A myringoplasty is the operation to repair a hole in the eardrum. When more extensive work on the middle ear is needed, for example to repair or rebuild the small hearing bones, the operation is called a tympanoplasty. The two terms often get used interchangeably, but the basic principle is the same: a graft is used to patch the hole and restore an intact eardrum.

If you have not already read it, my Hole in the Eardrum page covers why a hole happens, how it affects the ear, and the situations in which surgery is and is not needed. This page focuses on the operation itself: how it is done, what to expect afterwards, and what the risks and benefits are.

I have performed a large number of these operations over the course of my NHS and private practice. I am happy to talk through the operation in detail in clinic, including showing you what your ear looks like, before you decide whether surgery is the right choice for you.

Why is the operation done?

The two main reasons to repair a hole in the eardrum are:

• To stop the ear getting repeatedly infected

• To give you a waterproof ear, so that you no longer have to keep doing water precautions every time you shower, wash your hair, or swim

A successful repair restores the eardrum's natural barrier between the outside world and the middle ear, which means water and bacteria can no longer get in. This is the main aim of the operation.

What about my hearing?

This is one of the most important points to understand before going ahead with surgery, and one I always discuss carefully with patients in clinic.

A hole in the eardrum often causes some hearing loss, but repairing the hole does not reliably improve the hearing. How much (if any) hearing benefit you get depends on the size of the hole, where it is positioned on the eardrum, and whether the hearing bones behind the eardrum are working normally. Some patients notice a clear improvement, some notice little or no change, and a small number can end up with hearing that is slightly worse than before.

Even when the hearing test does show an improvement, you may not actually perceive it day-to-day. This is particularly true if there is still a difference between your two ears. Your better ear can mask the change in the operated ear, so the gain you might see on paper may not feel obvious in real life.

For these reasons, I am always upfront with patients that the main aim of the operation is to give you a safer, drier, more reliable ear, not to chase a hearing gain. If hearing improves, that is a welcome bonus, but it is not what we are operating for.

How is the operation done?

The operation is usually performed under general anaesthetic (you are fully asleep) and is normally a day-case procedure, meaning you go home the same day.

My overriding aim during the operation is straightforward: to leave you with a fully closed eardrum at the end. Everything else, including the choice of approach, the choice of graft, and how the eardrum is reached, is in service of that goal. I always try to do this in the most minimally invasive way possible, but if better access is needed to give the best chance of closing the hole completely, then that is what is done.

In practice, the eardrum can be reached in two ways:

• Down the ear canal. Most of my patients do not need a cut behind the ear. I work through the natural opening of the ear canal, often using a high-definition endoscope (a small telescope) for a clear, magnified view, with the operating microscope used in addition if needed. This approach avoids any visible scar.

• Through a cut behind the ear. For some holes, particularly those that are very large or in a difficult position, better access is needed to be confident the repair will work. In that case a small cut is made in the natural skin crease just behind the ear. The scar settles well and is usually almost invisible once it has healed.

Once the edges of the hole have been freshened, a graft is laid against the eardrum to patch it. The graft heals into place over the following weeks and becomes part of the new eardrum.

What is the graft made of?

The graft is taken from your own body during the operation, so there is nothing artificial that your body needs to accept. The most common options are:

• Tragal cartilage and perichondrium, taken from the tragus, the small cartilage flap at the front of the ear. This is what I most often use. It is sturdy and durable, and gives very good long-term results. Taking the graft leaves a small cut on the inner side of the tragus, which is closed with dissolvable stitches that do not need to be removed. The tragus itself heals up well and the scar is almost always hidden, though you may be able to feel the stitches for a week or two while they dissolve. Try not to touch or pick at the area while it is healing.

• Temporalis fascia, a thin, tough layer of tissue from above the ear, beneath the skin. This has been the traditional graft material for many years and is still used in certain cases.

• Biodesign, a sterile, processed graft material that can be used in some situations, particularly when extra material is needed or natural tissue is not suitable.

