Otology & Neurotology

37:838–846 ! 2016, Otology & Neurotology, Inc.

Type I Tympanoplasty Meta-Analysis: A Single Variable Analysis

!yzHsern Ern Tan, !yz§Peter Luke Santa Maria, !yjjRobert Henry Eikelboom,
!yKeith Surendran Anandacoomaraswamy, and !yzMarcus David Atlas
!Ear Science Institute of Australia, Subiaco, Western Australia, Australia; yEar Sciences Centre, The University of Western Australia,
Nedlands, Western Australia, Australia; zDepartment of Otolaryngology, Head and Neck Surgery, Sir Charles Gairdner Hospital,
Perth, Western Australia, Australia; §Department of Otolaryngology, Head and Neck Surgery, Stanford University, Palo Alto,
California; and jjDepartment of Speech-Language Pathology and Audiology, University of Pretoria, South Africa

Objective: To determine which independent variables influence and surgical technique. Only those studies providing data on
the efficacy of type I tympanoplasty in adult and pediatric a given parameter of interest could be included when
populations. comparing each variable.
Data Sources: A search of the PubMed database and Conclusion: The weighted average success rate of tympanic
Cochrane Database of Systematic Reviews using the key closure was 86.6%. Based on this meta-analysis, pediatric
words ‘‘tympanoplasty OR myringoplasty’’ from January surgery has a 5.8% higher failure rate than adults and there
1966 to July 2014 was performed. is no correlation between follow-up period and success.
Study Selection: Studies reporting outcomes of myringo- Other variables associated with improved closure rates
plasty or Type I tympanoplasty in primary non-cholesteato- include perforation with a size less than 50% of total area
matous chronic tympanic membrane (TM) perforation were (improved by 6.1%) and the use of cartilage as a graft
included. (improved by 2.8% compared with fascia), while ears that
Data Extraction: Of 4,698 abstracts reviewed, 214 studies were operated on while still discharging, those in different
involving 26,097 patients met our inclusion criteria and locations of the pars tensa, or using different surgical
contributed to meta-analysis. approaches or techniques did not have significantly different
Data Synthesis: The primary outcome of success was outcomes. Key Words: Meta-analysis—Myringoplasty—
defined as closure rate at 12 months. The independent Tympanic membrane perforation—Tympanoplasty.
variables analyzed were age, follow-up period, approach,
graft material, perforation cause, size, location, ear dryness, Otol Neurotol 37:838–846, 2016.

Type I tympanoplasty is a relatively common pro- types as described first in 1956. Type I tympanoplasty,
cedure in otolaryngology. The history of the management involving an intact ossicular chain, involves the grafting of
of a perforated tympanic membrane (TM) can the traced TM alone onto an intact ossicular chain. The difference
back to 1644, when Banzer (1) used a tube of elk’s claw between type I tympanoplasty and myringoplasty is that
covered in pig’s bladder to close the perforation in a TM. tympanoplasty involves the raising of a tympanomeatal
It was not until the nineteenth centuries that the British flap whereas myringoplasty does not, although the terms
otologists, James Yearsley and Joseph Toynbee, targeted are often used interchangeably (7). To avoid confusion for
an improvement in hearing with their innovative devices the remainder of this analysis both type I tympanoplasty
(2,3). Berthold introduced the term ‘‘myringoplasty’’, and myringoplasty will be referred to as tympanoplasty.
when he performed the first surgical closure of a TM Two previous meta-analyses investigate outcomes in
perforation in 1878 (4). However, myringoplasty was not pediatric populations only (8,9). This study aims to
widely accepted until Wullstein and Zollner, utilizing the identify and analyze the variables that influence the suc-
operative microscope, re-introduced it in 1951 (5). Tym- cess of TM repair in terms of closure rates and hearing
panoplasty is the surgical repair of the TM and/or the outcomes in both the adult and pediatric population.
middle ear ossicles. Wullstein (6) classified it into five
METHODS
Address correspondence and reprint requests to Hsern Ern Tan, This meta-analysis was performed in accordance with the
M.B.B.S., Department of Otolaryngology, Head and Neck Surgery, PRISMA guidelines (10).
Sir Charles Gairdner Hospital, Perth, Western Australia, 6009, Aus-
tralia; E-mail: hsern.ern.tan@gmail.com
There was no funding received for this project. Search Method and Study Selection
The authors disclose no conflicts of interest. All observational and experimental studies reporting closure
Supplemental digital content is available in the text. rates were eligible for inclusion. Using the key words of
DOI: 10.1097/MAO.0000000000001099 tympanoplasty or myringoplasty a systematic literature search

