Myringoplasty - Meaning, Surgery Procedure and Results

Myringoplasty is a surgical procedure performed to repair the perforation in the tympanic membrane (eardrum). The perforation usually occurs on the more significant part of the eardrum, known as pars tensa. In this process, the perforation is fixed by placing a graft to patch up the eardrum.

Anatomy and Physiology of the Tympanic Membrane (Eardrum)

1. The tympanic membrane, or the eardrum, separates the outer ear from the middle ear. 
2. The membrane lies across the external canal and looks like a flattened cone with its tip pointing inwards. 
3. It comprises a thin connective tissue membrane covered by the skin on the outside and mucosa on the internal surface. 
4. This membrane has an abundant supply of blood vessels and also contains sensory nerve fibres that make it extra sensitive to pain. 
5. This membrane receives sound vibrations from the outside air and transmits them to the auditory ossicles, the tiny bones in the middle ear. 
6. The bones present in the middle ear transmit vibrations to the inner ear. 

Generally, myringoplasty is performed to repair a hole in the eardrum. Myringoplasty also helps treat other conditions such as:

1. Tinnitus (ringing in the ear)
2. Hearing loss
3. Vertigo (spinning sensation)

Myringoplasty is recommended for those patients who:

1. Are suffering from persistent perforation of the eardrum, resulting in enlargement of the hole to the extent that it has reduced the hearing capability,
2. Are diagnosed with chronic otitis media (infection in the middle ear) that is causing fluid discharge in the ear and causing gradual eardrum perforation,
3. Have dry tympanic membrane perforation for at least six weeks, and
4. Have a healthy middle ear mucosa (a membrane that lines the middle ear cavity).

In rare cases, a patient suffering from tinnitus, a continuous ringing sensation in the ear without the presence of an external sound in the environment, must undergo myringoplasty.

Myringoplasty should be avoided if the patient is:

1. Experiencing a continued discharge from the middle ear
2. Suffering from nasal allergy
3. Suffering from Otitis Externa or deafness
4. Below sixteen or more than sixty years of age
5. Suffering from a deformity of the external auditory canal
6. Suffering from upper respiratory tract problems such as sinusitis, chronic tonsillitis, DNS (deviated nasal septum), or pharyngitis
7. Suffering from diabetes, cancer, or any other debilitating disease

Myringoplasty is generally performed to repair minor tears in the tympanic membrane (eardrum). The procedure usually takes 1 to 3 hours to complete, depending on the patient's age, medical condition of the patient and the complexity of the case. The procedure is usually performed under general anaesthesia (medication used to reduce the sensation in the body) by a specialized team of anaesthetist, otolaryngologist (ENT specialist) and other medical staff. The following steps are involved in the procedure:

1. The surgeon will administer general anaesthesia to the patient.
2. Before starting the procedure, graft material is harvested to cover the hole. Most commonly, temporalis fascia (a strong fibrous tissue covering the temporalis muscle) is used to harvest the graft as it is located near the incision site.  
3. Myringoplasty can be performed using two types of procedures: the Underlay and the Overlay technique.
4. The Underlay Technique: The underlay technique is easier to perform and ideal for repairing small and easily visualised perforations. The steps include: 
   1. The surgeon makes an incision along the perforation to remove a strip of the epithelial layer. 
   2. He or she then places the graft on the inner surface of the tympanic membrane. 
   3. After the graft is placed in the right position, the ear is filled with antibiotic-soaked gel foam to pack the inner ear for stability. 
   4. The surgeon ensures that the graft completely covers the perforation and some of its parts extend over to the walls of the posterior canal. 
5. The Overlay Technique: The overlay technique is relatively difficult to perform and typically reserved for total perforations, anterior perforations, or a failed underlay surgery. 
   1. The surgeon makes an incision to raise the medial meatal skin of the ear canal. 
   2. The graft is placed at the outer surface of the eardrum. It is made stable by tucking it under the malleus handle (outermost and the largest of the three bones of the middle ear).
   3. A gel foam soaked in antibiotics is used to pack the inner ear. 
   4. The incision is closed once the graft is placed in the proper position.
6. Then the patient is will be moved to the hospital ward so that he/she can recover.

Before the myringoplasty, the doctor/surgeon will discuss and prepare the patient for the surgery. These steps often involve:

Before Myringoplasty

Before undergoing the myringoplasty procedure, the ENT specialist will:

1. Examine the patient’s ear to determine if the patient has a ruptured eardrum using a lighted instrument such as an otoscope or microscope. 
2. Explain the procedural approach in detail and mentions its potential risks. 
3. Provide precautionary measures that a patient needs to take before the surgery.
4. Prescribe some medicines that the patient needs to take on the day of the surgery. The patient should take these medicines with a sip of water.
5. Recommend some routine tests a few days before the surgery which include:
   1. Urine test: To check for diabetes and infection in the urinary tract.
   2. Blood tests: To check for blood type, infection, blood clotting time, and anaemia (a condition in which the body does not have enough blood cells to carry oxygen to the entire body).
   3. Chest X-ray or magnetic resonance imaging (MRI) scan: To rule out any problems associated with the lungs or the heart.
6. The patient should inform the ENT specialist if he/she has a cold or throat problem within seven days before surgery. 
7. The surgeon will postpone the surgery if the patient has a fever or cough as it can cause complications during surgery.

