Present-day Concepts of Tympanoplasty

TYMIPANOPLASTY was the subject of an earlier contribution to this Journal (Smyth, 1962). Since then there has been considerable controversy amongst E.N.T. surgeons about the operation, its value and techniques. The present article deals with personal observations made while visiting the major E.N.T. centres of the U.S.A. during 1962 and 1963, and is aimed at bringing the reader up to date, or as up to date as possible, with a subject which does not stand still for long. E.N.T. surgeons can be classified as those who believe that tympanoplasty is a good operation or at least one with a future, and those who will not have it at any price. These latter, complaining that the hearing results are almost always bad, prefer to stick to the old modified radical type of operation with all its post-operative problems. Somewhere between these two groups are those who are prepared to utilise modern techniques only to repair a simple perforation, and then only in a long, dry, uncomplicated ear. The presence of cholesteatoma or ossicular defects are to them contraindications to this type of surgery. Those who believe in the benefits of tympanoplasty can be again divided into the "old school" and the "new school." (a) The "old school," which includes Wullstein, the originiator of the operation, Portmanni, Bocca, Shambaugh, Schuknecht, anld Guilford, to mention only its better-known advocates, adheres strictly to the ideas originally proposed by Zoellner (1951) and Wullstein (1952). These embodied the use of post-aural full thickness or Theirsch grafts for drum reconstruction, and for lining the cavity, and five possible types of tympanic reconstruction which depended upon the degree of middle-ear disease. They rightly insisted on complete eradication of all irreversible pathology, good Eustachian function, and an adequate cochlear reserve. An ingenious system of burr holes around the annulus was devised to permit inspection and removal of diseased material from the aditus, antrum, and sinus tympani. However, in spite of this, removal of the bridge and posterior meatal wall was often necessary to completely remove dangerous disease, and the resulting cavity, in spite of the newly available antibiotics, was just as difficult to get healed as it had always been in the past. (British authorities state 40 per cent. cavities are either perpetually and intermittently moist-Beales, 1959.) In these cases the postero-superior segment of the annulus was necessarily lost and in the subsequent tympanic reconstruction a narrow middle ear …