Abstract
Background: Large tympanic membrane perforations often require
tympanoplasty for hearing restoration. The choice between endoscopic
and microscopic techniques can influence graft uptake success.
Aim: This study aimed to compare graft uptake rates and hearing
outcomes in patients with large tympanic membrane perforations
undergoing Type 1 tympanoplasty using temporalis fascia grafts via
endoscopic versus microscopic approaches.
Method: A total of 60 patients with large tympanic membrane
perforations were divided into two groups: Group A underwent
endoscopic tympanoplasty, while Group B underwent microscopic
tympanoplasty. Graft uptake was assessed at 30 days post-operation,
and hearing improvement was evaluated using audiometric testing.
Results: Graft uptake was successful in 90% of patients in Group B and
83.33% in Group A. Post-operative hearing gain was similar between the
two groups, with mean improvements of 9.29 dB in Group A and 10 dB in
Group B. No significant differences were observed in graft uptake or
hearing outcomes between the two techniques.
Conclusion: Both endoscopic and microscopic tympanoplasty
techniques yielded comparable graft uptake rates and hearing
improvements in patients with large tympanic membrane perforations,
indicating that the choice of technique should be based on surgeon
preference rather than expected outcomes. Further studies with larger
cohorts are warranted to confirm these findings.
Introduction:
Hearing loss and deafness are significant global health issues, impacting over 1.5 billion
individuals, or nearly 20% of the world’s population. Among these, approximately 430 million
people experience disabling hearing loss, with predictions indicating that by 2050, around
700 million individuals will suffer from debilitating hearing impairments. Children are
particularly affected, with 34 million children worldwide being deaf or having hearing loss,
60% of which are preventable. In Bangladesh, disabling hearing loss affects about 9.6% of
the population, with chronic otitis media (COM) emerging as a leading cause. COM,
characterized by the inflammation of the middle ear and mastoid cavity, often results in
persistent ear discharge through perforations in the tympanic membrane. This condition
poses a substantial challenge for children in developing countries, impacting their speech,
cognitive, educational, and psychological development.
Tympanoplasty is a surgical procedure commonly performed to treat COM, aiming to repair
tympanic membrane perforations and restore hearing function. First described in 1953, this
procedure is vital for managing middle ear pathologies, such as COM and cholesteatoma,
and has been refined over the years. For patients with inactive mucosal COM, Type 1
tympanoplasty, or myringoplasty, is typically the preferred approach. This procedure involves
reconstructing the tympanic membrane using graft material, such as temporalis fascia, while
preserving the integrity of other middle ear structures.
Traditionally, tympanoplasty has been performed using an operating microscope, which
provides excellent visualization of the surgical field. However, this method has certain
limitations, particularly in accessing specific areas of the middle ear. In recent years,
endoscopy has gained popularity in middle ear surgery, offering advantages such as a wider
field of view, high magnification, and the ability to achieve angled views, which facilitate
comprehensive visual access to the surgical site. Endoscopic tympanoplasty is also
associated with reduced soft tissue dissection, potentially enhancing graft uptake and
promoting successful healing outcomes. Despite these promising developments, there is
limited data comparing the surgical outcomes of endoscopic and microscopic approaches in
Type 1 tympanoplasty, particularly concerning graft uptake success in patients with large
tympanic membrane perforations.
Given that chronic otitis media is prevalent in Bangladesh, especially among rural
populations with limited access to advanced healthcare, understanding the comparative
effectiveness of these surgical techniques is crucial. While microscopic tympanoplasty is
effective, it often poses challenges due to the high cost and maintenance requirements
associated with microscopy equipment. In contrast, endoscopes are more accessible,
affordable, and portable, making them a valuable option for both diagnostic and surgical
procedures.
