What is Tympanoplasty?
Tympanoplasty is a surgical procedure to repair a perforation (hole) of the tympanic membrane (eardrum). The tympanic membrane is a thin, cone-shaped structure approximately 9–10 mm in diameter that separates the external ear canal from the middle ear. It serves two critical functions: it transmits sound vibrations to the ossicular chain (the three hearing bones) and it protects the middle ear cavity from the external environment. When the eardrum is perforated — whether from infection, trauma, or a previously extruded ventilation tube — both functions are compromised: hearing is reduced and the middle ear is vulnerable to water contamination and infection.
Causes of Eardrum Perforation
- Chronic suppurative otitis media (CSOM): Long-standing middle ear infection that erodes the eardrum over time.
- Acute trauma: Slap to the ear, blast injury, cotton swab injury, or sudden extreme pressure change (barotrauma).
- Previously extruded ventilation tube: Grommet tubes occasionally leave a persistent perforation when they extrude, particularly long-stay T-tubes.
- Cholesteatoma: An abnormal accumulation of keratinized squamous epithelium in the middle ear that progressively erodes surrounding structures, including the eardrum. Cholesteatoma requires urgent surgical treatment due to its potential to erode the ossicles, facial nerve canal, and skull base.
Surgical Approach
Endoscopic Tympanoplasty
At our clinic, the primary approach for most eardrum perforations is endoscopic. An endoscope — a rigid rod-lens telescope — is introduced through the ear canal, providing an extremely wide-angle, high-definition view of the entire eardrum and middle ear without any external incision behind the ear. For patients with central, uncomplicated perforations, this approach is minimally invasive, leaves no scar, and is associated with significantly faster recovery than traditional microscopic surgery.
Microscopic Tympanoplasty
For larger or more complex perforations, for cases involving extensive middle ear pathology, or when the ear canal anatomy limits endoscopic access, the traditional microscopic approach is used. A post-auricular (behind-the-ear) incision is made; the ear is reflected forward to expose the eardrum under the operating microscope. This approach provides excellent visualization and the space needed for complex middle ear reconstruction.
Graft Materials
The perforation is closed by placing a graft of autologous tissue — tissue harvested from the patient's own body. The two most commonly used materials are:
- Temporalis fascia: The fibrous connective tissue layer overlying the temporalis muscle, located just above and behind the ear. It is the gold standard graft material — thin, strong, biocompatible, and available in generous quantities through the same surgical field.
- Tragal cartilage with perichondrium: The cartilage from the small projection at the entrance of the ear canal (the tragus). Cartilage grafts are used for larger perforations or cases with Eustachian tube dysfunction, as cartilage is more rigid and resistant to recurrent retraction.
Recovery and Hearing Outcomes
The ear is packed with a dissolving gelatin sponge and protected with an external cotton plug for the first 2–3 weeks. During this period, the ear must be kept completely dry. No water, no swimming. After the surgeon confirms graft take at the first post-operative visit (typically 3–4 weeks), the activity restrictions are lifted gradually.
The graft heals and becomes incorporated into the eardrum over 2–3 months. Hearing improves progressively as post-operative swelling resolves and the graft stiffens slightly. Final hearing outcomes are assessed with an audiogram at 3 months; success rates for primary tympanoplasty performed by experienced ENT surgeons exceed 90%.
Frequently Asked Questions
Will my hearing return to normal after tympanoplasty?
In most cases, successful closure of the perforation improves hearing significantly — typically bringing it to within normal limits. However, the final hearing result depends on additional factors including the status of the ossicular chain and the pre-operative hearing level.
What is the most important rule after tympanoplasty?
Strict water protection of the operated ear is the single most important post-operative instruction. Water contamination of the middle ear during the healing phase can cause graft failure and infection. The ear must be kept completely dry for the full post-operative period specified by the surgeon.
What happens if the graft doesn't take?
Graft failure (partial or complete) occurs in approximately 5–10% of primary tympanoplasties. In most cases, the failed graft can be revised after 6–12 months with a good success rate at the second attempt.
