Tympanoplasty

Definition

• Cummings Otolaryngology Head and Neck Surgery, p. 2726
• Shambaugh Surgery of the Ear, p. 390

Wullstein Classification

• Minor columella (PORP): bone or Partial Ossicular Replacement Prosthesis between capitulum and TM undersurface
• Major columella (TORP): Total Ossicular Replacement Prosthesis from stapes footplate to TM

Preoperative Evaluation

• Detailed history: prior infections, drainage, previous surgery (PE tubes, prior tympanoplasty)
• Otomicroscopic exam: perforation character (central vs. marginal), TM remnant health, atrophic areas, myringosclerosis, ossicular chain assessment
• Perforation >50% of TM has lower success rates
• Audiometric evaluation + tuning fork tests (confirm audiogram)
• Eustachian tube (ET) function: no current test accurately predicts postoperative ET function; the contralateral ear's behaviour after Valsalva/Toynbee is used as a surrogate
• Radiographic evaluation not needed for dry central perforations

Pathophysiology of Hearing Loss

1. Hearing loss is proportional to perforation size and is frequency dependent (largest losses at low frequencies)
2. Loss varies inversely with middle ear air volume (including mastoid)
3. Location of perforation does not significantly affect degree of hearing loss (contrary to old teaching)
4. Middle ear aeration (minimum ~0.5 mL air) is essential for normal ossicular coupling
5. Round window protection from phase cancellation is less critical than previously believed

Surgical Approaches

1. Transcanal Approach

• Best for small posterior perforations with a large canal
• Avoids mastoid dressing and postauricular morbidity (pain, hematoma, infection)
• Tympanomeatal flap elevated; middle ear explored; graft placed medially
• Fat graft myringoplasty: for small persistent perforations (post-PE tube); can be done under local anesthesia; adipose from ear lobe inserted in dumbbell fashion through perforation

2. Endaural Approach

• More common in Europe
• Useful when limited atticotomy is anticipated concurrently
• Self-retaining retractor can be used

3. Postauricular Approach

• Most commonly used in the United States
• Suitable for all perforation sizes, especially large perforations
• Better angle for anterior TM visualization without canalplasty
• Self-retaining retractors allow bimanual instrumentation

Graft Materials

Temporalis Fascia

• Gold standard; most widely used
• Harvested from the postauricular area or temporalis muscle
• Used in underlay (medial) or overlay (lateral) technique

Perichondrium

• Harvested from tragus or concha
• Good rigidity; similar success rates to fascia

Cartilage (with perichondrium)

• Indications: Atelectatic ear, revision surgery, perforation >50%, drainage at time of surgery, bilateral perforations, reconstruction after cholesteatoma, eustachian tube dysfunction
• Resistance to retraction/perforation even with ongoing ET dysfunction
• Decreases prosthesis extrusion risk when placed between TM and ossicular prosthesis
• Harvested from tragus (thicker, flatter - better for large perforations) or concha
• Techniques: composite cartilage-perichondrium graft ("island"), palisade array

Fat Graft

• Small lobed fat from earlobe; for small residual perforations
• Used in dumbbell/butterfly fashion; excellent for appropriate cases

Butterfly Cartilage Inlay

• For small-medium central perforations
• No need to elevate tympanomeatal flap
• Scored circumferentially; perforation edges nestled between medial and lateral "wings"

Graft Placement Techniques

Underlay (Medial) Technique

• Graft placed medial to TM remnant and malleus handle
• More common technique
• Requires adequate anterior support to prevent graft migration

Overlay (Lateral) Technique

• Graft placed lateral to malleus/TM remnant
• Higher rate of anterior blunting and epithelial pearl formation (complications)
• Used when medial technique is inadequate (total perforations, anterior marginal perforations)
• Canalplasty often required to remove anterior canal hump

Cartilage Tympanoplasty (Special Considerations)

• Attic defects
• Posterosuperior retraction pockets
• Atelectatic ear
• Cases with increased failure risk with fascia (revision, large perforation, cholesteatoma)

Ossiculoplasty

Ossicular Defect Classification (Austin-Kartush)