I will discuss with you which graft is most likely to be needed before the operation. In some cases a combination of materials is used, for example cartilage with a layer of fascia. The final choice is sometimes only made during surgery itself, once I can see exactly what the eardrum looks like and what is going to give the best, most durable repair. The principle is always the same: use whatever is needed to give the eardrum the best chance of healing fully and staying healed.

What are the risks of the operation?

Myringoplasty is generally a safe operation, but no surgery is risk-free. I always discuss the main risks with patients before they make a decision so that they can weigh things up properly. They are:

• The graft not taking, leaving a residual hole. Overall, the operation is successful in the large majority of cases, but a small residual hole remains in a minority. This is the most common reason an operation is repeated.

• Re-perforation. Uncommon. Sometimes the eardrum heals fully then a hole reopens later, particularly after a subsequent ear infection (see "Does the operation always work?" below).

• Infection of the operated ear in the early weeks. Uncommon if water precautions are followed and any prescribed ear drops are used as instructed.

• A change in hearing. Most patients have either no change or a small improvement once the eardrum has fully healed. Uncommonly, the hearing on the operated side can end up slightly worse than before. A significant or permanent hearing loss is rare.

• Tinnitus. New or louder ringing, buzzing, or humming in the ear is fairly common in the first few weeks and usually settles as the ear heals. Persistent new tinnitus is uncommon.

• Dizziness or unsteadiness. Common in the first few hours to days and usually settles quickly. Persistent dizziness is uncommon.

• Altered or metallic taste on one side of the tongue. This is caused by handling of the chorda tympani, a small taste nerve that runs across the middle ear. Some change in taste in the early weeks is fairly common, but is usually temporary and recovers as the nerve settles. In patients who have had many years of ear infections, the chorda tympani may already not be working well, in which case you may not notice any taste change at all, even if the nerve is affected during surgery.

• Facial weakness. The facial nerve runs through the middle ear, so there is a small risk of injury during surgery. If facial weakness does occur, it is usually temporary and recovers over weeks to months. Very rarely, it can be permanent. To minimise this risk, a facial nerve monitor is used throughout every operation, which alerts me immediately if the nerve is being approached. With this in place, long-term facial nerve damage is extremely rare.

• A small scar on the inner side of the tragus if cartilage is taken from there, and behind the ear if that approach is used. Both heal well and are almost always hidden once settled.

• General anaesthetic risks. These are generally low in fit, healthy adults and will be discussed with you separately by the anaesthetist.

I will go through these risks in detail with you in clinic before the operation, and you will have the chance to ask any questions before signing the consent form.

Does the operation always work?

In the majority of cases, the operation is successful and gives a fully healed, intact eardrum. However, no surgery is guaranteed. There are two main ways the operation can fall short:

• The graft does not fully take in the first place, and a small residual hole remains. This is sometimes manageable with conservative measures, and sometimes a further operation is considered.

• The eardrum heals well initially but a hole reopens later, usually following an ear infection or, in some cases, where Eustachian tube function remains poor. This is called a re-perforation.

Several factors can reduce the chance of a fully successful repair, and these are worth being aware of when weighing up the operation:

• A very large hole. Bigger holes are technically harder to close and have lower success rates than small ones.

• A long-standing hole. The longer the eardrum has been perforated, the less reliably it heals.

• Revision surgery. If a previous repair has not worked, the success rate of a second attempt is lower than for a first operation, although it is still often worthwhile.

• Poor Eustachian tube function. An ear that cannot ventilate well is at higher risk of the graft failing or re-perforating later.

If a repeat operation is needed, it can usually be done, and I will discuss with you what your options are if this happens.

When is the best time to do the operation?

Ideally, I prefer to operate on an ear that is dry and free of infection, as this gives the graft the best possible chance of taking. Where possible, I will treat any active infection first with ear drops, microsuction, and sometimes oral antibiotics, and aim to operate once the ear has settled.

