This study was performed to compare the operation time, graft outcomes and complications between the endoscopic cartilage-perichondrium button technique and over-under technique for repairing large perforations.

A total of 52 chronic large perforations were randomly allocated to receive treatment using the endoscopic cartilage-perichondrium button technique (n = 26) or over-under technique (n = 26). The graft outcomes, mean operation time and post-operative complications were compared between the two groups at 12 months.

The study population consisted of 52 patients with unilateral chronic large perforations. All patients completed 12 months of follow up. The mean operation time was 32.3 ± 4.2 minutes in the button technique group and 51.6 ± 2.8 minutes in the over-underlay technique group (p < 0.01). The graft success rate at 12 months was 92.3 per cent (24 out of 26) in the button technique group and 96.2 per cent (25 out of 26) in the over-underlay group (p = 0.552).

The endoscopic cartilage-perichondrium button technique had similar graft success rates and hearing outcomes for large chronic perforations to the over-under technique, but significantly shortened the mean operation time.

Myringoplasty success rate is estimated to be between 60 and 90 per cent. Factors predicting success include the choice of graft and use of auditory canal packing. This study aimed to determine the intra-operative factors associated with endoscopic myringoplasty success.

A retrospective review of all endoscopic myringoplasty cases between January 2017 and January 2020 was undertaken. Data were collected on: patient demographics, tympanic membrane perforation size, intra-operative details, audiology and post-operative outcomes.

There was no significant difference in graft success rates between cases using bismuth iodoform paraffin paste and Spongostan packing (86.7 per cent vs 84.9 per cent, respectively). Conchal cartilage graft had a higher success rate (100.0 per cent) compared with Biodesign grafting biomaterial (66.7 per cent), but was not superior to tragal cartilage (84.6 per cent) or temporalis fat or fascia (80.0 per cent).

Spongostan packing is equivalent to bismuth iodoform paraffin paste in terms of endoscopic myringoplasty success rate. Although conchal cartilage graft had higher success rates, it was not statistically significantly different from tragal cartilage.

To determine the outcomes of tympanoplasty surgery using porcine-derived small intestinal submucosa.

A retrospective audit was conducted in a hospital setting. Thirty-five adult and paediatric patients who received a small intestinal submucosa graft as part of tympanoplasty surgery were retrospectively reviewed. Patients underwent either simple tympanoplasty (n = 26) or complex tympanoplasty as part of a concurrent otological procedure such as atticotomy and mastoidectomy. The main outcome measures were rate of tympanic membrane closure and change in four-frequency mean air–bone gap.

Thirty-one patients had a follow-up period of longer than two months. Closure was obtained in 22 patients (71 per cent). The mean air–bone gap improved from 20.7 to 12.3 dB HL in the simple tympanoplasty group and from 22.3 to 12 dB HL in the complex tympanoplasty group.

Tympanoplasty surgery with small intestinal submucosa is a viable option for patients where autologous graft is not available or in order to minimise donor site morbidity.

In spite of continuous refinements in tympanoplasty techniques, results are variable, and it is not uncommon to see a discharging eardrum even after a good graft uptake. This study aimed to evaluate the efficacy of total annulus excision tympanoplasty in comparison with conventional underlay tympanoplasty.

This was a double blinded, randomised, controlled trial performed at a tertiary care centre. After inclusion and exclusion criteria were met, 56 patients were enrolled and randomised, and 28 patients were allocated to each group (group A (conventional tympanoplasty) and group B (total annulus excision)). Patients and evaluators were blind to the procedure performed.

Patients in group B (total annulus excision) showed better graft uptake and no discharge with better gains in air conduction thresholds (p < 0.05) when compared with group A (conventional tympanoplasty).

In view of the advantages it offers, total annulus excision tympanoplasty may be preferred over the conventional techniques in patients with central perforations.

Dural venous sinus injury is a rare complication of otological surgery that can lead to life-threatening sequelae, the management of which is complex and poorly described.

This paper describes the case of a 40-year-old female who underwent routine right myringoplasty complicated by sigmoid sinus laceration. The patient subsequently developed right-sided lateral sinus thrombosis leading to fulminant intracranial hypertension. The patient underwent successful emergency management by surgical reconstruction of the sigmoid sinus, followed by endovascular thrombolysis, catheter balloon angioplasty and endovascular stenting.