This study aims to explore the feasibility and success rates of endoscopic versus
microscopic Type 1 tympanoplasty, specifically focusing on the uptake of temporalis fascia
grafts in patients with large tympanic membrane perforations. By examining postoperative
outcomes and addressing the research question of whether endoscopic techniques yield
better graft uptake compared to traditional microscopic approaches, this research endeavors
to provide insights that could guide surgical decision-making and improve outcomes for
patients undergoing tympanoplasty for large tympanic membrane perforations.
Methodology:
The methodology for the research study on the comparison of temporalis fascia graft uptake
in patients with large tympanic membrane perforation undergoing Type 1 tympanoplasty
involved a prospective cohort study conducted at the Department of Otolaryngology-Head &
Neck Surgery of Sir Salimullah Medical College Mitford Hospital from July 2022 to June
2023.
The study population consisted of patients diagnosed with large tympanic membrane
perforations requiring Type 1 tympanoplasty. Participants were selected based on specific
inclusion criteria, which included being within the age range of 15 to 55 years, having a
patent eustachian tube confirmed by impedance audiometry, and presenting with a hearing
loss of 20-55 dB. Exclusion criteria included patients with sensorineural or mixed hearing
loss, active ear disease, previous revision surgeries, narrow ear canals, and chronic
respiratory conditions such as bronchial asthma or COPD.
A purposive sampling technique was employed to create two groups. Odd-numbered
patients were allocated to the endoscopic procedure group, while even-numbered patients
were assigned to the microscopic procedure group. The sample size calculation was based
on previous studies, which indicated mean hearing gains and standard deviations for both
endoscopic and microscopic groups. The minimum required sample size was calculated
using a statistical formula that accounted for significance levels and effect sizes, resulting in
a final adjusted sample size of 60 patients, with 30 in each group.
Prior to the surgical procedure, informed consent was obtained from all participants or their
legal guardians. A thorough history and clinical examination were conducted, followed by
preoperative pure tone audiometry to assess hearing levels. Intraoperative documentation
was maintained, particularly regarding any injury to the chorda tympani nerve. Post-
operative assessments were performed on the first and seventh days using a pain scale
grading system, and follow-ups were scheduled for six weeks post-operation to evaluate
graft uptake and hearing status.
All surgeries were performed under general anesthesia with endotracheal intubation by
experienced otolaryngologists. Type 1 tympanoplasty was conducted using temporalis fascia
as the graft material. For the endoscopic group, a transcanal approach was utilized, while
the microscopic group underwent a postauricular approach. Grafts were placed using the
underlay technique, and hemostatic measures were taken. Post-operative care included the
use of aural packs and prophylactic antibiotics.
Data analysis involved statistical evaluation using Microsoft Office software. The results
were presented as mean ± standard deviation or percentages. Statistical significance was
determined using chi-square tests for qualitative data and independent t-tests for hearing
status comparison, with a p-value of less than 0.05 considered statistically significant.
Ethical considerations were adhered to, with approval obtained from the research review
committee and ethical clearance from the Institutional Ethics Committee. Participants were
informed of the study's nature, risks, and benefits, ensuring confidentiality and voluntary
participation throughout the research process.
Results
A total of 60 patients with large tympanic membrane perforations were included in the study,
all of whom underwent Type 1 tympanoplasty using temporalis fascia grafts. The subjects
were divided into two groups: Group A underwent endoscopic tympanoplasty, while Group B
underwent microscopic tympanoplasty.
Age Distribution
The age distribution of the study participants revealed that the majority fell within the 15-24
years age group. The following table illustrates the distribution of age across both groups:
Age Group Endoscopic Mean Microscopic Mean
(years) Tympanoplasty (Group Age Tympanoplasty (Group Age
A) B)
15-24 15 (50%) 26.5 15 (50%) -
25-34 8 (26.7%) - 7 (23.4%) -
35-44 3 (10%) - 4 (13.3%) 29.8
45-55 4 (13.3%) - 4 (13.3%) -
Total 30 (100%) 30 (100%)
Sex Distribution
The sex distribution indicated a higher proportion of males in Group A (60%) compared to
females, while Group B had a greater number of females (56%). Overall, the male-to-female
ratio across both groups was approximately 3:2.