However, some patients have a chronically discharging ear that simply will not stay dry no matter what we do. In that situation, waiting indefinitely for a perfectly dry ear is not always realistic, and we sometimes have to make a pragmatic decision to go ahead with surgery despite some discharge. The reasoning is that a successful repair, even when started on a less-than-perfect ear, is often what finally breaks the cycle of infection. I will talk this through with you if it applies to your situation.

What is the packing in my ear?

To support the graft while it heals, the middle ear and ear canal are filled with a soft, dissolvable packing material called Spongostan. This is a gelatin sponge that gradually breaks down on its own over a number of weeks.

Because the ear canal is filled with packing, your ear will feel completely blocked after the operation, and your hearing on that side will be muffled. Sometimes patients describe it as feeling like the ear is full of water or wax. This is entirely expected and is not a sign that anything has gone wrong. Hearing improves once the packing has dissolved or been removed.

It is also normal for some of the packing to work its way out of the ear canal on its own over the first few weeks, often mixed with a little blood-stained fluid. This can look alarming but it is not. There is plenty more packing still inside doing its job. Just gently wipe away anything that comes onto the outside of the ear with a clean tissue, and do not try to clean further inside.

What stitches do I have, and do they need to be removed?

Everything used during the operation is dissolvable, so no stitch removal is required. If a cut has been made behind the ear, it is closed with stitches under the skin that dissolve on their own, and the outside is usually covered with thin sticky paper strips that can be peeled off after about a week.

What might I notice after the operation?

It is common to experience some or all of the following in the first few days or weeks. Most settle quickly:

• A blocked, full feeling in the ear and muffled hearing, caused by the packing

• New or louder noises in the ear (ringing, buzzing, humming, squelching), usually settles

• Mild dizziness or unsteadiness, particularly with sudden movements

• A metallic taste, or altered taste on one side of the tongue, caused by handling of a small taste nerve (the chorda tympani) that runs across the middle ear

• Some blood-stained ooze from the ear in the first few days

• Occasional sharp shooting pains, usually settled with simple painkillers

• A few small pin-prick marks and sometimes a little bruising on the face. These are from the facial nerve monitor electrodes used during the operation (see the risks section above). They settle quickly, usually within a few days.

Most of these settle within a few days to a couple of weeks. Occasionally some symptoms, particularly tinnitus and altered taste, can persist for longer.

Looking after the ear at home

The most important rule is the same one I emphasise to patients with an unrepaired hole: keep the ear clean and dry.

• Keep the ear canal dry at all times. When you shower, place a fresh ball of cotton wool smeared with Vaseline in the outer ear before getting wet, then throw it away afterwards.

• Wearing a small dry cotton wool plug in the outer ear during the day is optional. Some patients find it comforting; others prefer not to bother. If you do use one, change it for a fresh one if it gets damp, and always take it out before putting any ear drops in.

• Wash your hands thoroughly before touching the ear, changing the cotton wool, or putting drops in. This is the simplest and most important way to avoid carrying bacteria to a vulnerable ear.

• Try to avoid touching, rubbing, or poking the ear in general. If you have had a tragal cartilage graft, this includes the small area at the front of the ear where the cartilage was taken.

• Do not poke or clean inside the ear. The packing must be left undisturbed.

• If you have been given antibiotic ear drops, apply them as instructed. Usually two to three drops twice a day onto the dressing, while lying with the operated ear facing up. Do not push them in deeply.

• Avoid blowing your nose hard. If you need to sneeze, do so with your mouth open to reduce the pressure transmitted up to the ear.

• Avoid heavy lifting, strenuous exercise, and contact sports for at least two to three weeks.

• When sleeping in the first week or two, it is a good idea to lay a towel over your pillow on the operated side. There is often a little blood-stained discharge from the ear in the early days, particularly overnight, and this saves your bedding.

• Do not get the cut behind the ear wet for the first seven days if you have one. After that, the paper strips can be removed and the area gently washed and dried.

If your operation involved repair or replacement of the small hearing bones (an ossiculoplasty), I will give you additional advice, usually to avoid any vigorous head movements for around four weeks.