Torrential haemorrhage following otological procedures is uncommon and rarely requires packing of a bleeding venous sinus. This case highlights that injury to a highly dominant venous sinus can lead to venous outflow obstruction and life-threatening intracranial hypertension. To our knowledge, the development of this complication following otological surgery and its management has not been reported previously.

The aim of this study was to compare the differences between the no tympanomeatal flap approach and the tympanomeatal flap approach in endoscopic myringoplasty.

A total of 132 patients with tympanic membrane perforation were randomly divided into two groups: the no tympanomeatal flap approach group (group A, 56 ears) and the tympanomeatal flap approach group (group B, 76 ears). A comparison between the two groups was made.

The average operation time of group A was 36.00 ± 5.24 minutes, which was significantly shorter than that of group B, which was 43.89 ± 4.57 minutes (p = 0.002). The blood loss of group A was 5.08 ± 1.83 ml, which was significantly less than that of group B (9.67 ± 2.29 ml; p < 0.001). There were no differences in the degree of hearing improvement, the rate of hearing improvement, the dry ear time (when the external auditory canal and the operating cavity were dry) after operation and the success rate of tympanic membrane repair when compared between the two groups.

Compared with group B, group A (no tympanomeatal flap approach) can achieve the same effect but has the advantages of a shorter operation time and less blood loss during the operation.

Multiple tympanoplasty techniques have been developed with numerous differences in grafting and approach. This study aimed to improve type 1 tympanoplasty outcomes by using the ‘en hamac’ technique as well as performing a complete canalplasty for anterior perforations.

A retrospective review was performed using the prospective Otology-Neurotology Database tool for otological surgery. All primary type 1 tympanoplasty cases performed for tympanic membrane perforations from 2010 to 2016 were selected for analysis, all performed by one author. Minimal clinical and audiometric follow up was 18 months.

Tympanic membrane perforation closure was achieved in 62 of the patients (96.88 per cent). None of the en hamac cases had residual or recurrent perforation (p = 0.02). The mean remaining air–bone gap was 8.50 dB. The remaining air–bone gap was less than 10 dB in 72.55 per cent, 10–20 dB in 25.49 per cent and more than 20 dB in 1.96 per cent.

Using the en hamac technique for anterior perforations as well as systematically performing a complete canalplasty provides multiple surgical advantages with excellent post-operative results.

The outcomes of dry and wet ears were compared following endoscopic cartilage myringoplasty performed to treat chronic tympanic membrane perforations in patients with mucosal chronic otitis media.

Patients with chronic perforations, and with mucosal chronic otitis media with or without discharge, were recruited; all underwent endoscopic cartilage myringoplasty. The graft success rate and hearing gain were evaluated at six months post-operatively.

The graft success rates were 85.9 per cent (67 out of 78) in dry ears and 86.2 per cent (25 out of 29) in wet ears; the difference was not significant (p = 0.583). Among the 29 wet ears, the graft success rates were 100 per cent in 11 ears with mucoid discharge and 77.8 per cent in the 18 patients with mucopurulent otorrhoea.

The wet or dry status of ears in patients with chronic perforations with mucosal chronic otitis media did not affect graft success rate or hearing gain after endoscopic cartilage myringoplasty. However, ears with mucopurulent discharge were associated with increased failure rates and graft collapse, whereas ears with mucoid discharge were associated with higher graft success rates.

This study aimed to assess whether increasing operative experience results in better surgical outcomes in endoscopic middle-ear surgery.

A retrospective single-institution cohort study was performed. Patients underwent endoscopic tympanoplasty between May 2013 and April 2019 performed by the senior surgeon or a trainee surgeon under direct supervision from the senior surgeon. Following data collection, statistical analysis compared success rates between early (learning curve) surgical procedures and later (experienced) tympanoplasties.

In total, 157 patients (86 male, 71 female), with a mean age of 41.6 years, were included. The patients were followed up for an average of 43.2 weeks. The overall primary closure rate was 90.0 per cent.

This study demonstrates an early learning curve for endoscopic ear surgery that improves with surgical experience. Adoption of the endoscopic technique did not impair the success rates of tympanoplasty.

Surgery for chronic suppurative otitis media performed in low- and middle-income countries creates specific challenges. This paper describes the equipment and a variety of techniques that we find best suited to these conditions. These have been used over many years in remote areas of Nepal.