Residential Status
The majority of patients resided in urban areas, with 14 out of 30 in Group A and 11 out of
30 in Group B.
Socioeconomic Status
Most patients (26) belonged to lower socioeconomic conditions, with 20 in Group A and 16 in
Group B. This trend may be attributed to the higher prevalence of chronic otitis media (COM)
in populations with limited access to nutrition, hygiene, and healthcare.
Side of Perforation
Analysis of perforation sides showed that 14 patients (46.67%) in Group A and 17 patients
(56.67%) in Group B had right-sided tympanic membrane perforations, suggesting a
possible trend for right-sided perforations in the general population.
Size of Perforation
In Group A, 23.33% of patients had small perforations, 40% had medium perforations,
16.67% had large perforations, and 20% had subtotal perforations.
Graft Uptake Rates
Postoperatively, the graft uptake rate was assessed at the 30-day follow-up. In Group A, 22
out of 30 patients (73.33%) had successful graft uptake, while 24 out of 30 patients (80%) in
Group B achieved the same outcome. This comparison indicates a favorable outcome for
both surgical approaches, with no statistically significant difference in graft success rates
between the two groups, as shown in the following table:
Interventi Uptake Faile Tot Graft Success Graft Failed χ² P-
on n d al Percentage Percentage value
Group A 25 5 30 83.33% 16.67% 0.5 0.45
8
Group B 27 3 30 90% 10% - -
Hearing Gain Comparison
Hearing outcomes were measured preoperatively and postoperatively across different
perforation sizes. No statistically significant differences in hearing gains were observed
between the two surgical techniques for small, medium, large, or subtotal perforations.
Postoperative Complications
The incidence of complications was recorded, with Group A exhibiting a complication rate of
3.33% and Group B a rate of 10%. Statistical analysis revealed no significant difference
between the groups in terms of complications.
Pain Scores
Pain assessments at the first postoperative day (POD) showed a mean pain score of 4.3 ±
0.87 in Group A compared to 6.1 ± 0.81 in Group B, indicating statistically significant lower
pain levels in the endoscopic group (p < 0.05). However, pain scores recorded on the 7th
POD were similar across both groups, with Group A scoring 4.2 ± 0.76 and Group B scoring
4.4 ± 1.00, leading to a p-value greater than 0.05, indicating no significant difference.
In summary, the study found comparable outcomes in terms of graft uptake rates, hearing
gains, and complication rates between endoscopic and microscopic tympanoplasty in
patients with large tympanic membrane perforations. Notably, the endoscopic approach was
associated with significantly lower pain scores in the immediate postoperative period.
Discussion
In this study, we examined the comparison of temporalis fascia graft uptake in patients with
large tympanic membrane perforation undergoing Type 1 tympanoplasty. Our patient
population consisted of individuals aged between 15 and 55 years, which aligns with typical
demographic patterns observed in previous studies related to tympanic membrane issues.
The patients were divided into two groups based on the grafting technique used, with odd-
numbered patients undergoing endoscopic tympanoplasty and even-numbered patients
undergoing microscopic tympanoplasty.
The mean age of participants in our study was 26.5 years for the endoscopic group and 29.8
years for the microscopic group. This age distribution is consistent with existing literature,
which often indicates a higher prevalence of tympanic membrane perforations among
younger individuals due to increased susceptibility to respiratory infections and
environmental factors. The predominance of younger patients in our study may reflect
heightened awareness of ear health and access to medical care.
In terms of sex distribution, our findings showed that the endoscopic group had a higher
proportion of male patients (60%) compared to the microscopic group (43%). While our
overall male-to-female ratio of 3:2 is similar to other studies, such as Tawab et al. (2014), the
differences in gender ratios highlight variations in patient demographics that may influence
clinical outcomes.