838

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 TYPE I TYMPANOPLASTY META-ANALYSIS 839

of the PubMed database and Cochrane Database of Systematic Data Synthesis

Reviews for studies published, in the English language, from A meta-analysis applying the methodology of Einarson was
January 1966 to July 2014 was conducted (July 2nd, 2014), performed using S-PLUS 2000 (Insightful Corporation, Seattle,
yielding 4,698 articles. The search strategy for PubMed was WA) (11). An overall success rate was calculated, as well as
(‘‘myringoplasty’’[MeSH Terms] OR ‘‘myringoplasty’’[All rates for each variable. For each category, the number of studies
Fields]) OR (‘‘tympanoplasty’’[MeSH Terms] OR ‘‘tympano- that the results were based on was recorded, and the homogen-
plasty’’[All Fields]) AND (‘‘1966/01/01’’[PDAT]: ‘‘2014/07/ eity of the studies ( p < 0.05 indicates a non-homogeneous
01’’[PDAT]). The primary author reviewed all abstracts of population), the meta-analytic average success rate, the stand-
studies found with the above search strategy before two other ard error, and 95% confidence intervals were calculated. A p
independent authors selected studies for inclusion based on the value less than 0.05 was considered statistically significant.
defined criteria. If there were any abstracts that lacked clarity or Linear regression technique was used to analyze the correlation
adequate detail in their methodology or results, the full article between follow-up period and success rate.
was read to assess suitability for inclusion. The inclusion and
exclusion criteria were only applied after detailed assessment of RESULTS
full-text articles. Duplicate reporting of results by authors were
discarded. Studies were classified by a particular variable, if at The search strategy identified 4,704 articles after
least 90% of the population fitted into that category, otherwise
the options of unclassified, mixed, or other were used and, duplicates were removed. Figure 1 shows the method
therefore, being excluded in data analysis. of study identification according to PRISMA (10). After
screening, 321 full-text articles were assessed for eligi-
Study Inclusion Criteria bility and 107 articles were excluded. A total of 214
The inclusion criteria for individual studies were any obser- studies were included in quantitative analysis (see
vational (retrospective or prospective) or treatment (random- Supplemental Digital Content, http://links.lww.com/
ized or non-randomized clinical trials) study reporting the MAO/A426). Of the 214 studies, two were randomized
outcome of tympanoplasty in adult and pediatric populations. control trials and the rest were observational retrospec-
Only studies reporting clinically diagnosed, primary non-cho- tive or prospective cohort studies. Across 214 included
lesteatomatous chronic TM perforations were included. Studies studies, there were 26,097 patients and the mean number
were excluded if they reported patients who had tympanoplasty of patients in each study was 122 (121.92 " 149.51, range
for acute perforations, for conditions other than perforation, of 7–1298 patients). The mean closure rate was 86.6%
revision surgery (if >10% of study population required revision
surgery), other types of tympanoplasty (non-type I), ossicular (range of 46.8–100%, 95% CI [85.3, 87.9]) and the mean
chain pathology, or mastoidectomy. age of patients in the included studies was 28
(27.63 " 13.59, range of 5.50–70.70 years of age).
Variables Figure 2 demonstrates the increasing trend in the number
Variables examined included: the patient’s age (at the time of of articles published concerning Type I tympanoplasty or
surgery), follow-up period (months from surgery to the latest myringoplasty since 1970.
follow-up appointment), surgical approach (endaural or post- The results of the meta-analysis are plotted in Figure 3
aural), perforation cause (otitis media or traumatic—as defined and summarized in Table 1, showing that the overall
by individual studies), graft material (cartilage, fascia, fat or meta-analytic average success rate for closure of perfor-
other materials), perforation size (above or below 50% of TM ations was 86.6%. Highest failure rates were detected in
surface area), perforation location (anterior, central, or studies with follow-up periods greater than 12 months
posterior), ear status (dry ear or ‘‘wet’’ ear—defined as dis-
(4.38% worse with follow-up periods >12 months com-
charge from the middle ear at time of preadmission surgery
appointment or a history of discharge within 3 months before pared with #6 months). Though a decreasing success rate
surgery), and surgical technique (underlay, inlay, or overlay is observed with average longer follow-up times (#6
graft positioning). For clarification, only chronic perforations months: 87.15%, #12 months: 85.61%, >12months:
were included and traumatic or other perforations that were not 82.77%), simple linear regression analysis calculated
chronic were not included. Age and follow-up period were no correlation between success rate and follow-up period
analyzed as a continuous variables with the range of ages, mean (Pearson’s r ¼ 0.037, p ¼ 0.625, after adjusting for outlier
age, and mean follow-up period extracted from each study. studies). The adult population (defined as 18 years and
above) had 5.8% better closure rates compared with the
Outcome Measures pediatric population (defined as 17 years old and below)
The primary outcome measure was the complete closure of (adult: 89.25%, pediatric: 83.42%). Within the pediatric
the TM perforation, defined as an intact neo-membrane at 12 population, children <12 years had the worst closure rate
months follow-up. Secondary outcome measures were the
of all age groups (#12 years: 83.11%, >12 years 88.23%,
presence of adverse events (re-perforation, re-operation/revi-
sion surgery, blunting, lateralization) and degree of improve- 13–17 years: 92.81%). Patients with otitis media pre-
ment of conductive hearing loss (by pure tone audiometry). operatively had 3.4% worse closure rates compared with
patients with traumatic perforations (otitis media:
Assessment of Risk of Bias in Included Studies 83.86%, traumatic: 87.25%). Patients with actively dis-
Risk of bias was assessed at the individual study level at time charging ears had 3.6% worse closure rates compared
of first appraisal and in the finally included studies, using the with pre-operatively dry ears (dry: 87.02%, wet:
studies own summary assessment of the risk of bias. No studies 83.44%). Perforations greater than 50% have a 6.1%
were excluded on this basis. lower success rate than those less than 50% in size

