John L. Domhoffer Michael B.
Gluth
Seeking knowledge and expertise in the art of tympano-
plasty and ossiculoplasty can be a difficult task, in part due
to the overwhelming number of techniques that have been
described, but also because of the plethora of dogma and
surgical tradition that circulates throughout the otologic
surgery community. In the following chapter, the authors
seek not to champion a particular set of techniques, but to
provide a broad overview of this topic with a focus on fun-
damental principles that apply globally. This information
is delivered under the assertion that it is wise for otologists
to acquire a working mastery of several techniques that
may be applied in a customized manner based on pathol-
ogy and conditions at hand.
DEFINITION OF TERMS
Canalplasty refers to surgical modification of the bony
external auditory canal. This is often used as an adju-
vant procedure in tympanoplasty to improve surgical
access.
Meatoplasty refers to surgical modification of the cartilag-
inous external auditory canal and external auditory
meatus. This is often used as an adjuvant procedure
in tympanoplasty to provide improved postoperative
access or to attain consistent lateral-to-medial ear
canal size matching following canalplasty.
Myringoplasty refers to surgical repair of the tympanic
membrane that involves work confined to the
drumhead only.
Ossiculoplasty refers to surgical modification of the ossicu-
lar chain, including reconstruction and mobilization.
Tympanoplasty refers to surgical repair of the tympanic
membrane in combination with work within the tym-
panic deft, such as ossiculoplasty, middle ear explo-
ration, or lysis of tympanic adhesions. Traditionally.
elevation of the annulus within a tympanomeatal
flap has served as a practical boundary that differen-
tiates tympanoplasty from myringoplasty.
TYPES OF TYMPANOPLASTY
AND OSSICULAR RECONSTRUCTION
Tympanoplasty techniques were classically outlined by
Zollner (1) and Wullstein (2). Subsequent modifica-
tions of Wullstein's classification have been based on the
underlying properties of acoustic mechanics associated
with each tympanoplasty type as opposed to classification
based on underlying tympanic and ossicular pathology.
Understanding this classification system is helpful not only
for purposes of grasping a global and historical view of
tympanic membrane and ossicular chain reconstruction,
but also for understanding basic principles of middle ear
acoustic mechanics.
Type I Tympanoplasty
This procedure involves repair of the tympanic membrane
in the setting of an intact native ossicular chain. At most
manipulation of the ossicular chain is limited to interven-
tions aimed at improving mobility. such as lysis of tym-
panic adhesions or removal of tympanosderotic foci.
Type II Tympanoplasty
This procedure involves repair of the tympanic membrane
in combination with any type of ossiculoplasty proce-
dure that preserves the integrity of the malleoincudal lever
mechanism. The most common example of this is repair
of a dysfunctional (eroded) incudostapedial articulation.
Tympanoplasty with delayed staged ossiculoplasty consist-
ing of an incus-grip stapedotomy could also be considered
a subgroup within this category. It is perhaps worth noting
that these modem depictions of type II tympanoplasty dif-
fer somewhat from the classic description that was devised
to deal with the uncommon scenario of isolated malleus
erosion, wherein tympanic membrane grafting is applied
directly upon the intact long process of the incus.
2465
2466 Section IX: Otology
Type Ill Tympanoplasty
This procedure involves repair of the tympanic membrane
in combination with any type of ossiculoplasty procedure
that does not preserve the integrity of the malleoincudal
lever mechanism. Type III tympanoplasty includes the
vast majority of techniques described for routine ossicular
chain reconstruction. Accordingly, type III tympanoplasty
classification has been further subdivided according to
ossiculoplasty technique.
Stapes Columella Subtype
This type III tympanoplasty involves placement of a tym-
panic membrane graft directly onto the superstructure of
the stapes without the use of a prosthesis or any other sub-
stantial interpositional material.
Minor Columella Subtype
This involves the use of an interpositional graft or pros-
thesis to establish continuity between the tympanic mem-
brane and the superstructure of the stapes. Examples of this
include the use of a synthetic partial ossicular replacement
prosthesis (PORP) or sculpted ossicular (incus or malleus
head) autograft. Interpositional ossiculoplasty techniques
that employ a lateral contact point with the malleus manu-
brium also fall within this subtype.
Major Columella Subtype
This procedure is exactly the same as the minor columella
subtype except that the stapes superstructure is absent; thus,
with a major columella subtype the interpositional graft or
prosthesis is set upon the stapes footplate. An example of
this is use of a synthetic total ossicular replacement pros-
