A Minimally Traumatic Eardrum Repair Technique: Transcanal Myringoplasty
It can be done to close the holes in the eardrum, to increase the hearing level of the patients and to prevent recurrent middle ear infections. In other words, it is aimed that the eardrum can perform its barrier function and hearing-related function again. Link where you can find detailed information >> Perforated Eardrum - Definition, Causes, Symptoms, Treatment
Myringoplasty, which is generally the smallest surgical procedure among eardrum hole repair procedures, can be performed without a visible skin incision. Link where you can find detailed information >> Myringoplasty Operation in Istanbul, Turkey
In this operation, the most commonly used graft materials to close the eardrum hole are cartilage, cartilage membrane (perichondrium) and muscle membrane (fascia). After an incision of approximately 2 cm on the inner side of the protruding area just in front of the ear canal, called the tragus, the cartilage graft can be taken very easily.
Island Graft Preparation From Cartilage
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| Island Graft For Tympanic Membrane Repairing In the image above, the cartilage graft prepared in a nearly round shape, and the perichondrium in its larger outer part are seen. The notch-shaped area excised from the cartilage is placed on the manubrium mallei. A well thought-out graft preparation technique with a low probability of slipping into the middle ear or rotating in place when placed overlay. Scientific article link where you can find detailed information >> Preparation and placement of cartilage island graft in tympanoplasty |
As seen in the photo above and the video above, the "island graft" is a very cleverly prepared cartilage graft used to close the eardrum hole.
What Is an Island Cartilage Graft?
An island cartilage graft is a grafting technique used particularly in the repair of tympanic membrane perforations, where a specific portion of the cartilage, along with the surrounding perichondrium, is preserved during preparation. Thanks to its thin and durable structure, cartilage can help stabilize the eardrum, especially in patients with retraction, Eustachian tube dysfunction, or negative middle ear pressure.
In this technique, a piece of cartilage of appropriate size is prepared from tragal or conchal cartilage. The central part of the cartilage can be thinned to make it more flexible, leaving a strong cartilage frame (rim) around it. Thus, the cartilage creates a structure that provides both mechanical support and helps in the proper positioning of the graft within the tympanic membrane. The prepared cartilage island can be placed using underlay, overlay, or modified techniques, depending on the size and location of the perforation.
One of the significant advantages of island cartilage grafts is their higher mechanical strength compared to fascial grafts. Therefore, it is particularly preferable in cases of extensive perforations or where the risk of re-perforation and retraction is higher. Proper thinning of the cartilage helps provide adequate structural support without negatively impacting voice transmission.
Following surgery, healing occurs between the perichondrium and tympanic membrane tissues surrounding the graft, and a new, stable tympanic membrane structure forms over time. When applied with the correct patient selection and appropriate surgical technique, island cartilage grafting is a valuable myringoplasty option that can improve both anatomical success and long-term tympanic membrane stability.
How is this graft prepared?
Cartilage graft taken from the tragus with perichondrium on both sides is removed by peeling the perichondrium on one side. The cartilage section is brought into a nearly round shape by removing the outer edges with the help of an elevator. In this way, the circular shaped cartilage and the perichondrium, which is slightly wider than it, remain. Then, a notch-shaped or triangular piece of cartilage is removed to fit the "malleus", which is the tongue of the tongue in the middle ear, and a vir image is revealed, as in the photo above. In this graft, which is usually "overlay", that is, placed over the eardrum hole, the cartilage is inside and the perichondrium is outside. In "island grafts" prepared in this way, the possibility of the graft falling into the middle reaches and the possibility of slipping of the graft are reduced. As seen in the video above, at the end of the operation, the unilateral perichondrium, which is removed by peeling the cartilage, can be dried on the operating table and laid as the outermost graft. You can see by following the above video.
It is an aesthetic and minimally traumatic eardrum operation as there is no additional skin incision!
The tympanic membrane surgery, which I have shared here and performed as "transcanal", requires surgical experience and is frequently preferred in selected patients because it is an ideal method.
Audiometric tests and thin-section temporal bone tomography may also be requested during detailed examination before eardrum surgery in patients who are planning an eardrum operation in Istanbul. In patients with signs of infection in the mastoid bone, chronic suppurative otitis media or otitis media with cholesteatoma, patients who require additional ossicular chain reconstruction, much more complicated operations may be required than the operation I have shared with you here. Unlike the endoscopic transcanal myringoplasty operation, the surgeon can use both hands at the same time in the microscopic transcanal myringoplasty operation.
Hospital conditions, microscope features are also important!
The instruments and operating microscope used during the recording in this video are very high quality and high resolution devices. For this reason, it is ideal to perform minimally traumatic eardrum operations in well-equipped, quality hospitals.
What is the Cost of this Operation?
I usually prefer to perform this operation in well-equipped, high-quality hospitals, and the average cost, including one day hospitalization, doctor and material fees, is around 3500-4500 US dollars.