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840 H. E. TAN ET AL.

compared with temporalis fascia, fat, and ‘‘other’’

Identification
Records identified through Additional records identified materials such as paper, alloderm, perichondrium, other
database searching through other sources
(n = 4698) (n = 12)
synthetic materials (cartilage: 90.80%, fascia 88.00%,
fat: 86.52%, other 85.39%). Pairwise comparisons of
graft materials showed that cartilage compared with
Records after duplicates removed fascia as the only significant pair comparison with a p
(n = 4704) value of 0.048. When cartilage was compared with fat or
to ‘‘other’’ materials, there was no significant advantage
Sreening

( p value 0.366 and 0.110, respectively). Likewise, fascia

Records screened Records excluded compared with fat and to ‘‘other’’ materials was not
(n = 4704) (n = 4383)
significant ( p value 0.581 and 0.560, respectively).
Lastly, fat compared with ‘‘other’’ materials was not
Full-text articles Full-text articles
significant ( p value 0.4692). Audiometry data were
Eligibillity

assessed for eligibility excluded, with reasons inconsistently reported, and a mean improvement in
(n = 321) (n = 107)
ABG postoperatively could not be ascertained. However,
data at the 10 dB, 20 dB, and 30 dB postoperative ABG
Studies included in thresholds was available in 29, 32, and 30 studies,
qualitative synthesis
(n = 214)
respectively. Looking at the postoperative ABG within
these studies, 42.5% of patients (n ¼ 1,380 of 3,247) were
Included