Geographical and socioeconomic factors were also notable in our findings. Most patients in
both groups were from urban areas, suggesting better access to healthcare resources and
awareness regarding tympanic membrane issues among urban populations. Conversely, the
lower representation of patients from slum areas indicates potential barriers to healthcare
access. The high prevalence of patients from lower socioeconomic backgrounds aligns with
findings from Adoga et al. (2010), which emphasize the correlation between socioeconomic
status and health outcomes.
Our analysis of tympanic membrane perforation characteristics revealed that a significant
number of patients in both groups had right-sided perforations, with a right-to-left ratio of
approximately 1.4:1.0. This is consistent with studies indicating side predominance in
perforation occurrences, although variations exist across different studies. The majority of
patients had medium-sized perforations, correlating with findings from previous research that
suggests medium-sized perforations are most common in tympanoplasty cases.
The graft uptake rates observed in our study were significant, with 90% of grafts successfully
taken in the microscopic group compared to 83.33% in the endoscopic group. While our
findings contrast with some studies that report higher graft uptake rates in endoscopic
tympanoplasty (Choi et al., 2017; Ravi et al., 2021), they are in line with other research (Jain
et al., 2018; Bingel et al., 2007) suggesting that microscopic techniques may yield higher
success rates. The lack of statistical significance in graft uptake between the two groups, as
indicated by the chi-square test results, suggests that both techniques can be effective,
though patient-specific factors may play a crucial role in outcomes.
Moreover, the size of the tympanic membrane perforation was directly related to graft uptake
success, echoing findings from previous literature that larger perforations are associated
with decreased graft success rates. Our results demonstrate that small and medium
perforations had 100% graft uptake success, whereas larger and subtotal perforations
showed higher failure rates. This underscores the importance of perforation size in predicting
surgical outcomes and aligns with the conclusions of Smyth et al. (1976) and Ahmed &
Palliyalippadi (2016).
Hearing assessment post-operatively revealed that both groups achieved notable hearing
gains, though there were no statistically significant differences in outcomes between the
endoscopic and microscopic techniques. Mean hearing gains were comparable across both
groups, which aligns with findings from similar studies, including Kawale et al. (2023) and
Harugop et al. (2008). The lack of significant difference suggests that both surgical
approaches effectively restore hearing capabilities in patients with large tympanic membrane
perforations.
Post-operative complications were less frequent in the endoscopic group (13.3%) compared
to the microscopic group (23.33%), though the difference was not statistically significant.
This finding is crucial as it indicates a trend toward reduced complication rates in endoscopic
procedures, which may enhance patient satisfaction and outcomes. Additionally, pain scores
were significantly lower in the endoscopic group, supporting the notion that endoscopic
techniques may result in less tissue trauma and discomfort for patients.
In conclusion, our study demonstrates that both endoscopic and microscopic tympanoplasty
techniques can achieve favorable graft uptake and hearing improvement in patients with
large tympanic membrane perforations. While graft uptake rates were slightly higher in the
microscopic group, both techniques proved effective, with endoscopic approaches offering
advantages in terms of reduced complications and pain scores. Further research with larger
sample sizes and longer follow-up periods is needed to solidify these findings and explore
additional factors influencing surgical outcomes in tympanoplasty.
Conclusion
This study compared graft uptake in patients with large tympanic membrane perforations
undergoing Type 1 tympanoplasty using temporalis fascia grafts. Both endoscopic and
microscopic techniques showed similar graft success rates and post-operative hearing
improvement, suggesting that the choice of surgical approach can be based on surgeon
preference rather than anticipated outcomes.
Limitations
The study's limitations include a small sample size and single-center design, which may limit
the generalizability of the findings. Additionally, variations in surgical techniques and lack of
long-term follow-up restrict the evaluation of outcomes over time. Future research should
involve larger, multicenter studies with extended follow-up periods to validate these results.
___________________________
Abstract
Background: Managing a large tympanic membrane perforation almost
invariably involves hearing rehabilitation through tympanoplasty. Graft uptake
may be highly influenced by the choice of either an endoscopic or microscopic
modality.
