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BackTable / ENT / Article
Tympanoplasty 101: How to Fix a Tympanic Membrane Perforation
Julia Casazza • Jan 17, 2024 • 37 hits
Seemingly countless decisions confront the surgeon planning tympanoplasty: microscopic or endoscopic approach? Lateral or medial graft? Cartilage or fascia? In this article, expert otologists Dr. Walter Kutz of UT Southwestern and Dr. Daniel Choo of Cincinnati Children’s Hospital share pearls to approaching tympanoplasty in pediatric patients with tympanic membrane perforation.
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable ENT Brief
• Surgeon preference and perforation characteristics determine the best strategy to repair a tympanic membrane perforation. When performing tympanoplasty, graft material is placed laterally (“lateral graft approach”) or medially (“medial graft approach”) to the annulus. Either an endoscope or a microscope is necessary to visualize the operative field.
• Many different materials are currently used as tympanoplasty grafts. These include but are not limited to tragal/conchal cartilage, temporalis fascia, perichondrium and xenografts.
• Otorrhea on the day of surgery is not a reason to cancel or reschedule tympanoplasty. Nonetheless, surgeons should be aware that surgery, especially hemostasis, will be more challenging in the setting of active inflammation.
• Post-operative management following tympanoplasty consists of a 7-10 day course of ear drops (following clinic removal of packing material), dry ear precautions for 4-6 weeks after surgery, and multiple audiograms (typically three weeks and three months post-surgery) to track improvement in hearing.
Table of Contents
(1) Grafts Used in Tympanoplasty Surgery
(2) Otorrhea & Tympanoplasty Surgery Planning
(3) Post-Operative Tympanoplasty Management
Grafts Used in Tympanoplasty Surgery
Perforation characteristics (e.g. size, location) and surgeon preference influence the graft used in tympanoplasty. Graft materials include cartilage, fascia, perichondrium, and xenografts. When repairing a smaller perforation, the “butterfly” cartilage graft is a classic choice. Porcine submucosal intestinal grafts are a newer option that more directly adhere to the curvature of the tympanic membrane. When repairing a larger perforation, cartilage also remains an option, though temporalis fascia and perichondrium are more flexible.
[Dr. Gopi Shah]
Is there a certain size criteria for a butterfly cartilage graft besides that it's too big that you were like, "No, I think I'm going to have to do a standard tympanoplasty?" For our listeners who may not know this is the cartilage graft where you're making it into a grommet, correct? You're taking some of the epithelium off of the tympanic membrane and making sure so that skin isn't trapped in it and then popping it in like a tube?
[Dr. Daniel Choo]
There's a lot of variables. The location of it definitely makes a difference. In some ways having a little myringosclerosis around the perforation in those actually can be a little bit helpful because it gives your graft something to really butt up against and holds it steady. In very rough terms, I'd say if it's more than three millimeters in size, I'm probably going to do something more formal and lift up the drum and try and graft it.
…
[Dr. Walter Kutz]
Dan, you mentioned use of cartilage. I've actually interestingly probably used less cartilage over time even in kids and it seems like my results have been-- they seem good. I haven't looked at them systematically. If you really don't know your results you'll be humbled if you look at them systematically. You're usually like, "oh, it holds every time." They're like, "oh, well, it only held 70% of the time," but I think one of the challenges, maybe one of the points you brought up is when you use cartilage, cartilage is pretty rigid and the drum's actually a very dynamic almost like a cone-shaped. I think sometimes I put cartilage in there and I think just that the cartilage doesn't really sit under the drum and you have that little gap but I've seen some of these heal up and we have this little crescent-shaped residual perforation. It sounded like you may take some of the porcine submucosal or a little perichondrium and fill in that little gap. Is that right? Is that what you were describing?
[Dr. Daniel Choo]
Yes, exactly. That's a really helpful tip. I'm curious so I'm going in the opposite direction. I'm probably using more cartilage than I did 10 years ago. I'm really happy with the healing outcomes. It has made a little bit of a difference in a positive way and so far I think I'm still seeing good hearing results from it and especially on those anterior superior perforations that we talked about. I think that area really helps me. What's made you shift the other way, Walt?
[Dr. Walter Kutz]
I think it's just that I think the fascia or the perichondrium is just pretty no-nonsense. It's simply placed in there, it's going to really form underneath the drum, you put some packing, and I think some of the cartilage, I think it's a little hard to size. If you're going to do a shield piece of cartilage, you're going to cut out that strip of the malleus. Sometimes it's difficult to make sure that's not contacting the malleus at the right angle but like you said, in reality, all the literature and our experience shows that cartilage doesn't seem to really negatively affect the hearing results which is really surprising but there's been literature upon literature that really shows there's really not much of a difference. I think the fascia and perichondrium are just simple to work with.
Now, a kid with cleft palate, recurrent perforations those sort of things, yes, I'm going to use cartilage just to buy yourself more time and have a better chance of healing results but these kids that maybe it's just a tube that came out that didn't heal well, they had a traumatic perforation, eustachian tubes go in the other side, I just usually use these fascia and perichondrium. I think that more people lean to using more cartilage over time but I've just used a little less recently and it seems to be working okay.
