Eardrum Repairing Surgery

Eardrum Hole and Treatment

Eardrum rupture (eardrum perforation or ruptured eardrum) is a condition in which a small hole or tear appears in or in the eardrum (also called eardrum perforation or tympanic membrane perforation)

Ear infections, pressure changes, and injury are common causes of perforation of the eardrum.

Does the perforated eardrum renew itself?

Most ruptured tympanic membranes heal without invasive treatment and rarely cause permanent hearing loss (in traumatic tympanic perforations, the membrane is likely to close spontaneously if water is not missed. However, in tympanic membrane perforations due to gunshot wounds or hot burns, cells at the edges of the hole can also be found. It's ruined, so it's unlikely to shut itself off).

What is the eardrum and what does it do?

The eardrums are a thin membrane-shaped tissue that divides your middle ear and outer ear canal. This membrane vibrates when sound waves enter your ear. Vibration passes through the middle ear bones. This allows you to hear vibration because if the eardrum is damaged, your hearing may be affected as the surface area against which sound waves strike will be reduced. Apart from this, since the feature of the eardrum that separates the middle ear from the external environment by playing a barrier role will be damaged, middle ear infections can easily occur in case of water in the ear in those with a perforated eardrum.

What are the functions of the eardrum?

Hearing-related tasks:

The eardrum is a vibrating surface on which sound waves hit. This vibration provides an increasing energy transmission to the inner ear due to the large surface area and the leverage effect of the middle ear ossicles to which it is attached.

Barrier duty:

The eardrum acts as a barrier between the middle ear and the outer ear. In the event of a perforation in the eardrum, billions of bacteria in a drop of water that can come into contact with the external ear canal can easily reach the middle ear and from there to structures such as the facial nerve, neck veins and brain, which it is in close proximity to. For this reason, patients with a hole in the eardrum should protect their ears from water contact.

Causes of perforation of the eardrum

Having a hole in the eardrum, the two main functions of the eardrum, which are its functions in hearing, and its barrier function against middle ear infections are adversely affected in varying amounts according to the age and location of the hole. If the eardrum hole is not treated and the ear with the eardrum is not protected from water contact, recurrent middle ear infections, damage to the auditory nerves, destruction of the ear ossicles, enlargement of the hole in the eardrum, and a ball of inflammation (cholesteatoma) that can dissolve the trapped bone may occur. As a result of recurrent chronic middle ear infections, spread of infection and tissue damage may occur that can affect the facial nerve, cerebral cortex and neck vessels.

Infection

Ear infections are the most common cause of perforation of the eardrum, especially in children. During an ear infection, fluids build up behind the eardrum. The pressure from the fluid buildup can cause the tympanic membrane to rupture or rupture.

Pressure changes

Some activities can cause pressure changes in the ear and cause a perforated eardrum. This is known as barotrauma and occurs mainly when the pressure inside the ear is significantly different from the pressure outside the ear. Activities that can cause barotraumatic perforation of the eardrum include:

• Scuba diving
• Airplane trip
• Traveling by car at high altitudes
• shock waves
• Direct, strong impact on the ear

Injury or trauma

During traumatic injuries, the eardrum can also perforate. Any trauma near the head or ear can cause a rupture. The following are the most common traumatic causes of eardrum ruptures:

• tapping in the ear

• having an injury during sports

• falling on the ear

• car accidents

Inserting any object, such as a cotton swab, fingernail or pen, into the ear can also damage your eardrum.

Energy from acoustic trauma or extremely loud sounds can burst the eardrum. However, these cases are not that common.

Eardrum perforation symptoms

Pain is the main symptom of acute perforation of the eardrum. It can stay constant throughout the day or increase or decrease its intensity. For some, the pain can be severe. In traumatic eardrum perforations, tinnitus and hearing loss may occur at the same time. Over time, watery, bloody, or pus-filled fluids may drain from the affected ear. A rupture from a middle ear infection usually causes bleeding. These ear infections are more likely to occur in young children, people with cold or flu, or in areas with poor air quality.

There may be temporary hearing loss in the affected ear. You may experience tinnitus, constant ringing or buzzing in the ears, or dizziness.

