What is the most appropriate surgical technique for a 21-year-old man with a 30% right tympanic membrane (eardrum) perforation who wants to improve his hearing and return to swimming?

Underlay Tympanoplasty for Tympanic Membrane Perforation

Underlay tympanoplasty is the most appropriate surgical technique for this 21-year-old man with a 30% right tympanic membrane perforation adjacent to the malleus. This technique offers the best balance of surgical success, hearing improvement, and reduced complication risk for this specific perforation type and location.

Rationale for Underlay Tympanoplasty

Advantages for This Patient

• Perforation Characteristics: The 30% perforation adjacent to the malleus is ideally suited for underlay technique, which provides excellent visualization and access to this area
• Hearing Outcomes: Underlay technique has demonstrated significant improvement in air-bone gap (mean gain of 13.3 dB), addressing the patient's mild conductive hearing loss 1
• Success Rate: High anatomical success rate of 94% reported with underlay technique 1
• Lower Risk of Complications: Underlay technique has fewer complications compared to overlay technique, particularly epithelial pearl formation 1

Comparison with Other Techniques

Overlay Tympanoplasty

• While effective, overlay technique has higher risk of epithelial pearls when fibro-epidermal cleaving is required across large areas 1
• More technically challenging with longer healing time
• Better suited for anterior perforations or subtotal defects, which is not the case here

Fat Graft Myringoplasty

• Limited to small perforations (typically <30% of drum area)
• Less durable for active patients who want to return to swimming
• Not optimal for this patient's perforation size and activity goals

Cartilage Tympanoplasty

• Offers greater structural support but may impact sound conduction
• Generally reserved for recurrent perforations, atelectatic ears, or revision cases
• Excessive for this patient's uncomplicated perforation

Technical Considerations

For this patient's specific perforation (30% adjacent to malleus), a modified underlay technique should be employed:

1. Graft Placement: The temporalis fascia graft should be placed medial to the tympanic membrane remnant but can be positioned lateral to the malleus handle for better anterior support 2
2. Approach: A transcanal or endaural approach is sufficient for this perforation size and location
3. Graft Material: Temporalis fascia is preferred (84% success rate) though tragal perichondrium is an acceptable alternative (80% success rate) 3

Expected Outcomes

• Hearing Improvement: Anticipate closure of air-bone gap to within 10 dB 3
• Graft Take Rate: Approximately 84-94% success rate 1, 3
• Return to Activities: Patient can return to swimming after complete healing (typically 8-12 weeks post-surgery)

Postoperative Considerations

• Water precautions until complete healing is confirmed
• Follow-up examination within 3 months of surgery to assess healing 4
• Audiometric testing at least 6 weeks post-surgery to document hearing improvement 4

Common Pitfalls to Avoid

• Inadequate Exposure: Ensure proper visualization of the entire perforation margin
• Graft Placement: Avoid graft lateralization by ensuring proper sizing and positioning
• Middle Ear Packing: Use appropriate amount of gelfoam to support the graft without excessive pressure
• Postoperative Care: Maintain dry ear precautions to prevent infection and graft failure

The evidence clearly supports underlay tympanoplasty as the optimal technique for this young patient with a 30% perforation adjacent to the malleus who wishes to improve hearing and return to swimming activities.