Tympanoplasty in the Setting of Complex Middle Ear Pathology: A Systematic Review

Abstract

Objective:

To assess the prognostic factors for anatomic and hearing success after tympanoplasty in the setting of complex middle ear pathology.

Methods:

A systematic review was performed in January 2022. English-language articles describing outcome data for tympanoplasty repair variables including underlying pathology, perforation location, smoking status, graft technique, reconstruction material, anatomic success, and hearing success were extracted. Articles were included when tympanosclerosis, retraction pockets, adhesions, cholesteatoma, chronic suppurative otitis media, anterior perforations, and smoking were included. Underlying pathology, perforation location, smoking status, graft technique, reconstruction material, anatomic success, and hearing success were extracted. Any factors analyzed as potential indicators of success were sought out.

Results:

Data sources included PubMed, OVID, Cochrane, Web of Science, Scopus, and manual search of bibliographies. Ninety-three articles met final criteria, which accounted for 6685 patients. Fifty articles presented data on both anatomic and hearing outcomes, 32 articles presented data on anatomic outcomes only, and 11 articles presented data on hearing outcomes only. This systematic review found that adhesions and tympanosclerosis were prognostic factors for poorer hearing. Additionally, smoking and tympanosclerosis may be predictive of anatomic failure; however, the significance of this finding was mixed in included studies. This analysis is significantly limited by both the heterogeneity within the patients and the lack of controls.

Conclusion:

Adhesions and tympanosclerosis were prognostic factors for poorer hearing. Clearly documented methods and outcomes for the included pathologies could lead to more definitive conclusions regarding prognostic factors for success.

Level of Evidence:

Keywords

middle ear pathology surgical outcomes hearing outcomes tympanoplasty adhesive

Introduction

Tympanoplasty was introduced in the early 1950s by Zollner¹ and Wullstein.² The goals of tympanoplasty are to achieve an intact tympanic membrane, improve hearing, and repair the middle ear cavity when necessary. Reported success rates range from 35% to 100%^3,4; much of this variability stems from authors’ differing definitions of success. Many authors report high success rates for simple tympanic membrane repair, but several ear pathologies can complicate tympanoplasty and reduce favorable outcomes. While extensive literature exists regarding simple tympanic membrane repair, significantly less data is available regarding tympanoplasty repair complicated by other pathology.

The goal of this systematic review was to investigate potential prognostic factors for success in complicated cases of tympanoplasty repair which included underlying pathology of tympanosclerosis, retraction pockets, cholesteatoma, chronic suppurative otitis media (CSOM), anterior perforations, and smoking. We reviewed prospective and retrospective studies which analyzed graft technique, ossicular reconstruction material, and these factors’ subsequent impact on anatomic or functional success. To our knowledge, this is the first systematic review to analyze the overall impact of middle ear pathology on tympanoplasty outcomes and examine prognostic factors for success in that setting.

Methods

The systematic review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines⁵ (Figure 1). The PICO question (Population (P), Intervention (I), Comparison (C), Outcome (O)) was: for patients of any age undergoing tympanoplasty, does the presence of tympanosclerosis, retraction pockets, cholesteatoma, chronic suppurative otitis media, anterior perforations, or smoking predict anatomic or hearing success? A comprehensive search of PubMed, OVID, Cochrane, Web of Science, and Scopus was used searching for English-language publications dating from January 2010 to December 2021. Keywords searched included: ((((((tympanoplasty[mesh]) OR (tympanoplast*[tiab])) OR (myringoplasty[mesh])) OR (myringoplast*[tiab])) OR (repair*[tiab] AND (tympanic membrane[mesh] OR tympanic membrane*[tiab]))) AND ((((prognosis[mesh]) OR (prognos*[tiab])) OR (predict*[tiab])) OR (determinant*[tiab]))) AND (success*[tiab]) AND english[lang].

Prospective and retrospective articles investigating tympanoplasty repair were considered. Authors (J.A.G. and C.I.C.) independently screened titles, abstracts, and full text publication. Participants of any age undergoing tympanoplasty repair were considered for inclusion, with no minimum length of follow-up required. Non-English language publications and articles published prior to 2010 were excluded. Studies lacking explicit outcome data for tympanoplasty repair for tympanosclerosis, retraction pockets, cholesteatoma, chronic suppurative otitis media, anterior perforations, and smoking were excluded. Reference lists of selected publications were reviewed for additional articles.

One author (J.A.G.) extracted data from selected studies, which was reviewed by a second author (C.I.C.). Information extracted included characteristics of patients, intervention type, outcome measures, and factors analyzed as potential indicators of success. Primary investigators of selected studies were not contacted to obtain data. Patient information was extracted regarding underlying pathology, perforation location, and smoking status. Intervention information was noted, including graft technique, reconstruction material, reconstruction technique, and performance of associated mastoidectomy and ossiculoplasty. Outcome measures included anatomic success (intact graft) and functional success (hearing improvement indicated by reduction of the air-bone gap (ABG)). The Methodological Index for Non-Randomized Studies (MINORS) Criteria was used to assess the quality of studies and risk of bias (Supplemental Table 1).⁶

Results

Initial literature searches yielded 637 potential studies. Further screening and matching to inclusion criteria resulted in 93 studies qualifying for analysis in this review (Figure 1).

Smoking Impact

Ten studies assessed the impact of smoking on tympanoplasty success. Two studies found smoking to increase risk for anatomic failure^7,8 while one found smoking to have significantly lower rates of functional success (Table 1).⁹

Table 1.

Summary of Articles Discussing Impact of Smoking on Tympanoplasty Outcomes.

