European Journal of Cardiovascular Medicine

Tympanoplasty is the fundamental surgical procedure for addressing chronic tympanic membrane (TM) perforations, with temporalis fascia being the predominant graft material utilized. Nonetheless, underlay fascia graft tympanoplasty presents challenges for marginal perforations due to insufficient residual tympanic membrane, which may cause the fascia graft to dislodge, leading to reperforation [1]. Overlay tympanoplasty exhibits a high success rate.

The success rate has proven especially beneficial for substantial anterior holes. The main drawbacks of this approach encompass heightened technical requirements for surgery and postoperative attenuation or lateral displacement of the TM graft. Significant disturbance of normal tissue relationships necessary for this technique may result in delayed healing or persistent granular myringitis [2].A range of surgical methodologies has been established to enhance the efficacy of addressing marginal perforations,[3] including sandwich graft tympanoplasty,[4] over-under tympanoplasty, mediolateral graft tympanoplasty, [5]the “windowshade” [6]  technique, “hammock” [7]tympanoplasty,[8] loop underlay tympanoplasty, and anterior interlay myringoplasty. [9]Tympanomeatal flap elevation (TFE) is an essential component of these surgical techniques.The extent of the elevated tympanomeatal flap is contingent upon the site and size of the perforation. Recently, several publications documented endoscopic tympanoplasty without tympanic flap elevation (TFE) for core holes [10, 11] and with restricted TFE for extensive marginal perforations [12–14]. The technical challenges of TFE include the integral detachment of the tympanomeatal flap and the formation of the tunnel, mostly due to the hemorrhagic skin of the external auditory canal (EAC) and the constraints of one-handed operation in endoscopic techniques. Despite the fact that butterfly cartilage myringoplasty typically does not necessitate TFE for the majority of TM perforations, the medial canal wall skin must be lifted to reveal the bony annulus in cases of significant marginal perforations [15, 16]. This study investigated endoscopic cartilage myringoplasty with the excision of a tiny segment of the external auditory canal to rectify marginal perforations. 

Study Design

This was a prospective, interventional study conducted over a period of one year to evaluate the effectiveness of percutaneous endoscopic transcanal cartilage myringoplasty as a minimally invasive, postauricular incision-free treatment for subtotal tympanic membrane perforation (STMP).

Study Population

A total of 40 patients diagnosed with STMP were included in the study. Patients were selected based on predefined inclusion and exclusion criteria.

Inclusion Criteria

• Patients aged 18–60 years with a confirmed diagnosis of subtotal tympanic membrane perforation.
• Persistent perforation for at least three months despite conservative management.
• Good Eustachian tube function, as assessed by tympanometry.
• No evidence of active ear infection at the time of surgery.

Exclusion Criteria

• Patients with total or marginal tympanic membrane perforations.
• Presence of cholesteatoma or chronic otitis media with active discharge.
• Previous history of ear surgery.
• Patients with uncontrolled systemic diseases (e.g., diabetes mellitus, hypertension) that could interfere with wound healing.

Surgical Technique

All procedures were performed under local anesthesia using a transcanal endoscopic approach.

1. Patient Preparation: Patients were placed in a supine position with the head turned to the contralateral side. Local anesthesia (2% lignocaine with adrenaline) was infiltrated into the external auditory canal.
2. Endoscopic Visualization: A rigid 0-degree endoscope (2.7 mm, 14 cm) was introduced transcanally for visualization of the tympanic membrane perforation.
3. Cartilage Harvesting: Conchal cartilage was harvested under aseptic conditions and shaped to match the perforation size while preserving the perichondrium on one side.
4. Graft Placement: The cartilage graft was placed via an underlay technique, ensuring complete closure of the perforation while maintaining tympanic membrane contour.
5. Stabilization: Gelfoam soaked in antibiotic solution was used to secure the graft in place within the middle ear.
6. Postoperative Care: Patients were prescribed topical and systemic antibiotics, analgesics, and instructed on postoperative ear precautions. Follow-up otoscopic examinations were conducted at 1, 3, and 6 months postoperatively.

Outcome Measures

• Primary Outcome: Tympanic membrane closure rate at six months.
• Secondary Outcomes: Postoperative hearing improvement assessed via pure-tone audiometry (PTA), complication rates, and patient-reported satisfaction.

Data Analysis

Descriptive statistics were used to summarize demographic and clinical characteristics. The preoperative and postoperative audiometric data were compared using a paired t-test, with statistical significance set at p < 0.05.

Table:1 Demographic and Surgical Details of Study Participants (n=40)

Description:

• This table presents the demographic and surgical details of 40 patients with unilateral dry subtotal tympanum perforation, divided into Group A and Group B with 20 patients each.
• Both groups had an equal distribution of gender, with 9 females and 11 males in each group, and the mean age was 33 years.
• In Group A, all 20 patients underwent transcanal underlay grafting, while in Group B, 20 patients underwent microscopic postauricular grafting.
• Both groups used the same graft material, autologous thin (0.2 mm) cartilage covered with temporalis muscle fascia.
• All patients were followed up for a minimum period of six months, allowing for consistent postoperative evaluation and comparison between the two surgical techniques.

Table 2: Intraoperative Findings of External Canal Bony Humps

Description:

• In Group A, 4 out of 20 patients (20%) had external canal bony humps, but canaloplasty was not needed as the surgical view was unobstructed.
• In Group B, 3 out of 20 patients (15%) had bony humps that required drilling for adequate visualization.
• Overall, 7 patients (17.5%) had bony humps, with canaloplasty needed in 3 cases (7.5%) from Group B.

