health

1. SURGERIES OF EAR
BY- DR SUBRAT KUMAR PATRA(PGT-2)

2. MYRINGOPLASTY
• Myringoplasty can be defined as the
surgical repair of the tympanic membrane
without need to examine the middle ear.

3. AETIOLOGY
• TRAUMA-direct blow to the ear can result in
rupture of the tympanic membrane
• INFECTION-The commonest cause of an
acute perforation is following an episode of
acute otitis media. Spontaneous healing of
such perforations is the norm, with 70–80%
healing within 30 days.
• IATROGENIC-Iatrogenic trauma from middle
ear surgery or following the extrusion of a
ventilating tube (VT)

4. SYMPTOMS
• May be completely asymptomatic and can be found incidentally.
The majority of patients, however, will present as a result of their
symptoms, the commonest being discharge and hearing loss.

5. DISCHARGE
• A mucoid discharge from the ear, be it simple
mucus or mucopurulent.
• This can be from ingress of potentially infective
organisms from the outside into the middle ear
through a pre-existing perforation or from
mucosal reaction to a systemic infection (e.g. an
upper respiratory tract infection), with the rapid
build-up of mucopus resulting in an acute
perforation.

6. HEARING LOSS
• The repeated insult of infections can lead to loss
of continuity with the stapes and hence a CHL.
Small perforations under 25% may not lead to
any significant hearing deficit. Perforations
greater than 25% have been shown to cause a
greater CHL as size increases.
• Perforation-induced hearing losses appear
greatest at lower frequencies with less influence
on higher frequencies.

7. INDICATIONS FOR MYRINGOPLASTY
• The three principal indications for myringoplasty
are:-
• Recurrent otorrhoea
• Hearing loss due to a chronic perforation
• Desire to swim without waterproofing the ear.

8. CONTRAINDICATIONS
• CHOLESTEATOMA
• CONTRALATERAL HEARING
• BILATERAL PERFORATION
• EUSTACHIAN TUBE DYSFUNCTION

9. CHOLESTEATOMA
• The presence of cholesteatoma is an
absolute contraindication to
myringoplasty alone. All squamous
epithelium must be excised from the
middle ear prior to closure of the
tympanic membrane defect to prevent
further progression of the
cholesteatoma and its subsequent
well-recognized complications.

10. CONTRALATERAL HEARING
• Relative contraindications include a contralateral
dead ear.

11. BILATERAL PERFORATION
• Bilateral perforations be present, most would
advocate operating on one ear at a time. While
the incidence of severe hearing loss from
myringoplasty is rare,unilateral surgery avoids
any risks to the contralateral ear, leaving this
side available for hearing and communication.

12. EUSTACHIAN TUBE DYSFUNCTION
• Severe Eustachian tube dysfunction can be extremely
challenging to treat. Attempting to elevate a Sade grade IV
retraction from the ossicular chain can increase the risk of
hearing loss. There is also an increased chance of an
iatrogenic cholesteatoma should any epithelial cells be left
,Reconstructing the tympanic membrane using cartilage can
provide more resilience against the negative middle ear but,
despite this, recurrence of the retraction can occur.

13. INVESTIGATIONS
• AURAL SWAB
• AUDIOMETRY
• IMAGING

14. AUDIOMETRY
• All patients with a perforation or perceived hearing loss
should undergo audiometric testing at the time of their
clinic visit. This quantifies the degree of hearing loss
and can assist the surgeon in predicting what may be
found in the middle ear at the time of surgery.

15. IMAGING
• Most myringoplasties do not require pre-operative imaging.
In those in whom the history is unusual, or examination
findings suggest further pathology, a fine-cut CT of the
temporal bone can reveal unexpected opacification or
unusual bone erosion, together with providing some insight
into the state of the ossicular chain.

16. PRE-OPERATIVE EVALUATION
1. DETAILED HISTORY OF PATIENT
2. PHYSICAL EXAMINATION
3. OTOSCOPIC EXAMINATION-EAR CANAL
TM-PERFORATION-SIZE & LOCATION
4.TUNING FORK TEST
5.AUDIOMETRY

17. SURGICAL APPROACHES
• ENDOMEATAL OR TRANSCANAL APPROACH
• ENDAURAL APPROACH
• POST AURAL APPROACH

18. ENDOMEATAL APPROACH(ROSEN’S
INCISION)
• Requires wide meatus and EAC,
consists of two parts:-
• A small vertical incision at 12’o clock
position near annulus.
• A curvilinear incision starting at 6,o
clock poster superior region of the
canal 5-7mm away from annulus.