Post-Operative Care Recommendations
We usually advise our patients to avoid pressure trauma and water contact to the ear for several months. The tampons in the external ear canal can stay for 1-3 weeks, and then antiseptic solutions can be recommended to the external ear canal. It is normal for patients to have an annoying "crunchy, slippery and wet sound" from the ear during mouth opening or swallowing, which may occur a few days after the operation. We advise our patients to be careful about keeping their mouth open during sneezing and not to hit the ear. During the flight, especially when the descent begins, it is necessary to pay attention to the recommendations of our patients, such as medical treatments that relieve the nasal airways, intermittent swallowing or drinking water. You can find detailed information in the links above.
Beneficial Effects of Closure of Eardrum Perforation
If you have a hole in your eardrum, the problems it may cause for you in terms of your health are problems related to hearing and the barrier function of the eardrum. When the eardrum is perforated, that is, in the eardrum perforation, different symptoms may occur depending on the location of the hole in the membrane and the size of the perforation. Normally, our eardrum is a membrane-shaped anatomical structure that acts as a barrier between the middle ear and the outer ear. The eardrum basically has two functions. The first is the separation of the middle ear from the outer ear canal by acting as a barrier between the middle ear and the outer ear canal, preventing the microorganisms that can come through the outer ear canal from reaching the middle ear. In other words, the eardrum acts as a barrier. The second important task of the eardrum is the vibration of the sound waves coming from the external ear canal by hitting it on itself and the transfer of this vibration energy to the inner ear with the help of 3 ossicles in the middle ear. In other words, when the eardrum has a hole, there will be a decrease in the surface area hit by sound waves in varying amounts depending on the size of the hole, and therefore the vibration energy will be less. The result will be conductive hearing loss. As the diameter of the eardrum perforation increases, the vibration surface will decrease, the probability of hearing loss and also the barrier function will decrease, and the probability of recurrent middle ear infections and related complications increases. When eardrum perforations are small, they may not show any symptoms; however, regardless of whether the perforation of the eardrum is small or large; Since the barrier function is impaired, patients should protect their ears from water contact during bathing, swim superficially during swimming and use very tight ear pads. It is not always possible to protect the ear from water contact in patients with a perforated eardrum. If you walk in the rain, do a sportive movement that can cause sweating, and accidentally get water on your face, there is a possibility of water in the middle ear. In patients with a hole in the eardrum, the frequency of otitis media increases due to the deterioration of the function of the eardrum, and various changes in anatomical structures may occur due to recurrent middle ear infections, and complications related to the spread of infections to neighboring areas may occur. In patients with a hole in the eardrum, various complications such as chronic otitis media, deformation of the middle ear ossicles, mastoiditis, meningitis due to recurrent infections, brain inflammation, neck and cerebrovascular inflammation, facial paralysis may occur, albeit rare. Closing and repairing the perforation of the eardrum can eliminate the risk of developing these future complications in patients, and anatomical adverse effects can also be eliminated. In patients with tympanic membrane perforation and recurrent otitis media, damage to the cells of the inner ear may occur over time due to contact with inflammation. Especially in patients who are young and have eardrum perforation, surgical procedure is more appropriate in terms of eardrum repair; follow-up can be planned for elderly patients who have no complaints and have perforation of the eardrum. An important condition that may affect the success of the surgery in terms of eardrum perforation is; it is to protect the patient's ear from serious water contact and to have a healthy middle ear that has not been infected. If we want to briefly summarize the beneficial effects of a successful eardrum surgery for you, it can be counted as being able to swim freely without placing any outer ear pads while swimming in the water during vacation periods, preventing middle ear infections from being seen anymore, protecting the patient from risks related to infection, increasing the level of hearing, and better perception.
Frequently Asked Questions About Transcanal Myringoplasty
What Is a Perforated Eardrum?
Holes can occur in the eardrum due to trauma or infection. This permanent eardrum perforation is called a "perforated eardrum."
What Causes a Hole in the Eardrum?
Eardrum perforations can occur due to mechanical trauma or acoustic blast-type trauma. In addition, eardrum perforation can occur due to infections. Sometimes it can occur only after travel or sporting activities where there are changes in external pressure, such as air travel or diving.
What Are the Symptoms of Eardrum Perforation?
The main functions of the eardrum are to act as a "vibrating surface where sound waves strike," related to hearing, and as an anatomical separator "barrier" between the middle and outer ear. When there is a defect in the eardrum, symptoms such as "hearing loss" due to a decrease in the vibration surface and "recurrent middle ear infections" due to impaired barrier function may occur simultaneously.
Can a Perforated Eardrum Heal by Itself?
If a healthy eardrum is perforated due to traumatic causes, and if there is no water contact and the trauma does not recur, the perforated eardrum usually heals spontaneously. However, in cases of recurrent middle ear infections, trauma, or middle ear ventilation problems (Eustachian tube dysfunction, problems due to nasal congestion), the perforation may become permanent. During examination, it may be noticed that white fibrotic scar tissue has developed at the edges of the perforation and the diameter of the perforation has not decreased.