If the eardrum hole is old, symptoms such as constant hearing loss and occasional discharge from the ear are predominant, depending on the size and location of the hole in the membrane.

Diagnosis of perforation of the eardrum

The hole in the eardrum can be detected in a simple ear, nose and throat examination. In endoscopic or microscopic ear examination, the size and location of the hole in the eardrum are evaluated. Hearing tests may be requested to evaluate inner ear functions and hearing loss due to the hole in the membrane.

Ear hole treatment

Eardrum perforation treatment is mostly designed to eliminate the infection and prevent my future infection risks.

Treatment of acute eardrum perforation

In case of newly emerging eardrum perforation (such as traumatic eardrum perforation...), it is sufficient to protect the ear only from water contact and there is a high probability of self-healing. If the patient leaks water in the ear after the rupture of the eardrum, the death of the cells on the edges of the rupture with infection may make the eardrum hole permanent.

Eardrum surgery (eardrum hole repair)

Eardrum repair procedures are performed in patients with pre-existing epithelialization at the edges of the hole and permanent tympanic membrane perforation. In patients with a hole in the eardrum alone and without hidden inflammation areas in the middle ear and no damage to the ear ossicles, tympanic or endoscopic surgery without additional incision in the ear canal (transcanal myringoplasty - endoscopic transcanal myringoplasty - endoscopic tympanic membrane repair - endoscopic tympanic membrane surgery -) endoscopic tympanoplasty) can also be performed. After removing the dead epiel area at the edges of the hole in the eardrum (dezepithelization), cartilage, cartilage membrane, muscle membrane or artificially imported collagen membrane, silicone membrane, bovine pericardium can be used to lay on the eardrum. In general, I prefer to take cartilage and cartilaginous membrane from the tragal cartilage, which is in the patient's own auricle, just in front of the ear canal, and has a flat surface like the eardrum. Approximately 1 - 1.5 cm incision is required for this graft removal and it is not visible from the outside.

Along with tympanic membrane surgeries, surgery to repair the ossicular chain in the middle ear (ossiculoplasty) and cleaning the inflamed areas in the mastoid bone (mastoidectomy surgery) can be performed.

Eardrum surgery technique

Eardrum perforation surgery can be performed by endoscopic and microscopic methods. Eardrum surgeries, which are performed on the auricle from the back and in which the auricle is tilted forward after an incision along the length, are performed as much as possible only for the patients who will be accompanied by mastoidectomy, and for patients with a very anterior tympanic hole. Recovery is much faster and patient complaints are much less after eardrum surgeries performed microscopically or endoscopically without incision in the ear canal.

Endoscopic Eardrum Repair

Eardrum surgeries can be performed in several ways. Simple eardrum repair surgery (myringoplasty surgery) can be performed in patients who do not have middle ear inflammation and have a small eardrum hole (perforation). For this, surgical techniques that are sometimes made without making an additional incision from the external ear canal can also be used (transcanal myringoplasty). In general, the operation time in such surgeries is around 45 minutes.

In patients who have a large hole in the eardrum and have adhesions around the ossicles in the middle ear or damage to the ossicles, "tympanoplasty" surgery, which is a larger operation, in which the eardrum is removed and the middle ear is treated, can be performed.

In patients with closed or trapped inflammation in the middle ear or the mastoid bone, which is the bone just behind, mastoidectomy operations are also performed to clear the inflammation in addition to eardrum operations. Here, an incision made behind the auricle (retroauricular incision) is used and the operation time may exceed 2 hours.

Different Details about Endoscopic and Microscopic Ear Surgery

With the help of endoscopic eardrum surgeries, which have become increasingly common recently, with the help of an endoscope placed in the external ear canal, the holes in the eardrum can be closed without making a visible skin incision outside the ear. Middle ear surgery is usually performed using a surgical microscope. Initially, endoscopes were used in otolaryngology practice for paranasal sinus surgeries.

In fact, incisionless eardrum surgeries through the external ear canal have been performed for a long time. Eardrum surgeries called transcanal myringoplasty or transcanal tympanoplasty can be performed with the help of both a microscope and an endoscope. Endoscopic eardrum repair operation is an ideal procedure for repairing simple tympanic membrane holes alone in ears that do not have chronic inflammation residues in the middle ear, no inflammation in the bones around the middle ear, and roughly described as "clean - dry ear". Cartilage, cartilage membrane or both can be used to repair the hole in the eardrum during the procedure, which can be taken only after a 1 cm hidden skin incision from the tragus region in the anterior part of the auricle.

