Preoperative points

• Indication: a tympanic membrane perforation with hearing loss, with or without middle-ear pathology. - Shambaugh Surgery of the Ear, p. 493
• Control any acute exacerbation of chronic otitis media, allergic rhinosinusitis discharge, or otitis externa before surgery. Smoking carries about a threefold higher risk of long-term graft failure. - p. 493
• Avoid operating on an only-hearing or significantly better-hearing ear. A nonfunctioning Eustachian tube is a relative contraindication. - p. 493
• In children without cholesteatoma or bilateral perforations, surgery can wait until age 8 to 10. - p. 493
• Choose the approach by canal size, perforation size and site, and surgeon experience:
  • Transcanal: small posterior perforations in a wide canal.
  • Postauricular: large perforations or total replacement, or a narrow canal.
  • Endaural: an incision along the posterior half of the canal at the bony-cartilaginous junction, joined by a vertical incision in the incisura. - p. 496-497

Underlay technique (postauricular), step by step

1. Anesthesia.
   • Use short-acting paralytic agents only at induction, because facial nerve monitoring is used.
   • Avoid nitrous oxide. It diffuses into the middle ear and can displace the graft.
2. Canal injection. Inject lidocaine 2% with 1:100,000 epinephrine into the external canal.
3. Vascular strip incisions.
   • Make one incision just lateral to the annulus with a No. 72 Beaver blade.
   • Make a second along the tympanomastoid suture line with a No. 67 blade.
4. Postauricular incision. Make it about 5 mm behind the postauricular sulcus and control bleeding with cautery.
5. Graft harvest.
   • Pull the auricle forward and outward to find the avascular areolar plane over the temporalis fascia.
   • Retract with a Weitlaner and a Senn retractor.
   • Infiltrate local anesthetic to help separate the plane.
   • Harvest loose areolar temporalis fascia with Metzenbaum scissors.
   • Press it on a Teflon block and dehydrate it under a lamp on the back table.
6. Mastoid exposure.
   • Make a T-shaped incision in the musculoperiosteal layer. The horizontal limb follows the linea temporalis. The vertical limb runs from the mastoid tip to the middle of the horizontal limb.
   • Elevate flaps with a Lempert elevator.
   • Lift the vascular strip out of the canal and hold it under a self-retaining retractor.
   • Place a second retractor vertically. This gives exposure without a speculum.
   • If the tympanosquamous suture line is prominent, cut it with a No. 67 blade before elevating the strip. Otherwise the strip may tear.
7. Canaloplasty, if needed. Do this when an anterior bony bulge limits view of the anterior sulcus. Poor anterior exposure causes improper graft placement and failure.
8. Tympanomeatal flaps.
   • Elevate the inferior canal skin to the fibrous annulus, forming an inferiorly based flap.
   • Then elevate the superior flap.
9. Enter the middle ear and inspect the ossicular chain.
   • Remove polypoid mucosa, granulation tissue, and cholesteatoma. Mild polypoid change usually reverts once the perforation is closed.
   • Remove matrix around the stapes and promontory last, working posterior to anterior along the stapedial tendon.
   • Matrix that is very adherent to the stapes or facial nerve can be left for a second stage about a year later.
   • Look for a dehiscent jugular bulb, an exposed facial nerve, or a dehiscent carotid.
   • Use Jacobson's nerve, the cochleariform process, the Eustachian tube orifice, the round window niche, and the stapedial tendon as landmarks.
10. Prepare the middle ear. Place Gelfilm over the medial wall to prevent adhesions. Pack the middle ear with absorbable Gelfoam, starting at the Eustachian tube orifice.
11. Place the graft.
    • Put the dried areolar graft medial to the tympanic membrane remnant and annulus. It lies under the annulus anteriorly and drapes posteriorly over the posterior canal wall.
    • For a total perforation, cut a slit in the superior graft so it sits medial to the manubrium.
12. Stabilize.
    • Place small Gelfoam pieces over the graft.
    • Return the canal skin flaps to their original position.
    • Apply antibiotic ointment over the Gelfoam.
    • For a cholesteatoma or retraction pocket, use tragal or conchal cartilage (with or without perichondrium) to reconstruct the posterosuperior membrane or attic.
13. Canal packing. Inspect through a Lempert speculum to confirm flap position. Insert one or two Pope's (Merocel) wicks soaked in antibiotic ointment laterally.
14. Closure.
    • Close the postauricular incision in two layers with 3-0 Vicryl.
    • Leave a rubber-band drain in the most dependent part.
    • Apply a mastoid dressing.
    • Remove the dressing and drain the next morning.

Variants in Shambaugh

• It uses the same postauricular exposure.
• Remove all canal skin medial to the bony-cartilaginous junction and the squamous epithelium of the lateral membrane remnant. Keep this skin in saline.
• Leave the annulus in place and do a canaloplasty if needed.
• Remove any middle-ear disease and pack the middle ear with Gelfoam.
• Place the graft lateral to the annulus and medial to the manubrium. Use a superior slit, and make the graft long enough to cover the posterior canal wall.
• Do not drape the graft over the anterior canal wall. This avoids blunting.
• Replace the saved epithelium and put Gelfoam in the anterior sulcus and over the graft.
• Return the vascular strip, pack the canal with wicks, and close as for the underlay.
• Drawbacks: anterior sulcus blunting, graft lateralization, epithelial pearls, and delayed healing. It is also technically more demanding.

• Denude the perforation edges and remove any tympanosclerosis.
• Elevate a tympanomeatal flap as in stapedectomy.
• Place Gelfilm over the promontory if needed.
• Pack the middle ear with Gelfoam.
• Place the graft medial to the remnant or annulus and the manubrium.
• Replace the flap and pack the canal with antibiotic-soaked Gelfoam.
• Use ofloxacin drops twice daily and review at 4 weeks.

• This is for small persistent perforations, for example after tube extrusion or a failed myringoplasty. It is usually done under local anesthesia.
• Inject local anesthetic into four canal quadrants and the lobe.
• Take a small piece of fat through a lobe-rim incision. Close it with 5-0 Monocryl and keep the fat in saline.
• Denude the perforation edges under the microscope with cup forceps.
• Insert a fat piece larger than the perforation in a dumbbell fashion.
• Cover with antibiotic-soaked Gelfoam.
• Give ofloxacin drops, advise no nose blowing and water precautions, and clean the ear at 4 weeks.

Expected results

Recent evidence check

• Platelet concentrates in myringoplasty (2025, PMID 39342500).
• Tympanic cavity packing in type 1 tympanoplasty (2024, PMID 39113516).