When Is Surgery Necessary for a Perforated Eardrum?
When there is a perforation in the eardrum, symptoms such as hearing loss and recurrent middle ear infections occur. Especially in young patients, it is important to perform surgery before the eardrum and middle ear changes worsen. Closing the tympanic membrane perforation here is important for both treating hearing loss and preventing middle ear infections.
What Is Myringoplasty?
Myringoplasty is a "simple, minimally traumatic tympanic membrane repair" procedure. It involves surgically repairing holes or tears in the tympanic membrane using a tissue patch such as cartilage, cartilage membrane, or muscle membrane. The main goal of myringoplasty is to reduce hearing loss by closing the membrane and protecting the middle ear from external factors. In myringoplasty, only the hole in the eardrum is treated; the middle ear ossicles are not touched. It can be performed using endoscopic or microscopic techniques through the external ear canal.
Myringoplasty vs. Tympanoplasty: What Is the Difference?
Myringoplasty is a simpler method where only the membrane is repaired, and only the hole in the eardrum is treated. Tympanoplasty is a more comprehensive surgical procedure that repairs both the eardrum and the ossicles in the middle ear. In tympanoplasty, the "tympanomeatal flap" containing the eardrum is lifted, and in this advanced surgery, the surgeon can also perform procedures targeting the middle ear.
What Is Transcanal Myringoplasty?
Transcanal myringoplasty is a procedure to close a hole in the eardrum by proceeding entirely through the external ear canal (transcanal), without making any incisions behind or outside the ear. It is generally a minimally traumatic eardrum procedure performed only for simple eardrum perforations. In patients, since the endoscopic or microscopic approach provides sufficient visualization, the eardrum perforation can be repaired directly from within the external ear canal without making a visible skin incision.
What Are the Advantages of Transcanal Myringoplasty?
The advantages of transcanal myringoplasty compared to classic eardrum surgery can be listed as follows:
No Incisions or Scars on the Skin: In suitable patients, unlike classic eardrum surgeries, no incisions are made behind or in front of the ear; the procedure is performed entirely through the external ear canal.
Reduced Pain: Since the skin and muscle tissue are not cut, pain after transcanal myringoplasty is much less than with classic eardrum surgeries. Pain is also less noticeable because there is no pressure on the ear or head bandage.
Faster Recovery: Since the skin incision and the surgical incision in the external ear canal are much more limited than in classic surgeries, tissue damage is much less, and recovery is much faster. Generally, patients can return home the same day after transcanal myringoplasty and quickly resume their daily lives.
Wide Surgical Field of View: Especially when performed endoscopically, high-resolution cameras allow for a much clearer view of all corners of the eardrum and the edges of the perforation during transcanal myringoplasty surgery compared to microscopes.
Shorter Operation Time: Since surgical preparation and tissue incision/dissection stages are limited, the total procedure time is shorter compared to classic eardrum surgeries. Patients also require less general anesthesia.
Who is a Good Candidate for Transcanal Myringoplasty?
Transcanal myringoplasty is an ideal surgical method for patients who only have a hole or tear in the eardrum, no damage to the middle ear ossicles, no hidden inflammatory foci (cholesteatoma) in the middle ear and behind it, and whose external auditory canal anatomy is suitable for this procedure. This method is used only for repairing the hole in the eardrum. In patients with chronic inflammatory foci in the middle ear or ossicular chain problems, more advanced ear surgeries such as tympanoplasty + ossiculoplasty or mastoidectomy may be necessary. Therefore, a detailed evaluation of patients is required before the procedure.
Who Is Not a Suitable Candidate for Transcanal Myringoplasty?
Transcanal myringoplasty is a closed surgery performed only on patients with a perforated eardrum, where the perforation is repaired solely through the external auditory canal (canal). In other words, it is suitable for patients with simple eardrum perforation and no other middle ear pathology.
A narrow external auditory canal, very large or anteriorly located eardrums, active middle ear inflammation, and additional middle ear problems such as cholesteatoma are not suitable for this method.
Conditions for Not Being Suitable for Transcanal Myringoplasty
Very Large Eardrum Perforations: Cases where almost the entire eardrum is damaged or the size of the perforation is very large.
Perforation Location That Is Difficult to Manage with a Transcanal Approach (Anterior Perforations): If the anterior edges of the perforation cannot be clearly seen through the canal due to the structure of the external auditory canal, the transcanal myringoplasty technique may not be sufficient. Additionally, combination with skin incisions or microscopic techniques may be required.
Narrow and Torn Ear Canal: The presence of an outer ear structure that is too narrow to allow comfortable operation of devices or instruments.
Active Ear Discharge and Infection: Presence of ongoing middle ear inflammation or discharge in the period immediately preceding surgery. In this case, the graft placed during surgery may be dislodged, negatively affecting tissue healing. Transcanal myringoplasty should not be performed in patients with active middle ear inflammation that is untreated or whose middle ear has not become dry and healthy.