Authors	Graft material	Graft technique	Number of smoking cases	Minimum follow-up	Mean follow-up	Anatomic outcomes	Functional outcomes	Other outcomes
Chen et al.⁷	Silastic sheet or gelfoam	Overlay	14	3 mo	N/A	Graft success = 3/14 (21.4%)^a, significantly worse OR on univariate and multivariate analysis (OR 0.1614) compared to nonsmokers	N/A	N/A
Salvador et al⁸	Temporalis fascia vs composite perichondrium/cartilage island flap (PCIF)	Underlay	30	12 mo	N/A	Anatomic success smokers = 17/30(56.7%)^a vs nonsmokers (79.2%); smoking found to be predictor of anatomic failure on univariate (OR = 2.91) and multivariate (OR = 3.29) analysis	N/A	N/A
Jung et al⁹	N/A	N/A	18	12 mo	17 mo	N/A	12/18 (66.7%) success rate (defined as more than 1 of following: postoperative ABG ≤ 20 dB, air gain ≥15 dB, or postoperative air conduction < 30 dB; significantly worse than non-smoking group (433/508 = 85.2%)^a	N/A
Naderpour et al¹⁰	Temporalis fascia	Underlay	18	12 wk	N/A	Graft success smokers = 88.8%, graft success nonsmokers = 95.2%	Hearing success (postoperative ABG ≤ 20 dB) smokers = 94.4%, hearing success nonsmokers = 92.8%	N/A
Lima et al.¹¹	N/A	Underlay	8	60 d	N/A	Graft integration smokers = 100%, graft integration nonsmokers = 93.5%, smoking status did not significantly impact graft integration	N/A	N/A
Salviz et al.¹²	Temporalis fascia or perichondrium-cartilage island flap(PCIF)	Underlay	31—history of smoking	6 mo	N/A	Temporalis fascia graft—anatomic success smokers = 66.7% vs anatomic success nonsmokers = 76.5%; PCIF graft—anatomic success smokers = 80% vs anatomic success nonsmokers = 93.3%	Mean PTA improvement smokers = 12.0 dB vs mean PTA improvement nonsmokers = 14.0 dB	N/A
Albu et al¹³	Temporalis fascia	Underlay	77	1 y	N/A	Graft success rate = 71%^b, univariate analysis—nonsmoker status significant predictor of success, multivariate analysis—nonsmoker status not significant predictor of success	N/A	N/A
Coelho et al.¹⁴	Cartilage	Cartilage shield technique or modified mosaic technique	45	N/A	Smokers = 18.4 mo, nonsmokers = 32.6 mo	Overall graft take rate—smokers (88.9%) vs nonsmokers(95.2%); graft take rate with minimum 12 month follow up—smokers(92.9%) vs nonsmokers(90.6%); rate of recurrence or persistent disease requiring further operation smokers(13.3%) vs nonsmokers(4.7%)(P = .09)	Mean ABG decrease—smokers(3.5 dB) vs nonsmokers(10.4 dB)	Smokers were significantly more likely to have cholesteatoma and need mastoidectomy, nonsmokers had significantly longer mean follow up period
Babu et al¹⁵	N/A	Over under(OUT) or medial technique	10 smokers, 13 exposed to secondhand smoke	18 mo	OUT group = 25.6 mo, medial group = 26.1 mo	Smoking and secondhand smoke did not significantly impact graft healing	N/A	N/A
Niazi et al¹⁶	N/A	End-aural (n = 9) or permeatal (n = 10)	19	6 mo	N/A	15/18 (78.9%) graft take	N/A	N/A

Statistically significant difference between groups.

Significantly worse than nonsmokers.

Middle Ear Adhesions

Six studies reported tympanoplasty outcomes in the presence of middle ear adhesions (Table 2). Five studies assessed anatomic outcomes which yielded graft take rates ranging from 83.33% to 100%.^4,17
-20 Hearing success was worse among the adhesion group than the non-adhesion group¹⁷ and anatomic success did not differ between the two.

Table 2.

Summary of Articles Discussing Outcomes of Tympanoplasty With Adhesions.

Authors	Graft material	Graft technique	Reconstruction material	Number of adhesion cases	Minimum follow-up	Mean follow-up	Anatomic outcomes	Functional outcomes	Other outcomes
Neumann et al.⁴	Cartilage	Cartilage palisade technique	Titanium	8	N/A	9.1 y	Graft take = 100%	N/A	N/A
Lesinskas and Stankeviciute¹⁷	Cartilage perichondrium composite	N/A	N/A	51	6 mo	Primary group = 8.2 mo, revision group = 11.9 mo	Graft take rate—primary tympanoplasty = 94.2%, revision tympanoplasty = 92.3%	Successful hearing(postoperative ABG < 20 dB)—primary tympanoplasty = 58.8%^b, revision tympanoplasty = 64.7%, primary tympanoplasty hearing outcomes significantly worse in adhesion group than non-adhesion group(82.9%)	N/A
Yurttas et al.¹⁸	Cartilage island	Underlay	N/A	6	N/A	15.3 mo	Graft take rate = 83.33%	N/A	N/A
Lou¹⁹	Tragal cartilage perichondrium composite graft	Underlay technique	N/A	26	24 mo	27.32 mo	Anatomic success = 23/26 (88.46%)	Mean preoperative ABG = 25.47 dB, mean postoperative ABG = 10.79 dB^a; functional success rate (ABG <= 20 dB) =22/26 (84.62%)	N/A
Sevil et al.²⁰	Tragal cartilage	N/A	N/A	3	N/A	N/A	3/3 (100%) success rate	N/A	N/A
Lee and Cho²¹	Tragal cartilage perichondrium	Transcanal totally endoscopic assisted technique	N/A	9	N/A	N/A	N/A	Mean AC gain = 2.30 dB, mean ABG gain = 3.50 dB	N/A

Significantly improved from preoperative value.

Significantly different from non-adhesion group

Retraction Pockets

Seven studies discussed outcomes in cases with retraction pockets (Table 3). Five studies reported anatomic outcomes with graft success ranging from 60% to 100%.^22
-26 None of the included studies compared anatomic success in cases with retraction pockets to cases without. Four studies assessed hearing outcomes ^23,25,27,28; however, only one of these compared success of cases with retraction pockets to cases without, finding that the presence of retraction pockets did not significantly impact hearing outcomes.²⁸

Table 3.

Summary of Articles Discussing Outcomes of Tympanoplasty With Retraction Pockets.

Authors	Graft material	Graft technique	Reconstruction material	Number of tympanoplasty procedures with retraction pocket	Minimum follow-up	Mean follow-up	Anatomic outcomes	Functional outcomes	Other outcomes
Comacchio et al.²²	Cartilage	N/A	N/A	25	N/A	6.16 y	Recurrence rate = 0%, all were Charachon stage II or stage III retraction pockets	N/A	N/A
Cassano and Cassano²³	Composite tragal cartilage-perichondrium	N/A	Autologous cartilage with perichondrium or synthetic ceramic or titanium	29	2 y	N/A	Anatomic success grade III retraction = 79.1%, anatomic success grade IV retraction = 60%, anatomic outcomes overall were significantly better than for the control group which consisted of 40 ears with untreated retraction pockets	Hearing success(postoperative ABG ≤ 10 dB) grade III = 47%, hearing success grade IV = 20%, rate of hearing success ossiculoplasty cases(N = 7) =71.4%	N/A
Khalilullah et al.²⁴	Tragal cartilage-perichondrum composite(N = 6) or temporalis fascia(N = 5)	N/A	N/A	11	12 wk	N/A	Graft uptake rate = 100%, postoperative retraction rate tragal cartilage-perichondrium composite = 0%, postoperative retraction rate temporalis fascia = 40%	N/A	N/A
Mierzwiński et al²⁵	Cartilage	N/A	N/A	25	N/A	5.3 y	Anatomic success short term = 88%, anatomic success long term = 82%	Preoperative mean ABG = 33 dB, short term postoperative mean ABG = 18.7 dB^a, long term postoperative mean ABG = 15.75 dB^a	No development of cholesteatoma
Shishegar et al.²⁶	Temporalis fascia	Underlay technique	N/A	11	6 mo	N/A	11/11 (100%) success at 3 month, 10/11 (90.9%) success at 6 month	N/A	N/A
Kasbekar et al²⁷	Tragal cartilage without perichondrium	Modified cartilage augmentation technique	N/A	42	N/A	38 mo	N/A	Mean ABG improvement Charachon stage II = 8.6 dB, mean ABG improvement Charachon stage III = 3 dB, ABG improvement rate stage II = 87%, ABG improvement rate stage III = 60%	N/A
Alaani and Raut²⁸	Conchal or tragal cartilage	N/A	Titanium	38	1 y	N/A	N/A	Presence of retraction pockets did not have significant impact on hearing outcomes	N/A

Significantly improved from preoperative value.

