Residency · Residency · Otolaryngology
Tympanoplasty Techniques and Grafting Materials
Overview
Tympanoplasty is the surgical repair of a tympanic membrane (TM) perforation with or without ossicular reconstruction. The goals are closure of the perforation, prevention of recurrent infection, and restoration of hearing. Technique selection (underlay vs. overlay) and graft material choice depend on perforation size, location, and surgeon experience.
Indications
Chronic TM perforation causing recurrent otorrhea despite medical management. Conductive hearing loss attributable to the perforation, Prevention of water entry into the middle ear, Prerequisite to hearing aid fitting in some cases. Relative contraindication: only hearing ear (risk of SNHL), active cholesteatoma (address cholesteatoma first).
Preoperative Assessment
Otoscopic examination: perforation size, location (anterior, posterior, central, marginal, subtotal), status of middle ear mucosa. Pure tone audiometry: air-bone gap quantification; speech discrimination. CT temporal bone: if cholesteatoma suspected, ossicular erosion, or revision surgery. Ensure dry ear for at least 4-6 weeks before surgery when possible. Assess eustachian tube function (although poor predictors of surgical outcome).
Classification (Wullstein)
| Type | Graft Placement | Ossicular Status |
|---|---|---|
| I (myringoplasty) | On intact ossicular chain | Intact; perforation repair only |
| II | Onto eroded incus or malleus | Partial erosion |
| III | Directly onto stapes head (columella) | Malleus and incus removed/absent |
| IV | Onto stapes footplate; round window shielded | Superstructure absent |
| V | Over fenestration in lateral SCC | Stapes fixed (rarely performed) |
Type I (myringoplasty): graft placed on intact ossicular chain; TM perforation repair only. Type II: graft placed onto an eroded incus or malleus. Type III: graft placed directly onto stapes head (columella effect); malleus and incus removed or absent. Type IV: graft placed onto stapes footplate; round window shielded for sound protection. Type V: graft over fenestration in the lateral semicircular canal (rarely performed).
Surgical Approaches
Transcanal
Performed entirely through the ear canal (speculum or endoscopic). Suitable for small to medium posterior perforations with adequate canal exposure. Limited visualization of anterior perforations in narrow or tortuous canals.
Endaural
Incision between tragus and helix; widens the EAC entrance, Better access than transcanal for some perforations, Less morbidity than postauricular.
Postauricular
Incision behind the ear; tympanomeatal flap elevated. Best exposure for anterior, subtotal, and large perforations. Allows harvesting of temporalis fascia and periosteum, Most commonly used approach for formal tympanoplasty.
Endoscopic Transcanal
Increasingly used; excellent visualization with angled endoscopes. No external incision. One-handed technique (endoscope in one hand, instrument in the other). Comparable outcomes to microscopic techniques in published series.
Underlay Technique (Most Common)
Principles
Graft placed medial to the TM remnant and malleus handle, Graft supported by middle ear packing (Gelfoam), Technically easier and more widely taught, Lower risk of graft lateralization.
Steps
Freshen the perforation edges (remove epithelium rim). Elevate tympanomeatal flap (posterior or circumferential). Assess and address ossicular chain pathology if present. Place absorbable gelatin sponge (Gelfoam) in the middle ear for graft support. Position graft medial to the drum remnant, extending under the malleus handle. Replace tympanomeatal flap over the graft. Pack the ear canal with Gelfoam or antibiotic-soaked pledgets.
Advantages
Technically simpler, Lower lateralization rate, Maintains middle ear space anatomy, Good results for posterior and central perforations.
Limitations
Anterior perforations: graft may not reach anterior annulus (higher failure rate). Subtotal perforations: less graft support medially.
Overlay Technique
Principles
Graft placed lateral to the fibrous annulus and drum remnant. Epithelium must be removed from the drum remnant surface, Technically more demanding.
Steps
Remove epithelial layer from TM remnant (meticulous de-epithelialization). Elevate the fibrous layer and annulus. Place graft lateral to the fibrous layer. Secure with packing.
Advantages
Better for anterior and subtotal perforations, Excellent anterior graft support, May produce better hearing results in some studies.
Disadvantages
Higher risk of graft lateralization (graft displaces lateral to annulus). Blunting of the anterior sulcus, Epithelial pearl/cholesteatoma formation, Longer healing time, Technically demanding.
Grafting Materials
| Material | Take Rate | Advantages | Disadvantages |
|---|---|---|---|
| Temporalis fascia | 85-95% | Thin, pliable, easy harvest | May atrophy; higher failure in revisions |
| Tragal perichondrium | 85-95% | No separate incision needed | Limited size |
| Cartilage (tragal/conchal) | 90-98% | Rigid; resists retraction; best for revisions | Theoretical stiffness concern; obscures view |
| AlloDerm | Comparable | Off-the-shelf; no donor site | Cost; limited long-term data |
| Fat plug | 80-90% | Office procedure; minimally invasive | Only for small perforations (<25% TM) |
Temporalis Fascia
Most commonly used graft material worldwide, Harvested from the same postauricular or endaural incision, Thin, pliable, easy to handle. Excellent take rate: 85-95% for primary cases. Disadvantage: thin; may atrophy over time; higher reperforation rate in revision cases or poor eustachian tube function.