Cholesteatoma or Ossicular Damage: Presence of an inflammation sac (cholesteatoma) in the middle ear or erosion/damage to the ossicles (these conditions require additional surgical intervention). In this case, operations such as tympanoplasty, ossiculoplasty, or mastoidectomy may be necessary.
Severe Eustachian Tube Dysfunction: In patients with severe ventilation problems that cannot equalize intraaural pressure, causing continuous fluid accumulation or eardrum collapse (atelectasis), simply closing the eardrum perforation is not sufficient for treatment. Ideally, existing middle ear ventilation problems should be resolved first, followed by transcanal myringoplasty surgery.
Endoscopic vs. Microscopic Transcanal Myringoplasty
Endoscopic and microscopic transcanal myringoplasty are two effective surgical methods used to repair holes in the eardrum. The main difference lies in the visualization of the surgical field and the way instruments are used. Both methods have similar success rates in eardrum preservation and hearing improvement, but each has advantages in terms of comfort, field of view, and technical details.
Key Differences Between Endoscopic and Microscopic Transcanal Myringoplasty
Field of View: An endoscope offers a wide and panoramic view; it easily shows the folds in the ear canal and hidden areas behind the eardrum. A microscope, on the other hand, looks along a straight, linear line, so the field of view may be limited in narrow ear canals.
Number of Hands Used: In microscopic surgery, both hands are free, and two instruments can be used simultaneously. In endoscopic surgery, since one hand must hold the endoscope, the procedures are usually performed with one hand.
Incision and Tissue Damage: In the endoscopic method, there is no need to make an incision behind the ear; the procedure is performed directly through the ear canal (transcanal). The external auditory canal can also be used in the microscopic transcanal approach, but an incision behind the ear is more frequently needed in narrow passages.
Advantages of Endoscopic Myringoplasty
Wide View: Thanks to angled endoscopes, membranous structures and the area behind prominent bones can be easily seen.
Cosmetic Superiority: There is no large incision scar behind the ear.
Less Pain: Because there is less tissue incision, there is less pain and faster healing in the postoperative period.
Shorter Duration: The operation time is generally shorter.
Disadvantages of Endoscopic Myringoplasty
One-Handed Operation: Having one hand on the endoscope can make bleeding control and delicate maneuvers more difficult.
Lack of Depth Perception: Since it is viewed on a two-dimensional screen, the sense of depth is less than with a microscope.
Risk of Heat: The tip of the endoscopic light source has the potential to generate a slight increase in heat (thermal effect). Since a cold light source is generally used, I have never encountered heat damage associated with endoscope use in my professional career.
Advantages of Microscopic Transcanal Myringoplasty
Three-Dimensional and Deep Vision: Excellent depth perception is achieved thanks to natural stereoscopic (3D) vision.
Hand Freedom: The ability of the surgeon to use both hands simultaneously greatly facilitates challenging and bleeding cases.
Specialized Training: It is the most commonly taught standard method in medical schools and residency programs.
Disadvantages of Microscopic Transcanal Myringoplasty
Blind Spots: If bony protrusions (overhang) of the ear canal are prominent, some anterior edge perforations in the eardrum may not be directly visible.
Need for Additional Incisions: Sometimes an incision behind the ear or canal widening (canaloplasty) may be necessary to improve visibility.
Higher Morbidity: Due to tissue manipulation and possible incisions, the postoperative recovery process may take slightly longer.
How Is Microscopic Transcanal Myringoplasty Performed?
Microscopic transcanal myringoplasty is a minimally invasive surgical technique that allows for the repair of tympanic membrane perforations through the external auditory canal with the aid of a microscope, without making an incision behind the auricle or in front of the ear. It is particularly preferred in tympanic membrane perforations with suitable localization and size. The procedure is usually performed under general anesthesia, although local anesthesia can also be used in suitable patients.
During surgery, the external auditory canal is evaluated under a microscope, and the edges of the perforation are carefully prepared. The epithelial tissues around the perforation are cleaned to create a viable surface for the graft to adhere to. Then, graft material is prepared to be placed under or on top of the tympanic membrane, depending on the appropriate technique. Tissues such as temporal muscle fascia, perichondrium, or tragal cartilage-perichondrium are frequently used as grafts.
The prepared graft is placed transcanally to cover the entire perforation and ensure sufficient contact with the surrounding intact tympanic membrane. An appropriate amount of gelatin sponge or similar material can be used to support the middle ear and graft position. Then, a supportive material is placed inside the external auditory canal to ensure the graft remains stable during the healing process.
One of the significant advantages of the microscopic transcanal approach is that it does not create a visible incision or external surgical scar on the skin. Furthermore, postoperative pain and the healing process may be shorter compared to more extensive surgical approaches. However, the suitability of the method depends on factors such as the size and location of the perforation, the anatomy of the external auditory canal, the condition of the middle ear, and the surgeon's experience.
Why Is Cartilage Used to Repair the Eardrum?