Tympanosclerosis

Six included studies presented outcomes of tympanoplasty in the presence of tympanosclerosis (Table 4). Two studies reported significantly worse anatomic outcomes in patients with tympanosclerosis.^8,29 Patients with tympanosclerosis had worse hearing outcomes than patients without tympanosclerosis.^17,29

Table 4.

Summary of Articles Discussing Outcomes of Tympanoplasty With Tympanosclerosis.

Authors	Graft material	Graft technique	Reconstruction material	Number of tympanosclerosis cases	Minimum follow-up	Mean follow-up	Anatomic outcomes	Functional outcomes	Other outcomes
Salvador et al⁸	Temporalis fascia vs composite perichondrium/cartilage island flap (PCIF)	Underlay	N/A	29	12 mo	N/A	Anatomic success = 10/29(34.5%)^a, significantly worse than normal or hyperplastic tissue; found to be predictor of anatomic failure on univariate (OR = 2.64) and multivariate (OR = 2.96) analysis	N/A	N/A
Lesinskas and Stankeviciute¹⁷	Tragal or conchal cartilage-perichondrium composite	Underlay	Modified autologous ossicle or titanium prosthesis	88	6 mo	Primary group = 8.2 mo, revision group = 11.9 mo	Graft take rate revision procedure = 88.5%, graft take rate primary procedure = 91.4%	Hearing success(postoperative ABG < 20 dB) revision procedure = 43.3%^a, hearing success primary procedure = 56.9%^a	N/A
Sevil et al.²⁰	Tragal cartilage	N/A	N/A	13	N/A	N/A	11/13 (84.6%), not significantly associated with graft success	N/A	Significant difference in proportion of patients with tympanosclerosis in older > 60(27.6%) vs younger 18-59 (9.7%) aged groups
Goncalves et al²⁹	Fascia, cartilage, or both	Underlay or overlay	N/A	9	6 mo	N/A	4/9 = 44.4%, significantly worse than cases without tympanosclerosis^a	5/9 = 55.6% for functional success (PTA < 20 dB), significantly worse than cases without tympanosclerosis^a	N/A
van Stekelenburg et al.³⁰	N/A	Endaural, endomeatal, postauricular, or transmeatal approach	N/A	33	2 mo	8.39 mo	24/33 (73%) anatomic success, not significantly different from no tympanosclerosis (75%)	N/A	N/A
Lima et al.¹¹	Temporalis fascia or tragal perichondrium	Underlay	N/A	13	60 d	N/A	Graft integration rate = 92.3%, presence of tympanosclerosis did not significantly impact anatomic success	N/A	N/A

Significantly worse than non tympanosclerosis group.

Chronic Suppurative Otitis Media (CSOM)

Twenty-six studies analyzed outcomes of tympanoplasty with an indication of chronic suppurative otitis media (Supplemental Table 2). None of these assessed the specific impact of suppuration on anatomic or functional success, instead focusing on different graft materials or techniques.

Twenty studies reported grafting technique, only one of which compared outcomes using multiple techniques in a single study.³¹ As predominantly single studies with different techniques, these publications could not be assessed for outcomes (Supplemental Table 2).

Anterior Perforations

Thirty-five studies provided data on tympanoplasty for anterior perforations (Supplemental Table 3). A single study found perforation location to be predictive of anatomic failure.⁸ The remaining studies showed that perforation location did not significantly impact anatomic^{10,26,29,30,32
-43} or functional^10,29,34,44 success.

Tympanoplasty in Cholesteatoma Cases

Twenty-four studies analyzed tympanoplasty repair in the presence of cholesteatoma (Supplemental Table 4). A single study claimed that the presence of cholesteatoma predicted anatomic failure; however, a statistical analysis supporting this claim was not presented.⁴⁵ Just 2 other studies analyzed the impact of presence of cholesteatoma on anatomic success and did not find it to predict failure compared to other causes of perforation⁴³ or other types of chronic ear inflammation.⁴⁶

Fifteen studies provided hearing outcomes for cholesteatoma cases. Five studies did not find a statistically significant difference in hearing outcomes when cholesteatoma was present^9,28,47
-49 while 1 study showed cholesteatoma cases had significantly worse hearing outcomes compared to other types of chronic ear inflammation.⁴⁶

Discussion

When tympanoplasty repair occurs in the presence of certain pathologies, colloquial wisdom is that the rate of success declines considerably. Despite this perception, a relative paucity of literature exists specifically analyzing tympanoplasty success in the face of these pathologies. Our goal was to determine the impact of these pathologies on outcomes and to identify potential predictors of success in more challenging surgical situations. Due to the small overall sample size of patients affected by each pathology, a meta-analysis was not appropriate.

Smoking

Ten studies analyzed the impact of smoking on tympanoplasty outcomes, 2 of which found smoking to be associated with anatomic failure.^7,8 None of the remaining studies found that smoking status significantly influenced success.^10
-15 Of these, two^10,12 studies yielded better anatomic outcomes in the nonsmoking group and one¹¹ showed higher anatomic success in the smoking group. Albu et al¹³ conducted a univariate analysis showing that nonsmoking status significantly predicted anatomic success. However, when the authors conducted a multivariate analysis on the same data, nonsmoking status was not considered a significant predictor of success.

The impact of smoking on hearing outcomes was assessed in just 4 studies.^9,10,12,14 Jung et al⁹ found rates of hearing success in smokers (66.7%) to be significantly lower than in nonsmokers (85.2%). Of the remaining studies, 2 showed better audiologic outcomes in the nonsmoking group^12,14 and one study had better hearing success in the smoking group.¹⁰ However, none of these findings met statistical significance.

Coelho et al.¹⁴ noted that a higher proportion of smokers (13.3%) than nonsmokers (4.7%) had recurrence or persistent disease requiring another operation, although this did not reach statistical significance (P = .09), and a power calculation was not presented; thus, a larger cohort may reveal a statistically significant difference.

Two studies found smoking status to be significantly associated with anatomic failure, while only one study found smoking to be significantly associated with worse hearing outcomes. Future authors should report their patients’ smoking status when assessing functional outcomes so a meta-analysis can be conducted to better characterize the impact of smoking on hearing success.

