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Right Tympanoplasty Under General Anesthesia

A Complete Pre-Operative Guide for the Junior Resident

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1. SURGICAL ANATOMY

The Tympanic Membrane (TM)

Middle Ear (Tympanic Cavity)

• Lateral wall: TM + scutum (bony outer attic wall)
• Medial wall: Promontory (basal turn of cochlea), oval window, round window, facial nerve canal (horizontal segment runs above oval window — critical to protect)
• Anterior wall: Eustachian tube opening + carotid canal (thin bone separates them)
• Posterior wall: Aditus ad antrum, pyramidal eminence (stapedius tendon), facial nerve (descending segment)
• Roof (tegmen tympani): Thin bone separating middle ear from middle cranial fossa dura
• Floor: Thin bone over jugular bulb (may be dehiscent — aberrant jugular bulb)

Ossicular Chain

• Malleus → Incus → Stapes → oval window
• The long process of incus articulates with stapes head at incudostapedial joint
• In simple CSOM (Type I tympanoplasty), the ossicular chain is intact — your job is only to repair the TM

Facial Nerve

• Horizontal (tympanic) segment: runs above oval window in the medial wall
• Vertical (mastoid) segment: posterior to the middle ear
• May be dehiscent in 10–25% of patients — always identify before drilling

Eustachian Tube

• Opens into anterior wall of tympanic cavity
• Patency is the single most important factor for graft success
• Dysfunction → graft failure / retraction pocket

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2. INDICATIONS

Absolute Indications

• Chronic Suppurative Otitis Media (CSOM) — Tubotympanic (Safe) type with central perforation
• Traumatic perforation not healed after 3 months
• Dry central perforation causing conductive hearing loss (CHL)
• Prevention of recurrent otitis media episodes
• Improvement of hearing (audiological rehabilitation)

Relative Indications

• Single hearing ear with perforation (with caution)
• Bilateral perforations (staged — worse ear first)
• Perforation in a child (debated — some prefer after age 7)

Wullstein Classification (Know This!)

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3. CONTRAINDICATIONS

Absolute

• Active wet ear / discharging ear — must treat medically first (minimum 6 weeks dry ear)
• Atticoantral (unsafe) disease / cholesteatoma — requires mastoidectomy first; tympanoplasty alone is contraindicated
• Only hearing ear with high surgical risk (relative)
• Malignancy of external/middle ear

Relative

• Eustachian tube dysfunction — graft failure rate very high; consider adenoidectomy/ET balloon dilation first
• Uncontrolled DM — poor healing, infection risk
• Immunocompromised patient
• Extremely young child — higher failure due to ET dysfunction (most centres prefer ≥5–7 years)
• Nasal/sinus disease uncontrolled — URTI, chronic sinusitis (impacts ET)
• Very poor contralateral ear — anaesthetic risk for the hearing

Practical Pre-Op Rule

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4. PRE-OPERATIVE PREPARATION

Clinical Assessment

• Full otoscopic/endoscopic examination — document perforation size (small <25%, medium 25–50%, large >50%, subtotal, total), location (anterior, posterior, central), and condition of remnant TM
• Examine other ear
• Tuning fork tests: Rinne (512 Hz) and Weber — establish whether conductive loss
• Nasal examination — rhinoscopy, assess for DNS, turbinate hypertrophy, nasal polyps (ET patency)
• Eustachian tube function test (Valsalva, Toynbee)

Audiological Workup

• Pure Tone Audiometry (PTA) — mandatory; establishes baseline; air-bone gap (ABG) should correlate with perforation size
  • Good prognosis if ABG < 30 dB
• Tympanometry — type B flat curve expected; check contralateral ear (As = stapes fixation, C = ET dysfunction)
• Speech discrimination score — helps counsel patient on expected post-op gain

Investigations

Note: HRCT temporal bone is NOT mandatory for straightforward Type I tympanoplasty in Indian practice, but obtain it if there is any suspicion of cholesteatoma, previous failed surgery, or unusual findings.