In eardrum repair (myringoplasty/tympanoplasty), cartilage is a durable graft material used, especially when structural support of the eardrum is needed. Because cartilage is more rigid than fascia or perichondrium, it can help create a neotympanic membrane that is more resistant to negative pressure and repetitive retraction forces in the middle ear.
Cartilage grafts can be particularly advantageous in cases of large tympanic membrane perforations, anterior perforations, pars tensa retractions, Eustachian tube dysfunction, and previously operated ears. The mechanical strength of cartilage helps the graft maintain its shape during the healing period and reduces the long-term risk of eardrum retraction or deformation.
Tragus or concha cartilage can be used in surgery. Cartilage is often prepared by thinning; this ensures adequate mechanical support while minimizing potential negative effects on the transmission of sound vibrations. In techniques such as cartilage island grafting, cartilage not only closes the perforation but also provides structural support to the tympanic membrane.
Therefore, the primary advantage of cartilage is not to "create a thicker eardrum," but to provide long-term mechanical stability to the eardrum when needed. However, cartilage is not necessary for every perforation; for small and conveniently located perforations, thinner grafts such as fascia or perichondrium may suffice. Graft selection is determined by factors such as the size and location of the perforation, middle ear ventilation, Eustachian tube function, and previous surgeries.
Where Is the Cartilage Graft Taken From?
Cartilage grafts used in eardrum repair are most often taken from the tragus or concha (the hollow part of the auricle). Cartilage from these areas is preferred because of its sufficient strength, ease of shaping, and proximity to the surgical field. Tragal cartilage, in particular, is a practical graft source in transcanal myringoplasty procedures due to its proximity to the external auditory canal.
Tragus cartilage is frequently used in the preparation of small to medium-sized grafts. The surgeon tries to preserve the external appearance as much as possible when taking the cartilage piece from the appropriate section of the tragus. The harvested cartilage can then be thinned or shaped to suit the size of the perforation and the surgical technique to be applied. Preserving the perichondrium may be important in some techniques for graft placement and healing.
Concha cartilage, on the other hand, may be preferred when a larger graft is required. Because it can be obtained from the larger cartilage surface of the auricle, it can offer an advantage, especially in the repair of large perforations, extensive reconstructions, or situations requiring strong structural support. When harvested properly, the shape of the auricle is usually preserved.
In rarer cases, particularly in revision surgeries or complex reconstructions requiring more cartilage, other sources such as rib cartilage may be used. However, for routine myringoplasty, tragal or conchal cartilage is sufficient for most patients. The area from which the graft is taken is determined by the size and location of the perforation, middle ear conditions, previous surgeries, and the surgeon's preferred technique.
Can Eardrum Surgery Be Performed Without an Incision Behind the Ear?
In suitable patients, eardrum surgery can be performed through the external auditory canal without making a skin incision behind the auricle. This approach is generally called transcanal myringoplasty or transcanal tympanoplasty. The surgeon reaches the eardrum perforation through the external auditory canal using a microscope or endoscope and performs the necessary repair through the same surgical area.
The transcanal approach is particularly advantageous for eardrum perforations of appropriate size and location. Since there is no incision behind the auricle, there is no visible surgical scar. Furthermore, the less severe surgical trauma may contribute to less postoperative pain and a more comfortable recovery process in some patients. If necessary, graft materials such as tragal cartilage, perichondrium, or fascia can also be prepared through the external auditory canal and used to repair the perforation.
However, not every eardrum perforation is suitable for the transcanal method. In cases of very large perforations, narrow external auditory canals, anteriorly located or difficult-to-see perforations, the presence of additional middle ear disease, or when surgical evaluation of the mastoid region is also required, approaches involving incisions behind or in front of the ear may be preferred.
Therefore, the size and location of the perforation, the anatomy of the external auditory canal, the condition of the middle ear and mastoid region, Eustachian tube function, and previous surgeries are all evaluated together to determine the surgical method. In appropriately selected patients, transcanal microscopic myringoplasty is a minimally invasive option that allows for the repair of the eardrum without an incision behind the auricle.
Is Transcanal Myringoplasty Minimally Invasive?
Transcanal myringoplasty can generally be considered a minimally invasive ear surgery. In particular, because suitable perforations in the eardrum are repaired through the external auditory canal with the aid of a microscope or endoscope, there may be no need for a skin incision behind or around the auricle.
One of the most important advantages of this approach is that surgical access is provided directly through the external auditory canal. This avoids the skin incision and visible surgical scarring that a wider postauricular surgical approach might cause. In suitable patients, graft materials such as tragal cartilage, perichondrium, or fascia can also be prepared and used via the transcanal.
However, being "minimally invasive" does not mean that the transcanal approach is suitable for every patient. The size and location of the perforation, the width of the external auditory canal, pathologies in the middle ear, and the need for evaluation of the mastoid region determine the surgical approach. For small to medium-sized perforations in suitable locations, transcanal myringoplasty can be a very good minimally invasive option.
How Successful Is Myringoplasty?