within 10 dB, 68.6% (n ¼ 2,428 of 3,540) within 20 dB

Studies included in and 95.5% (n ¼ 2,797 of 2,928) within 30 dB.
quantitative synthesis
(meta-analysis)
(n = 214)
DISCUSSION
FIG. 1. Preferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA) (10) flowchart summarizing the search
The overall closure rate for this meta-analysis was
results and the application of eligibility criteria. 86.6%, with an adult population success rate of 89.2%
and a pediatric population success rate of 83.4%, which is
the same success rate identified in a 2015 meta-analysis
(#50% perforation size: 85.56%, >50% perforation size: of pediatric tympanoplasty (9).
79.44%). Anterior perforations had lower closure rates
than central or posterior perforations by 0.6% and 3.3% Follow-up Period Does Not Correlate to Graft Success
respectively (anterior: 85.42%, central: 85.42%, Rate
posterior 88.72%). The postaural approach had an Through linear regression analysis, this study demon-
increased closure rate of 2.0% compared with endaural strates that there is no correlation between follow-up
approach, but the difference was not statistically signifi- period and success rate. In some series, the follow-up
cant. The underlay technique was the most commonly period is as little as 2 months while in others it was as
used graft technique (used in 75.5% of patients: 13,359 of high as 12 years (12–15). Some authors have suggested
17,697 total patients where surgical technique was speci- that late graft failure is relatively rare, therefore, stating
fied). The overlay technique was only 0.1% better in that a graft follow-up period of 6 months is sufficient
achieving successful closure compared with the underlay (16,17). However, others have compared short and long-
technique, and the inlay technique was the least common term follow-up periods and demonstrated that a signifi-
and successful (underlay: usage 75.5%, success 86.71%, cant number of failures occur after 1 year (18,19). It has
overlay: usage 15.5%, success 86.83%, inlay: usage been observed that regardless of any factors that can be
9.0%, 85.39%). Cartilage had superior closure rates controlled, a 10% deterioration in closure rate occurs

Number of studies published per 5-year interval

70

60
Number of studies

50

40

30

20

10

0
1970-1974 1975-1979 1980-1989 1990-1994 1995-1999 2000-2004 2005-2009 2010-2014
5-year interval

FIG. 2. Graph of results depicting the overall closure rate and success rates stratified by each variable.

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 TYPE I TYMPANOPLASTY META-ANALYSIS 841

Overall Success (214, 26097)

<=12 (20, 1182)

>12 (66, 5469)

Age <=17 (53, 4136)

>17 (26, 2049)

13 to <=17 (5, 214)

<=6 months (12, 2502)

Follow up
<=12 months (33, 8279)
period
Factor (Number of Studies, Number of Patients)

>12months (45, 10907)

Endaural (69, 5341)

Approach
Postaural (61, 8188)

Otis Media (69, 8597)

Cause
Traumatic (10, 472)

Cartilage (33, 1746)

Fat (22, 1507)

Material Fascia (121, 14806)

Other (36, 4217)

Perforation <=50% (74, 5859)

size >50% (58, 3374)

Central (53, 4948)

Perforation
Anterior (32, 1268)
location
Posterior (22, 479)

Dry (105, 13048)

Status
Wet (14, 741)

Underlay (110, 13359)

Technique Overlay (36, 2745)

Inlay (29, 1593)

mean

0 20 40 60 80 100
Success rate (% with 95% confidence interval)

FIG. 3. Displays the results depicting the overall closure rate and success rates stratified by each variable.

