Tympanoplasty: What You Need to Know About Eardrum Repair Surgery

The most common cause of tympanic perforation is acute otitis media, especially in children. As middle-ear pressure rises and drainage occurs, the drum ruptures. Most perforations heal spontaneously in 4-6 weeks, but 10-15% become chronic.

Traumatic causes: cotton-bud manipulation, slaps (pressure wave), explosive blast, barotrauma (diving, flying), foreign body. Traumatic perforations have cleaner edges and close spontaneously in 80-90% of cases.

Chronic suppurative otitis media (CSOM) is the most challenging picture. There may be associated mucosal inflammation, polyps, cholesteatoma and ossicular erosion. With repeated otorrhoea the drum loses its native healing capacity.

After ventilation tube extrusion, 1-3% of cases retain a persistent perforation. These are usually small, anterior, and have a good surgical outcome. Related overview: our otology and hearing centre.

The classic triad: conductive hearing loss (10-30 dB depending on size and location), recurrent otorrhoea (especially after water exposure), and discomfort when water enters. Some patients tolerate it well; others have major lifestyle limitations.

Diagnosis is by otoscopy. With a dry perforation, document its size (% of drum surface), location (anterior / posterior / inferior / attic), edge quality, ossicular chain appearance, and middle-ear mucosa. Microscopic examination adds detail.

Every patient undergoes audiometry. Pure-tone average, air-bone gap (typically 10-25 dB from the perforation alone; above 30 dB suggests an ossicular issue), and speech discrimination are recorded. These are the basis for both surgical indication and post-op comparison.

A high-resolution temporal-bone CT clarifies cholesteatoma, ossicular integrity and mastoid pneumatisation. Most Type I candidates can be assessed clinically; complex cases require CT.

Type I (myringoplasty): the ossicular chain is intact; only the drum is repaired. The most common tympanoplasty. Type II: defect between malleus and incus, ossicular reconstruction also performed. Type III: malleus erosion; the graft is laid on the stapes (columellar effect).

Type IV: malleus and incus absent, stapes intact and mobile; "round-window protection" — the graft drops on to the stapes, isolating the round window. Type V: stapes also damaged (fixed or absent); fenestration, rarely done today — prosthetic ossicles (PORP / TORP) are preferred.

In practice most cases are Type I — dry, simple perforation. Complex disease falls into Types II-IV. With cholesteatoma, mastoidectomy and clearance come first; reconstruction is done in the same operation or as a planned staged procedure 6-9 months later.

Temporalis fascia is the classic graft. Thin and functionally close to the native drum, it integrates well. Disadvantage: being thin, it can weaken over time in large defects or retraction-prone ears.

Tragal cartilage (taken from the tragus of the auricle) has become widespread in the last 20 years. More durable, resistant to retraction, and reduces cholesteatoma risk. Used as "cartilage palisade" or "cartilage island". Disadvantage: its thickness reduces acoustic transmission slightly — usually without clinical impact.

Choice depends on case: small, simple, anterior perforations do well with fascia. Large (over half the drum), subtotal, anterior-edge-uncertain, retraction-prone or revision cases benefit from cartilage. In adolescents and children cartilage tends to give more reliable success. Step-by-step details: cholesteatoma page.

In the classic microscopic approach a post-auricular or transcanal incision is used. Wide field of view, two-handed work, and the standard route when mastoidectomy is required. Disadvantage: bone curettage may be needed for the anterior margin.

The endoscopic approach has expanded rapidly in the last decade. 0°, 30° or 45° endoscopes are used via the ear canal. Advantages: minimally invasive (no external incision), direct view of the anterior margin, fast return to clinic life. Disadvantage: single-hand operation, limited in mastoidectomy cases.

A modern ENT surgeon knows both and chooses by case. Type I tympanoplasty — particularly anterior perforations — is ideal for endoscopic. In cholesteatoma cases a microscope + endoscope combination is becoming the standard.

Surgery is performed under general anaesthesia in 60-120 minutes. Same-day discharge is usually feasible; one-night observation may be advised in selected cases. Absorbable packing (Gelfoam) is placed in the middle ear, and sterile external canal packing stays for a few days.

Week 1: no swimming; protect the ear in the shower (cotton with petrolatum). First office visit at day 7, external packing removed. Weeks 2-3: Gelfoam begins to dissolve and falls into the canal or is cleaned by the surgeon.

Hearing can feel disappointing in the early weeks due to the sensation of fullness. By 6-8 weeks the Gelfoam is gone and true hearing emerges. Post-op audiometry at 3 months. Success rate 85-95% (graft taken, dry, functional ear). Revision needs 5-10%.

Flying is discouraged for 2-3 weeks (barotrauma risk). Swimming and diving free after 6-8 weeks. Sport and physical activity may restart at 3 weeks. Full recovery and final hearing assessment crystallise at month 3-6.

Graft take is 90-95% for Type I, 75-85% for more complex cases. Hearing gain (air-bone gap closure) is meaningful in 70-85% of patients. Children may have slightly lower success, mainly due to Eustachian-tube dysfunction and adenoid activity.

Possible risks: taste change (chorda tympani manipulation — usually transient, permanent in 1-2%), facial paresis (very rare, under 0.1%), sensorineural hearing loss (inner-ear trauma — 1-2%), vertigo (transient; perilymph fistula very rare), infection (2-3%), graft failure (5-15%).

Long-term follow-up: month 1 otoscopy and packing clearance, month 3 audiometry and otoscopy, month 6 otoscopy, then annual. The 5-year re-perforation risk is 5-10%; in patients with recurrent otitis, evaluate Eustachian tube function. Related reading: our patient testimonials.