The success rate of myringoplasty is generally high, depending on appropriate patient selection and surgical technique. Studies report success rates of approximately 80–95% for anatomical closure of eardrum perforations. The success rate can be affected by factors such as the size and location of the perforation, the condition of the middle ear mucosa, Eustachian tube function, the presence or absence of active infection, smoking habits, and previous ear surgeries.
Results are generally more successful in small to medium-sized perforations, especially when there is no active infection in the middle ear. High anatomical success can also be achieved in suitable cases with minimally invasive techniques such as transcanal microscopic or endoscopic myringoplasty. In some cases, the use of cartilage grafting can provide long-term structural stability, particularly in patients with Eustachian tube dysfunction or a tendency towards eardrum retraction.
In myringoplasty, success is not evaluated solely by the closure of the eardrum hole. Postoperative hearing improvement, improved middle ear ventilation, prevention of recurrent discharge, and long-term eardrum stability are also important. Therefore, preoperative hearing testing and a detailed evaluation of the eardrum and middle ear are crucial for surgical planning.
The success rate, particularly for transcanal myringoplasty, can vary depending on the characteristics of the perforation and the graft technique used. Therefore, instead of giving a "definite success rate," it is more accurate to provide information about the estimated success rate based on individual anatomical and clinical characteristics.
Does Myringoplasty Improve Hearing?
Myringoplasty can provide significant improvement in hearing loss in some patients, but the extent of this depends on the cause of the hearing loss.
A perforation in the eardrum can disrupt the transmission of sound vibrations to the middle ear, causing conductive hearing loss. When the perforation is closed with myringoplasty, the vibrational function of the eardrum and the sound transmission mechanism of the middle ear can improve. Therefore, improvement in hearing may be seen after surgery, especially in patients with mild or moderate conductive hearing loss due to perforation.
However, myringoplasty does not treat all types of hearing loss. If there is sensorineural hearing loss originating from the inner ear, age-related hearing loss, or problems related to the auditory nerve, repairing the eardrum will not directly correct this loss. Furthermore, if there is damage to the middle ear ossicles or chronic middle ear disease, repairing only the eardrum may not be sufficient, and additional surgical procedures such as ossicular reconstruction may be required.
Therefore, the type of hearing loss is determined before surgery with hearing tests such as audiometry and tympanometry. Following a successful myringoplasty, in addition to eardrum closure, a reduction in the air-bone gap and improvement in hearing thresholds can be expected. In other words, the primary goal of myringoplasty is to repair the eardrum; hearing improvement is one of the significant additional benefits expected in most suitable patients.
How Long Does It Take for the Eardrum to Heal After Myringoplasty?
The healing process of the eardrum after myringoplasty varies from person to person, but the initial attachment of the graft and the formation of new eardrum tissue usually begins within a few weeks. In the initial period, gelatin sponges or similar materials may be placed in the external auditory canal to support the graft. These materials dissolve spontaneously over time or are removed by the doctor in a controlled manner.
Significant healing of the eardrum usually begins within 2–4 weeks. However, it may take longer for the eardrum to fully mature and for the graft to integrate with the surrounding tissues. In many patients, eardrum healing is largely complete within 6–12 weeks post-operatively. This timeframe can be affected by factors such as the size of the perforation, the graft material used, and the condition of the middle ear and Eustachian tube.
Hearing improvement, however, may take slightly longer than the closure of the eardrum. Initially, hearing may be temporarily worse due to fluid, edema, or support materials used in the middle ear after surgery. Hearing usually improves gradually over weeks to a few months as the eardrum and middle ear heal.
During the healing period, it is important to protect the ear from water, take the medications prescribed by your doctor regularly, and not miss follow-up appointments. Especially in the early stages, getting water in the ear, forcefully blowing your nose, or applying ear drops without your doctor's recommendation can negatively affect graft healing.
What to Expect After Eardrum Surgery?
In the first few days after eardrum surgery (myringoplasty), you may experience a feeling of fullness in the ear, mild pain, pressure, and a temporary decrease in hearing. It's quite normal to feel like your ear is blocked due to the tampon or sponge material used to support the graft in the external auditory canal. Mild bloody or clear discharge may also be seen in the early stages. It's important to take the medications prescribed by your doctor regularly and attend follow-up appointments during this period.
The eardrum continues to heal in the first few weeks. It's normal for hearing not to improve immediately; it takes time for the graft to heal, for the materials in the external auditory canal to be cleared, and for the middle ear to return to its normal function. Generally, the appearance of the eardrum gradually improves within a few weeks, and a gradual improvement in hearing may begin. Final hearing results may appear in some patients within a few months.
Protecting the ear from water is especially important during the healing process. Swimming and activities that could cause water to enter the ear should be avoided until your doctor gives permission. It is also recommended to avoid forceful nose blowing, strenuous physical exertion, and activities that could significantly increase ear pressure in the early stages. The surgeon's recommendations should also be followed regarding activities that cause pressure changes, such as air travel or diving.