within the first 2 years postoperatively (13). These late no comparative analysis could be made between <12
re-perforations are attributed to either underlying Eusta- years and 13 to 17 years. Our findings are consistent with
chian tube dysfunction or to avascularity and inappro- a meta-analysis of pediatric tympanoplasty performed in
priate thickness of the graft (20). Future studies should 1997, which identified that age was a significant factor,
aim to follow-up graft success for a minimum of and that in children better outcomes are found with
12 months. increasing age (8). However, a more recent meta-analysis
of pediatric tympanoplasty has found through subgroup
Adult Populations Have Superior Closure Rates analysis that age was not a significant factor affecting the
In our analysis, it was demonstrated that adults had a closure rate (9). The lower success rate of tympanoplasty
better closure rate than the overall pediatric population. in children is thought to be related to Eustachian tube
Interestingly, the teenage subgroup (13 to 17 years of function and its relationship with otitis media (21–25).
age) had the highest success rate (92.81%), 9.7% higher There remains debate as to whether there should be a
than for children #12 years (83.11%), and 9.4% higher minimum age for tympanoplasty or not, with some
than success rate for children #17 years (83.42%) studies suggesting it should be performed after the
suggesting within children, better outcomes are found Eustachian tube is at adult development after 7 years
in older children. However, direct comparison of age of age (22,26–31). The decision to perform tympano-
groups above and below 12 years was not significant, and plasty in children remains a balance of the risks and

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842 H. E. TAN ET AL.
TABLE 1. Variables and their effects on the primary outcome of tympanoplasty success
Variable Type No. Studies No. Patients Success (%) 95% CI Range p
Overall success 214 26,097 86.62 85.27–87.92 –
Age #12 20 1,182 83.11 77.38–88.21 0.075
>12 66 5,469 88.23 85.55–90.68
#17 53 4,136 83.42 81.01–85.70 0.017
>17 26 2,049 89.25 84.17–93.52
13 to #17 5 214 92.81 88.49–96.33 –
Follow-up period #6 months 12 2,502 87.15 82.28–91.38 –
#12 months 33 8,279 85.61 83.07–87.98 0.320
>12months 45 10,907 82.77 79.11–86.15
Approach Endaural 69 5,341 86.02 83.35–88.51 0.112
Postaural 64 8,188 88.06 86.12–89.88
Perforation cause Otis Media 69 8,597 83.86 80.33–87.12 0.8610
Traumatic 10 472 87.25 70.21–98.62
Graft material Cartilage 33 1,746 90.80 86.85–94.19 0.048
Fascia 121 14,806 88.00 84.13–91.44
Fat 22 1,507 86.52 84.91–88.05 0.469
Other 36 4,217 85.39 80.23–89.92
Perforation size #50% 74 5,859 85.56 82.39–88.48 0.019
>50% 58 3,374 79.44 74.06–84.40
Perforation location Central 53 4,948 86.03 83.08–88.77 0.822
Anterior 32 1,268 85.42 80.68–89.66
Posterior 22 479 88.72 83.28–93.41
Ear status Dry 105 13,048 87.02 85.09–88.85 0.155
Wet 14 741 83.44 76.24–89.69
Surgical technique Underlay 110 13,359 86.71 85.09–88.26 0.712
Overlay 36 2745 86.83 82.78–90.45
Inlay 29 1593 85.39 79.69–90.36

CI indicates confidence interval. Boldface indicates statistical significance.

benefits within the individual patient with the additional higher rate of failures in larger perforations
added risk of an increased rate of failure. To determine a (9,17,20,26,32,34,37,38). There are also individual stud-
recommended minimum age for tympanoplasty, future ies where perforation size was not observed to affect
studies should aim to report age-specific closure rates. overall results (16,22,24,36,39–46). The major reasons
thought to be responsible for graft failure in larger
Discharging Ears and Perforations Because of Otitis perforations are increased technical difficulty, reduced
Media Do Not Significantly Affect Closure Rates visibility, reduced graft overlap with the residual TM, a
Closure rates in tympanoplasty performed in perfor- poor vascular bed for the graft and poor graft support or
ations because of otitis media and in those perforations fixation (16,34). Some studies have claimed that ante-
that were still discharging were not significantly affected. riorly placed perforations are associated with a poorer
It is important to recognize that discharging ears may not outcome, possibly because of reduced vascularity or
necessarily be infected, with multiple factors including exposure of the anterior TM (13,15,47,48). While our
tympanomastoid space mucosa, ventilation and Eusta- meta-analysis did not demonstrate statistical significance
chian tube dysfunction influencing the occurrence and with the location of the perforation, it is important to
presentation of infection (28). Individual studies looking acknowledge that large-sized perforations often include
at this specific issue have reported mixed results the anterior segment, as anterior-only perforations are
(15,17,22,26,32–36). Given that this meta-analysis and uncommon (49). Anteriorly located perforations also had
no individual study claims that perforations that are wet the lowest success rate (85.42% versus 86.03% for
have a higher success rate for closure, it would seem central and 88.72% for posterior) and so the site of the
reasonable to attempt to create a dry perforation but not perforation while not proving to be significant for success
make this a necessary condition for surgery. rate remains an important factor.

