--- title: "Tympanoplasty Part 2 - Approaches, Techniques, Steps & Complications" description: "ENT notes on surgical approaches, Underlay and Overlay grafting, surgical steps and complications of Tympanoplasty - for MBBS and ENT students." source: "The ENT Resident" author: "Dr. Mausumi Das" canonical_url: "https://www.theentresident.com/ent-notes-lectures/tympanoplasty-approaches-techniques-steps" categories: ["Otology", "Surgery"] video: "https://www.youtube.com/watch?v=-XnZQu0wCs0" image: "https://media.theentresident.com/og-images/tympanoplasty-approaches-techniques-steps.png" --- # Tympanoplasty Part 2 - Approaches, Techniques, Steps & Complications ENT notes on surgical approaches, Underlay and Overlay grafting, surgical steps and complications of Tympanoplasty - for MBBS and ENT students. Watch the full video lecture on YouTube: https://www.youtube.com/watch?v=-XnZQu0wCs0 ## Tympanoplasty : Part 2 - Approaches, Techniques, Steps & Complications Continued from **Part 1** - [Tympanoplasty Definition, Types, Grafts, Indications, Contraindications](https://www.theentresident.com/ent-notes-lectures/tympanoplasty-types-indications-contraindications.md). 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 --- ## About This Note This free ENT note on Tympanoplasty Part 2 - Approaches, Techniques, Steps & Complications was written by Dr. Mausumi Das and is paired with a corresponding video lecture. 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