Tympanoplasty14

http://www.surgeryencyclopedia.com/St-Wr/Tympanoplasty.html Definition
Tympanoplasty, also called eardrum repair, refers to surgery performed to reconstruct a perforated tympanic membrane (eardrum) or the small bones of the middle ear. Eardrum perforation may result from chronic infection or, less commonly, from trauma to the eardrum.

Purpose
The tympanic membrane of the ear is a three-layer structure. The outer and inner layers consist of epithelium cells. Perforations occur as a result of defects in the middle layer, which contains elastic collagen fibers. Small perforations usually heal spontaneously. Howe er, if the defect is relati ely large, or if there is a poor blood supply or an infection during the healing process, spontaneous repair may be hindered. Eardrums may also be perforated as a result of trauma, such as an ob!ect in the ear, a slap on the ear, or an e"plosion. The purpose of tympanoplasty is to repair the perforated eardrum, and sometimes the middle ear bones (ossicles) that consist of the incus, malleus, and stapes. Tympanic membrane grafting may be re#uired. $f needed, grafts are usually ta%en from a ein or fascia (muscle sheath) tissue on the lobe of the ear. Synthetic materials may be used if patients ha e had pre ious surgeries and ha e limited graft a ailability.

Demographics
$n the &nited States, ear disorders leading to hearing loss affect all ages. ' er ()* of the population with hearing loss is under the age of (+, although nearly ,+* of those abo e age (+ ha e a hearing loss that is considered significant. -auses include. birth defect (/./*), ear infection (0,.,*), ear in!ury (/.1*), damage due to e"cessi e noise le els (22.3*), ad anced age (,4*), and other problems (0(.4*).

Description
There are fi e basic types of tympanoplasty procedures.

Type $ tympanoplasty is called myringoplasty, and only in ol es the restoration of the perforated eardrum by grafting. Type $$ tympanoplasty is used for tympanic membrane perforations with erosion of the malleus. $t in ol es grafting onto the incus or the remains of the malleus. Type $$$ tympanoplasty is indicated for destruction of two ossicles, with the stapes still intact and mobile. $t in ol es placing a graft onto the stapes, and pro iding protection for the assembly. Type $5 tympanoplasty is used for ossicular destruction, which includes all or part of the stapes arch. $t in ol es placing a graft onto or around a mobile stapes footplate. Type 5 tympanoplasty is used when the footplate of the stapes is fi"ed.

6epending on its type, tympanoplasty can be performed under local or general anesthesia. $n small perforations of the eardrum, Type $ tympanoplasty can be easily performed under local anesthesia with intra enous sedation. 7n incision is made into the ear canal and the remaining eardrum is ele ated away from the bony ear canal, and lifted forward. The surgeon uses an operating microscope to enlarge the iew of the ear structures. $f the perforation is ery large or the hole is far forward and away from the iew of the surgeon, it may be necessary to perform an incision behind the ear. This ele ates the entire outer ear forward, pro iding access to the perforation. 'nce the hole is fully e"posed, the perforated remnant is rotated forward, and the bones of hearing are inspected. $f scar tissue is present, it is remo ed either with micro hoo%s or laser. Tissue is then ta%en either from the bac% of the ear, the tragus (small cartilaginous lobe of s%in in front the ear), or from a ein. The tissues are thinned and dried. 7n absorbable gelatin sponge is placed under the eardrum to support the graft. The graft is then inserted underneath the remaining eardrum remnant, which is folded bac% onto the perforation to pro ide closure. 5ery thin sheeting is usually placed against the top of the graft to pre ent it from sliding out of the ear when the patient snee8es. $f it was opened from behind, the ear is then stitched together. &sually, the stitches are buried in the s%in and do not ha e to be remo ed later. 7 sterile patch is placed on the outside of the ear canal and the patient returns to the reco ery room.

Diagnosis/Preparation
The e"amining physician performs a complete physical with diagnostic testing of the ear, which includes an audiogram and history of the hearing loss, as well as any ertigo or facial wea%ness. 7 microscopic e"am is also performed. 'toscopy is used to assess the mobility of the tympanic membrane and the malleus. 7 fistula test can be performed if there is a history of di88iness or a marginal perforation of the eardrum. Preparation for surgery depends upon the type of tympanoplasty. 9or all procedures, howe er: blood and urine studies, and hearing tests are conducted prior to surgery.

!ftercare
;enerally, the patient can return home within two to three hours. !nti"iotics are gi en, along with a mild pain relie er. 7fter 0) days, the pac%ing is remo ed and the ear is e aluated to see if the graft was successful. <ater is %ept away from the ear, and nose blowing is discouraged. $f there are allegies or a cold, antibiotics and a decongestant are usually prescribed. =ost patients can return to wor% after fi e or si" days, or two to three wee%s if they perform hea y physical labor. 7fter three wee%s, all pac%ing is completely remo ed under the operating microscope. $t is then determined whether or not the graft has fully ta%en. Post-operati e care is also designed to %eep the patient comfortable. $nfection is generally pre ented by soa%ing the ear canal with antibiotics. To heal, the graft must be %ept free from infection, and must not e"perience shearing forces or e"cessi e tension. 7cti ities that change the tympanic pressure are forbidden, such as snee8ing with the mouth shut, using a straw to drin%, or hea y nose blowing. 7 complete hearing test is performed four to si" wee%s after the operation.

