myringoplasty surgery

1. Myringoplasty and Various Graft
Materials
Dr Vaibhav Lahane

2. Definition :-
Myringoplasty is a procedure used to repair a perforated tympanic membrane using a
graft material , without need to examine the middle ear.
The idea of tissue grafting is to replace the missing fibrous element of the TM and to
allow normal epidermis and mucosa to regenerate over the graft.
Advantages :-
1. Restoring the hearing loss
2. Checking repeated infections from EAC and ET
3. Checking aeroallergens reaching the exposed middle ear mucosa l / t persistent ear
discharge.
Myringoplasty should not be confused with type I tympanoplasty.
Though both refer to TM perforation repair , T plasty entails exposure of the middle ear
to inspect and also ensure ossicular integrity.

3. Indications :-
1. Central perforation which has been dry atleast for a period of 6 weeks.
2. As a follow up to mastoidectomy procedure to recreate the hearing mechanism.
Contraindications :-
1. Active discharge from middle ear
2. Nasal allergy
3. Otitis externa
4. Ingrowth of squamous epithelium in middle ear
5. When other ear is dead or not suitable for hearing aid rehabilitation
6. Children below 3 years.

4. Prerequisite :-
1. Central perforation which has been dry for atleast 6 weeks
2. Normal middle ear mucosa
3. Intact ossicular chain
4. Good cochlear reserve
5. Patent eustachian tube
6. There should be no focus of infection in PNS , nose or nasopharynx

5. Pre operative evaluation :-
1. Detail history of patient
2. Physical examination
3. Otoscopic examination - Ear canal
TM
- Perforation – location, size
- Retraction pockets, granulation tissue
- Status of middle ear through perforation
4. Tuning fork test
5. Audiometry
6. Tympanometry – eustachian tube patency
7. Facial nerve

6. Preparation :-
• Proper I/V/W consent .
• XST and inj T.T 005 cc i.m
• A small portion of the hair is shaved just above the pinna, if a temporalis
graft is to be used.
Anesthetic Considerations :-
• In children, the procedure is performed under general anesthesia.
In addition, infiltration of a local anesthetic (1% lidocaine with 1:100,000
epinephrine) into the ear canal and the graft site is preferred.
• In adults , sedation with fortwin and phenargan is given along with local anaesthetic
infiltration.
Position of patient :-
Supine position with head turned towards the opposite side with head touching the
edge of table.
The ear to be operated is up.

7. Instruments required in myringoplasty :-

8. Surgical approaches for myringoplasty :-
1. Endomeatal or transcanal approach
2. Endaural approach
3. Post aural approach
By going through these approaches , we raise the tympanomeatal flap to enter into
middle ear.
1. Endomeatal approach (Rosen’s incision) :-
Requires wide meatus and EAC.
It consists of two parts –
a. A small vertical incision at 12 o’clock
position near annulus
b. A curvilinear incision starting at 6 o’clock
position to meet 1st incision in the
posterosuperior regions of the canal , 5-7
mm away from the annulus.

9. 2. Endaural approach :-
Made through Lempert’s incision. It
consists of two parts :-
Lempert I – It is semicircular incision ,
made from 12 ;o’clock to 6 o’clock position
in the posterior meatal wall at the bony
cartilaginous junction.
Lempert II – Starts from 1st incision at 12
o’clock & then passes upwards in a
curvilinear fashion between tragus & crus
of helix.
3. Post aural or Wilde ‘s incision :-
Starts at the highest attachment of the
pinna , follows the curve of retro auricular
groove , lying 1 cm behind it , ends at
mastoid tip.

10. Procedure :-
Under all aseptic precautions , P and D
done.
• Local anesthetic agent (2 %
xylocaine mixed with 1 in 10,000
adrenaline injection.) is injected in four
quadrants of cartilagenous canal & bony
external canal is injected in subperiosteal
plane at 6 and 12 o’clock.
• The anesthetic agent is also injected above
the pinna, the tragus, or the lobule, when
a graft is to be harvested from one of
these sites.
• When a fascia graft is desired, an incision
is made superior to the pinna just above
the hairline , and the graft is excised.

