How is a Hole in the Eardrum Repaired?

After a decision has been made to repair a hole in the eardrum (also known as tympanic membrane perforation), it is not uncommon for patients to get confused among the different surgical techniques used to fix it.

There are 3 major "flavors" of eardrum hole repair. 

• Paper patch: Paper patch technique involves putting a thin membrane (film paper, gelfoam, etc) OVER the eardrum hole.
• Medial or Underlay Tympanoplasty: In the underlay technique (also known as medial tympanoplasty), patient's own tissue (temporalis fascia) is used as a graft to reconstruct the eardrum by laying it UNDER the eardrum and ear canal wall skin.
• Lateral or Overlay Tympanoplasty: In the overlay technique (also known as lateral tympanoplasty), patient's own tissue (temporalis fascia) is used as a graft to reconstruct the eardrum by laying it OVER the eardrum extending from placement UNDER the ear canal wall skin.

Technically, the paper patch is easiest to perform and the overlay tympanoplasty the most technically difficult to perform.

SO... here's what a normal ear looks like (image modified from Wikipedia):

Here's a hole in the eardrum:

Paper patch technique (graft shown as a purple strip). Note the paper patch is laying OVER the ear canal skin and eardrum.

Medial or Underlay Tympanoplasty: Note the graft is laying UNDER the ear canal skin and eardrum.

Lateral or Overlay Tympanoplasty: Note the graft is laying UNDER the ear canal skin and OVER the eardrum.

Read more about eardrum holes and how they are corrected here.

Patulous Eustachian Tube Video

In perhaps one of the most flagrant cases of patulous eustachian tube I've ever seen, the New England Journal of Medicine published a video showing the eardrum moving with respiration.

Normally, the eustachian tube (which extends from the back of the nose to the ear) is closed unless one pops the ears (like when flying in an airplane). As such, one does not normally see the eardrum moving to and fro with breathing.

Symptoms this poor patient with patulous eustachian tube may exhibit include hearing one's own breathing inside the ear as well as autophonia (hearing yourself talk in the ear). Symptoms improve transiently when the head is placed in a dependent position (head between the knees).

Treatment is very difficult. Some medical treatments that can be tried that often is ineffective include placement of ear tubes, SSKI (super-saturated potassium iodide), premarin drops, and reserpine. Perhaps the best treatment I've seen for Patulous Eustachian Tube is that provided by Dr. Dennis Poe at Massachusetts Eye and Ear Infirmary in Boston, MA. He performs a minimally invasive endoscopic insertion of a tiny catheter into the eustachian tube. The catheter is just the right size that one can still pop ears easily to prevent eustachian tube dysfunction, but large enough so that one does not suffer the symptoms of patulous eustachian tube.

The most common problem seen in the clinic regarding the eustachian tube is actually the complete OPPOSITE problem of patulous eustachian tube. It is eustachian tube dysfunction or the "clogged" ears whereby the ear feels full of pressure and one just is not able to pop the ears to release the pressure. In this situation, the eustachian tube stays closed, even when trying to pop the ears.

Check out the video below or here illustrating the problem with patulous eustachian tube.