Most patients can return to daily activities shortly after; however, complete eardrum healing takes longer. If you experience severe or progressively worsening pain, heavy/purulent discharge, fever, significant dizziness, or sudden hearing loss, you should contact your surgeon immediately. Regular check-ups are important for assessing graft engraftment and healthy eardrum healing.
When Can You Swim After Myringoplasty?
After myringoplasty surgery, swimming and keeping the ear underwater are generally only permitted after the eardrum has fully healed. Swimming is not recommended in the early stages, as water entering the ear canal can negatively affect the healing graft and external ear canal tissues. Particular caution should be exercised during activities such as swimming in pools, the sea, and diving.
Many patients are advised to wait at least 4–6 weeks before returning to swimming; however, this time may vary depending on the type of surgery, the condition of the graft, and the rate of eardrum healing. In some patients, the surgeon may request a longer wait, especially to ensure the graft is fully secured. Therefore, the decision to resume swimming should be made after a follow-up examination confirms eardrum healing.
Even when swimming is permitted, prolonged underwater exposure, especially diving, should be avoided initially. During showering, care should be taken to prevent direct contact of the ear with water during the early healing period. Since microorganisms in pool water and seawater entering the external ear canal can increase the risk of infection, ear protection methods recommended by the surgeon can be used.
In summary, while a general approach is "you can swim after 4-6 weeks," the exact timeframe should be determined based on the patient's eardrum healing. It is safest to avoid swimming or especially diving until a follow-up examination confirms that the graft has fully taken hold and the eardrum is securely closed.
When Can You Fly After Eardrum Surgery?
It is recommended not to rush into air travel after myringoplasty or tympanoplasty. Changes in cabin pressure during takeoff and landing can affect middle ear pressure and the healing eardrum. Therefore, it is important for the ear to heal sufficiently after surgery and for the surgeon to evaluate it.
After an uncomplicated myringoplasty, many patients may be able to wait approximately 2–4 weeks before flying. However, this is not a hard and fast rule. The surgical technique used, the condition of the graft, the presence of fluid or infection in the middle ear, and the function of the Eustachian tube can all affect the flight time. In some cases, the surgeon may recommend waiting longer.
Air travel should be postponed, especially if there is a feeling of fullness, pain, discharge, significant hearing loss, or pressure equalization problems in the ear in the early post-operative period. If severe ear pain, pressure sensation, or other problems develop during flight, a medical evaluation may be necessary.
Therefore, it is beneficial for patients planning to travel by plane to inform their surgeon before surgery. The safest approach is to obtain approval for flight after the condition of the eardrum and middle ear is assessed during a post-operative check-up. Personal assessment is particularly important for long-haul flights and travel planned shortly after surgery.
When Can You Return to Work After Myringoplasty?
The time it takes to return to work after myringoplasty surgery varies depending on the scope of the surgery, the technique used, and the physical demands of the individual's job. Many patients in office or light work can return to their daily work life in about a week. Some people can start light activities earlier if they feel well; however, rest and protecting the ear are important, especially in the first few days.
Returning to work may take a little longer for those in physically demanding jobs. Heavy lifting, intense exercise, prolonged bending forward, and activities that may increase ear pressure may not be recommended during the early recovery period. Therefore, those working in construction, heavy industry, sports coaching, or similar physically demanding jobs may need to wait a few more weeks.
After surgery, a feeling of fullness in the ear, mild pain, a feeling of blockage, and temporary hearing loss may occur. The return-to-work time should be planned more carefully, especially if your job involves exposure to intense noise, dust, water, or pressure changes. It is important to follow your surgeon's recommendations to protect the healing of the eardrum and graft.
Generally, recovery may take approximately 5–7 days for light desk jobs and 2–3 weeks or longer for more physical jobs. However, the most appropriate time to return to work should be determined by the surgeon who performed the operation, based on the healing status of the eardrum, the surgical method used, and the individual's overall condition.
What Are the Risks and Complications of Myringoplasty?
Myringoplasty is generally a safe surgery with a high success rate. However, as with any surgical procedure, some risks and complications may occur. One of the most important risks is that the graft used may not completely close the perforation in the eardrum, or that a re-perforation may occur after healing. In this case, a second surgery may be necessary.
In the first few days after surgery, ear pain, fullness, blockage, mild discharge, and temporary hearing loss may be experienced. Hearing may feel worse for a while, especially if tampons or gelatin sponges were used in the external ear canal. These symptoms usually decrease with the healing process. However, further evaluation may be necessary if there is continued hearing loss or infection.
More rarely, ear infection, bleeding, dizziness, tinnitus, or changes in taste sensation may occur. Hearing may not improve to the expected level due to pre-existing damage to the ossicles in the middle ear or problems that arise during surgery. In very rare cases, more serious hearing loss or facial nerve complications may occur.
In the long term, especially in patients with Eustachian tube dysfunction, eardrum retraction, re-perforation, or middle ear pressure problems may develop. In some techniques using cartilage grafts, excessive graft thickness can affect sound transmission. Therefore, before surgery, the location and size of the perforation, the condition of the middle ear, hearing tests, and the patient's general ear health are evaluated to select the appropriate surgical technique.
