Recommendations for tympanoplasty in children

Many parents are concerned that a hole in the eardrum will cause permanent hearing loss. This is almost never the case. In fact, many perforation don’t even cause a temporary hearing loss. The effect a perforation has on hearing depends on the size of the hole and where it is located on the eardrum. Luckily, most perforations are relatively small and in areas that don’t affect the hearing too much.

Even so, large perforations and even some smaller ones can cause a temporary hearing loss. They do not cause complete deafness however. The degree of hearing loss varies and usually returns to normal (or very close to normal) after the perforation is fixed.

Some perforations do not require any special treatment. When an eardrum perforates during a bad ear infection, the infected ear fluid usually drains out through the hole. After a few day, the hole will usually close all by itself. Sometimes the infection lingers for a while and may need additional treatment with medicines or ear drops. After the infection is finally clear, the hole may still close all by itself.

If a perforation has been present for more than 3 months without infection or drainage it is unlikely to close by itself. At this point, your doctor may recommend that you consider having the hole closed surgically. The decision to surgically close a perforation is sometimes a difficult one to make. It depends on a variety of factors including the patient’s age, history of infections, problems with the other ear, and the degree of hearing loss (if any). A pediatric ear, nose, and throat specialist can help you decide if it’s the right time to repair your child’s eardrum perforation.

There are two basic of ways to repair an eardrum perforation. Your ears, nose, and throat (ENT) doctor will discuss which method is best for your child. All types of eardrum repairs are performed by an ENT surgeon in the operating room under general anesthesia. In this day and age, general anesthesia is very safe and your child will be carefully monitored during the procedure.

1. The simplest kind of repair is called a patch myringoplasty [mer-RING-go-plass-tee]. In this procedure, the eardrum perforation is covered with a material which temporarily plugs the hole. This encourages the body’s normal healing processes to close the hole. The material used can be a small piece of paper, a piece of gelatin (our preferred method), or even a small piece of fat taken from the ear lobe. A patch myringoplasty usually takes between 5 and 10 minutes. However, it is only useful for relatively small holes in the center of the eardrum.
2. The more common, and more lengthy, procedure for repairing a hole in the eardrum is called a tympanoplasty [tim-PAN-o-plass-tee]. For tympanoplasty in children, the hole in the eardrum is patched using material that replaces the missing portion of the eardrum. Sometimes this material is cartilage taken from the outer part of the ear (don’t worry, no one will ever know it’s missing) More often, the material used is a connective tissue, called fascia [FASH-ah], removed from underneath the skin behind the ear. This fascia is very similar to the material out of which the normal eardrum is made. During the tympanoplasty, the eardrum is lifted up like a trap door and the material used to repair the hole (called a tympanic membrane graft) is slipped behind the eardrum. Then the eardrum is put back where it started and the hole is patched from behind. The graft material is supported from behind with some packing material which slowly dissolves over the next 2 to 3 months. During this time, the eardrum heals over the graft and resumes a normal appearance. When the packing is all dissolved, the hearing is restored to normal.Sometimes a pediatric tympanoplasty can be performed completely through the ear canal without the need for a large incision in back of the ear (there is often a small incision behind the ear in order to get the fascia graft). However, many children have small ear canals that are difficult the work through. Or sometimes the hole is very large and cannot be completely seen through the ear canal. In these cases, a larger incision is made behind the ear (a postauricular incision) in order to improve the “working space”. Although a larger incision involves more healing and recovery, it improves the success of the operation considerably in these more difficult cases. And best of all, when completely healed, the scar is difficult to see and is hidden from view by the outer ear.

Your child must have a physical examination by his or her pediatrician or family doctor within seven days before surgery to make sure they are in good health. The doctor you see needs to complete the history and physical form provided by our office. You must bring the completed form with you the day of surgery, or fax it prior to the day of surgery.

• For your child’s safety, it is very important that he or she have an empty stomach when anesthesia is given. Please follow our preoperative eating and drinking guidelines. If you do not follow these guidelines, your child’s surgery will be cancelled.

A patch myringoplasty usually takes 10 to 15 minutes. Tympanoplasty in children can take 1 to 2 hours. Your doctor will talk to you as soon as the surgery is over.

Your child will wake up in the recovery room after surgery. This may take 45 minutes to an hour. When your child is awake, they will be taken to the short stay room post operative area to complete the recovery. You can be with your child once he or she has been transferred to this area.

Children can almost always go home the same day of surgery. In rare cases an overnight stay may be necessary (e.g., your child has excessive nausea or vomiting). If your child does stay overnight, one parent is required to stay overnight too.

Your child may have bloody discharge or drainage from the ear canal for a few days after surgery. This is normal and is no cause for alarm.

Ear pain and soreness are also common after surgery. These symptoms should go away during the first 3 to 5 days after surgery. Your doctor may prescribe pain medicine to take home for the first few days after surgery.

You should keep the ear canal clean and dry until you see your doctor after surgery (usually 3 weeks after surgery). During normal activities, keep a clean cotton ball in the ear canal. You can change the cotton as often as needed. You will probably need to change it quite often during the first few days if the ear has bleeding or other drainage.

During baths or showers, coat a cotton ball with ointment (bacitracin, Vaseline®, or triple antibiotic ointment) and place it in the ear canal. The ointment will prevent water from seeping into the ear canal. After bathing, replace the cotton with a fresh, clean, and dry cotton ball.

If your child had a postauricular tympanoplasty the ear was likely bandaged with a gauze dressing and a velcro strap. You may remove the strap and gauze the day after surgery. Keep the back of the ear dry for 3 days after surgery. You can then get the back of the ear wet. Pat the area dry after showers or baths—do not rub. If there are little tapes on the skin (Steri-Strips™) let them fall off on their own. They may even stay in place until you see your doctor for follow-up after surgery.

In most cases, your child may return to his or her regular activities within 1 or 2 days after surgery. There is no need to restrict regular activity after your child feels back to normal. Vigorous exercise (such as swimming and running) should be avoided until you see your doctor after surgery (usually 3 weeks).

If your child complains of pain in the ear you can safely give Tylenol®, Children’s Motrin®, or other pain medicine prescribed by your doctor. If you are not sure what medicines are safe, please call your doctor.

• Dizzyness or persistent vomiting are uncommon after eardrum surgery. Please call our office if your child continues to vomit more than 24 hours after surgery or is having difficulty standing or walking.
• Your child should not go swimming or fly in an airplane until your doctor specifically tells you that is okay to do so.
• If a tympanoplasty surgery was done, your child will not be able to hear normally in the operated ear until the packing behind the eardrum dissolves. Full tympanoplasty surgery recovery time can be 2 to 3 months. In fact, the hearing will probably be worse than it was before surgery until this packing dissolves.
• At the first post-operative visit, your doctor may gently clean the ear canal with a vacuum in order to inspect the reconstructed eardrum. You may be asked to use some antibiotic ear drops for a week or two to treat any postoperative inflammation.
• A hearing test will be done again in 8 to 12 weeks after surgery.

If you have any questions or would like further information specific to your child, please call our office at 612-874-1292.