Tympanoplasty

Tympanoplasty (from Greek týmpanon, meaning drum, and plastikē, meaning reconstruction) is a collective term for a group of reconstructive microsurgical procedures on the middle ear. These interventions pursue two primary goals: the first and the most important is eradication of chronic infection, and the second is to restore or improve the sound conduction mechanism to rehabilitate hearing.

The procedure is aimed at reconstruction of the tympanic membrane and/or the ossicular chain. Tympanoplasty is the principal surgical treatment for patients with chronic otitis media, cholesteatoma, and the consequences of ear trauma.

Goals and Objectives

Depending on the nature and extent of the pathological process, tympanoplasty may include several key stages.

1. Middle ear sanitation: The most critical step, particularly in suppurative otitis and cholesteatoma. It involves complete removal of pathologic tissue, including cholesteatoma matrix, granulation tissue, polyps, and infected mucosa. The goal is to create a dry, safe, epithelialized ear.
2. Myringoplasty (tympanic membrane repair): Restoration of the integrity of the tympanic membrane. An autologous graft is used (most commonly temporalis fascia or auricular cartilage). Closure of the perforation protects the middle ear from infection and provides conditions for hearing improvement.
3. Ossiculoplasty (ossicular chain reconstruction): Reconstruction of a disrupted or immobile ossicular chain (malleus, incus, stapes). Sound transmission from the tympanic membrane to the inner ear may be restored using autologous materials (cartilage or ossicular remnants) or prosthetic implants.

Types of Tympanoplasty (Wullstein Classification)

Historically, reconstruction of the sound-conducting mechanism has been described using the classification proposed by H. Wullstein.

• Type I (myringoplasty): Defect is limited to the tympanic membrane. The ossicular chain is intact and mobile.
• Type II: The handle of the malleus is damaged. The graft is placed onto the incus or the remnant of the malleus.
• Type III (columella tympanoplasty): The malleus and incus are absent, but the stapes is present and mobile. The graft is placed directly onto the stapes head, creating a direct sound transmission pathway (the “columella effect”).
• Type IV: Only the mobile stapes footplate remains. A small middle ear cavity is fashioned to protect the round window, while the oval window remains exposed to sound waves.
• Type V: The stapes footplate is immobile. A new window (fenestration) is created in the labyrinthine wall, typically in the horizontal semicircular canal (currently rarely used).

Modern surgery employs more flexible approaches, often combining different techniques to achieve the best outcomes.

Clinical Role

Tympanoplasty is the mainstay of chronic suppurative otitis media treatment. The extent and type of surgery are determined based on otomicroscopy, audiometry, and, most importantly, computed tomography of the temporal bones, which allows for assessment of the extent of the pathologic process and the condition of the bone structures. In the presence of cholesteatoma, tympanoplasty is almost always combined with mastoidectomy (sanitation surgery of the mastoid process). Although eradication of infection is the primary objective, the functional outcome (hearing improvement) is the second major goal, and it plays a crucial role in the patient’s postoperative quality of life.