In general, the reasons why patients prefer endoscopic eardrum surgery can be listed as follows:

absence of a visible incision behind the ear or in front of the ear

• changing the anatomy of the ear as little as possible
• being a simple and quick process
• can be listed as an easily repeatable process

As in other surgical fields, there is a trend towards minimally invasive intervention in the field of otorhinolaryngology. Small incisions made under the guidance of endoscopes are preferred over conventional large incisions. By using this approach, better results can be achieved and postoperative morbidities can be reduced. In addition, the results of grafts made using the endoscopic approach are similar to those obtained with the microscopic approach. Therefore, endoscopic ear surgery applications are becoming more and more popular (source link >> Endoscopic tympanoplasty - ScienceDirect). It was originally used only to visualize the middle ear. They were later used in addition to microscopes during all surgical procedures involving the middle ear and are now used as standalone instruments (source link >> History of the Endoscopic Ear Surgery). While microscopes require image adjustment during operation, forward and backward movements of the endoscope can easily produce close and angled images when necessary. In addition, the rotational motion of angled endoscopes can provide panoramic views of the deep and hidden regions of the middle ear.

Advantages of endoscopic eardrum surgery

The endoscopic approach is a less invasive approach as it does not require incision or canalplasty (expansion and reshaping of the outer ear), and there is no need for hair transplantation for the treatment of hair loss that may occur at the incision site in the ear area, and there is no risk of prominent ears due to the incision made behind the auricle. It has many advantages such as

Compared to the microscopic approach, the endoscopic approach is associated with less postoperative bleeding and pain and provides better cosmetic results.

Endoscopic Eardrum Surgery Is Not Suitable For Every Patient!

It is ideal for patients with a hole in the eardrum alone, in patients who have chosen endoscopic repair of the tympanic membrane. It is not a suitable method in chronic middle ear infections with cholesteatoma where there are chronic inflammation residues and in ears that are constantly infected. It would be better to leave the choice of technique in this regard to the physician who examined you. It may not be suitable for patients with a very narrow external ear canal.

Contraindications for endoscopic eardrum surgery

In cases where membrane repair with endoscopic technique is not appropriate, it can be summarized as "large middle ear cholesteatoma containing mastoid, presence of obstruction and exocytosis in the external ear canal that prevents endoscopic access, and insufficient equipment availability".

In Endoscopic Technique, Membrane Repair Can Be Done Without "Canalplasty" in Patients with Curved External Ear Canal!

The convoluted anatomy and bony prominences of the outer ear impair microscopic views and impair the visualization of deep structures. In such cases, canalplasty may be required. On the other hand, panoramic and wide-angle views obtained by the forward and backward movements of the endoscope are not affected by the curved anatomy of the external ear canal. The view beyond the end of the endoscopy is easily presented to the surgeon, while at the same time magnification can be achieved with various endoscope manipulations, which eliminates the need for the canal plate. Besides the panoramic, wide-angle and magnified view provided by the endoscope, it eliminates most of the disadvantage of the microscope to provide an uninterrupted view.

Loss of depth perception and one hand technique are some of the disadvantages of the endoscope that can be overcome with practice. Therefore, Endoscopic tympanoplasty can be a good alternative to microscopic tympanoplasty.

Endoscopic Eardrum Surgery Can Be Performed In Patients Who Have Had Previously Unsuccessful Eardrum Surgery!

As in the animation photo above, in patients who have had eardrum surgery before and have small holes or holes in the eardrum, the tympanic membrane can be repaired using the endoscopic method.

Are Special Instruments and Surgical Materials Required for Endoscopic Eardrum Surgery?

Unlike classical eardrum surgeries, endoscopic myringoplasty or endoscopic tympanoplasty operations can be completed without using a microscope. In other words, the endoscopic system is used during the surgery instead of the microscope. In addition, the use of the endoscope to be placed in the external ear canal as a thin and if possible short-sized "pediatric endoscope" may allow other instruments to be placed in the outer ear canal during the surgery in a more efficient way.

