My daughter has had two unsuccessful tympanoplasties. What causes this to happen? And how many times should I allow the doctor to do this surgery before it is time to give up? She does have hearing loss in her left ear.

M.G.

Tympanoplasty is an operation in which the surgeon repairs a hole in the eardrum. There are a few different techniques for this operation, but the success/failure rates are similar for the various techniques. For an uninfected ear, the chance of failure is about 10 to 15 percent; for an infected ear, it can be as high as 30 percent. Assuming that the surgeon is using the technique with which he/she is most experienced (and not "trying out a new technique"), the most important factor for success is the presence or absence of infection.

The decision to proceed with tympanoplasty in an infected ear is difficult. (How would you know if the ear was infected? The usual symptoms are drainage of pus, pain, itching and worsened hearing.) Every effort should be made to clear the infection before tympanoplasty. Unfortunately, some ears improve only after tympanoplasty. Thus, the surgeon may reluctantly proceed with tympanoplasty in an infected ear, hoping that the operation will solve a problem that has not responded to a variety of oral and topical antibiotics.

In some cases, tympanoplasty may not be sufficient to solve the problem. Some chronically infected ears require a combination tympanoplasty and mastoidectomy. In this operation, infected tissue in the bone behind the external ear (the mastoid bone) is removed; the infected tissue is literally drilled out of the bone.

What if your daughter's ear was not infected? Should two failures suggest that something is amiss with her surgeon's technical skills? Not necessarily. As I mentioned above, even in the best of circumstances, the probability for failure is 10 to 15 percent. So the question really is this: What are the odds that your daughter's operation would fail twice due to chance alone?

In a purely theoretical world (not the one WE live in), the odds would be multiplied. The probability of two failed operations would be (1 in 10) times (1 in 10), or 1 in 100. However, this assumes that failure is due to chance alone. If failure is NOT due to chance -- if something else is "setting your daughter up" for failure -- then the odds would be much higher than 1 in 100.

Her surgeon's technical ability may be at fault, but the problem could also lie with your daughter. (For example, some individuals have problems with wound healing.) You would be within your rights to ask her surgeon about his or her success rate for this operation; most surgeons would not be offended by this question. If the quoted success rate does not differ significantly from the ones I have quoted, then the failures may have more to do with your daughter's tissues than with her surgeon's abilities.

Ultimately, I think this question must be decided with your heart, not your head. Speak frankly with the surgeon about the two failures. After this discussion, ask yourself: Do I feel comfortable with this doctor? Does this doctor really care about my daughter? If you find yourself having fundamental doubts about her ear, nose and throat specialist, it's time to seek out a second opinion.