thesis (IDRP). Tympanoplasty with delayed staged ossicu-
loplasty that consists of a malleus-grip stapedotomy could
also be considered to fall within this subtype.
Type IV Tympanoplasty
This procedure involves repair of the tympanic membrane
in such a manner that the boundary between the mucosal-
ized middle ear space and the epithelialized lateral com-
partment (external auditory canal, open mastoid cavity,
epitympanum) is shifted in a way that renders the stapes
footplate externalized as part of the latter. As a result, the
tympanic cavity is divided into a smaller-than-normal aer-
ated space in continuity with the eustachian tube, termed
the cavum minor, in which the round window is acous-
tically shielded, and an external component in which the
mobile stapes footplate is covered by a thin epithelial layer
and is directly exposed to incoming sound energy.
Type V Tympanoplasty
This procedure is the same as the type N tympano-
plasty, except that it also includes the need to address
an underlying immobile stapes footplate and, therefore,
is generally performed in a staged manner once active
infectious disease is controlled. Historically, fenestration
of the lateral semicircular canal was described as part of
this procedure to counteract stapes fixation; however, total
footplate removal and a soft tissue seal have generally
replaced fenestration.
PHYSIOLOGY: MECHANISMS OF GAIN
The modern view of middle ear acoustic science involves
two basic pathways by which sound is able to stimulate the
inner ear (3,4). The first involves transmission of sound
pressure through the tympanic membrane and ossicu-
lar chain via the oval window. This is known as ossicular
coupling. This mechanism is the primary means by which
the state of impedance mismatch that exists between the
air in the ear canal (low impedance) and the fluid within
the cochlea (high impedance) is overcome. In such a state,
sound pressure is deflected during passage through the air-
fluid interface, resulting in a loss of gain in the realm of
30 dB. The coupling effect of the tympanic membrane and
ossicles almost overcomes this loss.
Ossicular coupling has been attributed to the col-
lective effect of three characteristics of the tympano-
ossicular mechanism traditionally known as the acoustic
transformer theory (5). The first and most significant of
these characteristics is the hydraulic lever effect that results
from the difference between the surface area of the tym-
panic membrane relative to that of the oval window
(usually a ratio of nearly 21:1). This effect results in
compression of sound energy and increase in force at
the oval window, equating to a theoretic approximate
increase in gain of 26 dB. The second characteristic is
the malleoincudal lever effect that results from the differ-
ence in length between the malleus manubrium relative
to that of the long process of the incus along the axis of
ossicular rotation (a ratio of 1.3:1). However, this effect
only accounts for an additional 2 dB theoretical increase
in gain. The final factor is the so-called catenary lever
effect that is generated by the elastic stretching of the
tympanic membrane from the annulus to the malleus
manubrium-somewhat akin to the stretched strings
across a tennis racquet. The specific degree of acous-
tic benefit derived from the catenary effect is not well
understood but probably lies within a range similar to
that of the malleoincudal lever.
It is important to recognize that, in reality, ossicular
coupling is a much more complex phenomenon than what
is suggested by these simplified traditional models as they
do not account for factors such as variation in efficiency
with changes in frequency or inefficiencies in sound trans-
mission through the tympanic membrane and ossicular
chain attributed to the inherent tension or laxity of the
ossicular ligaments. Thus, it is perhaps not surprising that
the 25 to 30 dB of gain that is predicted by the acoustic
transformer theory does not equate well with experimental
 Chapter 153: Reconstruction of the Tympanic Membrane and Ossicular Chain
measurements, which suggest an actual more modest
increase in the realm of just over 20 dB (6-8).
The second pathway of sound stimulation of the
inner ear involves direct passage of sound pressure via
the oval and round windows without involvement of the
tympanic membrane or ossicular chain. This is known
as acoustic coupling (4). Given an intact tympanic mem-
brane and functional ossicular chain, this pathway is of
only minor importance. However, in the various condi-
tions of a diseased ear, acoustic coupling can be impor-
tant. This is why, for example, a conductive hearing loss
will be greater in the case of ossicular discontinuity and
an intact tympanic membrane (60 dB) compared with
ossicular discontinuity and an absent tympanic mem-
brane (40 to 50 dB). With the former, the intact tym-
panic membrane restricts the acoustic coupling pathway
by blocking direct access of sound pressure to the oval
and round window membranes.