Which Ear Surgery Can Be Performed With Endoscopic Method?

Endoscopic technique is not only for eardrum surgeries; It can also be preferred in procedures such as ventilation tube placement, myringoplasty, tympanoplasty, ossicular reconstruction for malformation and ossicular trauma, cholesteatoma surgeries, otosclerosis surgeries and cochlear implantation.

Tympanoplasty includes treatment of middle ear disease, repair of perforated eardrum and restoration of hearing. Endaural, transcanal, and postauricular approaches are used during myringoplasty and tympanoplasty. Recently, transcanal endoscopic approaches have become popular. The endoscopic approach provides a much wider field of view. In the microscopic approach, the retroauricular approach is preferred for anterior perforations (holes in the anterior part of the eardrum), while the endaural approach is preferred for posterior perforations, while small holes are usually treated with the transcanal approach. The main advantage of the microscopic approach is that it provides a view that also offers depth perception and allows the surgeon to work with both hands.

Disadvantages of Endoscopic Eardrum Surgeries Compared to Microscopic Eardrum Surgeries

Endoscopic eardrum surgery requires the surgeon's command of anatomical details and experience in ear surgery. In general, the disadvantages of eardrum surgery with the endoscopic technique can be listed as follows (source link >> Endoscopic Ear Surgery - Thieme Connect):

• Performing surgical manipulations using one hand
• Depth perception is difficult as the monitor provides two-dimensional views.
• The endoscope is easily affected by dirt and a small amount of blood in the external ear canal during the procedure and the endoscope tip needs to be cleaned frequently.
• Requires good hemostasis of the external ear canal
• Although this issue is controversial, it is argued that "the endoscope may cause potential damage to the surrounding structures caused by the heat generated from the light source". A cold light source is already used during the procedure and the tip of the endoscope does not come into contact with the structures in the middle ear.
• Endoscopes have limited magnification
• Requires training

Is eardrum surgery dangerous?

The risk of facial paralysis and other risks associated with simple eardrum surgeries is much less than the risks of mastoidectomy operations, which include removal of inflammation from the middle ear and its surroundings, and widening of the bony canal. There is an opinion among the public that all eardrum surgeries are quite risky.

How long does eardrum surgery take?

Depending on the technique used, the location and size of the hole, eardrum surgeries usually take between 30 minutes and 2 hours.

Is eardrum surgery difficult?

Eardrum surgeries performed in patients with a hole in the eardrum alone and without accompanying inflammation and ossicular chain damage in and around the middle ear, complete with minimal tissue damage, are easy and have low risks. In addition to eardrum surgeries, ossicular chain and inflammation removal surgeries are more effective in the process. makes it difficult and complex.

Hearing after eardrum surgery

Although it varies according to the surgery performed after the eardrum surgery, there is an increase in hearing up to 2 years in general. In order for the patient to feel the difference in hearing, apart from removing the external ear canal buffer, the soluble materials laid on the eardrum must be removed and the graft must be fixed with healing. In general, many patients begin to notice an increase in hearing after the first month. Most of the patients said, "I have had eardrum surgery, when will my hearing recover?" Even if they ask questions like; especially if there is a small perforation and the middle ear is clean and normal, the increase in hearing is felt much faster after simple membrane surgeries.

Possible risks after eardrum surgery

The risks of eardrum surgery can be listed as follows (most of these risks are not found in simple eardrum repair procedures!):

• taste changes in the mouth
• facial nerve damage (temporary or permanent)
• incomplete closure of the hole in the eardrum
• hearing loss
• dizziness
• rarely, cholesteatoma (aggressive inflammatory tissue) formation

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Dr. Murat Enöz - MD, Otorhinolaryngology, Head and Neck Surgeon - ENT Doctor in Istanbul

Private Office:

Address: İncirli Cad., No:41, Kat:4, Dilek Pastanesi Üstü (Dilek Patisserie Building), Posta kodu: 34147, Bakırköy - İstanbul

Appointment Phone: 0212 561 00 52

E-mail: muratenoz@gmail.com

Mobile phone: +90 533 6550199

Fax: +90 212 542 74 47

Fax: +90 212 542 74 47