19. ENDAURAL APPROACH
• Made through Lempert’s incision, consists
of two parts:-
• Lempert-I:- semicircular incision made from
12’o clock to 6’o clock position in the
posterior meatal wall at bony cartilaginous
junction
• Lempert-II:- starts from 1st incision at 12’o
clock & then passes upwards in curvilinear
fashion between tragus & crus of helix.

20. POST AURAL(WILDE’S INCISION)
• Starts at the highest attachment of the pinna, follows the curve of
retro auricular groove, lying 1cm behind it ending at mastoid tip.

21. PROCEDURE
• Local anesthetic agent(2% xylocaine mixed
with 1 in 10,000 adrenaline injection)
injected in four quadrants of cartilaginous
canal & bony external canal is injected in
subperiosteal plane at 6&12’o clock.
• Anesthetic agent also injected above the
pinna, tragus,or lobule.
• When fascia graft is desired incision is
made above the hairline and graft is
excised.

22. • As an alternative to fascia graft,
a perichondrial graft can also be
used.
• Another alternative is to
remove small piece of fat from
ear lobule, incision made on
posterior surface of lobule to
hide scar

23. TECHNIQUE OF MYRINGOPLASTY
• 1. UNDERLAY
• This is a simple and commonly used
technique
• Ideal to repair small and easily visualized
perforation
• Graft is placed under the tympanomeatal
flap
• Easy to perform with good success rate

24. • 2.OVERLAY
• Difficult technique to master
• Typically reserved for total
perforation,anterior perforation or failed
underlay technique.
• Graft is placed under the squamous
layer of tympanic membrane
• Difficult to perform

25. UNDERLAY TECHNIQUE
• Margin freshening of perforation using sickle knife or angled
pick
• A vascular strip is created in EAC by making incision at
tympanomastoid & tympano squamous suture line roughly to 6’
o clock and 12’o clock position extended upto annulus.
• Elevation of tympano meatal flap upto level of the annulus.
• Elevation of the annulus and incising the middle ear mucosa.

26. • Freeing of the tympanomeatal flap from the handle
of malleus by sharp dissection of middle ear mucosa.
• Graft placement-medial to the entire tympanic
membrane middle ear is packed with gel foam soaked
with antibiotic, a proper sized graft so that its edges
extend under margins of perforation all around &
small part extend over post canal wall
• TM flap is reposited, bits of gelfoam is placed around
the edges of raised flap, one gel foam bit placed over
sealed perforation.
• Closure

27. POST-OPERATIVE CARE
• Patient discharged on post-op Day-1
• Mastoid dressing changed on next day morning.
• Nose blowing should be avoided
• Medications in form of antibiotics, antihistaminesand analgesics are
prescribed.
• 1st post-op visit-after 1 week –suture removal to be done
• 2nd visit-after 3 to 4 week-gel foam over graft gently suctioned away
• Audiogram obtained 4 to 6 month after surgery.

28. COMPLICATION OF UNDERLAY
MYRINGOPLASTY
• Middle ear becomes narrow
• Graft may get adherent to promontory
• Anteriorly graft may loosened up

29. ADVANTAGES OF UNDERLAY TECHNIQUE
• Simple & easy to perform when perforation is small
• Avoids extensive dissection of anterior meatal skin preventing
blunting of anterior recess

30. DISADVANTAGES
• Reduction of middle ear space
• Limited bed of raw area for graft reception
• Difficult graft placement if perforation is more anteriorly
• Anterior reperforation
• Anterior tympanomeatal cholesteatoma
• Blunting of anterior tympanomeatal angle

31. OVERLAY TECHNIQUE
• Graft is harvested
• Incision is made over meatal skin &
raised along with all the epithelium from
outer surface of TM remnant to be used
later
• Graft being placed lateral to the fibrous
layer of the drumhead and hence over the
fibrous annulus
• Meatal skin remove earlier now replaced
covering the periphery of graft
• Graft supported with gelfoam in EAC.

