Tympanoplasty Part 2 - Approaches, Techniques, Steps & Complications

Tympanoplasty : Part 2 - Approaches, Techniques, Steps & Complications

Continued from Part 1 - Tympanoplasty Definition, Types, Grafts, Indications, Contraindications.

In Part 2 of Tympanoplasty, we'll delve into the following practical aspects:

• Different Surgical Approaches (Endomeatal, Endaural and Postaural)
• Anesthesia
• Patient Positioning & Hemostasis
• Prophylactic Antibiotics & Surgical Area Prep
• Grafting Techniques (Underlay vs. Overlay), including detailed steps
• Postoperative Care
• Potential Complications

✨ Surgical Approaches to the Ear

There are three main approaches to access the middle ear for Tympanoplasty:

1- Endomeatal / Transcanal Approach:

• Approach is through the External Auditory Canal (EAC).
• Incision: Rosen's incision

What is Rosen's incision?

What are the Indications, Advantages and Disadvantages of Endomeatal Approach?

2- Endaural Approach:

• Approach through the EAC, but requires a wider incision extending to the external ear.

• Incision: Lempert's incision

What is Lempert's incision?

What are the Indications, Advantages and Disadvantages of Endaural Approach?

3- Postaural Approach:

• Approach via an incision behind the ear.

• Incision: Wilde's incision

What is Wilde's incision? How is different in adults and children?

What are the Indications, Advantages and Disadvantages of Postaural Approach?

✨ Anesthesia

• Typically performed under Local Anesthesia (1% Xylocaine with 1:100,000 Adrenaline).
• General Anesthesia is used in children, anxious adults, or for complex/prolonged procedures.

Patient Positioning:

• Patient placed close to the table edge.

• Head turned 120 degrees away from the surgeon (ear being operated on faces upwards). Folded towel supports contralateral cheek. Rotating head towards surgeon improves posterior field view; rotating away improves anterior field view.

What are the different ways you can achieve good hemostasis during Tympanoplasty?

Prophylactic Antibiotics:

• Generally NOT needed for uncomplicated, dry central perforations.

• Recommended for patients with active/recently active draining ears.

Surgical Area Preparation:

• Shave hair ~2-3 cm above and behind the auricle (for graft harvest).
• Cleanse with alcohol and iodine solution.
• Drape area.
• Inject postauricular area with local anesthetic with adrenaline.

🧬 Tympanoplasty Grafting Techniques

The method of placing the graft relative to the TM remnant/annulus:

1- Underlay Technique:

• Graft is placed MEDIAL to the TM remnant (pars tensa) or the annulus and the malleus handle.

What are the Advantages and Disadvantages of Underlay Technique?

2- Overlay Technique:

• Graft is placed LATERAL to the TM remnant (pars tensa) or the annulus, but MEDIAL to the malleus handle.

What are the Advantages and Disadvantages of Overlay Technique?

✂️ Steps of Tympanoplasty

Steps vary based on approach and technique, but share core elements:

1. Approach Incision & Flap Elevation
2. Graft Harvest
3. Middle Ear Entry
4. Disease Eradication
5. Ossicular Chain Assessment & Reconstruction (if needed)
6. Middle Ear Packing
7. Graft Placement
8. Graft Stabilization
9. Flap Repositioning
10. EAC Packing
11. Closure
12. Dressing

📘 In my notes, I’ve discussed the surgical steps of both Underlay and Overlay techniques in great detail. Get full access by purchasing the notes.

👩‍⚕️ Postoperative Care in Tympanoplasty patient

• Discharge: Usually on the day of surgery or the next day (if nausea/vomiting).
• Mastoid Dressing: Removed after ~1 week.
• First Post-op Visit (around 7 days): Remove dressing and external sutures.
• Restrictions: Avoid nose blowing (can displace graft), heavy lifting, straining for a few weeks. Keep the ear dry (avoid water).
• Medications: Oral antibiotics (if ear was infected pre-op or for prophylaxis in some cases), analgesics.
• EAC Packing (Gel foam): Should NOT be removed by the patient. Will dissolve/fall out gradually over 3-4 weeks. Physician may remove it at follow-up visits if needed.

When is hearing improvement seen in Tympanoplasty patient post op?

When should you do repeat audiogram to check for hearing improvement in a post op Tympanoplasty patient?

⚠️ Complications of Tympanoplasty

Complications can occur early (intra-operative or shortly after) or late.

Early Complications:

• Intraoperative Bleeding

  • Jugular Bulb Injury
  • Internal Carotid Artery Injury

• Facial Nerve Injury

What should be your approach in case of a Facial nerve injury in a post operative case of Tympanoplasty?

• Wound Infection / Perichondritis

• Wound Hematoma

• Chorda Tympani Nerve Injury

How do you treat Chorda Tympani nerve injury?

• Sensorineural Hearing Loss (SNHL)

• CSF Leak

Late Complications:

• Tympanoplasty Failure

What are the causes of Tympanoplasty Failure?

• Graft Lateralization

• Epithelial Pearl/Cyst Formation

• Blunting

• Stenosis of EAC

• TM Retraction / Atelectasis

• Meningitis / Brain Abscess

• Granuloma Formation