Objective: This study aimed at comparing graft uptake rates and hearing results
for patients with large tympanic membrane perforations who received Type 1
tympanoplasty using temporalis fascia grafts via endoscopic and microscopic
modalities.
Materials and Methods: Sixty patients presenting with large-sized tympanic
membrane perforations were divided into two different groups, Group A
consisting of patients who underwent endoscopic tympanoplasty and Group B
consisting of patients who underwent microscopic tympanoplasty. The graft
uptake after 30 days of operation was analyzed and the hearing improvement
was noted by using audiometric tests.
Results: Graft uptake in Group B was 90% while in Group A it was 83.33%. The
average postoperative hearing gain in Group A and in Group B was 9.29 dB and
10 dB respectively. There has been no statistical difference found between the
two techniques regarding graft uptake and hearing outcome.
Conclusion: Both the endoscopic and microscopic tympanoplasty techniques
yielded equal graft uptake rates and hearing improvements in patients with
large tympanic membrane perforations, thus the choice of technique should
depend on surgeon preference rather than the expected outcome. More studies
are needed in larger cohorts for the validation of these results.
Introduction:
Hearing loss and deafness are great health burdens throughout the world,
presently affecting more than 1.5 billion, or approximately 20% of the world's
population. Of these, about 430 million have disabling hearing loss, and it is
estimated that by 2050, about 700 million people in the world will have
debilitating hearing impairment. Children are not spared, and almost 34 million
children around the world are deaf or suffering from hearing loss; 60% of this is
preventable. About 9.6% of the people in Bangladesh suffer from disabling
hearing loss, and COM is an emerging leading cause. COM is the inflammation of
the middle ear and mastoid cavity, often manifesting in the form of continuous
discharge through perforations of the tympanic membrane. The condition has
posed a high burden among children in developing countries, thus having
negative consequences on their speech, cognitive, educational, and
psychological development.
Tympanoplasty is one of the most commonest surgical operations conducted for
the treatment of COM to date, with primary objectives aimed at repairing
tympanic membrane perforations and restoring hearing function. This is a
procedure first described in 1953 and an integral part of the management of
middle ear pathologies, including COM and cholesteatoma; it has been refined
with time. In general, for patients with inactive mucosal COM, Type 1
tympanoplasty or myringoplasty is preferred. Surgery involves reconstructing
the tympanic membrane using graft material such as temporalis fascia while
preserving the integrity of other middle ear structures.
Traditionally, the operation of tympanoplasty has been performed with the use
of an operating microscope that allows excellent visualization of the surgical
field. However, this method has some limitations in accessing certain regions of
the middle ear. Over the past decade, there is growing interest in using
endoscopy in middle ear surgery because it allows better exposure of the field of
view, high magnification, and angled views-all advantages which confer very
good visual access to the site of surgery. Moreover, endoscopic tympanoplasty is
also associated with decreased soft tissue dissection, theoretically enhancing
graft uptake and successful healing outcomes. However, despite these
encouraging perspectives, there is limited data regarding the comparative
surgical outcome between the endoscopic and microscopic approaches of Type
1 tympanoplasty in terms of graft uptake in patients with large tympanic
membrane perforations.
It is indeed particularly common in the rural areas of Bangladesh, where most
people live and where access to more sophisticated health care is limited. Otitis
media, however, is not unique to Bangladesh; hence, understanding the relative
efficacies of these surgical techniques is paramount. Microscopic tympanoplasty
is by no means ineffective; however, there are very frequently issues concerning
high equipment costs and maintenance problems associated with microscopy.
On the other hand, endoscopes are generally more accessible, less costly, and
easily transportable-these make them an excellent tool not only for diagnosis
but also for therapy.