The tympanic mem"rane# or ear drum# may need surgical repair when punctured $!%. During a type & tympanoplasty# a perforation in the ear drum is isuali'ed $(%. ! tissue graft is placed o er the perforation $)% and held in place "y the e*isting ear drum $D%. ( $llustration by ;;S $nc. )

+is,s
Possible complications include failure of the graft to heal, causing recurrent eardrum perforation: narrowing (stenosis) of the ear canal: scarring or adhesions in the middle ear: perilymph fistula and hearing loss: erosion or e"trusion of the prosthesis: dislocation of the prosthesis: and facial ner e in!ury. 'ther problems such as recurrence of cholesteatoma, may or may not result from the surgery. Tinnitus (noises in the ear), particularly echo-type noises, may be present as a result of the perforation itself. &sually, with impro ement in hearing and closure of the eardrum, the tinnitus resol es. $n some cases, howe er, it may worsen after the operation. $t is rare for the tinnitus to be permanent after surgery.

-ormal results
Tympanoplasty is successful in o er 1)* of cases. $n most cases, the operation relie es pain and infection symptoms completely. Hearing loss is minor.

.or"idity and mortality rates

There can be imbalance and di88iness immediately after this procedure. 6i88iness, howe er, is uncommon in tympanoplasties that only in ol e the eardrum. >esides failure of the graft, there may be further hearing loss due to une"plained factors during the healing process. This occurs in less than +* of patients. 7 total hearing loss from tympanoplasty surgery is rare, occurring in less than 0* of operations. =ild postoperati e di88iness and imbalance can persist for about a wee% after surgery. $f the ear becomes

infected after surgery, the ris% of di88iness increases. ;enerally, imbalance and di88iness completely disappears after a wee% or two.

!lternati es
=yringoplasty is another operati e procedure used in the reconstruction of a perforation of the tympanic membrane. $t is performed when the middle ear space, its mucosa, and the ossicular chain are free of acti e infection. &nli%e tympanoplasty, there is no direct inspection of the middle ear during this procedure. See also =astoidectomy.

+esources
(//0S 9isch, H. and ?. =ay. Tympanoplasty, Mastoidectomy, and Stapes Surgery. @ew Aor%. Thieme =edical Pub., 011/. Boland, P. S. Tympanoplasty: Repair of the Tympanic Membrane. -ontinuing Education Program (7merican 7cademy of 'tolaryngology-Head and @ec% Surgery 9oundation). 7le"andria, 57. 7merican 7cademy of 'tolaryngology, 011/. Tos, =. Manual of Middle Ear Surgery: Approaches, Myringoplasty, Ossiculoplasty and Tympanoplasty. @ew Aor%. Thieme =edical Pub., 0112.

P1+&/D&)!2S 6owney, T. ?., 7. C. -hampeau", and 7. >. Sil a. D7llo6erm Tympanoplasty of Tympanic =embrane Perforations.D American Journal of Otolaryngology ,/ (?anuaryE9ebruary ,))2). (-02. 6uc%ert, C. ;., F. H. =a%iels%i, and ?. Helms. DProlonged =iddle Ear 5entilation with the -artilage Shield T-tube Tympanoplasty.D Otology !eurotology ,/ (=arch ,))2). 0+2-3. 'shima, T., A. Fasuya, A. '%umura, E. Tera8awa, and S. 6ohi. DPre ention of @ausea and 5omiting with Tandospirone in 7dults after Tympanoplasty.D Anesthesia Analgesia 1+ (@o ember ,)),). 2+)-0. Sheahan, P., T. 'G6wyer, and 7. >layney. DBesults of Type 0 Tympanoplasty in -hildren and Parental Perceptions of 'utcome of Surgery.D Journal of "aryngology Otology 00( (?une ,)),). /2)-/. &8un, -., =. 5elepic, 6. =anestar, 6. >onifacic, and T. >raut. D-artilage Palisade Tympanoplasty, 6i ing and Eustachian Tube 9unction.D Otology !eurotology ,/ (=arch ,))2). 2+)-0.

/+3!-&4!T&/-S 7merican 7cademy of 'tolaryngology - Head and @ec% Surgery. 'ne Prince Street, 7le"andria, 57 ,,20/. (3)2) 4)(-////. http.EEwww.entnet.org. 7merican Hearing Besearch 9oundation. ++ E. <ashington St., Suite ,),,, -hicago, $C ()(),. (20,) 3,(1(3). www.american-hearing.orgE