Chronic Ear Surgery: Tympanoplasty, Tympanic Membrane Reconstruction, and the Surgical Treatment of Chronic Ear Disease
Chronic Ear Surgery: Tympanoplasty, Tympanic Membrane Reconstruction, and the Surgical Treatment of Chronic Ear Disease
If you have experienced one or more failed ear surgeries, this article on chronic ear surgery was written for you.
Introduction
At AF Medico Belgrade in Belgrade, Serbia, Prof. Dr. Andrew J. Fishman — internationally recognized specialist in otology, neurotology, and cranial base surgery — provides advanced chronic ear surgery: tympanoplasty, tympanic membrane reconstruction, and the surgical treatment of chronic ear disease. Many patients who consult with Prof. Dr. Fishman have already undergone one or more ear procedures elsewhere, only to return to the same problems: persistent discharge, recurring infection, an eardrum that failed to heal, or hearing that improved briefly before deteriorating again. They were told the surgery was successful. They were told nothing more could be done. They were told to accept it.
That conclusion is rarely accurate.
In the overwhelming majority of revision cases — even following multiple prior failed procedures — meaningful improvement may be achievable. A dry, stable, infection-free ear is a realistic surgical goal for appropriate candidates. Tympanic membrane reconstruction, even in patients with complete loss of the original eardrum, is possible using advanced techniques. In many cases, improved hearing through middle ear reconstruction or modern hearing implant options may also be within reach.
Prof. Dr. Fishman evaluates each patient individually. The patients who benefit most from his practice are very often those who arrived most discouraged — and who discovered that their assumption that nothing more could help was incorrect.
What This Page Covers: The Full Scope of Chronic Ear Surgery
This page addresses chronic ear surgery for non-cholesteatoma conditions. Cholesteatoma — the destructive epidermal cyst that can invade the middle ear and mastoid — is addressed in a separate dedicated section of this site.
The conditions covered here include:
Chronic tympanic membrane perforations — large, small, central, marginal, or total
Tympanic membrane reconstruction, including Total Tympanic Membrane Reconstruction (TTMR) for complete eardrum loss
Chronic suppurative otitis media — persistent middle ear infection with ongoing otorrhea
Ossicular chain disruption — discontinuity, erosion, or fixation of the malleus, incus, or stapes
Tympanosclerosis — calcification and fibrosis of the middle ear structures
Chronic mastoiditis and chronic mastoid disease
Adhesive otitis media and retraction pockets
Iatrogenic damage from prior ear surgery
Traumatic perforation or ossicular injury
Conductive and mixed hearing loss arising from any of the above
Hearing implants — bone-anchored hearing aids (BAHA), active middle ear implants, and cochlear implants
Pediatric chronic ear disease, with the specific anatomical and surgical considerations that apply to children
What Makes Prof. Dr. Fishman's Approach Different
1. Inventor of the Total Tympanic Membrane Reconstruction (TTMR) Technique
Standard tympanoplasty techniques produce acceptable results for routine perforations but fail at unacceptably high rates in patients with complete tympanic membrane loss — those with no residual eardrum tissue onto which a graft could be placed, and those who have already undergone multiple failed repairs. This clinical gap motivated the development of a new reconstructive approach.
The result — published in 2005 in Otolaryngology–Head and Neck Surgery as "Total tympanic membrane reconstruction: AlloDerm versus temporalis fascia" and subsequently selected for the Mosby Yearbook of Otolaryngology, Head and Neck Surgery 2006 — is the TTMR technique. The procedure employs an extreme lateral anterior surgical approach with complete removal of the annular ligament, silicone stenting, and split-thickness skin grafting, combined with either autologous temporalis fascia or AlloDerm dermal allograft, depending on the individual clinical situation.
Published outcomes using autologous materials demonstrate closure rates exceeding 97% for complete tympanic membrane loss — a result that older standard techniques cannot consistently achieve. This technique is performed in Prof. Dr. Fishman's operating room every week and is one of the primary reasons patients with the most complex tympanic membrane problems are referred to him from across Europe and internationally.
