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Myringoplasty

Definition

Myringoplasty is the surgical repair of the tympanic membrane (eardrum) without additional intervention in the middle ear or mastoid region.

Large central perforation in the tympanic membrane

Historical Background

The practice of myringoplasty has evolved significantly over the centuries.

  • 1640s: The earliest attempts at tympanic membrane repair involved the use of artificial plugs made from animal materials.
  • Cotton Wool: Yearsley described an artificial eardrum constructed from moistened cotton wool.
  • Gutta-Percha Disc: Toynbee introduced an artificial eardrum made of a gutta-percha disc supported by a silver wire.
  • Cautery Techniques: William Wilde and Roosa promoted the application of cautery to the remnant tympanic membrane to facilitate healing, utilizing agents such as silver nitrate and trichloracetic acid.
  • Paper Patch Technique: In 1887, Blake first documented the use of a paper patch as a standalone treatment for tympanic membrane perforations.
  • Combination Techniques: Joynt (1919) combined cautery with the application of a paper patch over the perforation.
  • Full-Thickness Skin Graft: In 1878, Berthold described a technique involving a full-thickness skin graft, which included ‘freshening’ or excising the edges of the perforation to create a wound conducive to healing. He is credited with coining the term “myringoplasty.”
  • Publication of Similar Techniques: Ely described a similar technique, although his findings were not published until 1879.
  • Advancements in Techniques: Significant advancements in myringoplasty were reported in the 1950s, particularly with Wullstein’s split skin graft and Zollner’s pedicled skin graft, which resulted in higher rates of successful repair.
  • Classification: In 1956, Wullstein classified tympanoplasty, categorizing myringoplasty as a Type I tympanoplasty.

Indications for Myringoplasty

The primary indications for myringoplasty include:

  1. Recurrent Otorrhea: Persistent ear discharge.
  2. Hearing Loss: Resulting from chronic tympanic membrane perforation.
  3. Desire for Recreational Activities: Such as swimming, without the need for ear protection.

Contraindications for Myringoplasty

Myringoplasty may not be suitable in the following circumstances:

  • Presence of cholesteatoma
  • Contralateral dead ear
  • Actively discharging ear
  • Eustachian tube dysfunction
  • Otitis externa
  • Acute suppurative otitis media (ASOM)
  • Complicated chronic suppurative otitis media (CSOM)
  • Malignant tumors of the outer or middle ear
  • Unusual infections, such as malignant otitis externa
  • Patient medically unfit

Complications of Myringoplasty

Potential complications associated with myringoplasty include:

  • Intraoperative Bleeding: Often due to a high and uncovered jugular bulb.
  • Myringitis: Inflammation of the tympanic membrane.
  • Wound Infection: Including perichondritis.
  • Wound Hematoma: Accumulation of blood in the wound area.
  • Injury to Chorda Tympani: A nerve that can be affected during surgery.
  • Graft Failure: The potential for the graft to not adhere or integrate properly.
  • Sensorineural Hearing Loss or Dizziness: Possible adverse effects following the procedure.

Grafting Materials

The most commonly used graft materials in myringoplasty include the temporalis fascia or perichondrium (tragal or conchal) harvested from the patient. Temporalis fascia is the most commonly used graft for all perforations given its availability, the abundance of tissue and ease of use. Tragal perichondrium is preferred for the permeatal approach. Cartilage from the tragus or concha is becoming increasingly popular as a reliable material for repairing tympanic membrane perforations. One effective technique for smaller perforations, those less than 6mm, involves creating a cartilage “butterfly.” In this method, a cartilage disc is circumferentially incised by 1mm. This groove is then fitted into the perforation rim, stabilizing the graft and ensuring a secure fit. Occasionally, homografts such as dura mater, vein, fascia, or cadaver tympanic membrane may be utilized.

Graft Placement Techniques

There are two primary grafting techniques in tympanoplasty: underlay and overlay. Both techniques can yield excellent outcomes when performed by experienced surgeons.

  • Underlay Technique: The graft is positioned medial to the inner mucosal layer of the tympanic membrane remnant and hence over the fibrous annulus, stabilized by gelfoam in the middle ear. The underlay technique is considered superior for several reasons. It offers technical ease during the procedure, results in a shorter post-operative healing time, has fewer complications, and provides better hearing gain for patients. This technique is relatively straightforward but may lead to graft medialization and reduced middle ear space. It is essential to avoid nitrous oxide gas during graft placement, as it can diffuse into the middle ear and displace the graft.
  • Overlay Technique: The graft is placed lateral to the middle fibrous layer of the tympanic membrane remnant and hence over the fibrous annulus. This technique requires careful removal of the outer epithelial layer of the tympanic membrane remnant. Although the overlay technique can provide good results, it is associated with a higher incidence of complications, including the formation of epithelial pearls, anterior sulcus blunting, granulation tissue formation, and graft lateralization. It is considered a more technically demanding procedure.

Procedural Steps:

  1. EUM: Examination under the microscope is done to confirm the clinical findings.
  2. For local anaesthesia, 2% xylocaine with adrenaline is injected in the postaural region (from the root of the helix to the mastoid tip) and external auditory canal.
  3. Wilde’s incision: A postaural incision is given from the root of the helix to the mastoid tip.Types of Hearing loss
  4. Temporalis fascia graft is harvested.
  5. The margins of the perforation are freshened.
  6. A tympanomeatal flap, consisting of the posterior meatal canal skin, is elevated which is made in continuity with the tympanic membrane after dislocating the annulus from the sulcus.
  7. The incision is given in the middle ear mucosa below the annulus and the tympanomeatal flap is elevated.
  8. The handle of the malleus is denuded.
  9. The middle ear and ossicular chain are inspected and repaired as necessary.
  10. Any posterosuperior overhang of the bony meatus, if present, is removed to enhance the visibility of the ossicles.
  11. The middle ear is packed with gelfoam.
  12. The graft is placed medial to the tympanic membrane remnant or tympanic annulus, and lateral to the manubrium of the malleus.
  13. The tympanomeatal flap is returned to its original position, and the medial aspect of the ear canal is packed with gelfoam impregnated with antibiotic ointment.

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Reference Textbooks.

  • Scott-Brown, Textbook of Otorhinolaryngology-Head and Neck Surgery.
  • Glasscock-Shambaugh, Textbook of Surgery of the Ear.
  • P L Dhingra, Textbook of Diseases of Ear, Nose and Throat.
  • Hazarika P, Textbook of Ear Nose Throat And Head Neck Surgery Clinical Practical.
  • Mohan Bansal, Textbook of Diseases of Ear, Nose and Throat Head and Neck Surgery
  • Hans Behrbohm, Textbook of Ear, Nose, and Throat Diseases With Head and Neck Surgery.
  • Salah Mansour, Middle Ear Diseases – Advances in Diagnosis and Management.
  • Logan Turner, Textbook of Diseases of The Nose, Throat and Ear Head And Neck Surgery.
  • Rob and smith, Textbook of Operative surgery.
  • Arnold, U. Ganzer, Textbook of  Otorhinolaryngology, Head and Neck Surgery.

Author:

Dr Rahul Bagla ENT Textbook

Dr. Rahul Bagla
MBBS (MAMC, Delhi) MS (UCMS, Delhi)
Fellow Rhinoplasty & Facial Plastic Surgery.
Renowned Teaching Faculty
Mail: msrahulbagla@gmail.com
India

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