Tympanoplasty – Anesthetic Considerations                           

Tympanoplasty is a surgical procedure to repair the tympanic membrane (eardrum) and/or the ossicular chain to restore hearing and prevent recurrent infections. It is commonly performed for chronic otitis media, traumatic perforation, or cholesteatoma.

1. Indications for Tympanoplasty

✅ Chronic Otitis Media (COM) with Perforation

✅ Traumatic Tympanic Membrane Perforation

✅ Ossicular Chain Disruption

✅ Cholesteatoma (with intact ossicles)

✅ Conductive Hearing Loss due to Tympanic Membrane Defects

⚠️ Contraindications:

• Active ear infection (should be treated before surgery).

• Poor Eustachian tube function (increased risk of graft failure).

• Uncontrolled systemic illness.

📝 Grafts used: • Temporalis fascia (most common)• Tragal perichondrium• Vein graft

3. Preoperative Considerations

A. Airway & Anesthetic Concerns

✅ Airway assessment – Anticipate difficult mask ventilation if the patient has craniofacial anomalies.

✅ Check for history of obstructive sleep apnea (OSA), nasal congestion, or chronic sinusitis.

B. Otological & Neurological Assessment

✅ Assess preoperative hearing level (pure tone audiometry).

✅ Facial nerve function assessment (as it runs through the middle ear).

✅ History of vertigo, dizziness, or tinnitus.

C. Investigations

✅ Pure Tone Audiometry (PTA) – To evaluate hearing function.

✅ Impedance Audiometry – To assess middle ear function.

✅ HRCT Temporal Bone – To check for cholesteatoma, ossicular erosion, or mastoid involvement.

D. Preoperative Instructions

✅ Avoid anticoagulants for 1 week (risk of bleeding).

✅ Avoid excessive nasal blowing (can affect graft stability).

✅ Treat any preexisting upper respiratory tract infection before surgery.

4. Anesthetic Management

✅ Preferred technique:

• Intravenous induction with Propofol (2-3 mg/kg) ± Fentanyl (1-2 mcg/kg).

• Endotracheal intubation preferred (Rocuronium 0.6-1 mg/kg or Atracurium 0.5 mg/kg).

• If short-duration surgery, LMA may be used (avoid excessive head movement).

✅ Airway Management Considerations:

• Avoid excessive head rotation (to prevent dislodging ETT or affecting middle ear pressure).

• Nitrous oxide (N₂O) should be avoided (due to its effect on middle ear pressure).

✅ Ventilation Strategy:

• Use low tidal volume and normocapnia to prevent excessive movement of the graft.

✅ Maintenance of Anesthesia:

• Sevoflurane or Desflurane for easy wake-up.

• TIVA (Propofol + Remifentanil) preferred for middle ear microsurgery (provides better operating conditions).

• Minimal opioid use (to avoid PONV).

5. Intraoperative Considerations

✅ Avoid Nitrous Oxide (N₂O):

• N₂O expands middle ear gas, leading to graft displacement.

✅ Blood Pressure Control:

• Mild hypotension (MAP 60-70 mmHg) is preferred to reduce bleeding.

• Avoid sudden BP fluctuations, which may cause venous congestion.

✅ Patient Positioning:

• Supine with head turned to the opposite side.

• Headrest to stabilize neck position.

✅ Facial Nerve Protection:

• Facial nerve monitoring may be required if cholesteatoma is present.

• Avoid deep paralysis if nerve monitoring is used.

✅ Microscopic Surgery Considerations:

• Avoid patient movement (sudden movements can cause surgical injury).

• Ensure absolute stillness during graft placement.

6. Postoperative Care

✅ Immediate Priorities:

• Head elevation (30-45°) to reduce edema.

• Avoid sneezing, straining, or excessive coughing (increases middle ear pressure).

• Monitor for nausea/vomiting (common due to vestibular irritation).

✅ Pain Management:

• IV Paracetamol ± Fentanyl.

• Avoid NSAIDs initially (risk of bleeding).

✅ Ear Care & Precautions:

• Keep the operated ear dry for at least 4 weeks.

• Avoid flying, deep-sea diving, or altitude changes for 6 weeks.

• No nose-blowing for 2 weeks.

✅ Complications to Watch For:

Complication	Cause	Management
Graft Failure	Poor healing, infection	Revision surgery
Facial Nerve Injury	Iatrogenic damage	Steroids ± nerve grafting
Postoperative Bleeding	Vascular injury	Packing, cautery
Dizziness/Vertigo	Inner ear disturbance	Symptomatic treatment
Middle Ear Effusion	Eustachian tube dysfunction	Steroids, antihistamines
Sensorineural Hearing Loss	Inner ear trauma	Audiological rehabilitation

MCQs on Tympanoplasty

1. Which of the following is the most commonly used graft material in tympanoplasty?

A) Fat graft

B) Tragal perichondrium

C) Temporalis fascia

D) Vein graft

✅ Answer: C (Temporalis fascia is the most commonly used).

2. Which of the following anesthetic agents should be avoided in middle ear surgery?

A) Propofol

B) Sevoflurane

C) Nitrous Oxide

D) Remifentanil

✅ Answer: C (N₂O expands middle ear gases, causing graft displacement).

3. Which of the following types of tympanoplasty is performed when the stapes is absent?

A) Type I

B) Type III

C) Type IV

D) Type V

✅ Answer: C (Type IV tympanoplasty involves grafting over a mobile stapes footplate).