Prostheses

• PORP (Partial Ossicular Replacement Prosthesis): stapes capitulum to TM; used when stapes superstructure is intact
• TORP (Total Ossicular Replacement Prosthesis): stapes footplate to TM; used when superstructure is absent
• Cartilage interposition between prosthesis platform and TM significantly reduces extrusion risk
• Autograft options: incus (reshaped), cortical bone

TRACS Mnemonic for Ossiculoplasty Principles (Shambaugh)

• T - Tension: appropriate tightness of prosthesis fit; excessive laxity = sound energy loss
• R - Rigidity: prosthesis must be rigid enough to transmit vibrations
• A - Area ratio: preserve the TM-to-footplate area differential
• C - Coupling: ensure intimate contact at all interfaces
• S - Stability: prosthesis must self-stabilize and return to position when displaced

Timing Decisions

• Middle ear mucosa is thickened, infected, or partially missing (risk of fibrosis displacing prosthesis)
• Active bleeding obscures visualization
• Second-look for cholesteatoma recurrence is planned
• Eustachian tube function is uncertain

Complications

Graft Failure

• Perforation recurrence
• Graft lateralization (migrates away from manubrium - causes CHL; may need revision)
• Graft retraction/atrophy
• Blunting of anterior sulcus (especially with overlay technique)

Epithelial Pearl Formation

• Associated with overlay technique
• Meticulous epithelium removal from TM remnant and canal wall at primary surgery is preventive
• Office treatment: open and debride keratin debris

Ossiculoplasty Failure

• Prosthesis extrusion (most common with allograft prostheses contacting TM directly)
• Misdiagnosis: missing fixed malleus, fractured stapes superstructure, bony incudostapedial disarticulation with preserved soft tissue
• Persistent/recurrent middle ear pathology (ET dysfunction, mucosal disease, fibrosis)

Cholesteatoma

• Recurrent: 14%, Residual: 12% after tympanoplasty with ICW mastoidectomy
• Children: residual 20.5%, recurrent 8.9% (ICW); higher rates overall vs. adults

Outcomes

• Eustachian tube dysfunction
• Cholesteatoma or atelectasis
• Previous tympanoplasty failure
• Lateralized TM
• Smoking

Endoscopic vs. Microscopic Tympanoplasty

Postoperative Care

• Discharge same day (or next morning if nausea/vomiting)
• Mastoid dressing and drain removed day after surgery
• Antibiotic drops at bedtime
• Water precautions; no nose blowing until TM healed (sneezing with open mouth)
• Oral antibiotics if ear was infected at surgery
• First visit: 1 week (remove Merocel wick)
• Second visit: 3-4 weeks (suction residual Gelfoam)
• Hearing improvement noticed in 6-8 weeks
• Audiogram obtained at 4-6 months postoperatively

Pediatric Tympanoplasty

• More active Eustachian tube dysfunction
• Immune immaturity
• Higher rate of adenoid-related middle ear disease
• Cholesteatoma is more aggressive in children

What the Image Shows - and Why I Need to Be Honest With You

Why This Pattern Matters

"Ciliary injection (perilimbal injection, ciliary flush) is circumcorneal conjunctival hyperaemia with a violaceous hue due to involvement of deeper blood vessels and is typically seen in anterior uveitis of acute onset."

• Diffuse superficial conjunctival redness (not perilimbal)
• Itching as the dominant symptom
• Chemosis (swelling) and papillae on the inner lids
• No ciliary flush

What You Should Do

• Eye pain or aching (not just irritation)
• Sensitivity to light (photophobia)
• Blurred vision
• Seeing halos around lights

If It Truly Is Screen + Allergy Related (Once Confirmed by an Eye Doctor)

• Olopatadine 0.1% or 0.2% (OTC)
• Ketotifen 0.025% (OTC)
• Azelastine, bepotastine, or epinastine

• Reduce screen time during allergy episodes
• Position screen below eye level (reduces palpebral aperture, decreases evaporation)
• Conscious blinking while on screens
• 20-20-20 rule: every 20 minutes, look 20 feet away for 20 seconds
• Lubricating eye drops (preservative-free preferred)

