Incisions in tympanoplasty: anatomic considerations and indications

The endaural, postauricular and transmeatal incisions are the most commonly used surgical approaches for tympanoplasty. Each incision used in tympanoplasty has its own advantages and limitations so that no single approach is the best approach for all tympanic membrane perforations. The incision selected for tympanoplasty should be determined by the location and extent of disease. Forty adult temporal bones were studied to understand the limiting factors for each surgical approach used in tympanoplasty. The external endaural incision has been modified to permit easier visualization of the crescentic endomeatal canal incisions. The anterior external endaural incision allows direct exposure of temporalis fascia, the external meatus, bony canal and perforation involving the posterior tympanic membrane and ossicular chain. The postauricular incision gives direct exposure of the anterior tympanic membrane with preservation of the anterior canal wall skin. The transmeatal approach should be reserved for smaller central perforations with limited risk for squamous ingrowth into the middle ear. In the transmeatal tympanoplasty, the ear canal should permit the use of a speculum large enough to expose the entire perforation.