Myringoplasty

Dr Jason Roth (MED0001185485) — Specialist Otolaryngologist & Head and Neck Surgeon, specialist registration in Otorhinolaryngology, Head & Neck Surgery.

Myringoplasty is the surgical repair of a perforation (hole) in the eardrum (tympanic membrane). It is a well-established, effective procedure that aims to restore the integrity of the eardrum — eliminating the risk of water and bacterial entry into the middle ear, reducing the frequency of recurrent infections, and in most cases improving hearing. When the procedure also involves exploration or reconstruction of the middle ear ossicular chain (the three hearing bones), the operation is termed a tympanoplasty.

Read about perforated eardrums and when surgery is indicated →

Indications for Myringoplasty

Not every eardrum perforation requires surgical repair. The initial management of most perforations is a period of watchful waiting — keeping the ear dry and treating any infections promptly — during which many perforations, particularly those caused by acute infection or trauma, heal spontaneously within weeks to months. Surgical repair is considered when:

The perforation has not healed spontaneously after an adequate observation period (typically at least three to six months)
Recurrent acute otitis media is occurring through the perforation despite meticulous ear protection
Persistent mucopurulent discharge is present that has not responded to antibiotic ear drops and dry ear care
The hearing loss attributable to the perforation is significantly affecting the patient’s daily life
The patient wishes to be able to swim without ear protection
Eardrum retraction or early cholesteatoma associated with the perforation is identified
A residual perforation remains after grommet extrusion that has not closed spontaneously after twelve to eighteen months

The success rate of myringoplasty is generally quoted at 85–90% for closure of the perforation in experienced hands, with hearing improvement achieved in the majority of patients with a significant pre-operative air-bone gap. Success is influenced by the size and location of the perforation, the state of the middle ear, the patient’s Eustachian tube function, and whether the ear is dry at the time of surgery.

Graft Materials

The eardrum is repaired using a graft — biological tissue harvested from the patient at the time of surgery to close and support the perforation. Several materials are used, each with distinct properties:

Temporalis fascia (most commonly used)

The temporalis fascia is the fibrous layer overlying the temporalis muscle above and behind the ear. It is the standard graft for most myringoplasties. Harvested through the post-auricular incision or a small separate scalp incision, it is thin, flat, and flexible — ideal properties for an eardrum graft. It integrates reliably and the donor site heals without functional deficit. The graft is trimmed to the appropriate size and placed either on the under surface of the eardrum remnant (underlay technique) or on top of it (overlay technique).

Cartilage (tragal or conchal)

Cartilage — typically from the tragus (the small prominence in front of the ear canal opening) or the conchal bowl — provides a stiffer, more robust graft that is preferred in situations where the probability of graft failure with fascia is higher: very large perforations, revision surgery after failed previous repair, ears with poor Eustachian tube function, and perforations in which negative middle ear pressure is likely to continue after surgery. A cartilage graft does not vibrate as freely as a fascial graft and may result in a slightly higher degree of residual hearing loss, but it is substantially less likely to re-perforate. A very thin slice of cartilage with intact perichondrium (the cartilage-perichondrium composite graft) provides an intermediate option: the stiffness of cartilage with the flexibility of perichondrium on the eardrum surface.

Fat (earlobe)

A small plug of fat harvested from the earlobe can be used for very small perforations (under 2mm) — the fat plug is placed through the perforation using a simplified technique that does not require elevation of the ear canal skin or an incision behind the ear. This “fat myringoplasty” is a minor outpatient procedure occasionally performed in adults under local anaesthesia for selected small central perforations.

Surgical Approaches

Post-Auricular Approach

An incision is made in the natural crease behind the ear, providing wide access to the ear canal and the temporalis fascia graft donor site in a single field. This is the most commonly used approach for standard myringoplasty, particularly for moderate or large perforations and when a canal widening (canalplasty) may also be needed. The scar is hidden behind the ear and is not visible.

Endaural (Trans-Canal) Approach

Access is achieved entirely through the ear canal, without an incision behind the ear. This approach is used for small to medium perforations in patients with adequate ear canal width and a perforation that can be fully visualised endoscopically. Recovery is faster and there is no post-auricular scar, but access is more limited and the approach is not appropriate for all anatomies.

Endoscopic Myringoplasty

Increasingly, myringoplasty is performed using a rigid endoscope rather than an operating microscope, providing a wide-angle, brighter view of the middle ear through the ear canal with minimal distortion. Endoscopic myringoplasty may reduce post-operative discomfort and recovery time compared with the post-auricular microscopic approach, and provides superior visualisation of anterior perforations. The technique requires specific training and experience.