11. • Still another highly successful
alternative is to remove a small
piece of fat from the ear lobule.
The incision is made on the
posterior surface of the lobule to
hide the scar, but caution should
be exercised while dissecting the
fat with scissors so as to prevent a
“button hole” perforation of the
Lobule.
• As an alternative to a fascia graft, a
perichondrial graft can also be used.
An incision for the perichondrial graft
is made in the tragus, slightly
toward the meatus, which leaves the
tiny scar hidden and perichondrial
graft is excised

12. Techniques of myringoplasty :-
1. Underlay :-
 This is a simpler and commonly used technique.
 Ideal to repair small and easily visualized perforations
 Here the graft is placed under the tympano meatal flap which has been elevated.
 Major advantage - it is easy to perform with a good success rate.
2. Overlay :-
 Difficult technique to master.
 Typically reserved for total perforations, anterior perforations, or failed underlay
surgery.
 Here the graft material is inserted under the squamous layer of the ear drum.
 It is a difficult task , peeling only the skin layer away from the tympanic membrane,
placing the graft over the perforation and redraping the skin layer.

13. Underlay technique :-
1. Freshening the margins of perforation using a sickle knife of an angled pick.
2. A vascular strip is created in the external auditory canal by making incision at
tympanomastoid and tympano squamous suture line corresponding roughly to 6 o
clock and 12 o clock positions. The incision extend upto the annulus.
3. Elevation of tympano meatal flap up to the level of the annulus.
4. Elevation of the annulus and incising the middle ear mucosa.
5. Freeing the tympano meatal flap from the handle of malleus by sharp dissection of
the middle ear mucosa.
6. Placement of graft - middle ear is packed with gel foam soaked with antibiotic. A
proper sized graft is placed so that its edges extend under the margins of perforation
all around and small part also extends over the posterior canal wall.
7. TM flap is reposited. Bits of gelfoam is placed around the edges of the raised
flap. One gel foam bit is placed over the sealed perforation.
8. Closure and dressing done.

14. Video – myringoplasty
Underlay myringoplasty

15. Post operative care :-
1. Patient is discharged on post of day 1.
2. Mastoid dressing is changed on next day morning.
3. Showering is allowed provided the patient places a cotton ball soaked with
petroleum ointment in outer ear canal.
4. Water should be kept away from postauricular incision for 2 days.
5. Nose blowing should be avoided. If snizzing is unavoidable , then mouth should be
kept open.
6. Medications in the form of antibiotics , antihistaminics and analgesics are
prescribed.
7. 1st post op visit – after 1 week – suture removal is done
8. 2nd visit –after 3 to 4 weeks – gel foam over graft is gently suctioned away.
9. Audiogram is obtained 4 to 6 months after surgery.

16. Complications of underlay myringoplasty :-
1. Middle ear becomes narrow.
2. Graft may get adherent to promontary.
3. Anteriorly graft may loose contact from remnant of tympanic membrane l / t
antrior perforation.

17. Advantages and disadvantages of underlay technique –
Advantages :-
1. Simple and easy to perform when
perforation is small.
2. Avoids extensive dissection of
anterior meatal skin, thus
preventing blunting of anterior
recess.
3. Ensures healing of drum at
correct level relative to fibrous
annulus and osseous remnant.
Disadvantages :-
1. Reduction of middle ear space.
2. Limited bed of raw area for graft
reception.
3. Difficult graft placement if perforation
extends more anteriorly.
4. Three layer formation of TM is unlikely.
5. Anterior reperforation.
6. Anterior tympanomeatal cholesteatoma.
7. Blunting of anterior tympanomeatal angle.

18. Overlay technique :-
Graft is harvested.
Incision is made over meatal skin (shown in figure ) & meatal skin raised along with
all epithelium from the outer surface of tympanic membrane remnant preserved to
be used later.
Graft placed on the outer surface of tympanic membrane. A slit is made in the graft
to tuck it under handle of malleus.
Meatal skin removed earlier is now replaced , covering the periphery of the graft.
Graft is supported with gelfoams in EAC.