In summary, serious complications are rare, and the surgery is completed without problems in most patients. However, if severe or progressively worsening pain, foul-smelling/purulent discharge, high fever, significant dizziness, or sudden hearing loss develop after surgery, the surgeon who performed the operation should be contacted immediately.
What Causes Myringoplasty to Fail?
Myringoplasty failure most often occurs when a perforation in the eardrum does not close completely or reopens after healing. There can be many reasons for this. A very large perforation, especially if it is anteriorly located or lacks sufficient support at its edges, can make surgical success difficult. Additionally, an anatomically narrow external auditory canal can hinder surgical access to the perforation and proper graft placement.
Ongoing infection or inflammation in the middle ear is another significant factor that can prevent healthy graft healing. Similarly, persistent negative pressure in the middle ear due to Eustachian tube dysfunction can cause the healing eardrum to be pulled inward or the graft to weaken over time. Therefore, controlling active infection and assessing middle ear ventilation before surgery is crucial.
Several patient-related factors can also affect the outcome. Smoking is one such factor that can negatively impact the healing process. Exposure of the ear to water after surgery, interventions on the ear other than those recommended by the doctor, forceful nose blowing, or activities that create pressure in the early stages can also lead to graft displacement or impaired healing.
In addition, previous ear surgeries, damage to the middle ear ossicles, chronic middle ear diseases, and improper placement of the graft in the perforation can also affect success. Cartilage grafts may provide stronger structural support, especially in some patients with retraction tendencies or Eustachian tube problems.
In conclusion, the success of myringoplasty depends not only on the surgical technique but also on the characteristics of the perforation, the condition of the middle ear and Eustachian tube, the patient's healing process, and postoperative care. After an unsuccessful surgery, revision myringoplasty can be planned in suitable patients after determining the cause and thoroughly evaluating the ear.
What Happens If the Eardrum Perforation Comes Back After Surgery?
Re-perforation of the eardrum after myringoplasty or tympanoplasty can occur as a result of incomplete graft engraftment or the reopening of a perforation that initially closed. This doesn't always indicate a serious problem; the appropriate approach is determined by evaluating the size and location of the perforation and the condition of the middle ear.
A small perforation may close spontaneously in some patients and can be monitored with regular check-ups. However, if the perforation becomes permanent, water entering the ear can lead to infection and discharge, and conductive hearing loss may recur. Therefore, it is important to protect the perforated ear from water and avoid using drops not recommended by a doctor.
The reason for the re-opening of the perforation is also investigated. Factors such as middle ear infection, Eustachian tube dysfunction, eardrum retraction, smoking, or graft damage during the healing period may play a role. Especially in recurrent perforations, not only closing the hole but also the ventilation of the middle ear and the long-term stability of the eardrum are evaluated.
If the perforation is persistent and causes problems such as discharge or hearing loss, revision myringoplasty or tympanoplasty may be considered. In the second surgery, a different graft or technique may be chosen depending on why the first surgery failed. For example, in some patients with a high risk of eardrum retraction, a cartilage graft may provide stronger structural support.
In short, re-perforation of the eardrum after surgery is not an untreatable condition. First, the cause of the perforation and the current condition inside the ear are determined; then, the appropriate option is planned from among follow-up, medical treatment, or revision surgery if necessary.
Can a Small Eardrum Hole Be Repaired Without Major Surgery?
In some patients, a small eardrum perforation can be repaired without major surgery. First, the doctor assesses whether the hole is new, its size and location, the presence of infection or discharge, and the condition of the middle ear. Some newly formed small perforations may close spontaneously if the ear is kept dry and the infection is controlled.
If the perforation does not close spontaneously, smaller interventions may be considered in suitable patients. For example, healing can be supported by refreshing the edges of the perforation and placing a suitable material over it. In some small perforations, patch methods or similar minimally invasive techniques performed in an office setting may be used. The suitability of these methods depends on the characteristics of the hole and the eardrum's healing potential.
If the hole is larger, has been present for a long time, has recurred, or there is an additional problem in the middle ear, myringoplasty may be necessary. However, even in this case, a large incision behind the ear is not always required. In suitable patients, transcanal microscopic or endoscopic myringoplasty can be performed through the external auditory canal, leaving no visible incision behind the earlobe.
In summary, it is not always necessary to proceed directly to major surgery for a small eardrum perforation. First, the likelihood of the perforation closing spontaneously and whether it can be treated with less extensive procedures is assessed. An examination by an ENT specialist is particularly important if there is ear discharge, hearing loss, or recurrent infections.
Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon
Private Office:
Address: İncirli Cad. No:41, Kat:4 (Dilek Patisserie Building), Postal code: 34147, Bakırköy - İstanbul
Appointment Phone: +90 212 561 00 52
Appointment Phone: +90 212 561 00 52
Fax: +90 212 542 74 47
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