On the day of Myringoplasty

1. The patient should go to the hospital before the scheduled time.
2. The patient will be asked to sign the consent form before the surgery.
3. The patient will be instructed to remove his/her street clothes and jewellery and wear a hospital gown.
4. A nurse will place an intravenous catheter in the patient’s hand or forearm, and then general anaesthesia will be administered.
5. The vitals of the patient will also be monitored.
6. The patient will be shifted to the operation theatre for the procedure.

A patient who has undergone myringoplasty can expect the following after the surgery:

The recovery process at the hospital

1. Post-surgery, the patient will be moved to the hospital ward so that he/she can recover.
2. The patient will be kept in observation until the after-effect of anaesthesia wears off.
3. Myringoplasty is an outpatient surgery, so the patient is usually allowed to go home on the same day once the patient's condition is stabilised.
4. In case the procedure is performed in the afternoon, and if the patient requires medical observation, they will be advised to remain in the hospital for one night.
5. The doctor may prescribe an antibiotic ear drop to prevent the risk of infection. The drop has to get into the ear canal, so it may be necessary to temporarily remove the gel foam or cotton (which was used for packing). 

Recovery process/expectation after hospital discharge

1. The patient should follow all the instructions and medications as prescribed by the ENT specialist.
2. The patient must rest for three to four days before resuming normal activities. 
3. Soft and non-spicy food items are recommended until recovery.
4. Sneezing with a closed mouth and blowing the nose must be avoided for several weeks. 
5. The ears must be kept dry while taking a shower. 
6. Swimming is discouraged until the doctor allows it. 
7. The patient may experience mild ear pain and soreness for three to five days after the surgery. 
8. He or she may also experience popping, clicking, or other sounds in the ear, which is normal. These sounds usually go away in a few days. 
9. The patient must not insert anything into the ear canal except the prescribed amount of antibiotic ear drops.

First follow-up appointment

1. The ENT specialist will recommend a follow-up four to six weeks after the surgery.
2. The ENT specialist will remove the packing after examining the ear. The stitches or sutures need not be removed as they dissolve independently.
3. The ENT specialist might also change the medication or advise the patient to continue with the previous medication for some more time, depending on the condition and recovery of the surgical area.
4. The ENT specialist will advise the patient for further timely follow-ups as well.

Myringoplasty is a safe procedure with several benefits that improve the quality of life of an individual. Below mentioned are some of the benefits of myringoplasty:

1. Restores hearing loss and in certain cases cures tinnitus
2. Prevents re-infection from the external auditory canal and eustachian tube
3. Prevents aeroallergens from reaching the exposed middle ear mucosa, leading to persistent ear discharge
4. Fewer chances of other types of ear infections
5. Hearing power is enhanced

The patients usually recover quickly after myringoplasty, and there are rarely any risks and complications in this procedure. But in some cases, the patients may experience the following:

1. Blood clots
2. Bleeding
3. Scarring
4. Pain
5. Allergies
6. Taste changes
7. Post-operative infection
8. Dizziness
9. Tinnitus (ringing in the ear)
10. Hearing loss
11. Injury in the Chorda Tympani (a nerve that carries the sensation of taste to the brain from the anterior part of the tongue via the middle ear) results in an altered taste perception
12. Graft failure leads to persistent perforation. This would require a second myringoplasty for resolution.

When is consultation with the doctor needed?

The patient must consult the doctor immediately if he or she notices the following symptoms:

1. Severe nausea
2. Intense pain in the ear
3. Bright red blood
4. Fever
5. Rashes
6. Troubled breathing
7. Weakness of the face
8. Dizziness persisting for more than 2-3 hours
9. Tinnitus

Delaying a myringoplasty procedure can increase the severity of the pain and discomfort leading to reduced quality of life. Below mentioned are some of the common risks of delayed myringoplasty:

1. Damage to the surrounding ear parts
2. Hearing loss (temporary until the perforation is repaired)
3. Middle ear infection
4. Cholesteatoma (Middle ear cyst): an abnormal skin growth behind the eardrum

The cost of myringoplasty ranges from ₹35,000 to ₹75,000. The cost varies based on the following factors:

1. Age of the patient
2. Type of the procedure done
3. Technique and equipment used
4. The medical condition of the patient
5. The type of hospital facility availed - individual room or shared.