The current study will compare the feasibility and success rates of both
endoscopic and microscopic Type 1 tympanoplasty in terms of the temporal
fascia graft uptake in patients presenting with large tympanic membrane
perforations. This study looks into the postoperative outcomes and attempts to
provide answers to whether the endoscopic technique has better graft uptake
compared to the traditional microscopic approach. In this way, it hopefully
provides some insight that can help in making decisions during surgery, thereby
bringing better results to patients with large tympanic membrane perforations
undergoing tympanoplasty.
Methodology:
In the study regarding the comparison of the temporalis fascia graft uptake in
cases of large tympanic membrane perforation for Type 1 tympanoplasty, the
methodology will be as follows: a prospective cohort study conducted at the
Department of Otolaryngology-Head & Neck Surgery of Sir Salimullah Medical
College Mitford Hospital from July 2022 to June 2023. The study population will
include all the patients diagnosed with large tympanic membrane perforation
requiring Type 1 tympanoplasty. Participants were selected based on strict
criteria wherein the patient must be between 15 to 55 years of age; the patent
eustachian tube has been confirmed by impedance audiometry; and hearing
loss was between 20-55 dB. The exclusion criteria included sensorineural or
mixed hearing loss, active ear disease, prior revision surgeries, narrow ear
canals, and chronic respiratory conditions such as bronchial asthma or COPD.
Subjects were divided into two groups using a purposive sampling technique.
Odd-numbered patients were put into the endoscopic procedure group,
whereas even-numbered patients were put into the microscopic procedure
group. Sample size estimation was calculated based on previous studies
showing the mean hearing gain for both the groups with standard deviation. The
sample size was estimated by using a statistical formula incorporating
significance levels and effect sizes that yielded an adjusted sample size of 60
patients, 30 in each group.
Informed consent was taken from all participants or their guardians prior to the
surgical intervention. Detailed history and clinical examination were performed
and followed by preoperative pure tone audiometry depicting hearing levels.
Intraoperative documentation was performed, especially any injury to the
chorda tympani nerve. The post-operative assessments were done on the first
and seventh days using a pain scale grading system, and follow-ups were
scheduled for six weeks post-operation to assess graft uptake and hearing
status.
All the surgeries were performed under general anesthesia with endotracheal
intubation by otolaryngologists who had adequate experience in the surgical
field. The graft material used during type 1 tympanoplasty was temporalis fascia.
The endoscopic group received a transcanal approach whereas the microscopic
group received a postauricular approach. The grafts were thus placed using the
underlay technique. Hemostatic measures were taken and post-operative care
included aural packs and the use of prophylactic antibiotics.
The analysis of data was done through a statistical assessment by using
Microsoft Office software. The results have been expressed as mean ± SD or
percentages. Statistical significance was done by chi-square tests in qualitative
data, and to compare hearing status, independent t-test; p-value < 0.05 was
considered to be statistically significant.
Ethical considerations were followed to the latter by having approval from the
research review committee and ethical clearance from the Institutional Ethics
Committee. The participants were also informed of the nature of the study, the
risks, and benefits of the study, during which confidentiality and voluntary
participation throughout the process were considered.
Results
Group A consisted of patients who underwent endoscopic tympanoplasty, while
Group B consisted of patients who underwent microscopic tympanoplasty. Sixty
patients with large perforations of the tympanic membrane underwent Type 1
tympanoplasty performed with temporalis fascia grafts. The subjects were
further divided into two groups.
The distribution according to age in the study population was such that the
highest number of patients belonged to the 15-24-year-old age bracket. The age
distribution in both groups is as follows (table below):
Age Group (years)
Endoscopic Tympanoplasty
(Group A)
Mean Age
Microscopic Tympanoplasty
(Group B)
Mean Age
15-24
15 (50%)
26.5
15 (50%)
-
25-34
8 (26.7%)
-
7 (23.4%)
-
35-44
3 (10%)
-
4 (13.3%)
29.8
45-55
4 (13.3%)
-
4 (13.3%)
-
Total
30 (100%)
30 (100%)
Sex Distribution
The sex distribution revealed that in Group A, there were more males, 60%, than
females, while in Group B, the female sex was predominant, 56% In general, the
male to female ratio in both groups was roughly 3:2.
