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Myringoplasty is a surgical restoration of the integral structure of the tympanic membrane, one of the varieties of tympanoplasty. It is performed only in those patients whose auditory ossicles are intact and function correctly. The operation is intended to close the hole in the eardrum, which appeared either as a result of trauma or after purulent otitis media. The myringoplasty procedure is often the final stage of multi-stage operations performed through the external ear opening (transmeatally).
Functions of the tympanic membrane
The tympanic membrane (tympanic membrane) is a dense elastic three-layer membrane that separates the tympanic cavity of the middle ear, in which the auditory ossicles are located, from the external auditory canal (meatus). Normally, the eardrum has no holes and is impermeable to air and water. Its main functions are participation in sound conduction and protection of the middle ear cavity from infection.
The size of the tympanic membrane in an adult does not exceed one square centimeter. If its integrity is violated, a person’s hearing is reduced. Damage to the eardrum is accompanied by severe pain, because it is innervated by the branches of the tympanic nerve.
Causes and clinical features
Causes that lead to rupture of the eardrum include otitis media (acute or chronic purulent), aerootitis, direct trauma (direct injury), chemical or noise (acoustic) trauma, skull base fracture.
Average otitis media
Perforation of the tympanic membrane occurs in the second period of acute otitis media. In patients, against the background of severe pain in the ear and high temperature, pus accumulates in the tympanic cavity, which breaks through the tympanic membrane. Immediately after the breakthrough, patients pay attention to an improvement in well-being, a decrease in ear pain, and a decrease in temperature. A characteristic sign of perforation of the membrane against the background of acute otitis media is suppuration from the ear against the background of alleviating the condition of patients.
Prolonged chronic mesotympanitis and epitympanitis also lead to perforation of the tympanic membrane, which is difficult to treat conservatively and is accompanied by persistent hearing loss and frequent dizziness.
Aerootitis (aerogenous perforation)
Aerootitis occurs due to a sharp drop in atmospheric pressure, which happens most often during takeoff or landing. A sharp decrease in air pressure on the eardrum deforms or ruptures it only in case of concomitant obstruction of the Eustachian tube.
Tearing of the tympanic membrane with aerootitis is accompanied by congestion, pain, noise, ringing in the ears, dizziness and hearing loss. When ruptured, bloody discharge appears from the affected ear.
Direct membrane damage
Mechanical direct damage to the tympanic membrane often occurs in everyday life. Its rupture occurs with deep penetration into the ear canal of objects used to cleanse the ears of sulfur (matches, cotton swabs, hairpins) or by pushing foreign bodies into the ear canal when trying to remove them on their own. Such injuries of the membrane are always accompanied by severe pain and bloody discharge from the external auditory canal.
Acoustic (noise) injury
Violation of the integrity of the tympanic membrane occurs from the impact of a strong noise (acoustic) wave on it. This can happen, for example, with an explosion or a sudden turn on of loud music. The gap is accompanied by sharp pain, noise, ringing in the ears, hearing loss. Some patients even lose consciousness from pain shock. The consequences of severe acoustic trauma may be brain contusion.
The presence of a large defect in the tympanic membrane or a persistent rupture that cannot be eliminated with the help of ongoing conservative therapy is an indication for myringoplasty.
Rupture diagnostics
A rupture of the tympanic membrane is easily identified using otoscopy, a diagnostic non-invasive procedure for examining the ear canal. When the tympanic membrane is ruptured, otoscopy makes it possible to assess the state of the meatus, the tympanic membrane itself, and, in some cases, the structures of the middle ear. For its implementation, ear funnels and a forehead reflector or a modern otoscope are used, which combines an ear funnel, a light source and a magnifying device.
In order for the eardrum to become accessible for inspection, it is necessary to first clean the ear canal from sulfur, dirt, blood, secretions or a foreign body. When otoscopy is determined:
- increased vascular pattern with minor trauma;
- hemorrhages in the membrane with acoustic trauma;
- visible defects with significant damage;
- the place of rupture with jagged edges, as well as the inner wall of the tympanic cavity;
- hematoma of the tympanic cavity.