A final relevant consideration in middle ear acoustic
mechanics is that of phase. A sound stimulus to the inner
ear is detected as the net difference in sound pressures
applied to the round and oval windows that results in
movement of intracochlear fluids. If these sound pressures
are simultaneously applied to the round and oval windows
with equal amplitude and phase, they will counteract each
other and no resultant intracochlear fluid displacement
will occur. In the normal situation, this does not occur
due to the unbalanced selective effect of ossicular coupling
upon the oval window, the acoustic shielding effect of the
tympanic membrane upon the round window, and the
uneven anatomical positioning of the round window ver-
sus the oval widow relative to incoming sound. However,
when the tympana-ossicular mechanism is absent and
acoustic coupling is primarily relied upon (as in the case of
a type N or V tympanoplasty), an unshielded round win-
dow can yield significant negative acoustic consequences
due to phase cancellation (4 ).
A simplified chart depicting the theoretic ideal acoustic
effects of various tympana-ossicular scenarios is shown in
Table 153.1.
PREOPERATIVE EVALUATION
When a patient is considered for tympanoplasty or ossi-
culoplasty, a thorough history, examination, and audio-
metric evaluation should be performed on both ears.
Otoscopy and pneumatic insufflation under the binocular
microscope, following careful removal of debris, provide a
wealth of information. The results of the audiogram should
always be correlated with the physical exam, including
Weber and Rinne tuning fork tests, especially when a mask-
ing dilemma is present. If the audiogram and tuning fork
exam do not agree. surgery should not be performed until
this is reconciled.
A preoperative audiogram can be helpful in suggesting
underlying pathology. Generally, a perforation will cause
2467
a conductive hearing loss between 5 and 40 dB depending
on its characteristics (9). Controversy exists as to whether
or not the location of a perforation impacts the degree of
hearing loss, yet perforation size and underlying middle
ear volume do matter (an ear with a smaller volume tends
to have worse hearing than one with a larger volume, even
given identical perforations) .
When the tympanic membrane is intact, a conductive
hearing loss greater than 35 to 40 dB strongly suggests the
possibility of ossicular chain dysfunction. Furthermore,
the pattern of hearing loss may be typical of particular
scenarios; for example. ossicular fixation generally causes
a low-tone conductive hearing loss, the degree of which
is related to the extent and location of the fixation. With
malleus head fixation, the low-tone air-bone gap gener-
ally closes at the higher frequencies, whereas stapes fixa-
tion tends to affect the middle and high frequencies to a
relatively greater degree (10).
The status of the eustachian tube will impact surgical
outcomes, yet there is no consensus on the optimal way
to reliably assess its function (11). Auto-inflation using the
Valsalva or Toyenbee maneuver is helpful, albeit a non-
physiologic test of tubal patency. The clinical status of the
contralateral ear likewise can provide insight into tubal
maturity and function in the diseased ear ( 12). As part of
the eustachian tube evaluation. the nose should be exam-
ined so that allergy, adenoiditis, and rhinosinusitis can
be treated in an effort to promote optimized tubal func-
tion (13). Furthermore, aggressive medical treatment of
infection involving the ear itself should be undertaken
prior to surgery, including aural toilet and ototopical agent
application. When an ear will not dry with medical ther-
apy, culture acquisition may be useful in helping to iden-
tify antimicrobial-resistant pathogens.
Once patient assessment is complete, a few general rules
should be applied to surgical candidacy. First, one should
avoid elective surgery on an only-hearing ear as much as is
reasonably possible. Exceptions to this would be situations
where surgery is primarily confined to the tympanic mem-
brane, and drilling or significant ossicular manipulation is
unlikely, or when a perforation is contributing to difficulty
with hearing aid usage. Also, cases that involve disease pro-
cesses that impart risk of hearing loss, such as cholestea-
toma, will generally warrant intervention. Second, when
bilateral disease is present, surgery should be undertaken
on the worse-hearing ear in the absence of any other com-
pelling reason to do otherwise on account of underlying
disease. Finally, special consideration should be given to
the timing of surgery in the pediatric patient.
Age as a prognostic factor in tympanoplasty is contro-
versial, with contradicting reports present in the litera-
ture (14,15). The authors' approach to pediatric patients
is to avoid repairing the tympanic membrane during the
otitis-prone years (:S:3 years). If the contralateral ear is
normal, routine tympanoplasty is considered at age 4 for
an ear that is dry or only occasionally drains with water
I