Residential Status
There were 14 urban patients out of 30 in Group A and 11 out of 30 in Group B.
Socioeconomic Status
Most of the patients, 26, were from the lower socioeconomic class. Group A
consisted of 20 such patients while Group B had 16. This trend may be because
the prevalence of COM is higher in populations devoid of nutrition, hygiene and
health care.
Side of Perforation
Analysis of the laterality of perforation showed that 14 patients, 46.67%, in
Group A and 17 patients, 56.67%, in Group B had perforation of the right
tympanic membrane, which indicates a possible trend in the general population
towards right-sided perforation.
Size of Perforation
For the size of perforation, it was observed that the cases showed 23.33% small,
40% medium, 16.67% large, and 20% subtotal in Group A.
Graft Take-Up Rates
The postoperative graft uptake rate was measured on follow-up at 30 days. In
Group A, 22 out of 30 patients had taken up the graft successfully, accounting
for 73.33%. In Group B, the uptake was successful in 24 out of 30 patients,
accounting for 80%. This comparison will be indicative of a favorable outcome
from the two surgical approaches. There is no statistically significant difference
in graft success rates between the two groups, as evidenced in the table below.
Intervention
Uptaken
Failed
Total
Graft Success Percentage
Graft Failed Percentage
χ²
P-value
Group A
25
5
30
83.33%
16.67%
0.58
0.45
Group B
27
3
30
90%
10%
-
-
Noise Hearing Gain Comparison
In the following table, hearing outcomes for various sizes of perforation were
measured preoperatively and postoperatively: For small, medium, large, and
subtotal perforations, the differences in hearing gain between the two surgical
techniques were not statistically significant.
Postoperative Complications
The incidence of complications was noted. Complication rate in Group A was
3.33% and that in Group B was 10%. On statistical analysis, no significant
difference was found among the groups regarding complications.
Pain Scores
Pain assessments at POD-1st postoperative day-revealed a mean pain score in
Group A of 4.3 ± 0.87 versus 6.1 ± 0.81 in Group B, thus noting statistically
significant lower levels of pain in the endoscopic group, with p < 0.05. This is
because there was no statistical difference between the two groups, as pain
scores recorded on the 7th POD were, in fact, similar: Group A scored 4.2 ± 0.76
while Group B scored 4.4 ± 1.00, yielding a p-value of greater than 0.05.
In essence, this study elicited the same findings regarding graft uptake rates,
hearing gains, and complication rates following either endoscopic or microscopic
tympanoplasty for patients with large tympanic membrane perforations. More
important, however, was that the endoscopic approach produced lesser pain
scores in the immediate postoperative period.
Discussion
The present study was performed to evaluate the difference in uptake of
temporalis fascia graft among patients with large tympanic membrane
perforation following Type 1 tympanoplasty. As far as our observation is
concerned, we have included patients from 15 to 55 years in age, which reflects
typical demographic features observed in other similar studies associated with
the tympanic membrane. Patients were then divided into two categories
depending on the grafting technique: odd-numbered patients were subjected to
endoscopic tympanoplasty and even-numbered patients were given microscopic
tympanoplasty.
In our study, the mean age was 26.5 years for the endoscopic group and 29.8
years for the microscopic group. The age distribution seems logical and
consistent with most studies that invariably report a higher tympanic membrane
perforation rate among younger people, presumably because they have high
susceptibility to respiratory infections and environmental factors. Younger age
groups may reflect better awareness of ear health and utilization of available
medical services.
Concerning the sex distribution, our findings revealed that there were more
males in the endoscopic group of patients - 60 percent compared to the
microscopic group, which stood at 43 percent - even though our overall ratio
was 3:2 for males to females, just like many other works, for instance, Tawab et
al. (2014). The discrepancy in gender ratios reflects a difference in demographics
of the patient population that could affect the clinical outcomes.