In addition to otoscopy, if a perforation of the tympanic membrane is suspected or established, additional examinations are performed: stabilography, vestibulometry, audiometry, caloric test, acoustic impendancemetry, electrocochlearography, tuning fork examination. With the help of these diagnostic methods, the degree of damage to the structures inside the tympanic cavity is clarified and the level of hearing loss is assessed.
Operation technique
Myringoplasty can be performed both under local anesthesia and under general anesthesia. The operation is carried out in several stages. The first step is to assess the state of the tympanic membrane and the size of the defect in it.
The method of restoring the tympanic membrane consists in closing the defect with an autograft – a skin flap that is taken behind the patient’s ear. An autograft, unlike synthetic or animal skin flaps, takes root faster and is not rejected by the body.
After taking the skin flap, a special microscope is inserted into the external auditory canal, with the help of which all the actions of the surgeon are controlled. Miniature instruments are used for the operation. They lift the membrane, “refresh” the edges of the defect, apply a flap and fix it with absorbable suture materials.
After the reconstruction of the membrane, a swab is placed in the meatus, richly moistened with a solution of an antibacterial drug. With a certain frequency, the ear canal must be cleaned, and the tampon must be changed. The place where the skin flap was taken behind the ear is sutured, and an aseptic dressing is applied on top.
Postoperative period
Operation, as a rule, does not demand hospitalization of the patient in a hospital. He is in the ward under medical supervision only until he recovers from anesthesia (in the case of general anesthesia).
Pain in a patient after myringoplasty occurs after anesthesia passes. To reduce them, patients are prescribed painkillers. In the first days after surgery, patients are prohibited from blowing their nose, sneezing, breathing heavily or coughing heavily: these movements increase pressure in the tympanic cavity, which can cause rupture of the sutures on the eardrum.
Some patients after surgery experience dizziness, buzzing and tinnitus, discomfort in the operated ear, difficulty opening the mouth or pain in the ear when it is opened. These symptoms are explained by the presence of a tampon in the ear and swelling of the operated area. After it is removed from the external auditory canal, such sensations cease. The wound behind the ear heals within 5-7 days. At the next examination, the patient, the surgeon removes the external sutures.
Within a month after myringoplasty, patients are prohibited from swimming in ponds, pools, diving, and flying on airplanes. Any sudden change in atmospheric pressure can cause the tympanic membrane to rupture again. A month later, the question of the possibility of air travel or visits to the pool must be addressed with the attending physician.
Possible complications
Myringoplasty is a surgical intervention, which, like any other operation, has its complications. Some patients may experience bleeding from wounds during surgery or in the early postoperative period. If the tactics of conducting the recovery period are incorrect or if the patient does not follow the rules of behavior during this period, infection of the surgical wound may occur, which threatens with purulent otitis media.
During the operation, the branches of the nerve passing behind the tympanic membrane can be damaged. These branches are sensitive and are responsible for taste sensations. Their damage causes numbness of half of the tongue and impaired taste perception.
In some patients, especially those with allergies and asthma, there is a possibility of developing an allergic reaction to medications used for anesthesia. To avoid this complication, the anesthesiologist should take a detailed allergic history and assess the anesthetic risks before surgery.
Minor injuries to the eardrum may heal on their own. But in some cases, self-healing can be complicated by purulent or adhesive otitis media. Whether myringoplasty is needed or not in the event of a defect in the tympanic membrane, the doctor must decide, weighing all the pros and cons of the surgical intervention.
The price of myringoplasty depends on the scope of the operation, location and ownership of the clinic. At the same time, the larger the city, the more expensive the operation will be. So, for example, plastic surgery of the eardrum in Rostov-on-Don can be done for 2-6 thousand rubles, and in Moscow – for 3-12 thousand rubles. If myringoplasty is only the final stage of one of the types of tympanoplasty, its cost increases due to the cost of this operation. When choosing a place for myringoplasty, patients need to read the reviews of other patients about the clinic and its otosurgeons: the well-known name of a medical institution does not guarantee the high quality of the operations performed.