2. Microsurgical Technique with Continuous Facial Nerve Monitoring
Every chronic ear surgery performed by Prof. Dr. Fishman is conducted under the operating microscope at 10× to 25× magnification, with continuous intraoperative electrophysiological monitoring of the facial nerve. The facial nerve traverses the surgical field of every mastoid and middle ear procedure, separated from the surgeon's instruments by less than one millimeter of bone in many locations. Continuous monitoring — applied by a surgeon who interprets the neurophysiological signals in real time — represents the standard of care in modern chronic ear surgery.
Prof. Dr. Fishman has published and lectured internationally on facial nerve electrophysiology and has served as a consultant in the design and development of nerve monitoring systems used in ear surgery worldwide.
3. Industry Consulting and Surgical Instrument Design Experience
Prof. Dr. Fishman has served as a design and development consultant for surgical drill manufacturers, nerve monitoring companies, middle ear implant manufacturers, and cochlear implant companies. His direct involvement in the design of instruments and devices used in ear and skull base surgery is uncommon among practicing surgeons. For patients, this translates to familiarity with available technology that is not theoretical — it is built into the design of the tools themselves.
4. High Case Volume, Teaching, and Academic Depth
Prof. Dr. Fishman has performed thousands of adult and pediatric ear operations across academic medical centers in the United States and Europe. He has authored chapters in the Encyclopedia of Otolaryngology on tympanic membrane surgery, tympanoplasty, and zone-based analysis of tympanic membrane perforations, and teaches these surgical techniques in international courses.
The butterfly inlay tympanoplasty — a minimally invasive transcanal procedure for selected smaller perforations, performable in the office or operating room setting — is a technique Prof. Dr. Fishman has applied in thousands of patients, both adults and children.
Who May Be a Candidate for Chronic Ear Surgery
Prof. Dr. Fishman evaluates each patient individually. In appropriate candidates, surgical treatment of chronic ear disease may be considered when:
A chronic tympanic membrane perforation has persisted for three months or longer
Recurrent or chronic ear infections have not responded adequately to medical management
There is documented ossicular chain disruption resulting in conductive or mixed hearing loss
A patient has experienced one or more failed prior tympanoplasties with persistent perforation or hearing loss
Tympanosclerosis, retraction pockets, or adhesive otitis media is contributing to hearing impairment
Hearing implant candidacy — BAHA, active middle ear implant, or cochlear implant — has been identified following audiological evaluation
Pediatric patients meet the anatomical and developmental criteria for surgical intervention
The Surgical Procedure: What to Expect
The specific operative approach is determined by the anatomy and pathology of each individual ear. The instruments and techniques available in Prof. Dr. Fishman's operating room include:
High-magnification operating microscope and endoscopes for visualization through narrow surgical corridors
Continuous facial nerve monitoring throughout every procedure
Surgical lasers for precise tissue dissection and ossicular work
Ossicular replacement prostheses (PORPs and TORPs) — fabricated from titanium, hydroxyapatite, and other biocompatible materials
Autograft materials — temporalis fascia, tragal and conchal cartilage, and remodeled autologous ossicles where applicable
Allograft and synthetic materials — AlloDerm dermal allograft, cartilage substitutes, and synthetic graft materials
Silicone sheeting and stenting for middle ear space management during healing
Powered instrumentation including specialized surgical drills, some of which Prof. Dr. Fishman contributed to designing
Hearing implant systems — BAHA, active middle ear implants, and cochlear implants — for patients in whom conventional ossicular reconstruction cannot restore adequate hearing
Recovery: What the Postoperative Course Looks Like
Recovery from tympanoplasty and tympanic membrane reconstruction is generally more comfortable than most patients anticipate. Key recovery milestones in appropriate candidates include:
Return to office work: typically within 1–2 weeks
Hearing during recovery: muffled for the first several weeks as absorbable middle ear packing gradually dissolves
Tympanic membrane healing: typically occurs within 8–12 weeks in successful reconstructions
Final audiological outcome: generally assessable by 3–6 months postoperatively
External incisions: usually placed in a postauricular location or entirely within the ear canal, with minimal visible scarring
Prof. Dr. Fishman emphasizes that recovery quality is largely determined by the planning and execution of the operation itself. A well-planned procedure that fully addresses the underlying pathology typically follows a predictable, uncomplicated postoperative course.