32. COMPLICATIONS
• Blunting of anterior sulcus
• Epithelial pearls-epidermal cyst, when squamous ep is buried under
graft
• Lateralisation of graft- graft looses contact from malleus resulting in
conductive loss

33. ADVANTAGES OF OVERLAY TECHNIQUE
• Anterior recess can be visualized
• Anterior overhanging can be drilled out
• Middle ear space not reduced

34. DISADVANTAGES
• Poor exposure of tympanic cavity
• Delayed healing
• Epithelial pearls
• Lateral displacement of graft
• Residual cholesteatoma
• Retraction pocket due to ETD

35. TYPES OF GRAFT
• AUTOGRAFT
• ISOGRAFT
• Xenograft-Equine and bovine pericardium

36. TYPES OF AUTOGRAFT
• Temporalis fascia
• Tragal cartilage
• Tragal/Chonchal cartilage
• Periosteum
• Fascia lata
• Heterotropic skin:- full thickness & split thickness

37. TEMPORALIS FASCIA
• It was first used in myringoplasty by Ortegren(1958-59),Heerman(1961)&
Storrs(1961).
• It remains the most commonly used material for tympanic membrane
reconstruction with success rate of 93% to 97%.
• ADVANTAGES:-
• Location of donor site
• Easy to harvest
• Low BMR- requires less nutrition
• It can be used as onlay/underlay/inlay.
• It can be used in sandwich technique as one of graft with canal skin on fascia.

38. DISADVANTAGES
• Can eventually become thin &
atrophic.
• Lacks elasticity and resistance to
pressure changes in external ear canal.

39. CARTILAGE & PERICHONDRIAL GRAFT
• Keeping the cartilage attached to the perichondrium helps placement
and aids graft stabilization and is now considered one of the best
materials for use in larger perforations (greater than 50%).
• Good long term survival.
• Relatively resistant to infection.
• More rigid & resistant to pressure changes in EAC.

41. POST-OP PERICHONDRIUM/CARTILAGE
ISLAND GRAFT

42. CARTILAGE SHIELD TECHNIQUE
• Cartilage is harvested and wedge is removed to fit manubrium.
• Cymba concha cartilage has an average thickness of 0.8mm & its
concave contour resembles normal shape of TM.
• Preferred for total replacement of TM.

43. CARTILAGE PALISADE TECHNIQUE
• Curve cymba concha is considered more suitable.
• Useful in posterior perforation associated with ossicular diseases.
• Cartilage ois sectioned in slices which are then placed together used
to reconstruct TM.

45. CARTILAGE BUTTERFLY TECHNIQUE
• Fashioning a cartilage ‘butterfly’ is a
technique that has been proposed for
smaller perforations less than 6 mm,
with the cartilage disc being
circumferentially incised by 1 mm. This
groove is engaged into the perforation
rim, thereby stabilizing the graft.

46. FAT GRAFT MYRINGOPLASTY
• Used for small perforations.
• Fat is harvested from inferior aspect of
ear lobule.
• Small piece of fat is plugged into the
perforation like an hour glass.
• Fat graft adheres & closes the
perforation.
• Overall success rate:-90-95%

47. VEIN GRAFT
• Advantages of vein graft:-
• Readily available from varicose clinics.
• Sufficient quantity of tissue is available.
• Can be stored in cold storage & at time of operation it is thawed to
room temperature before trimming.

48. OTHER TECHNIQUE
Splintage:-
• Used in fresh traumatic perforations.
• Torn edges of perforation are everted,
splinted with absorbable gel foam
within middle ear.
• Smaller tears can be splinted on the
outer surface with piece of cigarette
paper, gel film or silicon sheet.
Cautery patching
• Useful in small long standing
perforations.
• Margins of perforation are cauterized
with 50% trichloracetic acid to remove
epithelized edge.
• Perforation is then supported with
cigarette paper moistened with 1%
phenol in glycerine.
• Repeated after 2 weeks intervals

49. REFERENCES
1. SCOTT BROWN’S
2. CUMMINGS
3. SHAMBAUG- SURGERY OF EAR
4. Kartush JM, Michaelides EM, Becvarovski Z, LaRouere MJ. Over-under
tympanoplasty. Laryngoscope. 2002;112:802–7.
5. Maran RK, Jain AK, Haripriya GR, Jain S. Microscopic Versus Endoscopic
Myringoplasty: A comparative study. Indian J Otolaryngol Head Neck Surg. 2019
Nov;71(Suppl 2):1287-1291.