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Myringoplasty

Myringoplasty is a surgical procedure perform to close a perforated tympainic membrane (ear drum).

Pre-requisites for Myringoplasty

  • 1. Perforation size and location

    The perforation should be relatively small (less than 50% of the tympanic membrane) and located in the central or anterior part of the eardrum.

  • 2. Hearing status

    The patient should have a reasonable hearing threshold, as myringoplasty is primarily aimed at improving hearing.

  • 3. Middle ear status

    The middle ear should be free of infection, and the ossicles (middle ear bones) should be intact.

  • 4. Eustachian tube function

    The Eustachian tube should be functioning properly to ensure adequate ventilation of the middle ear.

  • 5. Absence of cholesteatoma

    There should be no evidence of cholesteatoma, a type of skin cyst that can occur in the middle ear.

  • 6. Patient's overall health

    The patient should be in good overall health and free of any medical conditions that may compromise the success of the surgery.

TYPES OF MYRINGOPLASTY

Here are the types of myringoplasty, their indications, advantages, disadvantages, and success rates:

Underlay Myringoplasty

Indications

1. Small to medium-sized perforations: Perforations that are less than 50% of the tympanic membrane.
2. Anterior or central perforations: Perforations located in the anterior or central part of the tympanic membrane.

Advantages

  • 1. Less traumatic

    The underlay technique is less traumatic to the middle ear structures.

  • 2. Faster healing

    The underlay technique promotes faster healing and reduces the risk of complications.

  • 3. Better hearing outcomes:

    The underlay technique can provide better hearing outcomes, especially in cases with small perforations.

Disadvantages

  • 1. Limited access

    The underlay technique can provide limited access to the middle ear, making it more challenging to visualize and repair the perforation.

  • 2. Risk of graft displacement

    There is a risk of graft displacement or rejection, especially if the graft is not properly secured.

Success Rate

The success rate for underlay myringoplasty is reported to be around 80-90%.

Overlay Myringoplasty

Indications

1. Large perforations: Perforations that are greater than 50% of the tympanic membrane.

2. Posterior perforations: Perforations located in the posterior part of the tympanic membrane.
3. Recurrent perforations: Perforations that have recurred after previous repair attempts.

Advantages

  • 1. Better access

    The overlay technique provides better access to the middle ear, making it easier to visualize and repair the perforation.

  • 2. Reduced risk of graft displacement

    The overlay technique reduces the risk of graft displacement or rejection.

  • 3. Improved hearing outcomes

    The overlay technique can provide improved hearing outcomes, especially in cases with large perforations.

Disadvantages

  • 1. More traumatic

    The overlay technique is more traumatic to the middle ear structures, which can increase the risk of complications.

  • 2. Slower healing

    The overlay technique can result in slower healing and a higher risk of complications.

Success Rate

The success rate for overlay myringoplasty is reported to be around 70-80%.

Complications of Myringoplasty

  • 1. Graft failure

    The graft may fail to take, resulting in a recurrent perforation.

  • 2. Infection

    Infection can occur, especially if the graft is not properly secured or if the middle ear is not properly cleaned and prepared.

  • 3. Hearing loss

    Hearing loss can occur, especially if the middle ear structures are damaged during the procedure.

  • 4. Tinnitus

    Tinnitus (ringing in the ears) can occur, especially if the middle ear structures are damaged during the procedure.

  • 5. Facial nerve weakness:

    Facial nerve weakness or paralysis can occur, especially if the facial nerve is damaged during the procedure.

It’s essential to discuss the risks and benefits of myringoplasty with an ear, nose, and throat (ENT) specialist to determine the best course of treatment for your specific condition.

 Here’s a step-by-step outline:

Pre-Operative Steps

1. Pre-anesthetic evaluation: Assess the patient's overall health and anesthesia risks.

2. Informed consent: : Obtain consent from the patient or guardian.

3. Preparation: Prepare the operating room, instruments, and equipment.

Operative Steps

1. Positioning: Place the patient in a supine position with their head turned to the side.

2. Anesthesia: Administer general anesthesia and/or local infiltration of incision site.

3. Cleaning and preparation: Clean the ear canal and surrounding area with povidone iodine or any appropriate cleaning antiseptic.

4. Incision: Make an incision in the external auditory canal (permeatal approach) or behind the ear (postaural approach).

5. Exposure: A meatal flap is meticulously raised to the annulus for permeatal approach. Expose the tympanic membrane and surrounding structures. Edges of perforation freshened.

6. Dissection: Dissect car perforated area of the tympanic membrane.

7. Graft harvesting: Harvest a graft from the temporalis fascia, perichondrium, or other suitable sites.

8. Graft placement: Place the graft over the perforated area, ensuring it is securely positioned.

9. Securing the graft: Secure the graft with gelfoam or other suitable materials

Microscopic versus Endoscopic Myringoplasty:

The Advantages and Disadvantages

Microscopic Myringoplasty
Advantages

  • 1. High magnification

    Provides high-quality magnification, allowing for precise dissection and graft placement.

  • 2. Wide availability

    Microscopes are widely available in most operating rooms.

  • 3. Established technique

    Microscopic myringoplasty is a well-established technique with a long history of successful outcomes.

Disadvantages

  • 1. Limited field of view

    The microscope's field of view is limited, requiring frequent adjustments to visualize the entire surgical site.

  • 2. Need for assistant

    A skilled assistant is required to hold the microscope and adjust its position.

  • 3. Potential for eye strain

    Prolonged use of the microscope can cause eye strain for the surgeon.

Endoscopic Myringoplasty:
Advantages

  • 1. Wide field of view

    Endoscopes provide a wide field of view, allowing for better visualization of the surgical site.

  • 2. Minimally invasive

    Endoscopic myringoplasty is a minimally invasive technique, reducing trauma to surrounding tissues.

  • 3. Reduced need for assistants

    The endoscope can be held by the surgeon, reducing the need for assistants.

Disadvantages

  • 1. Steep learning curve

    Endoscopic myringoplasty requires specialized training and experience.

  • 2. Equipment costs

    Endoscopes and associated equipment can be expensive.

  • 3. Potential for limited depth perception

    Endoscopes can provide a two-dimensional view, potentially limiting depth perception.

Comparison of Outcomes

Studies comparing microscopic and endoscopic myringoplasty have shown:

  • Similar success rates

    Both techniques have similar success rates in terms of graft uptake and hearing improvement.

  • Reduced operative time

    Endoscopic myringoplasty may have shorter operative times compared to microscopic myringoplasty.

  • Less postoperative pain

    Endoscopic myringoplasty may result in less postoperative pain and discomfort.

Ultimately, the choice between microscopic and endoscopic myringoplasty depends on the surgeon’s experience, the patient’s specific needs, and the available equipment.

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