Adhesions

Six studies reported outcomes of tympanoplasty repair in the setting of adhesions. Lesinskas and Stankeviciute¹⁷ showed that graft take rate did not significantly differ between patients with and without adhesions for both primary and revision tympanoplasty. However, hearing success in primary tympanoplasty was significantly worse in the adhesion group than in the non- adhesion group. Revision tympanoplasty followed this trend but did not reach statistical significance. Lee and Cho²¹ showed that neither mean air conduction thresholds nor mean air bone gap improved significantly from adhesion patients’ preoperative values. In contrast to these studies, Lou¹⁹ found that mean ABG improved significantly from preoperative values and reported a hearing success rate of 84.62%. Of note, none of the studies reporting hearing outcomes utilized ossicular reconstruction as part of their procedure.^17,19,21 In patients with extensive middle ear adhesive disease, ossicular reconstruction is often not feasible due to lack of aeration.

The single study comparing patients with adhesions to those without found no significant difference in anatomic success.¹⁷ There were no particularly poorer anatomic outcomes to indicate a higher failure rate in cases with adhesions as compared to those without (graft success range 83.33%–100%) ^4,17
-20; however, significantly more data is required to make this conclusion.

Retraction Pockets

Seven studies discussed outcomes regarding tympanoplasty cases with retraction pockets. Only Alaani and Raut²⁸ analyzed the statistical significance of the presence of retraction pockets on hearing outcomes, finding no significant impact on audiologic success. Graft technique was reported in only 2 studies so no conclusions could be drawn regarding how technique impacted success.^26,27 Cassano and Cassano compared anatomic success of tympanoplasty on retraction pockets to a control group of cases without surgical intervention.²³ The graft success rate of the tympanoplasty group was significantly higher than the spontaneous healing rate of the control group.

One challenge of analyzing tympanoplasty studies in the setting of retraction pockets is the heterogeneity of classification systems. Retraction pockets would ideally be compared to similarly severe retraction pockets, but the use of different classification systems made this a challenge. Cassano and Cassano²³ utilized the Sadé classification system and Kasbekar et al²⁷ used the Charachon classification, while the remaining authors did not separate different classifications or did not report classifications at all. Studies have found these staging systems to be poor indicators of management strategy^50,51 with low intra- and inter-rater reliability.^52,53 While the use of a single classification system would be ideal to promote uniformity of assessment, development of a more reliable system is needed before enacting such a change.

Tympanosclerosis

Six studies reported data for tympanoplasty in the setting of tympanosclerosis. Two studies illustrated significantly worse anatomic outcomes in tympanosclerosis cases.^8,29 The remaining studies did not find tympanosclerosis to be associated with anatomic failure.^11,17,20,30

Lesinskas and Stankeviciute¹⁷ showed that hearing success was significantly lower in patients with tympanosclerosis than in those without tympanosclerosis for both primary and revision procedures. These operations included the use of a modified autologous ossicular or titanium prosthetics for ossicular reconstruction when needed. Goncalves et al²⁹ also found significantly worse hearing outcomes in patients with tympanosclerosis. The presence of tympanosclerosis may impact both anatomic and functional success of tympanoplasty; however, more studies are needed before accepting this conclusion.

Suppurative Otitis Media

Twenty-six studies discussing the outcomes of tympanoplasty in the setting of chronic suppurative otitis media met inclusion criteria. Sahoo et al³¹ compared the use of an underlay technique with or without the supporting gelfoam packing. Patients without gelfoam packing had significantly higher postoperative ABG gain at 1 month. ABG gain was also higher in the non-gelfoam group at 3 months, however, this did not meet statistical significance. Across the remaining 19 studies reporting surgical technique, the underlay, inlay, over underlay, shield cartilage, endomeatal tympano-meatal flap, circumferential subannular, and interlay techniques were used. No difference in outcome based on graft technique could be discerned.

Four of the included studies analyzed the impact of concomitant mastoidectomy on outcomes.^13,54
-56 Graft success rate was higher in each of these studies for the groups that underwent mastoidectomy, however, this only met statistical significance for a single study.⁵⁴

Four studies analyzed perforation size and found that it did not significantly impact success.^55,57
-59 Outcomes were not significantly influenced by a unilateral operation compared to a bilateral operation.^55,60 Age,⁵⁸ gender,⁵⁸ mucosal status,⁵⁸ vascularization time,⁵⁸ discharge type,⁵⁹ tympanic membrane vascularity,⁵⁹ and tympanometric volume⁶¹ did not significantly impact anatomic outcomes in patients with CSOM. Graft success was found to be significantly impacted by laterality in one study,⁵⁸ with right ears having a significantly higher failure rate than left ears; the reason for this is unclear. Receiving nitrous oxide anesthesia did not significantly impact anatomic or hearing outcomes.⁶² The univariate analysis conducted by Albu et al¹³ showed that having a healthy opposite ear, a long dry period leading up to operation, and nonsmoking status all significantly predicted anatomic success. Their multivariate analysis confirmed that the dry period was a significant predictor of success. However, 2 additional studies investigated preoperative ear status and found no significant differences in anatomic outcomes between wet and dry ears.^59,63

Ossicular reconstruction material was compared by Haberman and Salapatas who found that using hydroxyapatite yielded significantly worse hearing outcomes compared to titanium.⁶⁴ This finding applied to both partial and total ossicular replacement prostheses.

The major challenge specific to this portion of the review is the variety of diagnoses classified under chronic suppurative otitis media, including active, inactive, tubotympanic, mucosal, and “safe” chronic suppurative otitis media. Despite the relatively robust sample size, few studies analyzed the impact of different graft techniques on successful outcomes and none specifically analyzed the impact of CSOM on success compared to COM. Analyzing outcomes of operating on a wet or dry ear also showed mixed results. These are potential future areas of study that may improve surgical outcomes.

Anterior Perforations

Thirty-five studies containing data for anterior perforation tympanoplasty met the inclusion criteria. Just one of the 17 studies which analyzed the impact of perforation location found that it significantly impacted success.⁸ Four studies analyzed the relationship between perforation location and hearing outcomes; none found significant effects on success.^10,29,34,44

Authors utilized a number of different graft techniques to repair anterior perforations, including overlay or lateral graft,^65,66 inlay graft,^33,67 circumferential subannular,⁴⁰ interlay,⁶⁸ window shade,⁶⁹ and medial or underlay graft (including over-underlay and inferior flap).^{10,15,26,32,34
-38,44,65,66,70
-78} Although generally outcomes did not appear to differ, statistical analysis was not possible due to potential confounding variables such as differing graft materials. Six studies actually compared the use of different techniques.^{15,65,66,71,75,77} Just one of these found that graft technique had a significant impact on anatomic success. Choi et al found that the endoscopic lateral underlay technique had a significantly higher success rate (95.1%) than the endoscopic medial underlay technique (85.3%).⁷⁵ Babu et al¹⁵ utilized an over-under technique (81% closure rate) and medial technique (100%), but did not assess statistical significance. Presence of anterior canal wall protrusion,⁷¹ visualization of the perforation margin,⁷² age,^20,72 sex,⁷² perforation size,⁷² laterality,⁷² and primary vs revision surgery⁷² also did not significantly impact anatomic success.