Ia I

I
II I
~
I I
1
I
 Chapter 153: Reconstruction of the Tympanic Membrane and Ossicular Chain
contamination (16). Ho~ if the contralateral ear is
abnormal at this time,. adenoidectomy is considered and
tympanoplasty is deferred until the contralateral ear reaches
stable quiescence or the patient reaches age 7. If contralat-
eral disease is still present at this time, a more aggressive
technique, such as cartilage tympanoplasty, is performed
on the worse-hearing ear. The second ear is repaired several
months later, but only after the first ear is documented to
have a stable satisfactory outcome and is not expected to
require further surgery.
TYMPANOPLASTY
General Principles
Modern tympanoplasty techniques all have common
ground in that they endeavor to reconstruct the deficient
middle fibrous layer of a tympanic membrane perforation
with graft materials that then act as a scaffold for lateral
epithelial growth. Although simplified myringoplasty tech-
niques that utilize non-grafted temporary scaffold mate-
rials, such as a thin paper patch, can be used for small
perforations, they are relatively limited in application and
simple to learn. Thus, patch myringoplasty techniques are
not a focus of this discussion.
The common goals of tympanic membrane repair are to
Create a barrier between the dry lateral epithelialized
compartment (drumhead, external auditory canal, open
mastoid cavity) and the moist medial mucosalized com-
partment (middle ear, eustachian tube)
Provide reinforcement to correct tympanic membrane
wealmesses in order to resist future disease processes
(atelectasis, perforation)
Create an optimized sound-conducting platform for
ossicular coupling or a round window shield for acous-
tic coupling depending on tympanoplasty type
Create a contour favorable for outward keratin debris
migration
Applied Tympanic Membrane Mechanics
The tympanic membrane is the major element of the
middle ear transformer mechanism and acts as a barrier
between the sound pressure of the ear canal and middle
ear. Its motion, which has been studied with laservibrome-
try and stroboscopic holography. is both complex and vari-
able depending on the frequency of stimulation (17,18).
At frequencies up to 1,000 Hz, the tympanic membrane
tends to vibrate in one consolidated phase, but as fre-
quency rises further, its vibration splits into a state of phase
subdivision, with overall diminished efficiency.
While it is intellectually satisfying to assert that recon-
struction of the tympanic membrane must endeavor to
exactly recreate these native vibratoiY patterns, in truth it is
unknown if this is possible or even necessaey. Numerous
tympanic membrane graft materials have been used that are
2469
quite dissimilar to the native drumhead in rigidity and thick-
ness, yet excellent acoustic outcomes have been attained.
For example, reconstruction with large cartilage grafts has
been reported to result in hearing outcomes equal to those
with more pliable temporalis fascia (15,19-21 ), including
occurrences of complete air-bone gap closure in the speech
frequencies. Further complicating the situation is uncertainty
regarding the interplay between an aphysiologic recon-
structed tympanic membrane and the underlying aphysi-
ologic reconstructed ossicular chain in collectively providing
acoustic gain (22). Gaps between observed clinical outcomes
and predicted tympanoplasty outcomes based on tympanic
membrane acoustic models highlight the fact that there is
still much to be learned.
Surgical Exposure
The importance of assuring proper visualization and expo-
sure in order to surgically manipulate the tympanic mem-
brane and middle ear may seem obvious, but if taken for
granted, surgical results can be compromised. Line-of-sight
visualization in itself does not always signify adequate
exposure. The surgeon must assure that instruments are
allowed to enter the microscopic field at a sufficiently
open lateral angle so as not to impede binocular vision or
require awkward manipulation. Although minimally inva-
sive approaches can be desirable, these should only be uti-
lized if they provide equally sufficient access and exposure
to the surgical target. The morbidity associated with even
the widest tympanoplasty access route (postauricular with
canalplasty) is generally not high. Table 153.2 provides a
suggested guide for choosing appropriate access for tym-
panic membrane repair. One noteworthy consideration is
that when a perforation involves the anterior drumhead,
wide exposure via a postauricular incision and, when
needed, a canalplasty may be helpful.
Canal Incisions
Numerous sites for canal incisions have been described to
raise a tympanomeatal flap, and generally these are chosen
according to the anticipated surgical plan. Many surgeons
have traditionally insisted upon preservation of the poste-
rior-superior vascular strip of canal skin or avoidance of
transecting the tympanic annulus. However, many of these
dictums seem to be routinely ignored by accomplished otol-
ogists with little if any apparent negative consequence. In
reality, quality surgical execution and careful atraumatic han-
dling of canal skin are probably the key factors to a success-
ful outcome regardless of how this is done (see Fig. 153.1).
Preparing the Drumhead
Prior to graft placement, the tympanic membrane
should be prepared to maximize the chances of graft
take and rapid epithelialization. This typically involves
2470 Section IX: Otology