Extensive chronic suppurative otitis media is frequently encountered, with limited pre-operative investigation or treatment possible. Techniques learnt in better-resourced settings with good follow up need to be modified. The paper describes surgical methods suitable for resource-poor conditions, with rationales. These include methods of tympanoplasty for subtotal wet perforations, hearing reconstruction in wet ears and open cavities, large aural polyps, and canal wall down mastoidectomy with cavity obliteration. Various types of autologous ossiculoplasty are described in detail for use in the absence of prostheses. The following topics are discussed: decision-making for surgery on wet or best hearing ears, children, bilateral surgery, working with local anaesthesia, and obtaining adequate consent in this environment.

Perforations of the tympanic membrane are treated with various surgical techniques and materials. This study aimed to determine the efficacy of platelet-rich plasma during underlay myringoplasty.

The study included 40 patients. Autologous platelet-rich plasma was applied in-between temporalis fascia graft and tympanic membrane remnant during underlay myringoplasty in group 1 (n = 20). The outcome was evaluated after three months and compared with group 2 (n = 20), a control group that underwent routine underlay tympanoplasty.

After three months’ follow up, graft uptake was 95 per cent in group 1 and 85 per cent in group 2 (p < 0.03). Mean hearing threshold gain was 18.62 dB in group 1 and 13.15 dB in group 2. This difference was statistically significant (p < 0.01).

Platelet-rich plasma, with its ease of preparation technique, availability, low cost, autologous nature and good graft uptake rate, justifies its use in tympanoplasty type I procedures.

To review the history of moist therapy used to regenerate traumatic tympanic membrane perforations.

Literature review.

The literature on topical agents used to treat traumatic tympanic membrane perforations was reviewed, and the advantages and disadvantages of moist therapy were analysed.

A total of 76 studies were included in the analysis. Topical applications of certain agents (e.g. growth factors, Ofloxacin Otic Solution, and insulin solutions) to the moist edges of traumatic tympanic membrane perforations shortened closure times and improved closure rates.

Dry tympanic membrane perforation edges may be associated with crust formation and centrifugal migration, delaying perforation closure. On the contrary, moist edges inhibit necrosis at the perforation margins, stimulate proliferation of granulation tissue and aid eardrum healing. Thus, moist perforation margins upon topical application of solutions of appropriate agents aid the regeneration of traumatic tympanic membrane perforations.

This study investigated the performance of a cartilage slicer device referred to as the ‘Hacettepe cartilage slicer’.

Forty-one cartilage pieces were harvested from eight fresh frozen human ears and measured in thickness with a digital micrometer. These pieces were randomly sliced using four different thickness settings and two different types of blades. The thicknesses of the slices and remaining pieces were measured also. Scanning electron microscopy was utilised to determine the surface smoothness of the slices.

Thickness results showed a proportional increase with the increasing thickness setting, with a ±0.1 mm margin of error. The measurements showed that over 95 per cent of the slices’ structural integrity was preserved. Although both blades provided satisfactory results, scanning electron microscopy revealed that the slices cut with a single bevel blade had superior surface smoothness.

To our knowledge, the current study is the first to evaluate the performance of a cartilage slicer device. Based on the thickness results, the Hacettepe cartilage slicer fulfilled its design goals: to consistently produce slices at the intended thickness with a ±0.1 mm tolerance, and to preserve over 95.3 per cent of cartilage thickness thereby ensuring undamaged, strong cartilage slices.

Temporalis fascia has become the most widely used graft for tympanoplasty, as it is strong, durable, and easy to procure and handle. However, the type of temporalis fascia graft to use (i.e. dry or wet) remains controversial. The present review aimed to evaluate the success rates of dry and wet temporalis fascia grafts in type I underlay tympanoplasty.

A literature search was performed, using PubMed up to August 2016, to identify all studies of dry and wet temporalis fascia grafts in type I underlay tympanoplasty. The initial search using the key words ‘temporalis fascia’ and ‘tympanoplasty’ identified 130 articles; these were screened by reviewing the titles or abstracts based on the inclusion and exclusion criteria. Ultimately, this review included seven articles.

A dry or wet temporalis fascia graft did not affect the outcome of type I underlay tympanoplasty. However, using wet temporalis fascia could shorten the duration of surgery in type I underlay tympanoplasty. Concerns that the fibroblast count of temporalis fascia may beneficially affect success rate have not been substantiated in clinical reports thus far.

The middle ear and mastoid are complex three-dimensional structures and therefore tympanomastoid procedures require detailed documentation. Traditional written accounts can be inaccurate and difficult to interpret.

This audit of 95 patients compares the completion of essential operative details using: an all-electronic version of a standardised proforma with a diagrammatic template, a non-electronic version with a diagrammatic template, and a traditional handwritten template.

