Myringoplasty and the factors that affect its success- a case based review

Myringoplasty is the surgical treatment for the repair of tympanic membrane (TM) perforations. It is indicated for treatment of recurrent ear discharge, improving conductive hearing loss, and preventing future infections, especially in high risk groups. In this case-based review, the normal anatomy and physiology of the ear is described, followed by the way conductive and sensorineural hearing loss are differentiated through a detailed history, examination and investigations, including audiometry and tympanometry. The anatomy of the TM is explored and the causes, presentation and diagnosis of TM perforations, which are a cause of conductive hearing loss, are described This review focuses on how myringoplasty is used to repair TM perforations, and what factors affect its success, relating the findings to four patients who have undergone myringoplasty. The underlay technique is used more frequently, yielding better results with fewer side-effects, especially for posterior perforations, whereas overlay is shown to be better for anterior perforations due to a better view of the TM, but has higher risks for graft lateralisation and blunting. Over-underlay is similar to underlay in success, but can only be applied where the handle of malleus is intact. TM repair was shown to be independent of age, sex and timing of antibiotic administration, although chronic perforations take longer to heal. The effect of size on the surgical outcome is debatable, with different studies showing opposite results. Side-effects, alternative treatment options and potential biases in the studies are discussed, as well as the limitations of the information obtained from the cases. The conclusion is that there is no “one-fits-all” procedure or graft that is suitable for the repair of all TM perforations, and each patient should be assessed on an individual basis, taking into consideration their own needs and wishes.