19. In the overlay technique, the graft is placed lateral to the annulus and any remaining
fibrous middle layer after the squamous layer has to be carefully removed.
In this technique, there is an excellent visualization of the anterior meatal recess, which
is important in cases of anterior perforations reaching the anterior annulus.
A modification of overlay technique is to place the anterior edge of fascia graft under the
annulus after removing the epithelium from its undersurface. This prevents blunting of
anterior canal is seen as a complication of overlay technique.

20. Complications of overlay technique :-
1. Blunting of anterior sulcus.
2. Epithelial pearls – they are epidermal cyst , when squamous epithelium is buried
under the graft.
3. Lateralization of graft – graft loses contact from the malleus handle resulting in
conductive loss. It is prevented by tucking the graft under the handle.

21. Advantages and disadvantages of overlay technique :-
Advantages :-
1. Anterior recess can be visaulized
2. Anterior overhang can be drilled out
3. Middle ear space is not reduced
4. Take up rate should be high as graft
bed is broad
Disadvantages :-
1. Poor exposure of vital areas of tympanic
cavity
2. Delayed healing
3. Epithelial pearls from remanants of drum
epithelium
4. Lateral displacement of graft
5. Inclusion or residual cholesteatoma
6. Retraction pocket due to ET dysfunction
7. Blunting of anterior meatal recess due to;
• Accumulation and organization of
blood deep to graft
• Inadequate removal of anterior canal
hang

22. Causes of failure of myringoplasty :-
1. Upper air way infection
2. Type of surgical procedure
3. Type of tissue used to graft the perforation
4. Trapped epithelial seed cells post operatively
Type of surgical procedure –
1. Exposure of ear drum – in some cases Prominent bulge in the anterior canal wall
obscuring the anterior rim of the ear drum and the anterior portion of the annulusis
present. Myringoplasty performed under these conditions may fail because the graft
could medialize in the anterior recess area. This scenario can be prevented by elevation
of Wright Guilford flap in these patient. This flap is raised from over the bulge of the
anterior canal wall through an incision made circumferentially lateral to the ear drum

23. 2. Preparation of drum head
before grafting:
This involves freshening the edges
of the perforation. The under
surface of the tympanic
membrane must be scraped
using a instrument called drum
scraper. The aim is to create raw
area on the undersurface of the
ear drum facilitating a better graft
take.
3. Positioning of graft –
In underlay technique of myringoplasty , the
graft must be positioned in such a way that it
lies under the handle of malleus. The handle
of malleus is exteriorised. This method
prevents lateralisation of the graft due to pull
by the migating squamous epithelium.
Gelfoam packs must be placed in the middle
ear cavity inorder to enhance the nutritional
status of the graft material, it also helps to
prevent medialisation of the graft

24. Presence of secondary pathology in the middle ear:
The following disorders of the middle ear can lead to graft rejection:
1. Tubal obstruction
2. Presence of cholesteatoma
3. Presence of tympanosclerosis
4. Presence of adhesions binding the handle of malleus to the promontory
5. Ossicular chain necrosis

25. Various Graft materials used :-
Are classified as –
1. AUTOGRAFT : same person
2. ISOGRAFT: genetically identical twins
3. HOMOGRAFT: Another person( SAME SPECIES)
4. HETEROGRAFT: Another species like: fetal serosa, bovine jugular vein
ADVANTAGES OF AUTOGRAFT
1. No immunological reaction
2. Inexpensive
3. No risk of HIV or other infections

26. TYPES OF AUTOGRAFT:
1. Temporalis fascia
2. Tragal cartilage
3. Conchal perichondrium
4. Tragal/conchal cartilage
5. Periosteum
6. Vein
7. Fatty tissue from ear lobule
8. Fascia lata
9. External auditory canal skin
10. Dura
11. Heterotropic skin : full thickness and split thickness
• Temporalis fascia, tragal & conchal perichondrium and fascia lata free grafts provide
viable autograft material for myringoplasty.
• These materials are mesodermal in origin which excludes the risk of iatrogenic
cholesteatoma.