The electronic template resulted in 81 per cent of essential operative items being recorded, compared to 78 per cent (p = 0.3) with a previous non-electronic template and 50 per cent (p = 0.0004) when using simple handwritten recording.

An electronic proforma with a diagrammatic template improves the documentation and interpretation of tympanomastoid procedures compared to traditional handwritten records.

Does revision myringoplasty have worse outcomes than primary surgery?

The International Otology Database has been used to record data on surgery for middle-ear disease in Norfolk, UK, over nine years. The data show the results of all myringoplasty cases and the results of revision cases. Outcome measures are perforation and hearing change. Comparison is made with benchmark centres of excellence.

A total of 611 operations included myringoplasty; 356 (58 per cent) of cases had a recorded follow up at 3 months. Twenty-nine patients (8.1 per cent) had a post-operative perforation. Benchmark centres performed 2319 operations; 1284 (55 per cent) of these had a follow up at 3 months, and 82 patients (6.4 per cent) had a perforation at follow up. Sixty-nine of the Norfolk patients were revision cases. Six of the 69 patients (8.7 per cent) had a perforation at follow up. The average hearing gain in the revision myringoplasty patients in Norfolk was 7 dB.

The results of the revision myringoplasty cases are the same as those for the primary myringoplasty cases in this series.

Bilateral tympanic membrane perforation closure is usually performed by otosurgeons in two sittings. However, in this study, transperforation myringoplasty was performed alongside contralateral tympanoplasty in a single sitting. The effectiveness of transperforation myringoplasty procedure and the benefits of single sitting bilateral surgery were evaluated.

A prospective study of 50 selected patients with mucosal-type bilateral chronic otitis media was conducted. All patients underwent transperforation myringoplasty on the side that met the inclusion criteria and tympanoplasty on the contralateral side. Graft uptake and hearing improvement were evaluated after 6 months.

At the 6-month follow up, the graft uptake rate was 82 per cent, the hearing gain was 11.5 dB and the air–bone gap gain was 11.6 dB.

This procedure offers perforation closure in a single sitting to patients with bilateral chronic otitis media who meet the inclusion criteria.

This paper presents our 10 years’ experience with Felix tympanoplasty. This surgical procedure is designed to repair large perforations of unhealthy tympanic membranes, providing good graft stability without blunting of the anterior tympanomeatal angle.

From January 2001 to December 2011, 64 Felix tympanoplasties were performed, conducted as the only surgical procedure. This paper describes the surgical technique and analyses the functional results.

Graft take was achieved in 61 ears (95.31 per cent). There was air–bone gap improvement in 84.6 per cent of cases.

Felix tympanoplasty was effective in repairing unhealthy tympanic membranes with large perforations; the avoidance of blunting at the anterior tympanomeatal angle achieved good functional results.

To determine the outcome of myringoplasty as undertaken by ENT surgeons in the UK, and to assess the current systems available for providing national outcome data.

A prospective national multicentre audit was conducted involving multiple hospitals throughout the UK. Participants consisted of ENT surgeons practising in the UK.

Data were prospectively collected over a three-year period between 1 March 2006 and 1 March 2009 using the web-based Common Otology Database. In total, 33 surgeons provided valid and complete data for 495 procedures. The overall closure rate for myringoplasty was 89.5 per cent. The average hearing gain for successful primary myringoplasties was 9.14 dB (standard deviation = 10.62). The Common Otology Database provided an effective platform for capturing outcome data.

Myringoplasty is a safe and effective procedure in the UK. With the introduction of revalidation by the General Medical Council, participation in national audits will be mandatory in the future. This study demonstrates that a web-based audit tool would be suitable for performing such audits.

There are many reports of operations performed to successfully close ear drum perforations. Hearing deterioration after myringoplasty is not a widely published topic. This paper presents an audit of this complication.

A six-year retrospective analysis of a series of myringoplasty operations was performed using electronic patient records. Patients with post-operative hearing loss were identified and those with hearing loss greater than 10 dB were further scrutinised.

Out of 187 patients who underwent myringoplasty procedures, 44 (23.53 per cent) experienced a reduction in hearing thresholds. In seven cases (3.74 per cent), the hearing loss was greater than 10 dB. A case note review revealed no obvious predictive factors, although posterior perforations and the possibility of ossicular chain manipulation were considered.

Hearing loss following myringoplasty is not rare, and this may alter the consent process for this procedure.