Cholesteatoma

Research on the impact of the presence of cholesteatoma on anatomic success yielded mixed outcomes. One study found that cholesteatoma predicted anatomic failure⁴⁵ while 2 others did not.^43,46 Investigation of the role of cholesteatoma on functional success showed similarly mixed results.^9,28,46
-49

Six studies reported using 5 different graft techniques. Three reported graft success and found no notably poorer outcomes.^43,45,79 Hearing results were reported in 3 of these studies.^27,47,79 In the study conducted by Kasbekar et al,²⁷ the authors used a modified tragal cartilage augmentation technique without ossicular reconstruction and found an increase of the mean postoperative ABG of 0.5 dB; however, the clinical relevance of this may be negligible. When ossiculoplasty was required, the prosthetic materials used included a titanium prosthesis,^{4,28,48,49,80
-83} autologous ossicles,^47,84,85 cavum conchae cartilage,⁸⁶ and Teflon.⁴⁷ It was impossible to discern the advantages of these ossicular reconstruction materials due to the different methods the studies used to analyze functional outcomes. One major limitation in analyzing the impact of cholesteatoma on outcomes is that the majority of studies included failed to classify the extent of disease. While some studies discussed the integrity of the ossicular chain, they did not classify the degree of cholesteatoma.

Conclusion

The current literature does not allow for many conclusions regarding prognostic factors for successful tympanoplasty in the setting of other middle ear pathologies. Many opportunities exist for future research that could clarify potential prognostic factors and improve surgical outcomes. Given the small number of studies looking at tympanoplasty for cases with adhesions, retraction pockets, and tympanosclerosis, investigation into prognostic factors for these cases could significantly improve surgical outcomes and opportunities for patient counseling.

A major limitation of this systematic review is the risk of type II error due to the small sample size of patients with included pathologies. Many of the included studies failed to report statistical power, making it difficult to form a sound conclusion that no association was found between the included pathologies and anatomic or hearing outcomes. We recognize that these pathologies are less common, but significantly more data is needed to draw any definitive conclusions. We recommend that future authors separate data with the pathologies listed in this paper and include procedures specific to tympanoplasty in that setting (Figure 2). Possible publication bias and the retrospective nature of the majority of included studies may have introduced bias as well. A well-constructed multi-institutional study of tympanoplasty would help mitigate bias. Additionally, the heterogeneity with which different authors analyzed their success and functional outcomes limited the ability to analyze results. A universally accepted standard of success would improve comparisons of outcomes.

The pathologies studied here did not appear to significantly impact anatomic outcomes, but we cannot definitively make this conclusion without more data. Middle ear adhesions and tympanosclerosis were poor prognostic factors for hearing, but the remaining pathologies analyzed were not. Smokers tended to have worse anatomic and functional outcomes; however, there were mixed results regarding the significance of these findings. Similarly, there were mixed results regarding the impact of cholesteatoma on hearing outcomes and tympanosclerosis on anatomic outcomes. A considerable amount of research opportunities exist, including potential options highlighted in this review, that could clarify underlying issues that factor into successful tympanoplasty. Most importantly, future research needs to be conducted with clearly documented methods and outcomes in order to inform best practice and improve surgical outcomes.

Supplemental Material

sj-doc-2-aor-10.1177_00034894231159000 – Supplemental material for Tympanoplasty in the Setting of Complex Middle Ear Pathology: A Systematic Review

Supplemental material, sj-doc-2-aor-10.1177_00034894231159000 for Tympanoplasty in the Setting of Complex Middle Ear Pathology: A Systematic Review by Jorge A. Gutierrez, Claudia I. Cabrera, Amber Stout and Sarah E. Mowry in Annals of Otology, Rhinology & Laryngology

Supplemental Material

sj-doc-3-aor-10.1177_00034894231159000 – Supplemental material for Tympanoplasty in the Setting of Complex Middle Ear Pathology: A Systematic Review

Supplemental material, sj-doc-3-aor-10.1177_00034894231159000 for Tympanoplasty in the Setting of Complex Middle Ear Pathology: A Systematic Review by Jorge A. Gutierrez, Claudia I. Cabrera, Amber Stout and Sarah E. Mowry in Annals of Otology, Rhinology & Laryngology

Supplemental Material

sj-doc-4-aor-10.1177_00034894231159000 – Supplemental material for Tympanoplasty in the Setting of Complex Middle Ear Pathology: A Systematic Review

Supplemental material, sj-doc-4-aor-10.1177_00034894231159000 for Tympanoplasty in the Setting of Complex Middle Ear Pathology: A Systematic Review by Jorge A. Gutierrez, Claudia I. Cabrera, Amber Stout and Sarah E. Mowry in Annals of Otology, Rhinology & Laryngology

Supplemental Material

sj-docx-5-aor-10.1177_00034894231159000 – Supplemental material for Tympanoplasty in the Setting of Complex Middle Ear Pathology: A Systematic Review

Supplemental material, sj-docx-5-aor-10.1177_00034894231159000 for Tympanoplasty in the Setting of Complex Middle Ear Pathology: A Systematic Review by Jorge A. Gutierrez, Claudia I. Cabrera, Amber Stout and Sarah E. Mowry in Annals of Otology, Rhinology & Laryngology

Supplemental Material

sj-xlsx-1-aor-10.1177_00034894231159000 – Supplemental material for Tympanoplasty in the Setting of Complex Middle Ear Pathology: A Systematic Review

Supplemental material, sj-xlsx-1-aor-10.1177_00034894231159000 for Tympanoplasty in the Setting of Complex Middle Ear Pathology: A Systematic Review by Jorge A. Gutierrez, Claudia I. Cabrera, Amber Stout and Sarah E. Mowry in Annals of Otology, Rhinology & Laryngology

Footnotes

Authors’ Note

This manuscript was previously presented at the Combined Otolaryngology Spring Meeting in New Orleans, LA on 4/10/21 – 4/11/21.

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Sarah E. Mowry, MD, is a paid consultant to Cochlear Americas, OtoMed, Medtronic, and Cook Medical and an unpaid consultant to Stryker. The remaining authors declare no conflicts of interest.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Jorge A. Gutierrez

Sarah E. Mowry

Supplemental Material

Supplemental material for this article is available online.

References

Zollner

The principles of Plastic Surgery of the sound-conducting apparatus. J Laryngol Otol. 1955;69(10):637-652.

Wullstein

Theory and practice of tympanoplasty. Laryngoscope. 1956;66(8):1076-1093. doi:10.1288/00005537-195608000-00008

Bluestone

Cantekin

Douglas

GS.

Eustachian tube function related to the results of tympanoplasty in children. Laryngoscope. 1979;89(3):450-458. doi:10.1288/00005537-197903000-00013

Neumann

Kevenhoerster

Gostian

AO.

Long-term results of palisade cartilage tympanoplasty. Otol Neurotol. 2010;31(6):936-939. doi:10.1097/MAO.0B013E3181E71479

Moher

Liberati

Tetzlaff

Altman

DG.

Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097. doi:10.1371/JOURNAL.PMED.1000097

Slim

Nini

Forestier

Kwiatkowski

Panis

Chipponi

Methodological index for non-randomized studies (minors): development and validation of a new instrument. ANZ J Surg. 2003;73(9):712-716. doi:10.1046/J.1445-2197.2003.02748.X

Chen

Yang

SW.

Factors affecting the treatment outcomes of myringoplasty in patients with small tympanic membrane perforations. Eur Arch Otorhinolaryngol. 2019;276(11):3005-3012. doi:10.1007/S00405-019-05583-6

Salvador

Gomes

Silva

Fonseca

Type I tympanoplasty: surgical success and prognostic factors. Acta Otorrinolaringol Esp. 2021;72(3):182-189. doi:10.1016/J.OTORRI.2020.04.009

Jung

Lee

Hong

, et al. Prediction of hearing outcomes in chronic otitis media patients underwent tympanoplasty using ossiculoplasty outcome parameter staging or middle ear risk indices. PLoS One. 2021;16(7):e0252812. doi:10.1371/JOURNAL.PONE.0252812

10.

Naderpour

Jabbari Moghadam

Ghanbarpour

Shahidi

Evaluation of factors affecting the surgical outcome in tympanoplasty. Iran J Otorhinolaryngol. 2016;28(85):99-104.

11.

Lima

JCBD

Marone

SAM

Martucci

Gonçalez

Silva Neto

JJD

Ramos

ACM

. Evaluation of the organic and functional results of tympanoplasties through a retro-auricular approach at a medical residency unit. Braz J Otorhinolaryngol. 2011;77(2):229-236. doi:10.1590/S1808-86942011000200013

12.

Salviz

Bayram

, et al. Prognostic factors in type I tympanoplasty. Auris Nasus Larynx. 2015;42(1):20-23. doi:10.1016/J.ANL.2014.08.010

13.

Albu

Trabalzini

Amadori

Usefulness of cortical mastoidectomy in myringoplasty. Otol Neurotol. 2012;33(4):604-609. doi:10.1097/MAO.0B013E31825368F2

14.

Coelho

Peng

Thompson

Sismanis

Cartilage tympanoplasty in smokers. Ann Otol Rhinol Laryngol. 2012;121(10):657-663. doi:10.1177/000348941212101006

15.

Babu

Luryi

Schutt

CA.

Over-under versus medial tympanoplasty: Comparison of benefit, success, and hearing results. Laryngoscope. 2019;129(5):1206-1210. doi:10.1002/LARY.27599

16.

Niazi

Khattak

Atif

Rafique

Gohar

MS.

Why myringoplasties fail? Impact of relevant clinical factors on the surgical outcome; a study from pakistan. J Ayub Med Coll Abbottabad. 2021;33(3):412-415.

17.

Lesinskas

Stankeviciute

Results of revision tympanoplasty for chronic non-cholesteatomatous otitis media. Auris Nasus Larynx. 2011;38(2):196-202. doi:10.1016/J.ANL.2010.07.010

18.

Yurttas

Yakut

Kutluhan

Bozdemir

Preparation and placement of cartilage island graft in tympanoplasty. Braz J Otorhinolaryngol. 2014;80(6):522-526. doi:10.1016/J.BJORL.2014.08.007

19.

Lou

Endoscopic full-thickness cartilage-perichondrium double graft myringoplasty in adhesive perforation: retrospective case series. Acta Otolaryngol. 2021;141(1):14-18. doi:10.1080/00016489.2020.1814406

20.

Sevil

Doblan

Significance of the middle ear risk index in predicting tympanoplasty success in the elderly. Eur Arch Otorhinolaryngol. 2021;278(10):3689-3695. doi:10.1007/S00405-020-06430-9

21.

Lee

Cho

HH.

Transcanal endoscopic tympanoplasty for pediatric patients under 15 years of age with chronic otitis media. Clin Exp Otorhinolaryngol. 2020;13(1):41-46. doi:10.21053/CEO.2019.00318

22.

Comacchio

Mion

Pedruzzi

Retraction pocket excision with cartilage grafting as a preventive surgery for cholesteatoma. J Otol. 2017;12(3):112-116. doi:10.1016/J.JOTO.2017.04.003

23.

Cassano

Retraction pockets of pars tensa in pediatric patients: clinical evolution and treatment. Int J Pediatr Otorhinolaryngol. 2010;74(2):178-182. doi:10.1016/J.IJPORL.2009.11.004

24.

Khalilullah

Shah

Yadav

Shrivastav

Bhattarai

Comparison of results of graft uptake using tragal cartilage perichondrium composite graft versus temporalis fascia in patients undergoing surgery for chronic otitis media - squamous type. Head Face Med. 2016;12(1):26. doi:10.1186/S13005-016-0123-Z

25.

Mierzwiński

Fishman

Otolaryngologii

Foniatrii Dziecięcej

Szpital Dziecięcy Bydgoszczy

Retraction pockets of tympanic membrane: protocol of management and results of treatment Protokół postępowania i wyniki leczenia kieszonek retrakcyjnych błony bębenkowej. Otorynolaryngologia. 2014;13(2):114-121.

26.

Shishegar

Faramarzi

Rashidi Ravari

Evaluation of middle ear risk index in patients undergoing tympanoplasty. Eur Arch Otorhinolaryngol. 2019;276(10):2769-2774. doi:10.1007/S00405-019-05539-W

27.

Kasbekar

Patel

Rubasinghe

Srinivasan

The surgical management of tympanic membrane retraction pockets using cartilage tympanoplasty. Indian J Otolaryngol Head Neck Surg. 2014;66(4):449-454. doi:10.1007/S12070-014-0764-9

28.

Alaani

Raut

VV.

Kurz titanium prosthesis ossiculoplasty—Follow-up statistical analysis of factors affecting one year hearing results. Auris Nasus Larynx. 2010;37(2):150-154. doi:10.1016/J.ANL.2009.05.004

29.

Gonçalves

Rato

Duarte

de Vilhena

Type I tympanoplasty in pediatric age - the results of a tertiary hospital. Int J Pediatr Otorhinolaryngol. 2021;150:110899. doi:10.1016/J.IJPORL.2021.110899

30.

van Stekelenburg

BCA

Aarts

MCJ.

Determinants influencing success rates of myringoplasty in daily practice: a retrospective analysis. Eur Arch Otorhinolaryngol. 2019;276(11):3081-3087. doi:10.1007/S00405-019-05611-5

31.

Sahoo

Tripathi

Kumari

Rastogi

Efficacy of middle-ear packing in success of type 1 tympanoplasty: a prospective randomised study. J Laryngol Otol. 2021;135(10):864-868. doi:10.1017/S0022215121002012

32.

Baklaci

Guler

Kuzucu

Kum

Ozcan

Type 1 tympanoplasty in pediatric patients: a review of 102 cases. BMC Pediatr. 2018;18(1):345. doi:10.1186/S12887-018-1326-1

33.