Tragal Perichondrium
Harvested from the tragus with a small incision, Similar thickness and handling to fascia, Good take rate, Useful when a separate incision is undesirable.
Cartilage (with or without Perichondrium)
Types
Tragal cartilage: commonly used; adequate for most perforations. Conchal cartilage: larger piece available; good for subtotal perforations. Cartilage island flap: cartilage with perichondrium on one side.
Techniques
Palisade cartilage tympanoplasty: thin cartilage strips placed side by side. Cartilage shield (butterfly graft): full-thickness cartilage fitted into perforation without tympanomeatal flap elevation. Inlay cartilage (cartilage myringoplasty): cartilage wedged into perforation edges -- minimally invasive office technique for small perforations.
Advantages
More rigid -- resists retraction and negative middle ear pressure. Higher graft take rate in difficult situations (revision, eustachian tube dysfunction, adhesive otitis). Take rates: 90-98% in many series. Better for large, subtotal, and anterior perforations.
Disadvantages
Theoretical concern for reduced sound transmission (stiffness) -- but most studies show no significant hearing difference vs. fascia for thin cartilage. Thicker graft may obscure postoperative otoscopic view of middle ear.
Other Materials
AlloDerm (acellular dermal matrix): off-the-shelf; avoids donor site; comparable results in some series. Fat plug myringoplasty: small piece of lobular fat wedged into tiny perforations (<25% of TM); office procedure. Paper patch: office temporization; repeated application with growth factor-containing solutions.
Ossicular Reconstruction (Ossiculoplasty)
Incus Erosion (Most Common Ossicular Defect)
Long process of incus most commonly eroded in chronic otitis media. Interposition options: sculpted autologous incus, partial ossicular replacement prosthesis (PORP).
Prostheses
PORP (Partial Ossicular Replacement Prosthesis): placed from stapes head to TM/graft; replaces incus. TORP (Total Ossicular Replacement Prosthesis): placed from stapes footplate to TM/graft; replaces incus and stapes superstructure. Materials: titanium (most popular), hydroxyapatite, plastipore. Cartilage cap between prosthesis and graft reduces extrusion rate.
Hearing Outcomes
PORP: ABG closure to within 20 dB in 60-75%. TORP: ABG closure to within 20 dB in 50-65%. Staged procedures may be needed if middle ear mucosa is diseased.
<image>Comparison diagram of underlay vs. overlay tympanoplasty techniques shown in coronal cross-section through the ear canal and middle ear. Left panel (underlay): graft placed medial to the tympanic membrane remnant and malleus handle, supported by Gelfoam in the middle ear space, with the tympanomeatal flap draped over the graft. Right panel (overlay): epithelium removed from the drum remnant, graft placed lateral to the fibrous layer. Labels include external auditory canal, tympanic membrane remnant, graft position, malleus handle, middle ear space, Gelfoam, and annulus.</image>
<image>Surgical photograph series showing the steps of cartilage tympanoplasty using the palisade technique. Panel A: postauricular approach with tragal cartilage harvested. Panel B: cartilage cut into thin strips approximately 0.5 mm thick. Panel C: strips arranged in palisade fashion over Gelfoam in the middle ear, medial to the tympanic membrane remnant. Panel D: completed repair with tympanomeatal flap replaced. Endoscopic view inset showing the final result from the canal.</image>
<image>Illustrations of ossicular reconstruction prostheses. Left: PORP (partial ossicular replacement prosthesis) positioned from the stapes capitulum to the undersurface of the tympanic membrane graft, with a cartilage disc interposed between the prosthesis and graft. Right: TORP (total ossicular replacement prosthesis) positioned from the stapes footplate to the graft with cartilage cap. Labeled structures include the malleus handle, tympanic membrane graft, cartilage cap, prosthesis shaft, stapes head (PORP) or footplate (TORP), and facial nerve in the posterior tympanum.</image>
Clinical Pearls
Temporalis fascia remains the gold standard graft for primary uncomplicated tympanoplasty, but cartilage is increasingly preferred for revision cases, eustachian tube dysfunction, and large perforations. Anterior perforations have the highest failure rate regardless of technique due to difficulty in graft placement and limited anterior blood supply. Always place a cartilage cap between an ossicular prosthesis and the graft to prevent extrusion. Fat plug myringoplasty is an effective office procedure for small perforations (<25% of TM) with high success rates. A dry ear before surgery improves graft take rate; treat infection aggressively before tympanoplasty. Endoscopic tympanoplasty provides superior visualization of anterior perforations and hidden areas but requires one-handed surgical technique. Graft lateralization is the most common complication of the overlay technique and causes conductive hearing loss. Thin cartilage slices (0.5 mm) transmit sound as well as fascia grafts in most audiometric studies.
References
- Mohamad SH, Khan I, Hussain SS. "Is cartilage tympanoplasty more effective than fascia tympanoplasty? A systematic review." Otol Neurotol. 2012;33(5):699-705.
- Wullstein H. "Theory and practice of tympanoplasty." Laryngoscope. 1956;66(8):1076-1093.
- Dornhoffer JL. "Cartilage tympanoplasty." Otolaryngol Clin North Am. 2006;39(6):1161-1176.
- Sergi B, Galli J, De Corso E, et al. "Overlay versus underlay myringoplasty: report of outcomes considering closure of perforation and hearing function." Acta Otorhinolaryngol Ital. 2011;31(6):366-371.