Geographical and socio-economic background also featured in our results. It was
observed that the majority of both groups came from an urban background,
which could reflect improved health facilities and higher awareness about
tympanic membrane issues among the urban populations. Relatively less
number of patients belonged to slum areas, showing a potential barrier to
healthcare access. This was thought to be representative of the very high
prevalence rates seen among lower socioeconomic groups and is in line with
observations made by Adoga et al. (2010) that there is a direct relationship
between socioeconomic status and health.
Our analysis of the characteristics of the tympanic membrane perforation
indicated that the majority of the patients in both groups had right-sided
perforations at a right-to-left ratio of about 1.4:1.0. This agrees with several
studies showing that the occurrence of perforation predominates on one side,
though at a variable ratio in different studies. Medium-sized perforations
predominated in most of the patients, as expected and supported by other
studies stating that most perforations are of medium size in cases going for
tympanoplasty.
The overall rate of graft uptake in our series was remarkable, with 90% in the
microscopic group and 83.33% in the endoscopic group. The findings are in
contrast to some studies reporting higher graft uptake rates after endoscopic
tympanoplasty (Choi et al. 2017; Ravi et al. 2021) and are in concert with findings
from studies that microscopic approaches may yield higher success rates (Jain et
al. 2018; Bingel et al. 2007). Though the χ2 test for graft uptake did not show any
significant results between the two groups, it might be assumed that both
techniques stand a good chance; a lot might depend on the factors related to
the patient.
Again, the size of the perforation of the tympanic membrane was also directly
related to graft uptake success, which echoes previous literature findings that
larger perforations have reduced graft uptake rates. In summary, it was clear
from our findings that small and medium perforations had 100% graft uptake
success while larger and subtotal perforations resulted in a higher failure rate.
The size of the perforation was also a very important prognostic factor for
predicting surgical outcomes, which is in agreement with those by Smyth et al.
(1976) and Ahmed & Palliyalippadi (2016).
Whereas assessing hearing post-operatively, significant hearing gains were
realized by both groups, with no statistically significant differences in the
outcomes of the endoscopic and microscopic techniques. The mean hearing
gain was similar in both groups, which corresponded to similar studies, such as
Kawale et al., 2023; and Harugop et al., 2008. There is no significance in this
difference, therefore suggesting that both surgical techniques are effective in
restoring hearing capabilities among patients with large tympanic membrane
perforations.
In the series, postoperative complications were fewer in the endoscopic group-
13.3% compared to the microscopic group, which accounted for 23.33%, though
the difference was statistically insignificant. This finding is important because it
suggests a trend toward lower complication rates in endoscopic procedures that
could improve patient comfort and overall outcomes. Furthermore, pain scores
were significantly lower in the endoscopic group, thus supporting the fact that
endoscopic techniques may result in less tissue trauma and discomfort to the
patient.
Thus, the final result of our study is that both endoscopic and microscopic
tympanoplasty techniques have shown good graft uptake and hearing
improvement in patients with large tympanic membrane perforations. While the
graft uptake rates were marginally higher in the microscopic group, both
techniques have been effective, with advantages of the endoscopic approach
including reduced complications and pain scores. Thus, the establishment of
these findings through larger samples with longer follow-up periods may be
required, taking into consideration other factors that may affect surgical results
of tympanoplasty.
Conclusion
This study compared graft uptake in patients with large tympanic membrane
perforations who underwent Type 1 tympanoplasty using temporalis fascia
grafts. Both endoscopic and microscopic techniques had comparable graft
success rates and improvement in hearing post-operatively, thus indicating the
choice of the surgical approach based on a surgeon's preference and not an
anticipated outcome .
Limitations
Certain limitations of this study that may not allow generalization of findings are
the small sample size and a single-center design. Variability in surgical
techniques and short-term follow-up further limits the assessment of temporal
outcomes. Future studies need to be done with larger, multiple centers and
longer follow-ups to authenticate this study.