Anaesthetic Fitness

• ENT anaesthesia joint assessment
• Standard nil-by-mouth (6 hours solid, 2 hours clear fluids)
• Consent for: tympanoplasty, possible ossiculoplasty if chain disrupted intraoperatively, possible cortical mastoidectomy if disease found

Pre-operative Aural Toilet

• Dry mopping, suction clearance under microscope
• Antibiotic ear drops (ciprofloxacin) for 1–2 weeks pre-op if any discharge
• Nasal decongestants if any nasal congestion

Medications to Stop

• Aspirin, NSAIDs — 7–10 days before
• Anticoagulants — per haematology advice

Graft Harvesting Planning

• Temporalis fascia — gold standard; harvested from same side
• Tragal perichondrium — good alternative; quicker, less morbidity
• Cartilage (tragal/conchal) — for large perforations, revision cases, or when reinforcement needed

Patient Counselling

• Success rate: 85–95% for Type I in dry ear
• Hearing improvement expected but not guaranteed
• Risk of facial nerve injury, taste disturbance (chorda tympani), dead ear (rare), tinnitus, dizziness
• Post-op water precautions for 3–6 months

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5. DETAILED SURGICAL STEPS

Setup and Positioning

• GA with endotracheal intubation (RAE tube — south-facing, preferred in head and neck)
• Patient supine, head turned to left (for right ear)
• Head ring for stabilisation
• Ipsilateral shoulder slightly elevated with a roll
• Operating microscope / endoscope positioned
• Surgeon sits at head end (or at the side for endoscopic)

Injection

• Local infiltration (even under GA — reduces bleeding, aids hydrodissection):
  • 1% Lignocaine with 1:200,000 adrenaline
  • Inject at 4 points in posterior EAC skin (6, 9, 12 o'clock positions) and meatal incision site

Approach Options

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STEP-BY-STEP: Postaural Approach, Underlay Technique

• Incise skin 5–7 mm behind the postauricular sulcus (stay behind sulcus to avoid visible scar)
• Deepen to periosteum
• Graft harvest at this step — identify and harvest temporalis fascia through the same incision before it becomes vascular from retraction

• Elevate skin flap anteriorly to expose temporalis muscle
• Score fascia with a scalpel, harvest adequate piece (usually 2 × 2 cm)
• Stretch on flat surface (Teflon/glass), allow to dry for 15–20 minutes (important — wet fascia is slippery, hard to handle)

• Separate the auricle from the bony EAC by elevating soft tissue anteriorly
• Self-retaining retractor placed (Mollison's or mastoid retractor)
• Identify the bony EAC

• If canal is narrow, drill posterior-superior canal wall with Skeeter/cutting burr to improve visualisation

• Under the microscope, incisions are made in the EAC skin:
  • Posterior incision: from 12 to 6 o'clock at the bony-cartilaginous junction (about 6–8 mm from the annulus)
  • Radial incisions: at 12 and 6 o'clock extending to the annulus
• The tympanomeatal flap is elevated from lateral to medial using a round knife or Sickle knife

• Identify the annulus in the tympanic sulcus
• Elevate annulus using a Fisch or Rosen elevator — posteroinferiorly first (safer, away from chorda and ossicles)
• Lift the TM remnant and annulus forward — this exposes the middle ear

• Check ossicular chain: malleus, incus, stapes — mobility by gentle palpation
• Look for: disease (granulations, cholesteatoma — must be excluded), ossicular erosion
• Inspect: facial nerve canal, round window niche, ET orifice
• Chorda tympani — runs across the middle ear from posterior to anterior; preserve if possible; if it hinders access, can be sacrificed (causes temporary taste disturbance)
• Scutum — if needed, nibble with Citelli forceps for better visualisation of posterior epitympanum

• Freshen the edges of the perforation — remove all squamous epithelium from the rim
• Use fine cup forceps, sickle knife, or picks
• Important: Any residual epithelium → pearl cholesteatoma post-op
• Also de-epithelialize the medial surface of the TM remnant for ~2 mm — this creates a raw surface for graft take