Can I wash my hair?

Hair washing in the first three weeks needs a little planning, because both the ear canal and (if you have one) the cut behind the ear need to be kept dry until your follow-up appointment. A few approaches that work well:

• Wash your hair leaning back over a sink, like at a hairdresser's, so water runs away from the ear rather than into it.

• Use dry shampoo in between proper washes. Many patients find this is the simplest solution for the first couple of weeks.

• If you do prefer to shower and wash your hair normally, place a fresh ball of cotton wool smeared with Vaseline in the outer ear first, and try to avoid letting water run directly over the ear.

The skin behind the ear, if you have a cut there, should be kept completely dry for the first seven days. After that, once the paper strips have come off, you can gently wash and dry the area. The ear canal still needs to be kept dry until the packing has been removed at your three-week appointment.

When should I call for advice?

Most patients have a smooth recovery, but please contact my secretary or the hospital straight away if you notice any of the following:

• Weakness or drooping on one side of your face

• A high temperature or fever

• Severe spinning dizziness

• Increasing pain in or around the ear

• Increasing or smelly discharge from the ear

These can all be dealt with, but they need prompt assessment.

When can I go back to normal activities?

• Driving and operating machinery. Avoid for at least 48 hours after a general anaesthetic. Your insurance may not cover you within that time.

• Work. Two weeks off is usually enough for most jobs. Heavier or more physical jobs may need longer.

• Flying. I would generally avoid flying for around six weeks after the operation, to give the eardrum and middle ear plenty of time to settle before being exposed to the pressure changes of a flight.

• Swimming. Most ears have healed enough to allow swimming by around three months, but this varies and I will advise you specifically at your follow-up appointments.

• Scuba diving. This is a separate question and is covered on the Hole in the Eardrum page. A repaired eardrum is not the same as a native one, and return to diving is not guaranteed and requires formal fitness-to-dive assessment.

What follow-up appointments will I need?

• At around three weeks. I will see you in clinic to remove any remaining packing from the ear canal and check the eardrum is healing. By this stage much of the Spongostan will have already dissolved on its own, but anything left over is gently removed under the microscope.

• At around three months. I will see you again to confirm the eardrum has fully healed, and a hearing test is done at this visit so we can see exactly how the ear is working.

Further appointments may occasionally be needed if healing is slower than expected.

What about surgery in children?

I am cautious about operating on a hole in the eardrum in younger children, and I generally try not to rush into it.

The reason is that a successful eardrum repair depends on the middle ear being able to ventilate well, which depends on the Eustachian tube. In young children, the Eustachian tube is still developing and is more horizontal than in adults, which is one of the main reasons children get so many ear infections in the first place. Operating on an ear that cannot yet ventilate properly carries a higher risk of the graft failing or the hole reopening.

For most children, waiting until the ear has matured a little further, often into later childhood or early adolescence, gives the best chance of a long-lasting repair. In the meantime, the ear can usually be managed with good water precautions and prompt treatment of any infections.

That said, the decision is always individual. If a child is suffering with severe and recurrent infections that are not controlled despite all the usual precautions and medical treatment, then the balance can tip in favour of operating sooner. We weigh this up carefully together as parents and clinicians.

When should you come and see me?

Come and see me if:

• You have a hole in the eardrum and want to discuss whether surgery is the right next step

• You have already been told you need an operation and want a second opinion or a clearer explanation

• You are getting repeated ear infections and want to understand all your options

• You simply want to know more about what the operation involves before deciding

I will examine your ear under the microscope, arrange a hearing test, and talk through everything so you can make an informed decision.

Helpful resources

• NHS: Perforated Eardrum

• ENT UK: Hole in the Eardrum & Myringoplasty

Disclaimer

This page is intended as general information only. It does not replace a consultation, examination, or individual medical advice. If you are considering surgery to repair a hole in the eardrum, please get in touch to book an appointment so I can examine your ear properly and give you advice specific to your situation.