27. Temporalis fascia :-
Temporalis muscle fascia was first used in myringoplasty by Ortegren (1958-59),
Heermann (1961) and Storrs (1961).
Temporalis fascia remains the most commonly used material for tympanic membrane
reconstruction, with a success rate of 93% to 97% in primary surgery.
ADVANTAGES OF TEMPORALIS FASCIA :
1. Location of donor site
2. Easy to harvest
3. Close biological and segmental kinship
4. LOW BMR – requires less nutrition ----- high survival
5. No size limitation
6. The only suitable autologus memberane for reconstruction of tympanic cavity
and ear canal
7. It can be used as onlay /intermediate/underlay grafting
8. It can be used as more than one piece , overlapping the other .
9. It can be used in sandwich techniques as one of the grafts with canal skin on the
fascia.

28. Disadvantages of temporalis fascia :-
1. Can eventually become thin and atrophic.
2. It lacks elasticity and resistance to pressure changes in the external ear canal.
Video

29. Cartilage and perichondrial graft :-
Advantages over temporalis fascia –
1. More rigid and resistant to pressure changes in EAC
2. Good long-term survival.
3. Nourished largely by diffusion.
4. Relatively resistant to infection.
5. Feasibility of assiculat reconstruction at the time of grafting.
It was always a point of debate that whether cartilage graft is superior to fascia graft.
Some studies showed better morphological results with cartilage myringoplasty, which
is statistically significant. However, there was statistically no significant difference seen
in the hearing levels. (1).
However some studies showed similar results between cartilage and fascia
myringoplasty both morphologically and audiologically. (2)

30. Differentiation between cartilage and fascia graft is important in the pediatric group,
because the eustachian tube has a significant role on the success of myringoplasty.
Two studies show better morphological outcome with the use of cartilage when
compared with fascia grafts. (3)
Because one of effects of the eustachian tube dysfunction in the pediatric population
is the negative pressure in the middle ear cavity, which can cause retraction of the
tympanic membrane with resultant failure of myringoplasty.
The effect of this negative pressure can be counteracted by the use of cartilage which is
more stiff and resilient when compared with temporalis fascia.
Kazikdas et al and Zahnert et al. Concluded that both tragal and conchal cartilage
materials are useful for the reconstruction of tympanic membrane from the
perspective of their acoustic properties. Reducing the cartilage size to 500 micrometer
is regarded by the authors as a good compromise between sufficient mechanical
stability and providing adequate and comparable hearing levels when compared with
normal tympanic membrane.

31. • Tragal perichondrium and fascia lata are thicker and stiffer than temporalis fascia.
They are easier to manipulate in the middle ear as they do not get folded on itself,
thus have ideal handling qualities.
• However, graft preparation time for tragal perichondrium was longer and fascia lata
needed preparing, painting, and draping of a second surgical site increasing the
overall time of the surgery.
• Normal translucent appearance of neotympanum in the postoperative period was
seen only with temporalis fascia while in tragal perichondrial and fascia lata grafts
the neotympanum was whitish, thicker, and translucent to opaque

32. Cartilage graft techniques
Perichondrium/
Cartilage island flap
Cartilage shield
technique
Palisade
technique
Inlay Butterfly graft
Tragal cartilage Conchal cartilage Tragal cartilage Tragal cartilage
Conchal cymba
Tragal Cartilage Harvest –
• Cut on posterior surface
of tragus
• Leave 2 mm tragal
cartilage
for cosmesis
• Abundance: 15 x 10 mm
• Flat
• Approx - 1 mm thickness
• Perichondrium is
reflected from the surface
of the cartilage.
Perichondrium/ Cartilage
Graft

33. Postop Perichondrium/ Cartilage Island Graft

34. Cartilage Shield technique : -
• Preferred for total replacement of tympanic membrane.
• Less technically demanding and less time consuming.
• Cartilage is harvested and wedge is removed to fit manubrium .
• Tight fitting oversized graft should be avoided because of reduction in eventual
vibrational properties.
• Concha cymba cartilage has an average thickness of 0.8mm ;its concave
contour resembles the normal shape of TM.
• This thickness of cartilage is similar to fossa triangularis and thinner than tragal
cartilage.