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Otorrhea & Tympanoplasty Surgery Planning
When a patient scheduled for tympanoplasty presents with ear drainage, surgeons should take action to address any potential infection. If the otorrhea is found in the clinic, have the patient start Ciprodex (or an equivalent ear drop) one week prior to surgery. If the otorrhea is found the day of surgery, it is not a reason to cancel. However, surgeons should be aware that the operation will be more difficult and that greater attention should be paid to hemostasis in the context of active ear inflammation.
[Dr. Gopi Shah]
Tell me about otorrhea game day. Let's say, two scenarios. One is the patient's in pre-op and they got snot coming out of their ear. Let's say the second scenario is you don't really see anything in pre-op, but you go to the OR and there's drainage and there's some granulation tissue. How do you guys manage that? Also thirdly, do you routinely look with an otoscope before surgery, before the patient goes to the OR?
[Dr. Daniel Choo]
I was just trying to think the last time I canceled a case in pre-op because we were going to fix an eardrum and then the kid had some otorrhea at the time and I really can't remember. For better or worse, we kinda plow ahead. I am one of those believers where I think some of our chronic recurrent otorrhea kids have biofilm disease and cleaning them out at the time of tympanoplasty is probably a good idea. If anything, rather than doing something minimalistic like a butterfly graft, if the kid's draining and the ear looks fairly hot, we'll turn a tympanomeatal flap, clean everything out as good as we can. Up until recently, I was also a big fan of putting in some Otiprio into the middle ear space when we do that. That's that long-acting quinolone. It's in a hydrogel. You squirt it into a liquid and then when it hits a 37-degree environment, it gelatinizes and then it stays in there for about three to four weeks.
In the early healing period, you're giving the ear a fighting chance to stay clear of an acute infection, give that graft a chance to take. Unfortunately, they're going to stop marketing that in the U.S. because they didn't have a great demand for it.
…
[Dr. Walter Kutz]
Yes, I have a similar approach. I can't think of the last time I canceled a case because of otorrhea. Now, if I was intraoperative, I wish I would have canceled the case when it's a total disaster. I think one really good hint for newer surgeons, and I've been in practice a long time, just you keep learning things as you go, but if a child has any history of otorrhea, just tell them to start drops one week before surgery. I usually tell them to start Ciprodex or some drop with a fluoroquinolone and a steroid. I think that can really help prevent some of this. Sometimes I'll forget to tell them or they'll forget to start it, but I'll proceed. There was a good study at House years ago when they looked at patients that had a dry perforation or a draining perforation at the time of surgery and the healing results were really about the same.
It just makes surgery more challenging. The other thing too is sometimes you get such bad meningitis that it's hard to know where do you stop rimming the perforation. It does make it more challenging, but we typically push forward. I think Dan's got a good point. A lot of these kids just have biofilms and if they're going to drain-- you're going to cancel them and they come back three months later and they're draining again.
Post-Operative Tympanoplasty Management
Both Dr. Kutz and Dr. Choo start patients on Ciprodex (or equivalent) ear drops at the first postoperative visit, which usually occurs two to three weeks after surgery. Duration of treatment is usually 7-10 days. In cases where residual packing is left in the ear, a longer course may be necessary to dissolve any remaining packing material. Dry ear precautions are necessary for 4-6 weeks following surgery as the perforation continues to heal. Audiograms at three weeks and three months post-surgery can track improvement in hearing loss.
[Dr. Gopi Shah]
In terms of post-op, do you drops a couple of weeks later, for how long, if the kid doesn't do drops, does that change your management? Do you have to suck the packing out week three?
[Dr. Walter Kutz]
I usually have them start drops, I don't know, 10, 14 days after surgery. One trick, if the drops bother the kid, parent can put it in their pocket for 10, 15 minutes. I think warming it up a little bit can help. It's pretty rare that I think drops actually burn, but we do have patients that describe that sometimes. In reality for the young kids, I just put them on drop for a long time because I do like suctioning out the packing, but there comes a point where it is just not good for anybody to keep going after the packing. A lot of times there'll be a little packing anteriorly that you just can't remove on anybody. I just continue drops for a couple of more weeks. It usually takes care of it.
[Dr. Daniel Choo]
Yes. I think that sounds pretty familiar. I'll see my kids back somewhere around three weeks post-op from a typical tympanoplasty and then won't start drops until I see them and then cleaning out the gel foam, whatever is convenient and comes really easily enough so I can get a peek of at least part of the drum to see how it's healing up. Then they come back probably another month after that. That's when we'll do a more formal clean out if there's anything residual as well as an early hearing test to see where they're heading.
[Dr. Gopi Shah]
When do you usually get another audiogram after surgery?
[Dr. Daniel Choo]
It's typically at the second post-op visit, I'll get one and I'll give the parents the caveat. I said, "listen, I just want to know where they're heading and see if we're in a good place early on, but it'll still get better for another few more months." That's typically three weeks from the first visit and then four weeks after that one. Around seven, eight weeks, pretty typical.
[Dr. Walter Kutz]
I do a three-week and then I'll check the hearing in three months after surgery. Now, if there's some concern with healing, I'll see him again four weeks after that initial three-week visit. A lot of times if the thing looks like it's going well, say in about three weeks, I've already started my drops and then I'll just see them back in three months with an audiogram.
Podcast Contributors
Dr. Daniel Choo
Dr. Dana Thompson is the chair of pediatric otolaryngology with Lurie Children’s Hospital in Chicago.
Dr. Walter Kutz
#N/A
Dr. Gopi Shah
Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2023, March 30). Ep. 100 – Tympanic Membrane Perforation in Children [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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