Perforation Size Matters, but Location Does Not No Surgical Approach Has an Advantage
This meta-analysis indicates that perforations greater The type of surgical approach did not have an impact
than 50% have a lower success rate, while the location of on outcomes. Surgical approach depends on many factors
the perforation had no significant effect on success rate. including the perforation size, location, visualization,
Several individual studies also found a significantly and the individual surgeon’s preference. Typically, an

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 TYPE I TYMPANOPLASTY META-ANALYSIS 843

endaural or transcanal approach is used for smaller, more in terms of perforation closure. Cartilage is also often
posterior perforations in wider canals. Because there are used as a graft material for smaller sized perforations,
a number of variables that contribute to the decision of which innately have higher healing rates, and this may
approach and these are biased by the individual surgeon’s account for the increased closure rate with cartilage
preferences it is not surprising that this meta-analysis did compared with other graft material. Different graft
not detect a difference. materials can also be used in different situations and
the superiority of cartilage must still be balance for an
There Is No Superior Graft Placement Technique individual patient’s situation and the surgeon’s experi-
This meta-analysis demonstrates that there is no sig- ence with a particular material.
nificant difference between the grafting techniques used
(underlay, overlay, and inlay). While the underlay tech- Hearing Outcomes Were Inconsistently Reported
nique was the most commonly used graft technique Hearing outcomes after tympanoplasty are inconsist-
(75.5% of patients in this meta-analysis), there was no ently reported which limits the conclusions that are able
significant benefit of any individual technique. Some to be made. In this meta-analysis 39% (83 of 214 studies)
individual studies have claimed superiority in closure of the studies recorded postoperative hearing results.
rates for the overlay technique (50,51). Others have Because of inconsistency in reporting the overall mean
reported no difference; however, there is an identified hearing gain could not be calculated. The range of mean
increased risk of blunting of the anterior tympanomeatal postoperative air-bone gap (ABG) closures in individual
angle and lateralization of the TM are more common studies was 1.2 to 25.5 dB. A total of 32 studies in this
when utilizing the overlay technique (52–54). Blunting meta-analysis contributed data with complete reporting
may result in a persistent conductive hearing loss (16). of postoperative ABG (20,24,43,48,56,57,61,64,68–91).
The inlay technique was initially used for small perfor- Data at the 10, 20, and 30 dB postoperative ABG
ations utilizing a plug of adipose tissue (4,55). More thresholds was available in 29, 32, and 30 studies,
recently, this technique has been applied using cartilage respectively. Looking at the postoperative ABG within
(56–58). There does not appear to be a definitive indica- these studies, 42.5% of patients (n ¼ 1,380 of 3,247) were
tion for each technique, so to a large extent the choice within 10 dB, 68.6% (n ¼ 2,428 of 3,540) within 20 dB,
usually depends on the surgeon’s view of each tech- and 95.5% (n ¼ 2,797 of 2,928) within 30 dB, demon-
nique’s relative advantages or disadvantages (59,60). As strating that only a minority of patients achieved the best
each surgeon has personal preferences, it is almost postoperative ABG (<10 dB). While the ideal outcome in
impossible to compare grafting techniques performed tympanoplasty is the complete closure of the postoper-
by the same surgeon and excellent outcomes are achieved ative ABG to 0 dB (indicating no hearing loss), achieving
with all techniques (16,51,61–64). a postoperative ABG <10 dB should be considered good
clinical outcome as an ABG greater than 10 dB indicates
Cartilage Has Superior Closure Rates a conductive hearing loss. Though data were collected on
The most commonly used graft materials are tempo- pure-tone air-conduction thresholds, very few studies
ralis fascia, cartilage, and fat, which are all readily documented findings in adequate detail for a meaningful
accessible at the surgical site. Over the years many other analysis. When examining other individual studies ability
natural and synthetic materials have been trialed, but to achieve a postoperative ABG within 20 dB there are
there are very few published studies on outcomes. Our reports ranging from 60% to 90%, consistent with our
meta-analysis shows that cartilage (90.80%) has a small finding of 69% (12,35,48,51,70,72,92,93). The impact of
but significant superior closure rate to temporalis fascia variables on hearing outcomes could not be determined
(88.00%), with pairwise comparisons of other material because of the poor quality of reporting. Future studies
choices demonstrating no significance. A small random- should report audiometric outcomes in accordance to the
ized prospective clinical trial comparing fascia (20 ears) American Academy of Otolaryngology, Head and Neck
to cartilage (18 ears) found the graft uptake rates and Surgery’s Hearing Committee and with audiometry test
hearing outcomes were not significantly different at 24 results before and after surgery (94).
months (84.2% and 80% respectively) (65). Since the
literature review date of this meta-analysis one other Secondary Outcomes and Complications
randomized control trial showed a benefit for cartilage in The complications detected in this meta-analysis are
closure rate at 12 months, while another reported a reported in Table 2. Complication rates were reported in
reduced postoperative infection rate with cartilage only 21% of studies (44 of 214 studies). The most
(57,66,67). One possible suggested explanation of this commonly reported complications were reperforation
difference in cartilage success, between these two trials, (11.9%), revision surgery (11.4%), blunting (6.7%),
is that poorer results may occur with cartilage thickness and lateralization (4.2%). Re-operation or revision
over 500 mm (67). While graft choice ultimately depends surgery was defined as any operation caused by an
on the perforation type, size and surgeon preference, our event requiring return to theatre, or as defined by the
meta-analysis has shown that cartilage, as an independent individual study. Future studies should aim to report
variable, is a superior graft choice compared with tem- complications in greater details to help future analysis
poralis fascia in both the pediatric and adult populations of specific complications.