• Underlay = graft placed medial to the TM remnant and annulus — this is the most widely used technique
• Before placing graft:
  • Pack the middle ear with Gelfoam soaked in antibiotic solution (helps hold graft)
  • The Gelfoam supports the graft from below, preventing it from falling into the middle ear
• Slide the trimmed temporalis fascia graft under the TM remnant and annulus
• Ensure graft extends well beyond all margins of the perforation
• Anteriorly, slide the graft under the handle of malleus (some surgeons cut the mucosa over the handle and lay graft under it — meticulous step)
• Posteriorly and inferiorly, tuck under the annulus

• Lay the tympanomeatal flap back over the graft
• Ensure no dog-ears or folds — these cause epithelial migration
• Confirm graft position: no lateral displacement

• Pack the EAC with Gelfoam pieces over the repositioned flap
• This holds everything in position during healing
• Some surgeons use BIPP (Bismuth Iodoform Paraffin Paste) ribbon gauze on top

• Close periosteum (if opened) with absorbable sutures (Vicryl 3-0)
• Subcutaneous layer closed (Vicryl 3-0)
• Skin — subcuticular Monocryl 4-0 or interrupted nylon

• Mastoid pressure dressing (Jelonet + cotton wool + crepe bandage)

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Overlay Technique (brief awareness)

• Graft placed lateral to the annulus and TM remnant
• Technically easier for anterior perforations
• Higher risk of lateralisation of graft and blunting of anterior angle
• Rarely used now except in specific situations

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6. POST-OPERATIVE MANAGEMENT

Immediate (Recovery Room)

• Monitor vitals; watch for nausea/vomiting (common after middle ear surgery due to vestibular manipulation)
• Anti-emetics: Ondansetron 4 mg IV
• Analgesia: Paracetamol 1g IV + Diclofenac/Ketorolac
• Head end elevation (30°) to reduce oedema

Ward (Day 1–2)

Discharge (Usually Day 2–3)

• Change outer dressing; inner EAC pack left in situ
• Advise: no water in ear, no nose blowing, no strenuous activity, sneeze with mouth open
• EAC pack removal at 2 weeks (first follow-up)

Follow-Up Schedule

Criteria for Graft Uptake

• Opaque, pearlescent TM appearance
• No residual perforation
• ABG closure on PTA (aim for <20 dB)

Post-Op Complications to Watch

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7. SUGGESTED OPERATIVE CLIPS — INDIAN CONTEXT

YouTube Channels to Watch Tonight

1. Dr. Milind V. Kirtane (KEM Hospital, Mumbai) — detailed microscopic tympanoplasty with step-by-step narration; highly recommended for Indian trainees
2. Vijay ENT Guide (Dr. Vijayendra) — practical Indian context, postaural approach well demonstrated
3. ENT Surgery India — multiple cases including subtotal perforations
4. Nishchint ENT — good for endoscopic tympanoplasty comparisons
5. Dr. Suresh Muthusami (JIPMER, Puducherry) — academic quality, narrated for residents

Specific Search Terms for YouTube

• "Postaural tympanoplasty underlay technique India"
• "Type 1 tympanoplasty temporalis fascia India"
• "Tympanoplasty KEM Hospital Mumbai"
• "Myringoplasty under GA India resident"

PG-Level Reference Books

• Glasscock-Shambaugh: Surgery of the Ear — gold standard for operative steps
• Scott-Brown's Otorhinolaryngology — comprehensive anatomy and indications
• Stell & Maran's Operative Head and Neck Surgery
• Diseases of Ear, Nose and Throat — PL Dhingra (for quick Indian PG-level revision)

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QUICK OPERATIVE CHECKLIST FOR TOMORROW

□ Patient positioned correctly, right ear up
□ LA with adrenaline injected — wait 5 min before incision
□ Temporalis fascia harvested and drying on Teflon block
□ Tympanomeatal flap elevated cleanly — annulus identified
□ Middle ear explored — ossicles intact and mobile
□ Perforation margins freshened — all epithelium removed
□ Gelfoam packing of middle ear placed
□ Graft slid under annulus and TM remnant
□ Graft tucked under malleus handle anteriorly
□ Tympanomeatal flap repositioned without folds
□ EAC packed with Gelfoam
□ Wound closed in layers — pressure dressing applied

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