Ear drum repair (Myringoplasty) at Warwickshire Hospital

What is ear drum repair (myringoplasty)?

Ear drum repair, known medically as a myringoplasty, is an operation to close a hole (perforation) in your eardrum using a small patch of your own tissue, called a graft. It's usually offered once a perforation hasn't healed by itself.

What conditions does it treat?

This operation treats a perforated eardrum: a tear in the thin tissue (the tympanic membrane) separating your ear canal from your middle ear. It's usually caused by a middle ear infection bursting through the eardrum, trauma such as a head injury or an object poked into the ear, a sudden loud noise, or a change in pressure, such as while diving or flying.

Most perforated eardrums heal by themselves within a few weeks. If yours hasn't, or keeps causing problems such as hearing loss, discomfort, discharge or ringing in the ear (tinnitus), your surgeon may recommend a myringoplasty.

What are the benefits of ear drum repair?

Repairing your eardrum can help in three ways:

• it 'waterproofs' the ear so you can get it wet again when bathing or swimming
• it protects the middle ear and cuts down on repeat infections
• it can improve the conductive part of your hearing.

In some cases, it can also ease tinnitus. Closing the perforation reduces how easily infection or allergens can reach the middle ear through the ear canal and the eustachian tube, the passage that links your middle ear to the back of your nose and throat.

Success rates are generally good, though results tend to be less predictable for larger perforations. Smoking is one factor that can lower the chances of success.

Are there different types of surgical approaches?

Myringoplasty is sometimes called a type 1 tympanoplasty: a repair of the eardrum alone. Other types of tympanoplasty go further, also repairing the tiny hearing bones (the malleus, incus and stapes) in the middle ear if these have been damaged too.

Surgeons reach the eardrum in one of a few ways: through the ear canal, sometimes with the help of an endoscope or microscope and occasionally a small drill to widen the canal, through a small cut just in front of the ear, or through a cut behind the ear.

The graft itself is usually taken from tissue near your own ear, most often the lining over the muscle above your ear (temporalis fascia), or cartilage and its lining (perichondrium) from the ear itself; some surgeons use manmade grafts instead. It can be placed underneath the eardrum, or, less commonly, over the top of it, depending on your surgeon's preferred technique.

What happens before the procedure?

Before deciding on surgery, your surgeon checks that your ear is ready for it. You'll usually be seen 1 to 2 weeks beforehand so they can confirm the ear isn't infected and answer any questions; if there is an infection, this is treated with ear drops first.

Your surgeon will also check for things that could delay or rule out surgery, including:

• any active discharge from the middle ear
• nasal allergies that aren't yet under control
• whether your other ear has useful hearing that shouldn't be put at risk
• an outer ear infection (otitis externa)
• for children, whether they're old enough, since surgery isn't usually done under the age of 3.

What happens during the procedure?

1. You'll usually be given a general anaesthetic so you're asleep throughout, though local anaesthetic is an option some surgeons offer.
2. Your surgeon reaches the eardrum through your ear canal, or through a small cut near or behind your ear, using a microscope or endoscope to see clearly.
3. The edges of the hole are freshened up, and a small graft, usually taken from tissue near your ear, is prepared to patch it.
4. Your eardrum is gently lifted, and the graft is positioned to cover the hole, usually tucked underneath it and supported with a dissolvable sponge material.
5. Your eardrum is laid back down over the graft, which acts as a scaffold for new skin to grow across as it heals over the following weeks.
6. A protective dressing or pack is placed in your ear canal, and if a cut was made near your ear, this is closed with stitches and a head bandage applied.

The operation usually takes between 1 and 1.5 hours.

What does recovery look like?

In hospital

Myringoplasty is usually done as day surgery. You're taken to a recovery area as you wake up, then back to the ward once your anaesthetic is wearing off, and you can go home once the team is satisfied you've recovered; occasionally, a complication means a longer stay.

Practice on the head bandage varies: some hospitals remove it before you leave, so you go home without it, while others send you home with it in place for you to remove yourself the next day, as your surgeon will explain. If you've had a general anaesthetic, you shouldn't drive for at least 24 hours afterwards, and you'll need someone to take you home.

At home

Your ear may ache a little, which over-the-counter painkillers can usually ease. A small amount of discharge from the ear canal is normal in the first few days, and comes from the antiseptic in the dressings.

Keep your ear dry: a cotton wool ball coated in Vaseline (petroleum jelly) over your outer ear works well when showering or washing your hair. Avoid blowing your nose hard for the first 2 weeks, sneezing instead with your mouth open, and keep water out of your ear canal; avoid swimming until your healthcare team advises that you can swim again.

Some of the ear dressings may work loose and fall out; if this happens, simply trim the loose end with scissors rather than trying to push it back in. Any non-dissolvable packing is removed by your surgeon, typically 2 to 3 weeks after your operation, at the same visit where your graft is checked; stitches behind the ear, if you have them, are usually removed 1-2 weeks after surgery at your GP surgery.

Time off work varies a lot by job and how you feel, from under a week up to 2 weeks or more. You can usually resume driving after about 3-4 days, once you're confident you can turn your head quickly without feeling unsteady.

Build activity back up gradually: gentle activity such as walking or housework for the first 3 weeks, gentle exercise from 3 weeks, and normal gym activity from 4 weeks, while avoiding contact sports for 6 weeks. Avoid flying until you have had formal clearance to fly from your surgeon.

Contact your surgical team if you develop heavy discharge, worsening pain, dizziness, bleeding, a fever over 38.5°C, a severe headache that doesn't respond to standard painkillers, or any weakness in your face.

What are the risks and complications?

Myringoplasty is generally safe, but as with any operation, there are possible complications to be aware of:

• graft failure, sometimes called re-perforation, where the hole doesn't fully close or reopens later: this affects roughly 10-15% of operations overall (up to 3 in every 20), and can sometimes be treated with repeat surgery
• numbness or altered sensation at the top of the ear, if surgery was done through a cut behind the ear: usually improves over several months
• a change in taste on the side of the operated ear, from a small taste nerve that runs close to the eardrum: often temporary, though permanent change is possible
• a change in hearing: this usually improves or stays the same, very rarely gets worse, and total loss in the operated ear has been estimated at less than 1 in 1,000
• tinnitus (ringing or buzzing in the ear): often improves if you already had it, but rarely it can appear for the first time or get worse
• dizziness after the operation: accounts vary between sources, from common but usually lasting only a few hours, to very rare but lasting 2 to 3 days when it does happen
• infection at the operation site, which may affect how well the graft takes
• a small chance of an allergic reaction to the medication used in the ear dressings
• facial weakness: extremely rare, since the nerve controlling facial movement runs close to the ear; a monitoring machine is used throughout surgery to help protect it.

Your surgeon will talk through how these risks apply to your particular ear and operation.