Tympanoplasty —
16 Patient Questions Answered
by an ENT Specialist

The most common causes of a perforated eardrum are:

• Chronic suppurative otitis media (CSOM) — the most frequent cause in India. Repeated middle ear infections over years cause the eardrum to rupture and fail to heal, leaving a permanent central perforation with intermittent discharge.
• Acute otitis media — a single severe middle ear infection can cause the eardrum to rupture under pressure. Most acute perforations heal spontaneously.
• Trauma — a slap to the ear, a cotton bud inserted too far, or a blast or explosion can tear the eardrum acutely.
• Barotrauma — sudden pressure changes during diving, flying, or blast injury.
• Grommet (ventilation tube) extrusion — tubes placed for recurrent childhood ear infections occasionally leave a residual perforation after they fall out, particularly T-tubes and long-term tubes.

It depends entirely on whether the perforation is acute or chronic.

Acute traumatic perforations — caused by a sudden event such as a slap, blast, or barotrauma — have a high spontaneous healing rate. Published evidence shows approximately 94% close within one month if kept dry and infection-free. The ear should be kept dry, no eardrops used unless prescribed, and the patient reviewed at six to eight weeks.

Chronic perforations — those present for months or years, usually from chronic otitis media or a failed grommet site — do not heal spontaneously. The epithelial edges become inactive over time, and the body no longer initiates the repair mechanism. Evidence confirms that spontaneous closure is unlikely if a perforation has not healed within approximately 2.5 years. These require surgical repair.

A perforated eardrum causes conductive hearing loss — impaired sound transmission — while the inner ear (cochlea) and auditory nerve remain unaffected, unless there is additional disease.

• Small central perforations — typically 10 to 20 dB of conductive loss; often perceived as a mild reduction in hearing rather than significant impairment
• Large or subtotal perforations — 30 to 45 dB loss; significant and noticeable
• With ossicular disruption — if the small bones of the middle ear are eroded by infection or cholesteatoma, hearing loss can exceed 50 to 60 dB

Audiometry (pure tone audiogram) measures the degree of loss precisely and guides the surgical plan. It is always performed before tympanoplasty.

A chronic untreated perforation carries progressive risks:

• Recurrent infections — bacteria enter the middle ear through the opening whenever water contacts the ear, causing repeated episodes of discharge and pain
• Progressive hearing loss — ongoing infection gradually damages the ossicular chain and middle ear structures
• Cholesteatoma development — squamous epithelium can migrate through the perforation into the middle ear, forming a cholesteatoma that destroys surrounding bone
• Permanent water restriction — swimming, hair washing, and bathing all require permanent ear protection, significantly limiting daily life
• Increased surgical complexity — the longer surgery is delayed, the more middle ear disease may have accumulated, making a subsequent operation more complex with lower success rates

For patients with a dry, inactive perforation and minimal symptoms, watchful waiting with careful ear protection is an option — but the risks above should be clearly understood before deciding to defer surgery.

Cholesteatoma is an abnormal accumulation of squamous (skin-type) epithelial cells in the middle ear or mastoid cavity. Despite the name, it is not a tumour and is not cancerous — but it is locally destructive in a way that demands prompt surgical treatment.

It grows by releasing enzymes that erode bone, progressively destroying:

• The ossicles (hearing bones) — causing conductive and eventually mixed hearing loss
• The bone between the ear and the brain — risking intracranial complications
• The bony canal of the facial nerve — risking facial palsy
• The labyrinth (inner ear) — causing sensorineural hearing loss and vertigo

These terms are frequently used interchangeably, which causes confusion. The precise distinction:

• Myringoplasty — repair of the tympanic membrane (eardrum) perforation only, without entering or working within the middle ear space. This is also classified as Type I tympanoplasty in the standard Wullstein classification.
• Tympanoplasty — the broader term encompassing eardrum repair along with any work on the middle ear, including ossicular chain reconstruction (Types II–V) or removal of middle ear disease.

In practice, when a surgeon says "tympanoplasty," they may mean a straightforward myringoplasty — or they may mean a more complex procedure. Always ask your surgeon specifically what the operation involves and whether the middle ear will be explored.

All graft materials used are taken from the patient's own body — no donor or synthetic material is used in routine tympanoplasty.

• Temporalis fascia — the most commonly used graft worldwide. A thin sheet of connective tissue taken from the temporalis muscle behind the ear. Reliable, well-studied, and harvested through the same incision used for the operation.
• Tragal perichondrium — the fibrous tissue covering the tragal cartilage. Particularly useful in revision surgery and when temporalis fascia is not suitable.
• Cartilage grafts — from the tragus or conchal bowl. Increasingly preferred for large perforations, revision cases, and ears with poor Eustachian tube function, because cartilage is structurally rigid and more resistant to re-perforation. Published studies confirm superior success rates in challenging ears.
• Fat (ear lobule) — used for small perforations in a minor procedure called fat myringoplasty, which can be done under local anaesthesia as a clinic procedure.

In children and most adults undergoing standard tympanoplasty in India, the procedure is performed under general anaesthesia. This ensures complete stillness, which is essential for precise microsurgical work within the ear canal and middle ear.

In selected adults with small, anteriorly accessible perforations, the procedure can be performed under local anaesthesia with sedation. This is particularly suitable for fat myringoplasty for small perforations, or in patients where general anaesthesia carries elevated risk.