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844 H. E. TAN ET AL.
TABLE 2. Complication rates as reported by individual studies included in this meta-analysis
Complication Number of Studies Mean (%) Range (%) SD
Reperforation 22 11.88 2.25–31 7.72
Reoperation 14 11.43 1–87% 23.25
Blunting 17 6.65 1–54% 12.36
Lateralization 17 4.24 1–13% 3.75

SD indicates standard deviation.

The Effect of Mastoidectomy does not correlate to graft success. Surgical factors that
Mastoidectomy or other surgical adjunctive pro- led to improved closure rates include the use of cartilage
cedures were not included as a variable as the majority while other factors such as surgical approach or tech-
of studies did not discriminate between cholesteatoma nique of graft placement did not influence the closure rate
and non-cholesteatoma etiology when considering mas- overall. Future studies should, at a minimum, report
toidectomy. The current body of literature has been closure rates, hearing outcomes, complications, and
unable to demonstrate a clear benefit for TM healing report follow-up of at least 12 months.
when mastoidectomy is performed concurrently with
tympanoplasty. Several studies retrospectively compared Acknowledgments: The authors thank Dr Noweed Ahmed and
tympanoplasty alone to tympanoplasty with mastoidec- Dr Guy Watts for contributing to the review of the studies
tomy for TM perforation repair and did not find any included in the analysis, and Ms Charley Budgeon and Ms
statistical difference in repair success or hearing out- Chrianna Bharat for contributing to the statistical analysis.
comes for adults or children (95–98). A large prospective
randomized study of adults with chronic suppurative REFERENCES
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