Table 3: Surgical Time and Graft Success

Description:

• In Group A, the average surgical time was 40 ± 5.50 minutes, and all 20 patients (100%) achieved successful graft take.
• In Group B, the average surgical time was 55 ± 10.50 minutes, with 2 patients (10%) experiencing graft failure, resulting in a 90% success rate.
• Although Group B required more surgical time due to canaloplasty in some cases, the difference in graft success rates between the groups was not statistically significant.

Table 4: Audiological Outcome (Air-Bone Gap - ABG)

Description:

• In Group A, the mean preoperative ABG was 32.50 ± 1.50 dB, which improved to 8.50 ± 1.25 dB postoperatively. 85% of patients achieved ABG closure within 10 dB.
• In Group B, the mean preoperative ABG was 30.75 ± 1.25 dB, improving to 9.25 ± 0.75 dB postoperatively, with 70% achieving ABG closure within 10 dB.
• Group A showed significantly better ABG closure rates compared to Group B, highlighting superior audiological outcomes for the transcanal approach

The postauricular approach is the commonly employed technique for repairing subtotal tympanic membrane perforations, as indicated by utilizing the surgical magnifier [17]. The postauricular incision results in increased blood loss, prolonged duration, and disruption of the anatomy in the postauricular region, perhaps leading to scar formation [18]. The magnifier is relatively large; therefore, it is hazardous to handle and requires an extended period for adjustment. The optics of the magnifier depend on its alignment, often necessitating adjustments to either the patient's position or the magnifier itself to achieve optimal clarity [19,18]. A further limitation of the magnifier's optics is its inability to simultaneously observe many regions of the central ear in a single observation. Conversely, the medical device possesses the capability to visualize many components of the middle ear in a single frame [20,21]. The physician will maneuver the medical device vertically and horizontally to examine various sites and areas within the middle ear cavity. The task of utilizing the monitor is another aspect of evaluative benefit, as it provides enhanced magnification and precision in the work. The monitor's run provides a crucial advantage by allowing young surgeons and students to watch surgical procedures, hence enhancing the teaching and learning processes. In our investigation on blood type, we utilized the otoendoscope for all surgical steps without the necessity of a binocular microscope. The physician (first author) controls the endoscope/camera with his hand and consequently the tool with his hand. The physician did not mention hand fatigue or any discomfort. A crucial technique is that the instrument should slightly precede the medical instrument to facilitate visualization of its operational tip. Regular cleaning of the medical instrument's lens is often inadequate; however, this issue may be mitigated by preventing the instrument's tip from contacting tissue or other devices. We noticed that the display on the television monitor was more convenient than the display on the medical instrument's attention piece. Furthermore, it provides enhanced magnification and greater precision in surgical procedures. The magnification can be altered by altering the distance between the tip of the medical instrument and the working field; it will rise as the distance decreases. Numerous studies restrict the application of the medical instrument to the repair of minor tympanic membrane perforations; nevertheless, in this work, we employed the instrument for the repair of substantial holes, achieving outstanding anatomical and functional outcomes. Deformations of the external ear canal, such as irregular shape, constriction, and bony protrusions, complicate the visualization of the tympanic membrane when examined under magnification [21-23]. The transcanal operative examination circumvents the narrow portion of the acoustic meatus and yields a clear assessment even when a zero medical instrument is utilized [24,21]. The use of the medical instrument often obviates the necessity for canaloplasty in cases with humps, as the instrument can be maneuvered beyond the humps. However, we encountered challenges in navigating the instruments through narrow passages, yet we successfully completed the procedure without the need for canaloplasty. We believe that falcate devices are essential in cases involving humps. Examining the medial facet of the perforation edge and thoroughly removing animal tissue debris is a crucial step in surgical procedure [22-25]. We concluded that the use of the medical instrument facilitated the examination and eversion of the tympanic membrane by meticulous removal of tissue remains. We often fail to recognize challenges in victimization, hindering the completion of the process. Recently, Mobarak and Sapna [26] reported the idea and development of a new examination holding system for otolaryngologic procedures. Conversely, in the blood type where we employed the postauricular incision, we saw that it was significantly lengthier in terms of skin incision, tissue elevation, and hemostasis. During this cluster, we identified six instances with bony protrusions necessitating drilling to expand the field of vision. The take rate in the microscopic cluster was 90 percent, whereas in the examination cluster it was 100 percent. Operative infection was an additional drawback of the postauricular technique, occurring in three cases. Ultimately, we recommend against utilizing a postauricular incision for tympanic membrane perforation repair, regardless of size; instead, we strongly advocate for the endaural approach to mitigate the drawbacks associated with the postauricular method and to enhance the success rate due to its superior precision.

In conclusion, this study demonstrates that percutaneous endoscopic transcanal cartilage myringoplasty is an effective, minimally invasive approach for repairing subtotal tympanic membrane perforations, offering a shorter surgical time, higher graft success rate, and superior audiological outcomes compared to the traditional microscopic postauricular method. The endoscopic technique's enhanced visualization and precision, combined with the avoidance of postauricular incisions and canaloplasty, contribute to improved patient satisfaction and reduced complications. These findings support the endaural approach as a superior alternative to the postauricular method, advocating for its broader adoption in clinical practice to optimize surgical outcomes for tympanic membrane perforation repair.

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