What is the most appropriate technique for closing a 30% tympanic membrane perforation?

Most Appropriate Technique for Closing a 30% Tympanic Membrane Perforation

Cartilage reconstruction tympanoplasty is the most appropriate technique for closing a 30% tympanic membrane perforation due to its superior structural outcomes compared to temporalis muscle fascia techniques. 1

Surgical Approach Selection

The choice of surgical approach depends on several factors:

1. Perforation characteristics:

   • Size: 30% perforation is considered medium-sized
   • Location: Affects surgical approach selection

2. Graft material options:

   • Cartilage reconstruction (CR):

     • Offers superior structural outcomes with 92.4% graft integration rate compared to 84.3% with temporalis muscle fascia 1
     • Lower revision rate (10% vs 19%) compared to temporalis muscle fascia 1
     • Better morphologic success while maintaining comparable hearing outcomes

   • Temporalis muscle fascia (TMF):

     • Traditional approach but with lower success rates
     • May be suitable for smaller perforations

Surgical Technique Considerations

Approach Selection:

• Transcanal approach: Preferred for medium-sized central perforations 2
• Endaural approach: Better for posterior perforations 2
• Postauricular approach: Better for anterior perforations with preservation of anterior canal wall skin 2

Modern Considerations:

• Endoscopic tympanoplasty: Provides equivalent closure rates to traditional approaches with less postoperative morbidity and shorter hospital stays (13 hours shorter) 3
• Lateral graft technique: More successful than underlay technique when using endoscopic approach 3

Procedural Steps

1. Preparation:

   • Ensure proper visualization with adequate illumination
   • Select appropriate instrumentation based on ear canal anatomy
   • Avoid irrigation if perforation is present 1

2. Graft harvesting:

   • Cartilage with perichondrium is the preferred graft material
   • Harvest from tragus or concha

3. Perforation preparation:

   • Freshen the edges of the perforation to promote healing
   • Remove any epithelial ingrowth at the perforation margins

4. Graft placement:

   • Position the cartilage graft using either overlay, underlay, or combined technique
   • Ensure complete coverage of the perforation with appropriate overlap

5. Stabilization:

   • Secure the graft in position
   • Place appropriate packing material

Post-Operative Considerations

• Keep the ear dry during healing phase
• Monitor for complications including infection or graft displacement
• Follow-up to assess graft integration and hearing improvement

Special Considerations

• Persistent perforations: When tympanic membrane perforations persist after tympanostomy tube extrusion, surgical closure with myringoplasty or tympanoplasty may be required 1
• Success rates: Cartilage reconstruction techniques show 80-90% success rates for surgical closure with a single outpatient procedure 1
• Novel approaches: Tissue-engineered myringoplasty with basic fibroblast growth factor (b-FGF) has shown promising results with 98.1% closure rate in research settings 1

Potential Complications

• Persistent perforation
• Hearing loss
• Infection
• Tympanosclerosis
• Cholesteatoma formation

The cartilage reconstruction technique provides the best balance of structural integrity and hearing outcomes for a 30% tympanic membrane perforation, with endoscopic approaches offering additional benefits of reduced morbidity when appropriate equipment and surgical expertise are available.