SUGGES'I15D ROUTES OF ACCESS FOR TYMPANIC

MEMBRANE REPAIR

(
Transcanal J Small myringoplasty
Patch procedures)
(office
posterior underlay tympanoplasty

;::::::=======::::::::

( &mn }=.----
( -~~ }u--
Postaurlcular Underlay tympanoplasty with large anterior component
with Canalplasty Overlay tympanoplasty

freshening the maigins of the perforation with cold knife
rim resection or laser application in order to encourage
sprouting of new microvasculature. AJ a general rule, it is
better to be aggressive in completely removing unhealthy
portions of the tympanic membrane than to attempt
incorporation of them into the reconstruction process.
This includes myringitis (particularly important), tympa-
nosclerotic plaque, scat and old graft material. Pathologic
adhesions between the drumhead and middle ear should
also be released.
that have been stripped of perichondrium on the medial
surface but have adherent perichondrium or overlying
fascia on the lateral surface (26). In the authoD' experi-
ence, such grafts tend to be much more resistant to involve-
ment with postoperative middle ear adhesions than either
fascia or perichondrium.

Choosing, Preparing, and Shaping the Graft

The most commonly used tympanic membrane grafting
material is temporalis fascia, which is desired for its pli-
ability. This is harvested, via either an endaural or post-
auricular incision, as the glistening whitish layer of fascia
immediately overlying the temporalis muscle fibers. After
harvest. this is generally pressed thin and set aside for dJ:y-
ing, which may promote ease of trimming and placement
Readily available alternatives to tempomlis fascia that are
also thin and pliable include pressed perichondrium, peri-
osteum, and muscle. Cadaveric acellular dermal matri.x
(AlloDerm, LifeCell Corp, Branchburg, NJ) (23) has also
been used with Succe8S and may be particularly useful for
simple in-office tympanoplasty procedures where harvest
of a tissue graft is not desired.
Auricular cartilage grafts are very useful in tympano-
plasty (24,25) and may be harvested from various sites, but
are typically harvested from the tragus and the cymba with A
the overlying perichondrium intact These can be applied
Figur. 153.1 Canal incisions. A:. The dassic vascular strip inci-
with or without perichondrium or the concurrent use of sion involves preservation of the posterior canal skin to within a
fascia; howeve~;. the authoiS' bias is to apply cartilage grafts few millimeters of the annulus.
 Chapter 153: Reconstruction of the Tympanic Membrane and Ossicular Chain 2471