Karataş

Doğan

Endoscopic inlay butterfly cartilage tympanoplasty in pediatric patients. Int J Pediatr Otorhinolaryngol. 2019;121:10-14. doi:10.1016/J.IJPORL.2019.02.042

34.

Kaya

Benzer

Gode

Sahin

Bilgen

Kirazli

Pediatric type 1 cartilage tympanoplasty outcomes: A comparison of short and long term hearing results. Auris Nasus Larynx. 2018;45(4):722-727. doi:10.1016/J.ANL.2017.11.002

35.

Lee

Seo

Shim

Lee

Kim

SH.

Surgical outcomes of tympanoplasty using a sterile acellular dermal allograft: a prospective randomised controlled study. Acta Otorhinolaryngol Ital. 2018;38(6):554-562. doi:10.14639/0392-100X-1839

36.

Tek

Karaman

Uslu

, et al. Audiological and graft take results of cartilage reinforcement tympanoplasty (a new technique) versus fascia. Eur Arch Otorhinolaryngol. 2012;269(4):1117-1126. doi:10.1007/S00405-011-1779-4

37.

Yilmaz

Kara

Guven

Demir

Erkorkmaz

Assessment of the factors that affect the anatomic and functional success of cartilage tympanoplasty in children. J Craniofac Surg. 2017;28(2):e106-e110. doi:10.1097/SCS.0000000000003162

38.

Dursun

Terzi

Demir

, et al. The evaluation of prognostic factors in endoscopic cartilage tympanoplasty. Eur Arch Otorhinolaryngol. 2020;277(10):2687-2691. doi:10.1007/S00405-020-05992-Y

39.

Abood

Torzynski

Ovesen

Pediatric type 1 tympanoplasty - does age matter?

Int J Pediatr Otorhinolaryngol. 2020;137:110219. doi:10.1016/J.IJPORL.2020.110219

40.

Singh

Kwatra

Malhotra

Kumar

Circumferential subannular tympanoplasty: panacea for revision tympanoplasty. Am J Otolaryngol. 2020;41(6):102728. doi:10.1016/J.AMJOTO.2020.102728

41.

Fermi

Maccarrone

Villari

, et al. Endoscopic tympanoplasty type I for tympanic perforations: analysis of prognostic factors. Eur Arch Otorhinolaryngol. 2021;278(12):4715-4722. doi:10.1007/S00405-020-06588-2

42.

Marques

JAS

Sousa

Leal

Spratley

Santos

. Pediatric tympanoplasty: a paradigm shift? Acta Otorrinolaringol Esp. 2021;72(6):375-380. doi:10.1016/j.otorri.2020.10.003

43.

Cass

Patten

Cass

SP.

Collagen allografts compared with autologous tissue in tympanoplasty. Otol Neurotol. 2019;40(6):767-771. doi:10.1097/MAO.0000000000002254

44.

Dursun

Demir

Terzi

, et al. Endoscopic type 1 cartilage tympanoplasty in children. Int J Pediatr Otorhinolaryngol. 2020;131:109854. doi:10.1016/J.IJPORL.2019.109854

45.

Ryan

Briggs

RJ.

Outcomes of the overlay graft technique in tympanoplasty. ANZ J Surg. 2010;80(9):624-629. doi:10.1111/J.1445-2197.2010.05405.X

46.

Zwierz

Haber

Sinkiewicz

Kalińczak-Górna

Tyra

Mierzwiński

The significance of selected prognostic factors in pediatric tympanoplasty. Eur Arch Otorhinolaryngol. 2019;276(2):323-333. doi:10.1007/S00405-018-5193-Z

47.

Chavan

Jain

Vedi

Rai

Kadri

Ossiculoplasty: a prospective study of 80 cases. Iran J Otorhinolaryngol. 2014;26(76):143-150.

48.

Mardassi

Deveze

Sanjuan

, et al. Titanium ossicular chain replacement prostheses: prognostic factors and preliminary functional results. Eur Ann Otorhinolaryngol Head Neck Dis. 2011;128(2):53-58. doi:10.1016/J.ANORL.2010.11.005

49.

Meulemans

Wuyts

Forton

GE.

Middle ear reconstruction using the titanium Kurz variac partial ossicular replacement prosthesis: functional results. JAMA Otolaryngol Head Neck Surg. 2013;139(10):1017-1025. doi:10.1001/JAMAOTO.2013.4751

50.

Alzahrani

Saliba

Tympanic membrane retraction pocket staging: is it worthwhile?

Eur Arch Otorhinolaryngol. 2014;271(6):1361-1368. doi:10.1007/s00405-013-2644-4

51.

Spinos

Mallick

Judd

Management of retraction pockets: historic and novel approaches. J Laryngol Otol. 2022;136(7):582-587. doi:10.1017/S0022215121004321

52.

James

Papsin

Trimble

, et al. Tympanic membrane retraction: an endoscopic evaluation of staging systems. Laryngoscope. 2012;122(5):1115-1120. doi:10.1002/lary.23203

53.

Pothier

Sade and tos classifications of the tympanic membrane: not reliable?

Clin Otolaryngol. 2006;31(3):249-249. doi:10.1111/j.1749-4486.2006.01236_15.x

54.

Dave

Ruparel

Correlation of Eustachian tube dysfunction with results of tympanoplasty in mucosal type of chronic suppurative otitis media. Indian J Otolaryngol Head Neck Surg. 2019;71(1):10-13. doi:10.1007/S12070-018-1525-Y

55.

Kamath

Sreedharan

Rao

Raj

Raju

Success of myringoplasty: our experience. Indian J Otolaryngol Head Neck Surg. 2013;65(4):358-362. doi:10.1007/S12070-013-0651-9

56.

Toros

Habesoglu

, et al. Do patients with sclerotic mastoids require aeration to improve success of tympanoplasty? Acta Otolaryngol. 2010;130(8):909-912. doi:10.3109/00016480903559731

57.

Olusesi

Opaluwah

Hassan

SB.

Subjective and objective outcomes of tympanoplasty surgery at National Hospital Abuja, Nigeria 2005-2009. Eur Arch Otorhinolaryngol. 2011;268(3):367-372. doi:10.1007/S00405-010-1405-X

58.

Noh

Lee

DH.

Vascularisation of myringo-/tympanoplastic grafts in active and inactive chronic mucosal otitis media: a prospective cohort study. Clin Otolaryngol. 2012;37(5):355-361. doi:10.1111/COA.12014

59.

Shankar

Virk

Gupta

Bal

Bansal

Evaluation and comparison of type I tympanoplasty efficacy and histopathological changes to the tympanic membrane in dry and wet ear: a prospective study. J Laryngol Otol. 2015;129(10):945-949. doi:10.1017/S0022215115002091

60.

Rai

Singh

Sahu

Singh

Arora

Evaluation of simultaneous bilateral same day tympanoplasty type I in chronic suppurative otitis media. Auris Nasus Larynx. 2014;41(2):148-152. doi:10.1016/J.ANL.2013.10.007

61.

