Tympanoplasty is necessary if defects in the eardrum, cicatricial cords in the middle ear or interruptions in the ossicular chain lead to conductive hearing loss.

According to Wullstein , there are a total of 5 different types (tympanoplasty types I to V), whereby only type I to type III are relevant in everyday clinical practice.

Type I tympanoplasty or "myringoplasty" is performed when the ossicular chain is intact and only holes in the eardrum need to be closed or cicatricial cords removed.

The skin of the ear canal is incised and folded to the side together with the eardrum. You then have a good view of the middle ear and the ossicular chain through the ear canal under the microscope. Once the edges of the perforation have been smoothed, the eardrum defect is lined with muscle or cartilage (skin) and then folded back again. A tamponade in the ear canal protects the ear and remains in place for 2-3 weeks.

A type II tympanoplasty according to Wullstein is only rarely performed. As part of this procedure, the connection between the incus and stapes (stapedoincudial joint) is reinforced or reconstructed.

However, it is much more common for us to carry out the replacement of arroded ossicles(type III tympanoplasty). Depending on the extent of the destruction of the middle ear structures, a total(TORP) or partial(PORP) reconstruction of the ossicles is carried out using titanium prostheses or a remodelled anvil body.

• Ossicular replacement with autologous (body's own) anvil
• Ossicular replacement with a titanium prosthesis

Experienced ear surgeons have a broad portfolio of prostheses from market-leading manufacturers available to them intraoperatively at our clinic. However, titanium prostheses are now used almost exclusively, as they have the best sound transmission properties according to current studies.

All the procedures described can be carried out under local anaesthetic, but are usually performed under general anaesthetic in our clinic.

The other types according to Wullstein are no longer clinically relevant and are only listed here for the sake of completeness: In type IV, only a small flat tympanic membrane without ossicles is reconstructed. Type V involves the formation of a new inner ear window.

Cholesteatoma" is a chronic bone suppuration of the middle ear in which the cornea accumulates in a pocket in the middle ear and leads to chronic inflammation, which can destroy the middle ear and neighbouring structures (inner ear, facial nerve, base of the skull) and cause serious inflammation (meningitis, (brain) abscesses) and even thrombosis.

Inspection of the ear reveals either scaly "masses" or defects on the eardrum roof, a foul-smelling secretion or simply a protrusion of the eardrum.

The treatment of this disease is always surgical. The aim of these sanitising ear operations is to completely remove the cholesteatoma matrix. Depending on the extent of the findings, the procedure can be performed via the auditory canal or via an incision behind the eardrum.

Similar to tympanoplasty (see above), the eardrum is folded to the side and the middle ear inspected when accessing via the ear canal. The cholesteatoma is then removed completely if possible. Other affected ossicles and parts of the eardrum may also need to be resected. If parts of the posterior auditory canal wall are also drilled away for a better overview, a large cavity remains in the direction of the petrous bone (bone behind the ear), which is in contact with the auditory canal. In addition to removing the cholesteatoma and reconstructing the eardrum, the posterior auditory canal wall is therefore usually also reconstructed using pieces of cartilage (skin)(canal wall up technique). In some cases (e.g. repeat procedures or large choledochal steatomas) it may be necessary to dispense with the reconstruction of the auditory canal(canal wall down technique, creation of a radical cavity). In this case, a large cavity remains, which can later be viewed via the auditory canal and facilitates the early detection of recurrent choledochal steatomas. A major disadvantage of this procedure is that the patient has to visit the ENT specialist regularly for ear cleaning and is no longer allowed to swim or dive.

In the case of very extensive cholesteatomas, an incision is sometimes (additionally) made behind the pinna. The bone behind the ear is then drilled out until the cholestatoma masses are encountered. The advantage of this approach is a better overview and control of possible further cholesteatoma pockets.

Irrespective of the access route, the required hearing improvement is often only achieved after 10-12 months as part of a further surgical procedure, which also serves to rule out the possibility of renewed cholesteatoma growth(second look surgery).
This procedure is also performed almost exclusively under general anaesthetic. After the operation, a tamponade remains in the ear canal for 2-3 weeks.

Some patients complain of acute rotary vertigo at the same time as a sudden loss of hearing .

If the ENT examination and the diagnostics performed reveal a functional disorder of the vestibular organ on the affected side in addition to the hearing loss, the middle ear is opened via the auditory canal. The round window membrane is then located and examined for a membrane defect. After sealing with connective tissue, the eardrum is folded back again and the auditory canal is tamponaded. The tamponade remains in the ear canal for approx. 2 weeks.

The aim of the operation is to prevent the leakage of inner ear fluid via the round window membrane defect and thus to eliminate the deficient supply of inner ear cells that causes hearing loss and vertigo.
Due to the short duration of the operation and the good local anaesthetic options, the procedure is usually performed on an awake patient under local anaesthetic.