c D
Figure 153.1 (Continued) B: A "book page" flap provides particularly good access for graft plae
ment by dividing the annulus \'\lith an Incision through the c:.anal skin and tympanic membrane Into
the perforlrtlon. C: A "ship sail" ftap Is larger at the superior aspect and Is particularly uSQf'ul when
wide curettage of scutum bone results In the need for extra tympanomeatal Rap length for cover
age. D: Modified canal lndslons for underlay tympanoplasty can Incorporate both a standard tym
panomelrtal Rap as v-.11 as a separate anterior canal lndslon to elevate the annulus and anchor the
graft. (Continued on next page)
2472 Section IX: Otology
Figure 153.1 (Continued) E: Overlay tympano-
plasty naqulres Incisions thllt afford removal of the
anterior canal wall skin to allow ac:aw for canalplasty.
F: Overlay tympanoplasty lndsions can be modified
to allow wider removal of canal skin If deslnad.
When the use of a composite perichondrium-cartilage
island graft is desired, perichondrium is usually stripped
off of one side, and the remaining au'lilage is cut to the
desired shape as an "island upon the preserved opposite
side (see Fig. 153.2). If used for repair of a large perfora-
tion, a composite island graft is shaped into a thin circu-
lar disk 8 to 9 mm in diameter, with a notch cut to cradle
the malleus manubrium and tails of perichondrium on
the periphecy that can be anchored on the atemal audi-
toty canal wall under the annulus. For optimized acoustics,
;
/
......... __ _, .;'
/
F
a cartilage graft thickness of 0.7 mm or less is preferable;
hoM!Vel;. ifshaved too thin, undesirable curling of the graft
mayoCOJr.
lhe choice of graft material is made based on the com-
plexity of the reconsttuction and the activity of any under-
lying chronic ear disease. In higher risk situatiom, cartilage
tympanoplasty techniques may provide more durable
results (27,28). A high-risk perforation might be consid-
ered one that is huger than 50%, an anterior perforation,
a perforation draining at the time of surgery, a recurrent
 Chapter 153: Reconstruction of the Tympanic Membrane and Ossicular Chain 2473

External Auditory
Canal Skin _ _ _ __..,

A 6
Figure 153.2 Composite perichondrium-cartilage i'land graft. A:. A compo'ite perichondrium-
cartilage island graft is formed by stripping perichondrium off a 'ingle side of the graft. The carti-
lage i' then cut to the desired 'hape and size without violating the remaining perichondrium. For
total tympanic membrane reconsu-uc1ion, the preferred diameter of the graft i' 8 to 9 mm. A 1-mm
cemral su-ip of cartilage i' removed to accommodate the malleu' handle and to allow posterior graft
elevation for ossiculoplany. The remaining peripheral perichondrial "apron" i' 'et over the canal
wall bone. B: Cross 'action of a perichondriurn-c:artilage island used as an underlay graft.

perforation (29,30), or a perforation in the setting of per-
manent absent eustachian tube function. Other situations
where cartilage is useful are the atelectatic eat; retraction
pockets, and cholesteatoma as re-attophy and perforation
are common over the long term when fascia is used solely
in the reconstruction (31).
Mini split-thiclmess skin grafts may also be used as an
adjuvant in tympanoplasty. Although it is generally not
advisable to graft the entire reconstructed drumhead due
to the potential for dysfunctional postoperative epithelial
migration, small grafts (4 mm or less in any dimension)
tend to inco~porate well with adjacent native epithelium.
When utilized,. these grafts are best rendered very thin and
positioned partially upon the intended tympanic graft
target and at least partially upon adjacent healthy canal
bone. Instances where mini split-thiclmess skin grafts
may be particularly useful include correction of tympanic
membrane blunting, repair of total tympanic membrane
defects, removal of chronic granular myringitis, and treat-
ment of tympanic slag injury.
Underlay Repair
Underlay tympanoplasty is the most widely used tympanic
membrane repair technique and is suitable for perfora-
tions of all sizes and locations (see Fig. 153.3). The concept
of Wlderlay grafting involves placement of graft material
immediately Wlderneath the residual native drumhead in
a manner that accounts for the entire defect and all per-
foration m;ugins. 'Ihree forces typically support this graft.
First. medial support is obtained via absorbable middle
ear packing material. Second, adhesion occun between the
graft and the Wldersurface of the adjacent native drumhead
and between the graft and lateral packing material through
the perforation. Finally, the peripheral aspect of the graft
is anchored in place between the tympanic annulus/
canal skin and the Wlderlying bone of the external audi-
tory canal. Anchoring almost always involves the posterior
canal wall and tympanomeatal flap but has also been
described at various anterior points (32,33).
1he advantages of underlay grafting include simplicity,
rapid exeaJtion, and a high rate ofreponed success. Howevet
failures do occw;. and these are most often related to avm'eli-
anre on middle ear packing mate:rials. If peripheral annulus
anchoring is insufficient, packing may fail to prevent medial
(inwan:l) graft displarement and point separation of the graft
from the perfomtion edge This seems to be a particular risk
when repairing an anterior or near-total perforation. In the
autho:rs' experience, lalge rigid cartilage grafts are less likely
than fascia or perichondrium to displace medially.
Another theoretic negative consequence of underlay
grafting relates to development of postoperative middle
ear adhesions and ffmpanosclerosis. When middle ear
mucosa is denuded, the large volume of middle ear pack-
ing required for underlay graft support harbors the poten-
tial to increase scar formation between the walls of the
middle ear cleft and the undersurface of the drumhead.
Additionally, redundant margins of underlay graft that lie
in contact with the ossicular chain have the potential to
adhere and negatively affect ossicular mobility.
2474 Section IX: Otology

