Myringoplasty ent

Definition: Surgical closure of a perforation of the pars tensa of the tympanic membrane.

Objectives

• Restore hearing (and sometimes tinnitus).
• Prevent ascending infection from ET or external canal.
• Check aeroallergens from reaching middle ear mucosa.

Pre-requisites & Contraindications

Surgery is Contraindicated or delayed in:

• Active Discharge (Ear must be dry).
• Nasal Allergy (Must be controlled first).
• Otitis Externa.
• Squamous Ingrowth (Requires Tympanomastoidectomy).
• Dead Ear (Other ear is dead/unsuitable for aid).
• Age < 3 years.

Surgical Basics

• Anaesthesia: Local (Preferred) or General.
• Position: Supine, face turned to side.
• Graft Materials:
  • Temporalis Fascia (Most Common).
  • Tragal Perichondrium.
  • Vein / Cartilage / Periosteum.

Techniques: Underlay vs. Overlay

Feature	Underlay Technique	Overlay Technique
Placement	Graft placed UNDER the margins of perforation (medial to annulus).	Graft placed OVER the outer surface of malleus/TM remnant (lateral to annulus).
Procedure	1. Margins Freshened. 2. Tympanomeatal flap raised. 3. Middle ear packed (Gelfoam). 4. Graft placed under edges.	1. ALL Meatal skin + Epithelium of TM removed/raised. 2. Graft placed on outer surface. 3. Skin replaced over graft.
Advantages	• Easier to perform. • No risk of burying squamous epithelium (Pearls).	• Excellent anatomical exposure. • Good for anterior perforations.
Complications	• Middle ear narrowing. • Medialization (Adherent to promontory). • Anterior failure (graft falls away).	• Blunting of anterior sulcus. • Epithelial Pearls (Epidermal cysts). • Lateralization of graft (Conductive loss).

Other Procedures

1. Splintage

• Indication: Fresh traumatic perforations.
• Method: Edges everted; splinted with Gelfoam (inner) or Cigarette paper/Silicone (outer).

2. Cautery Patching

• Indication: Small, long-standing central perforations (dry).
• Agent: 50% Trichloracetic Acid (TCA).
• Method: Margins cauterized to remove epithelial edge → Supported with paper patch (moistened with phenol in glycerine). Repeated every 2 weeks.

3. Fat-Graft Myringoplasty

• Indication: Small perforations.
• Method: Fat from ear lobule plugged into perforation like an "hourglass" after freshening edges.

Post-Operative Care

• Stitches/Pack removal: 5–6 days.
• Graft epithelialization: Takes 6–8 weeks.