk of complications including cholesteatoma (skin cyst formation) that can cause serious local destruction, and prevents hearing from deteriorating further over time in affected ears.

Graft failure with re-perforation occurs in 10–15% of primary tympanoplasty cases with temporalis fascia and is more common in smokers, ears with active infection at surgery, patients with poor Eustachian tube function, and large or anteriorly placed perforations. Sensorineural hearing loss as a surgical complication is rare (under 1%) but can result from surgical manipulation near the oval window or inadvertent trauma during ossicular inspection. Taste disturbance or numbness on the same side of the tongue occurs in 5–15% of patients from stretching or section of the chorda tympani nerve, which crosses the middle ear cavity; this resolves in most cases over 3–6 months. Tinnitus may worsen transiently post-operatively. Dizziness lasting hours to days can follow middle ear manipulation. Post-auricular wound infection and delayed healing are uncommon. Unsuccessful repair can be reattempted with revision tympanoplasty using cartilage reinforcement.

The ear canal cotton wool plug is removed at 1–2 weeks at the post-operative clinic visit. Water must be kept completely out of the operated ear for 6–8 weeks to protect the healing graft — cotton wool with petroleum jelly is used to seal the canal when showering or washing hair. Forceful nose-blowing, heavy lifting, and straining (Valsalva manoeuvre) must be avoided for 4 weeks as increased middle ear pressure can displace the ungrafted tissue. Sneezing with an open mouth is advised. Flying should be avoided for 4–6 weeks. Hearing improvement begins at 4–6 weeks as the absorbable packing dissolves; maximum benefit is assessed at formal audiometry at 3 months post-operatively. Full activity including swimming in a chlorinated pool typically resumes at 8 weeks if the graft is confirmed healed on endoscopic examination. A follow-up audiogram at 6–12 months documents the final hearing outcome.