35. Cartilage palisade technique :-
• Curve cymba concha is considered more
suitable.
• Useful in posterior perforations associated with
ossicular disease.
• Cartilage is sectioned in slices which are then
together used to reconstruct TM.
Preparation of slices

36. Palisade technique intraoperative and postoperative.

37. Modified palisade technique :-

38. Cartilage butterfly technique :-
Video

39. Fat graft myringoplasty :-
• Used to close small perforations.
• Fat is harvested from inferior aspect of ear lobule.
• Small piece of fat is plugged into the perforation like an hour glass.
• Over a time , fat graft adheres and closes the perforation.
• Overall success rate – 90- 95 %

40. Skin graft :-
• Skin area free from hairs and sweat gland is ideally used as graft material
e.g. post auricular area , inner surface of arm , deep meatal skin (best for
tympanum)
• Skin grafts do not behave well particularly in mastoid segment , the graft
sometimes become beefy , may look raw or desqaumate excessively.
• This is d/t presence of glandular elements in skin resulting into recurrent episodes
of constant discharge from mastoid cavity.
• Meatal skin will survive well when placed over the tympanum but can cause
trouble in mastoid segment.
• Changes associated with skin grafts –
1. Choleastetomatous changes
2. Keratosis

41. Vein graft :-
Fate of vein graft –
Endothelium unites with middle ear mucosa , Muscles fibres of tunica media undergo
atrophy and replacement fibrosis.
Surviving graft is composed of endothelium , elastic and collegeous fibres.
Advantages of vein graft –
1. Readily available from varicose clinics
2. Sufficient quantity of tissue is available
3. No danger of cholesteatoma.
4. Hearing results are comparable with other graft materials
Vein graft is stored in clod storage and at the time of operation it is thawed to room
temperature before trimming.

42. Other techniques for tympanic membrane perforation repair
Splintage :-
• Used in fresh traumatic
perforations.
• Torn edges of perforation are
everted , splinted with absorbable
gelfoam within the middle ear
through the tear.
• Smaller tears can be splinted on the
outer surface with piece of cigarette
paper , gel film or silicon sheet.
Cautery patching :-
• Useful in small long standing perforations
with epithelised margins.
• Margins of perforation are cauterised with
50 % trichloracetic acid to remove the
epithelised edge.
• Perforation is then supported with a
cigerette paper moistened with 1 %
phenol in glycerine.
• Repeated after 2 weeks interval.

43. References –
1. Cabra J, Monoux’ A. Efficacy of cartilage palisade tympanoplasty: randomised controlled trial. Otol Neurotol
2010;31:589Y95.
Demirpehlivan IA, Onal, K, Aslanoglu S, et al. Comparison of different tympanic membrane reconstruction
techniques in Type 1 tympanoplasty. Eur Arch Otorhinolaryngol 2011;268:471Y4
Albirmawy OA. Comparison between cartilage-perichondrium composite ‘ring’ graft and temporalis
fascia in type one tympanoplastyin children. J Laryngol Otol 2010;124:967Y74.
2. Yung M, Vivekanandan S, Smith P. Randomized study comparing fascia and cartilage grafts in myringoplasty.
Ann Otol Rhinol Laryngol 2011;120:535Y41
Mauri M, Neto JFL, Fuchs SC. Evaluation of inlay butterfly cartilage tympanoplasty: a randomised clinical trial.
Laryngoscope 2001;111:1479Y85
3. Ozbek C, Ciftci O, Tuna EE, et al. A comparison of cartilage palisades and fascia in Type 1 tympanoplasty in
children: anatomic and functional results. Otol Neurotol 2008;29:679Y83.
Albirmawy OA. Comparison between cartilage-perichondrium composite ‘ring’ graft and temporalis fascia
in type one tympanoplasty in children. J Laryngol Otol 2010;124:967Y74.