Slit Lamp Examination - How to Perform

The Instrument

• Binocular eyepieces (oculars) - for stereoscopic (3D) viewing
• Slit beam light source - width, height, angle, and filter are all adjustable
• Joystick - moves the instrument forward/back (focus) and up/down
• Magnification dial - typically 10x, 16x, 25x
• Chin rest and forehead bar - positions the patient
• Filters: cobalt blue (for fluorescein), red-free (increases vascular contrast)

Step 1 - Patient Positioning

• Both examiner and patient sit on adjustable stools at the same level
• Cover the chin rest with a tissue
• Patient leans forward, forehead against the bar, chin on the rest
• Adjust chin rest height so the patient's lateral canthus aligns with the black line on the vertical bar
• Ask the patient to keep both eyes open and look straight ahead (or at a fixation target)

Step 2 - Initial Setup

• Set oculars to your interpupillary distance
• Start with low magnification (10x) and a diffuse, wide beam for the overview
• Position the light source and eyepieces directly in front (0° angle) for initial survey
• Move the joystick forward until the cornea comes into sharp focus

Step 3 - Systematic Anterior Segment Examination

1. Lids and Lashes

• Inspect for blepharitis (lid margin crusting/thickening), meibomian gland dysfunction, hordeolum (stye), entropion/ectropion
• Evert the upper lid to inspect for papillae (raised bumps - sign of allergy) or follicles

2. Conjunctiva and Sclera

• Diffuse beam, scan bulbar and palpebral conjunctiva
• Look for: hyperaemia pattern (superficial vs. ciliary/deep), chemosis, papillae, follicles, discharge
• Note if redness is diffuse (conjunctivitis) or perilimbal/circumcorneal = ciliary flush (deeper inflammation - uveitis)

3. Cornea - Use narrow oblique slit beam

• Angle the light ~45° from the side; narrow the beam to ~1 mm width, full height of cornea
• The beam creates an optical cross-section - you can see the layers of the cornea as a bright slice
• Moving this thin beam across the cornea tells you the depth of any lesion (epithelial, stromal, or endothelial)
• Examine for: abrasions, ulcers, foreign bodies, oedema (haze), scars
• Check endothelium (posterior corneal surface) for keratic precipitates (KPs) - these are white cell deposits, a hallmark of uveitis/iritis

4. Anterior Chamber - The Most Important for Your Case

• Move focus to the space between the cornea and iris, using the dark pupil as a backdrop
• Aim the narrow slit beam at an extreme temporal angle (from the side), across this dark space
• Look for:

• Grade 0: <1 cell in 1×1 mm field
• Grade 0.5+: 1-5 cells
• Grade 1+: 6-15 cells
• Grade 2+: 16-25 cells
• Grade 3+: 26-50 cells
• Grade 4+: >50 cells

5. Iris

• Inspect for tears, synechiae (adhesions between iris and lens = posterior synechiae, a complication of uveitis)
• Note pupil shape and reactivity (miosis = pupillary sphincter spasm in uveitis)
• Spiral muscle fibre disruption = acute angle closure glaucoma

6. Lens

• Aim beam posteriorly through the pupil
• Examine for position, clarity, opacities (cataracts), subluxation

Step 4 - Illumination Techniques

Step 5 - Special Tests

Fluorescein Staining (with Cobalt Blue Filter)

• Instill fluorescein dye (strip touched to conjunctiva, or drops)
• Switch to cobalt blue filter on the slit lamp
• Fluorescein does not penetrate intact corneal epithelium
• Bright green staining = epithelial defect (abrasion, ulcer, foreign body trauma)
• Seidel's test: leaking fluorescein streaming away from a wound = corneal perforation

Tonometry (Goldmann)

• Mounted on the slit lamp
• Applanates the cornea with a calibrated probe after topical anaesthetic
• Measures intraocular pressure - critical to rule out acute angle-closure glaucoma

What the Ophthalmologist Will Be Looking For in Your Eye

1. Are there cells or flare in the anterior chamber? - If yes → uveitis/iritis confirmed
2. Are there keratic precipitates on the corneal endothelium? - If yes → confirms intraocular inflammation
3. Is the cornea clear or hazy? - Hazy cornea + raised IOP = angle-closure glaucoma
4. Is it truly ciliary flush or just deep conjunctival injection? - Slit lamp resolves this in seconds
5. Pupil shape and reactivity - Irregular pupil or miosis → uveitis