Why Choose Prof. Dr. Andrew J. Fishman at AF Medico Belgrade
Patients travel to Belgrade, Serbia from across Europe and internationally to consult with Prof. Dr. Fishman for complex chronic ear surgery, revision tympanoplasty, tympanic membrane reconstruction, cochlear implant procedures, and skull base surgery — including acoustic neuroma treatment in Serbia and skull base tumor removal.
Key reasons patients choose Prof. Dr. Fishman include:
Inventor and published authority on TTMR — one of the most technically demanding reconstructive procedures in otologic surgery, with published closure rates exceeding 97%
International academic credentials including peer-reviewed publications, textbook chapters, and teaching faculty roles across the United States and Europe
Comprehensive surgical toolkit including full hearing implant expertise — cochlear implants, BAHA, and active middle ear implants
Subspecialty focus in otology, neurotology, and cranial base surgery, encompassing acoustic neuroma treatment and skull base tumor removal in Serbia
Patient-centered consultation with individualized evaluation and transparent discussion of realistic surgical goals
Frequently Asked Questions
Q: I have had two previous failed ear surgeries. Is there any point in seeking further evaluation?
A: In most cases, yes. Prof. Dr. Fishman regularly evaluates and operates on patients who have undergone multiple prior procedures without achieving a stable, dry ear or adequate hearing. The causes of failure in previous surgeries can often be identified through careful examination and imaging, and a revised surgical plan may address those causes directly. Patients in this situation may benefit from a formal consultation before concluding that nothing further can be done.
Q: What is the difference between tympanoplasty and the TTMR technique?
A: Tympanoplasty is the general surgical category for eardrum reconstruction. Standard tympanoplasty techniques are appropriate for most perforations where some residual tympanic membrane tissue remains. The Total Tympanic Membrane Reconstruction (TTMR) technique — developed and published by Prof. Dr. Fishman — is specifically designed for patients with complete or near-complete loss of the eardrum, in whom standard grafting approaches have historically shown high failure rates. TTMR employs a distinct surgical approach, silicone stenting, and precise graft selection to achieve reconstruction even in the most anatomically challenging cases.
Q: How long does chronic ear surgery take, and will I need general anesthesia?
A: Operative duration varies based on case complexity — ranging from approximately 1–2 hours for a straightforward tympanoplasty to 3–5 hours or more for complex revision surgery with ossicular reconstruction. Most chronic ear procedures are performed under general anesthesia, although selected minor procedures may be appropriate under local anesthesia with sedation. Prof. Dr. Fishman discusses the planned anesthetic approach during the preoperative consultation.
Q: What questions should I ask before undergoing chronic ear surgery?
A: Prof. Dr. Fishman recommends asking any prospective surgeon the following:
What specifically is the diagnosis, and what is the surgical plan to address it?
Will the procedure be performed under the operating microscope with continuous facial nerve monitoring?
If my eardrum is significantly damaged or completely absent, which reconstructive technique will be used — and what is the surgeon's personal experience and outcome data with that technique?
If I have had prior failed surgery, what is the plan to address the reason the previous operation did not succeed?
What is the contingency plan if intraoperative findings are more extensive than anticipated?
A surgeon who answers these questions specifically — based on your individual examination and imaging — is the surgeon best positioned to help you.
Q: Does Prof. Dr. Fishman treat patients traveling from outside Serbia?
A: Yes. Prof. Dr. Fishman and the team at AF Medico Belgrade regularly coordinate care for patients traveling from across Europe and internationally. Initial consultations may be arranged with preoperative imaging and audiological records submitted in advance, allowing Prof. Dr. Fishman to provide a meaningful preliminary assessment before your arrival in Belgrade, Serbia.
Book a Consultation at AF Medico Belgrade
If you are living with chronic ear disease, a persistent tympanic membrane perforation, a failed prior tympanoplasty, or significant hearing loss — and you have been told that nothing more can be done — a consultation with Prof. Dr. Andrew J. Fishman at AF Medico Belgrade may provide the expert, individualized evaluation you have not yet received.
Prof. Dr. Fishman evaluates each patient individually and provides a clear, honest assessment of what surgical options may be available, what the realistic goals of treatment are, and what recovery is likely to involve.
Visit: www.andrewfishmanmd.com
Location: AF Medico Beograd, Belgrade, Serbia
Schedule your consultation today and take the first step toward a comprehensive expert evaluation of your ear condition.