c D
Figure 153.3 Underlay tympanoplasty. A:. The rlm of the perforation ls freshened. 1: The tympa
nomeatal flap ls raised and middle ear work completed as needed, lndudlng palpation of the os-
sicular chain. C: The graft ls set In an underlay fashion to account for all margins of the perforation.
D: Afwr application of middle ear packing to support the graft medially, the t:ympanomeatal ftap Is
returned to the anatomical posh:lon, wh:fl perforation closure assunad.

Overlay Repair
The basic concept of overlay or "'ataal grafting.. involves
de-epithelialization of the tympanic membrane remnant
while preserving what exists of the native middle :fibrous
layer. This preserved middle layer remnant il!l then used as
partial medial support upon which grafting materiab are
set (see Fig. 153.4). Overlay techniques are robust and can
be applied to all perforations, but they are especially useful
in dealing with anterior and near total defects (34). They
have the advantage of being relatively resistant to graft fail-
ure due to inadequate medial support and inward graft
migration during the healing phase sometimes seen with
underlay techniques.
Most common overlay graft techniques are combined
with canalplasty to remove the bulge of the anterior canal
wall. De-epithelialization of the tympanic membrane is
often Wldertaken as part of the process of exposing the
 Chapter 153: Reconstruction of the Tympanic Membrane and Ossicular Chain 2475

A B

c
Figure 153.4 Overlay tympanoplasty. A: With e~~pQ,ure of the canal wall for canalplany, all lateral
epithelial components of the remnant tympanic membrane are di,9&Cted free. B: The graft is shaped
with a notch for the malleus to account fer the entire surfaat of Ute tympanic membrane. C: The
graft is plaatd medial to the malleus handle to prevent lateralization and then draped over Ute canal
wall on the periphery, lateral to Ute fibrous tympanic membrane remnant. (CIJntinued on next page)
2476 Section IX: Otology

D Ledge drilled at anterior annulus E

Figure 153.4 (Continued) D: Cross section of overlay graft in

place. Of note, the anterior canal wall mun be drilled with a groove
to open the acute anterior tympanomeatal angle. This area is also
tiglnly pEtdc:ed. E: If epithelium is left on the remnant tympanic
membrane, an imratympanic keratin cyst may result. F: Inadequate
packing or drilling of the anterior canal wall can result in blunting.
Functionally, this becomes a problem when the malleus handle
becomes fixed to the anterior canal wall by scar tissue. F

bone of the anterior canal wall for drilling, wherein the
canal skin is elevated in continuum with the epithelial
remnants of the drumhead. Usually, this canal wall skin
is removed and reset near the end of the swge:ry as a free
graft. Care should be taken that all epithelial remnants
have been removed prior to graft overlay in order to pre-
vent development of intratympanic keratin inclusion cysts.
It is important to understand that canalplasty is per-
formed with overlay grafting not only to provide adequate
exposure to the anterior tympanic ring, but also to open
the acute anterior tympanomeatal angle between the
anterior canal wall and drumhead in an effort to prevent
postoperative blunting of this area. Blunting can be fimc-
tionally undentood as dense scarring of the anterior tym-
panic membrane that results in reduction of the functional
surface area of the drumhead and ...pseudo-malleus fixa-
tion caused by adhesion between the manubrium and the
anterior canal wall. This risk can be minimized not only by
canalplasty, but also by strategically packing this area after
graft placement.
Unique Situations
Atelectasis
Tympanic membrane atelectasis may require augmenta-
tion with an underlay graft (usually cartilage) or;. rarely,
drum replacement (14). As a general rule, when atelectasis
is limited and has not resulted in the need for ossiculo-
plasty, medical management to promote eustachian tube
function or tympanostomy tube placement is sufficient.