Tympanoplasty
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Direct answer
Tympanoplasty eradicates middle ear disease and reconstructs the sound-conducting mechanism — drum and, when needed, ossicles — in one sitting, classified by Wullstein into five types by what the reconstructed drum contacts: type I, simple perforation closure with an intact ossicular chain (myringoplasty when ossicles are entirely normal); type II, graft applied to a partially defective chain (onto the incus or malleus remnant); type III, graft or a columella making direct contact with the stapes head; type IV, the round window shielded while the oval window is exposed to sound directly; and type V, a historic fenestration of the horizontal semicircular canal when the stapes and oval window are lost. Temporalis fascia is the standard graft, cartilage is chosen for atelectatic ears, and the procedure combines with mastoidectomy whenever cholesteatoma coexists.
What you must remember
- Goal statement: a dry, safe ear and serviceable hearing; closure stops the discharge, the air-bone gap typically falls 15-30 decibels, and type I success is quoted around 90 per cent in dry ears.
- Wullstein map: I — drum repair with intact chain; II — graft onto incus or malleus remnant; III — graft or columella onto the stapes head; IV — exposed footplate with the drum shielding the round window; V — historic fenestration of the lateral canal.
- Graft materials: temporalis fascia (workhorse), tragal perichondrium, cartilage (island or palisade) for retraction pockets and revisions, and partial or total ossicular prostheses for bridging.
- Approaches: transcanal, endaural or postauricular by exposure and perforation size; the graft sits medial (underlay) or lateral (overlay) to the drum remnant, underlay commonest.
- Indications: recurrent otorrhoea through a perforation, hearing rehabilitation, marginal perforations at risk of cholesteatoma, and swimming or occupational needs; discharge is controlled first when possible.
- When to add mastoidectomy: cholesteatoma, mucosal disease with ossicular erosion, or a long-standing unsafe ear — the combined operation (canal wall up or down) treats the cause of failure rather than only its perforation.
- Contraindications and cautions: active infection at the planned date (relative), unrepaired coagulopathy, and sole-hearing ears, where the risk-benefit discussion changes.
- Complications to quote: graft failure and reperforation, lateralisation or blunting at the anterior angle, chorda tympani taste disturbance, and rare sensorineural loss or facial nerve injury.
Worked example: one operation planned three ways
A 24-year-old swim instructor has a dry central anterior perforation since a childhood otitis, monsoon discharges, and a 30-decibel conductive loss with an intact, mobile ossicular chain. She is a straightforward type I candidate: raise a tympanomeatal flap, freshen the perforation rim, harvest temporalis fascia, underlay the graft medial to the drum remnant with gelatin sponge support. Graft take in a dry case is high, the discharge stops, the gap narrows, and she returns to the pool with a healed membrane — myringoplasty's goal in one biography.
Change one variable and the plan changes character. An eroded incus with an intact stapes makes it a type III: a cartilage island or partial prosthesis bridging malleus handle to stapes head, drum grafted over it. Cholesteatoma filling the attic adds a canal wall up mastoidectomy in the same sitting, with a planned second look if residual disease is a risk. And in the wet, actively discharging ear, aural toilet and topical quinolone drops precede any grafting, because operating through pus is how grafts fail. The Wullstein type is the last decision: disease extent, not the audiogram, writes the operative note.
Where students slip
Type III and IV are swapped: III places the graft or columella on the stapes head, IV leaves only the footplate mobile and depends on shielding the round window. Every discharging ear is grafted on the next list when control of infection first, graft second, is the sequence that passes. Fascia is chosen for retraction pockets and revisions when cartilage — resisting retraction — is the examinable choice. Finally, myringoplasty equals type I only when the chain is intact and the middle ear normal; erosion upgrades the type and the operation.
Frequently asked questions
What is a Wullstein type III tympanoplasty?
Reconstruction in which the graft or an ossicular columella makes direct contact with the head of the stapes, used when the incus and malleus are lost but the stapes superstructure remains.
Which graft material is standard, and when is cartilage preferred?
Temporalis fascia is standard; cartilage (island or palisade) is preferred for atelectatic ears, retraction pockets and revisions because it resists retraction.
When is myringoplasty distinguished from tympanoplasty?
Myringoplasty refers to closure of the perforation alone with an intact, healthy ossicular chain and normal middle ear mucosa; anything more — ossicular reconstruction or disease clearance — is tympanoplasty.
What hearing gain is expected after successful type I tympanoplasty?
Closure of the air-bone gap typically by 15-30 decibels with graft take rates around 90 per cent in dry, well-selected ears — a dry ear being the primary goal and hearing the second.
Why is mastoidectomy combined with tympanoplasty?
Because cholesteatoma or mastoid disease defeats any graft; the combined operation eradicates the sepsis source before reconstruction.