Correct Answer: A. Tympanoplasty
Tympanoplasty is the gold-standard surgical procedure for reconstruction of a perforated or completely absent tympanic membrane. In this case, the complete absence of the tympanic membrane (total perforation) with recurrent ear discharge indicates chronic suppurative otitis media (CSOM) with unsafe disease. The primary goal of tympanoplasty is to restore the integrity of the tympanic membrane, thereby preventing water and bacteria from entering the middle ear and mastoid, thus controlling the recurrent discharge. The procedure involves grafting autologous tissue (typically temporalis fascia or cartilage) to reconstruct the membrane. This restores the normal sound transmission mechanism and provides a barrier against infection. In Indian clinical practice, tympanoplasty is the first-line surgical intervention for CSOM with total perforation before considering more extensive procedures. The success rate is high (85–95%), and it addresses the root cause of recurrent discharge by reestablishing the protective barrier of the middle ear.
Why the other options are wrong
B. Radical mastoidectomy — Radical mastoidectomy is reserved for extensive mastoid disease with severe bone erosion or when tympanoplasty has failed. It is an ablative procedure that sacrifices middle ear function and is not indicated as first-line treatment for simple tympanic membrane perforation. This is a trap for students who confuse extensive mastoid disease with simple membrane perforation. C. Ossiculoplasty — Ossiculoplasty is performed to reconstruct damaged ossicles (malleus, incus, stapes) to restore hearing. However, the question does not mention ossicular damage or conductive hearing loss as the primary problem. The primary issue is the absent tympanic membrane causing recurrent discharge, not ossicular pathology. Ossiculoplasty is typically combined with tympanoplasty only when ossicular damage is confirmed. D. Myringoplasty — Myringoplasty is a minor procedure used for small perforations (typically <50% of membrane) without significant discharge or ossicular involvement. It is less robust than tympanoplasty and has lower success rates for large or total perforations. In this case of complete absence of the tympanic membrane with recurrent discharge, the more definitive tympanoplasty is indicated rather than the limited myringoplasty approach.
High-Yield Facts
- Tympanoplasty is the gold standard for reconstruction of perforated or absent tympanic membrane in CSOM.
- Complete tympanic membrane perforation with recurrent discharge indicates unsafe CSOM requiring surgical intervention.
- Temporalis fascia is the most commonly used graft material in Indian ENT practice for tympanoplasty.
- Success rate of tympanoplasty ranges from 85–95% in uncomplicated cases.
- Myringoplasty is limited to small perforations (<50%); total perforation requires tympanoplasty.
- Radical mastoidectomy is reserved for extensive mastoid disease or failed tympanoplasty, not first-line treatment.
Mnemonics
TYMPANO for Total membrane loss Tympanoplasty for Total perforation; Myringoplasty for Minor holes; Radical for Resistant/extensive disease. Use this when deciding between membrane repair procedures. CSOM Surgery Ladder Clean perforation → Myringoplasty; Complete perforation → Tympanoplasty; Complicated/failed → Radical mastoidectomy. Escalate only if lower rung fails.
NBE Trap
NBE pairs "complete absence of tympanic membrane" with "radical mastoidectomy" to trap students who confuse extensive mastoid disease with simple membrane perforation. The key discriminator is that the question specifies recurrent discharge from membrane loss, not mastoid bone erosion—tympanoplasty alone is sufficient.
Clinical Pearl
In Indian outpatient ENT clinics, CSOM with total perforation is one of the most common presentations, especially in children from lower socioeconomic backgrounds with poor water hygiene. Tympanoplasty performed under local anesthesia (endaural or transcanal approach) is the definitive outpatient procedure that stops the discharge and prevents complications like meningitis or lateral semicircular canal fistula.
_Reference: Bailey & Love Ch. 63 (Otology); Park's Textbook of Preventive and Social Medicine (CSOM epidemiology in India)_