The anaesthesia approach will be discussed and agreed at the pre-operative consultation.

Uncomplicated myringoplasty (Type I) is typically day-care surgery — admitted in the morning, discharged the same day after recovery from anaesthesia.

More complex procedures may require admission:

• Tympanomastoidectomy — usually one to two nights
• Extensive ossicular reconstruction — one night, occasionally two
• Cholesteatoma surgery — depends on extent; one to two nights is standard

Fat myringoplasty for small perforations can be performed under local anaesthesia in a clinic setting with no admission at all.

Yes. Tympanoplasty in children is a well-established and safe procedure. Published long-term data show a graft take rate of 84% for primary myringoplasty in children, comparable to adult outcomes.

Key considerations in the paediatric context:

• Most surgeons prefer to wait until the child is approximately 6 to 7 years old to allow Eustachian tube function to mature
• A pre-operative observation period of at least 12 months is recommended to confirm ear stability
• There is no evidence that delaying surgery beyond the age of 6–7 years improves outcomes
• If a child has active upper respiratory infections frequently, addressing adenoid disease first may improve surgical outcomes

Re-perforation after successful surgery can occur in children — long-term follow-up is recommended because spontaneous healing after re-perforation is still possible.

The standard approach is:

• Treat active infection with prescribed topical antibiotic eardrops (and systemic antibiotics if needed)
• Achieve a dry ear for a minimum of six to eight weeks before surgery
• If the ear does not become consistently dry despite adequate treatment, a cortical mastoidectomy to eradicate the infected mastoid may be performed before or at the time of grafting

Tympanoplasty is generally well tolerated in terms of pain — significantly less painful than, for example, tonsillectomy. Most patients describe mild to moderate discomfort in the first two to three days, managed with regular paracetamol.

What to expect:

• The donor site behind the ear (where temporalis fascia was harvested) may be more tender than the ear itself in the first few days
• A feeling of fullness or blockage in the ear is normal and expected — caused by the packing placed during surgery, which gradually dissolves or is removed at the first follow-up
• Significant or worsening pain after the first week should be reported to your surgeon

• Water in the ear — strictly for a minimum of six weeks. Use a cotton wool ball with petroleum jelly when showering. Swimming is prohibited until the surgeon confirms graft healing.
• Nose blowing — avoid for at least three weeks. Increased nasopharyngeal pressure can displace the graft before it has integrated. If you need to sneeze, do so with your mouth open.
• Strenuous exercise and heavy lifting — avoid for two weeks due to pressure and bleeding risk.
• Air travel — avoid for four to six weeks due to pressure changes at altitude. Confirm clearance with your surgeon before flying.
• Inserting anything into the ear canal — no cotton buds, no eardrops unless prescribed.
• Smoking — impairs wound healing and graft vascularisation. Avoid throughout the recovery period.

• Desk-based or office work: most patients return within one to two weeks
• Physical work, teaching, or noisy environments: two to three weeks
• Driving: typically three to five days — once off strong analgesics and comfortable
• Light walking and gentle activity: from one week
• Exercise and gym: two weeks minimum; contact sports three to four weeks
• Swimming: minimum six weeks, and only after surgeon confirms graft healing at follow-up
• Children returning to school: one to two weeks for standard activities; swimming and PE as above

For primary tympanoplasty (first-time surgery) on a dry, stable ear, published data consistently reports graft take rates of 80 to 96%, with most large series reporting around 85 to 88%.

Factors that improve success:

• Dry ear at the time of surgery — the single most important factor
• Central rather than marginal perforation location
• Cartilage grafting in revision cases and large perforations
• Good Eustachian tube function
• Surgeon experience and volume

For revision tympanoplasty (repeat surgery after a previous failure), success rates are lower — typically 53 to 78% — because scarring and reduced blood supply make graft integration more difficult.

If the graft heals successfully and the ossicular chain (the three small hearing bones) is intact, hearing improvement is expected and typically meaningful.

Published evidence from multiple studies consistently shows a mean air-bone gap improvement of 10 to 14 dB following successful tympanoplasty. Closure of the air-bone gap to within 20 dB of the sensorineural level is the accepted surgical target and is achieved in the majority of successful cases.

However, hearing improvement is not guaranteed. It depends on:

• Whether the graft takes fully
• Whether the ossicles are intact and mobile
• Whether there is pre-existing inner ear damage (sensorineural component) from chronic infection — this cannot be reversed by surgery
• Whether additional ossicular reconstruction is needed — this may be staged as a second procedure

Your surgeon will review your audiogram before the operation and give you a realistic estimate of expected hearing gain for your specific ear.

Yes. Revision tympanoplasty is a recognised and regularly performed procedure. Failure of a primary tympanoplasty is not a permanent outcome.

Before revision surgery is planned:

• The cause of failure must be investigated — Eustachian tube function, persistent infection, graft material choice, surgical technique
• A minimum waiting period of nine to twelve months after the initial surgery is recommended to allow full healing assessment and ensure a genuinely dry ear
• CT scanning of the temporal bone may be performed to assess middle ear status before re-operating

Cartilage grafts are strongly preferred for revision cases — their structural rigidity makes them more resistant to re-perforation in ears that have already failed once. Published data shows revision success rates of 53 to 78%, depending on the cause of the original failure.