Singh

Arora

Garg

Ranjan

Kumar

Role of tympanometric volume in paediatric tympanoplasty. Int J Pediatr Otorhinolaryngol. 2015;79(11):1872-1875. doi:10.1016/J.IJPORL.2015.08.027

62.

Düzenli

Bozan

Turan

Ağırbaş

Tekeli

Kıroğlu

AF.

The effect of nitrous oxide on the outcomes of underlay tympanoplasty: a prospective study. Ear Nose Throat J. 2019;98(10):621-624. doi:10.1177/0145561319846460

63.

Deosthale

Khadakkar

Kumar

, et al. Effectiveness of type I tympanoplasty in wet and dry ear in safe chronic suppurative otitis media. Indian J Otolaryngol Head Neck Surg. 2018;70(3):325-330. doi:10.1007/S12070-017-1075-8

64.

Haberman

Salapatas

AM.

Hearing outcomes after ossicular reconstruction with removal of the malleus. Otolaryngol Head Neck Surg. 2018;158(1):144-150. doi:10.1177/0194599817726279

65.

Mohanty

Manimaran

Umamaheswaran

Jeyabalakrishnan

Chelladurai

Endoscopic cartilage versus temporalis fascia grafting for anterior quadrant tympanic perforations — a prospective study in a tertiary care hospital. Auris Nasus Larynx. 2018;45(5):936-942. doi:10.1016/J.ANL.2018.01.002

66.

Dunya

Casazza

Blotter

Park

AH.

Comparing two different techniques to repair pediatric anterior tympanic membrane perforations. Int J Pediatr Otorhinolaryngol. 2021;150:110903. doi:10.1016/J.IJPORL.2021.110903

67.

Alharbi

Al Asseri

Ardi

Al-Qahtani

AS.

Myringoplasty outcome. Five-year experience at a tertiary teaching hospital. Saudi Med J. 2019;40(2):199-201. doi:10.15537/SMJ.2019.2.23896

68.

Kawano

Interlay myringoplasty with anterior subannular grafting technique for anterior and subtotal perforations. Otol Neurotol. 2020;41(6):791-794. doi:10.1097/MAO.0000000000002649

69.

Bluher

Mannino

Strasnick

Longitudinal analysis of “window shade” tympanoplasty outcomes for anterior marginal tympanic membrane perforations. Otol Neurotol. 2019;40(3):E173-E177. doi:10.1097/MAO.0000000000002147

70.

Gavriel

Eviatar

Inferior flap tympanoplasty: a novel technique for anterior perforation closure. Biomed Res Int. 2013;2013:758598. doi:10.1155/2013/758598

71.

Gülşen

Arıcı

Endoscopic transcanal versus conventional microscopic tympanoplasty in treatment of anterior tympanic membrane perforations. Eur Arch Otorhinolaryngol. 2019;276(12):3327-3333. doi:10.1007/S00405-019-05646-8

72.

Tseng

Lai

Yuan

Ding

YF.

Endoscopic transcanal myringoplasty for anterior perforations of the tympanic membrane. JAMA Otolaryngol Head Neck Surg. 2016;142(11):1088-1093. doi:10.1001/JAMAOTO.2016.2114

73.

Celik

Samim

Oztuna

Endoscopic “push-trough” technique cartilage myringoplasty in anterior tympanic membrane perforations. Clin Exp Otorhinolaryngol. 2015;8(3):224-229. doi:10.3342/CEO.2015.8.3.224

74.

Shoman

NM.

Clinical and audiometric outcomes of palisade cartilage myringoplasty under local anesthetic in an office setting. Am J Otolaryngol. 2019;40(4):482-486. doi:10.1016/J.AMJOTO.2019.03.015

75.

Choi

Kim

, et al. Comparison of medial underlay and lateral underlay endoscopic type I tympanoplasty for anterior perforations of the tympanic membrane. Otol Neurotol. 2021;42(8):1177-1183. doi:10.1097/MAO.0000000000003138

76.

Marchioni

Gazzini

De Rossi

, et al. The management of tympanic membrane perforation with endoscopic type I tympanoplasty. Otol Neurotol. 2020;41(2):214-221. doi:10.1097/MAO.0000000000002465

77.

Ozturk

Benzer

Kaya

Gode

Bilgen

Kirazli

Comparison of anterior and posterior tympanomeatal flap elevations in endoscopic transcanal tympanoplasty. Acta Otolaryngol. 2019;139(8):692-696. doi:10.1080/00016489.2019.1612533

78.

Lou

Endoscopic cartilage myringoplasty with inside out elevation of a tympanomeatal flap for repairing anterior tympanic membrane perforations. Ann Otol Rhinol Laryngol. 2020;129(8):795-800. doi:10.1177/0003489420915208

79.

Beutner

Huttenbrink

Stumpf

, et al. Cartilage plate tympanoplasty. Otol Neurotol. 2010;31(1):105-110. doi:10.1097/MAO.0B013E3181BE6B48

80.

Dumont

Abouzayd

Le Louarn

Pondaven

Bakhos

Lescanne

Total and partial ossiculoplasty in children: Audiological results and predictive factors. Eur Ann Otorhinolaryngol Head Neck Dis. 2019;136(3):161-164. doi:10.1016/J.ANORL.2019.02.012

81.

Hess-Erga

Møller

Vassbotn

FS.

Long-term hearing result using Kurz titanium ossicular implants. Eur Arch Otorhinolaryngol. 2013;270(6):1817-1821. doi:10.1007/S00405-012-2218-X

82.

Iñiguez-Cuadra

Alobid

Borés-Domenech

Menéndez-Colino

Caballero-Borrego

Bernal-Sprekelsen

Type III tympanoplasty with titanium total ossicular replacement prosthesis: anatomic and functional results. Otol Neurotol. 2010;31(3):409-414. doi:10.1097/MAO.0B013E3181CC04B5

83.

Quaranta

Zizzi

Quaranta

Hearing results using titanium ossicular replacement prosthesis in intact canal wall tympanoplasty for cholesteatoma. Acta Otolaryngol. 2011;131(1):36-40. doi:10.3109/00016489.2010.516014

84.

Wiatr

Składzień

Stręk

Determinants of change in air-bone gap and bone conduction in patients operated on for chronic otitis media. Med Sci Monit. 2015;21:2345-2351. doi:10.12659/MSM.894087

85.

Wiatr

Składzień

Tomik

Stręk

Przeklasa-Muszyńska

Type II tympanoplasty in chronic cholesteatoma and granulomatous otitis media - distant results of otosurgery. Adv Med Sci. 2014;59(1):44-46. doi:10.1016/J.ADVMS.2013.07.004

86.

Fukuda

Morita

Nakamaru

Hoshino

Fujiwara

Homma

Short-term hearing prognosis of ossiculoplasty in pars flaccida cholesteatoma using the EAONO/JOS staging system. J Int Adv Otol. 2019;15(1):2-7. doi:10.5152/IAO.2019.5983

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.07 MB

0.08 MB

0.06 MB

0.01 MB

0.02 MB