The Procedure in Detail

The following describes the standard post-auricular myringoplasty with underlay temporalis fascia graft:

Patient positioning: The patient is positioned with the head turned away from the operating side. The ear is cleaned and a small amount of hair behind the ear shaved.
Incision and graft harvest: A post-auricular incision is made in the crease behind the ear. The temporalis fascia is identified, and a piece approximately 15 × 20mm is harvested with scissors. The graft is compressed and dried on a flat surface.
Canal skin elevation: The ear canal skin is infiltrated with local anaesthetic containing adrenaline to reduce bleeding. A circumferential incision is made in the ear canal skin, and the skin is carefully elevated off the bony canal and reflected forward over the eardrum, exposing the perforation and eardrum remnant.
Perforation preparation: The edges of the perforation are freshened by removing the squamous epithelium from the rim, creating a bleeding surface onto which the graft will adhere. In an underlay technique, the fibrous annulus (the cartilaginous ring at the periphery of the eardrum) is elevated from its groove.
Graft placement: The trimmed fascia graft is slid through the perforation and positioned on the under surface of the eardrum remnant and the medial canal wall, held in place by absorbable gelatin sponge packing in the middle ear.
Canal skin repositioning: The elevated canal skin is laid back over the graft and the eardrum, and further gelatin sponge packing is placed in the ear canal to hold everything in position during initial healing.
Wound closure: The post-auricular incision is closed in layers with dissolving sutures. A mastoid bandage dressing is applied.

Recovery in Detail

Day of surgery / Day 1

Most patients stay one night in hospital. The mastoid bandage is removed the morning after surgery. A small soft dressing is left over the post-auricular incision. A cotton ball may be placed lightly at the ear canal entrance. Some blood-stained drainage in the first day or two is normal.

Week 1 — first post-operative visit

The ear is examined, the canal packing inspected, and the post-auricular wound checked. The ear remains blocked during this phase as the canal packing is present. Complete ear dryness is essential — cotton ball with Vaseline or a custom ear plug during showering. Most patients return to work at the end of the first week for office-based occupations.

Weeks 2–6 — packing removal and early healing

The canal packing is removed under the microscope at subsequent visits over two to four weeks. Hearing typically improves progressively as packing is removed. Ear drops may be prescribed to soften and assist packing removal. Gentle physical activity can resume, but contact sports, heavy lifting, and activities with risk of head injury should be avoided until six weeks.

Months 1–3 — graft maturation

The graft continues to mature and thicken over the first three months. Swimming is not permitted until Dr Roth confirms the eardrum has healed. Air travel should be avoided for six to eight weeks after surgery — the healing graft cannot withstand the pressure fluctuations of flying until it has developed adequate structural integrity.

Three months — audiological review

A formal hearing test is performed to document the post-operative hearing result and compare with the pre-operative audiogram. Where the eardrum has healed and the middle ear is healthy, hearing typically improves by 10–20 dB for a perforation of moderate size. Patients with longstanding perforations or history of recurrent infections may have some degree of permanent sensorineural or ossicular hearing loss that will not be corrected by eardrum closure alone.

Risks and Complications

Myringoplasty is a well-tolerated procedure with a low complication rate in experienced hands. Patients should nonetheless be aware of the following:

Graft failure: In approximately 10–15% of cases the graft does not fully integrate, leaving the perforation partially or completely open. This most commonly occurs when the ear is not completely dry at surgery, Eustachian tube function is poor, or in revision procedures. Further surgery using a cartilage graft may be offered.
Hearing unchanged or worse: Most patients experience hearing improvement. Permanent hearing loss directly caused by the surgery is very uncommon — less than 1% — but should not be confused with failure of the graft to improve hearing, which is a different outcome and more common.
Profound deafness in the operated ear: Extremely rare — less than 1 in 1,000 procedures — but possible from inner ear disturbance during surgery.
Tinnitus: New or changed tinnitus may occur post-operatively, usually temporary. It is common in the weeks after surgery while packing is in place.
Taste disturbance: The chorda tympani nerve — a branch of the facial nerve carrying taste from the anterior two-thirds of the tongue — passes through the middle ear beneath the eardrum and may be stretched or divided during surgery. This causes altered taste (usually metallic or reduced taste) on the same side of the tongue, affecting approximately 10–15% of patients. In most cases it resolves within six to twelve months. Permanent taste loss is uncommon.
Facial nerve weakness: The facial nerve passes through the temporal bone close to the middle ear. Injury producing facial weakness is very rare (less than 1 in 1,000) but is a serious complication that may require further surgery.
Canal stenosis: Scarring in the ear canal may narrow it, requiring further treatment.
Cholesteatoma: Migration of skin beneath the graft at the time of surgery can in rare cases produce a post-operative cholesteatoma, identified at surveillance follow-up.
General anaesthetic risks: Discussed with the anaesthetist pre-operatively.

Download the myringoplasty patient information handout (PDF) →

Dr Jason Roth | MBBS, FRACS (ORL-HNS) | MED0001185485
Specialist Otolaryngologist & Head and Neck Surgeon
Specialist registration — Otorhinolaryngology, Head & Neck Surgery
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