Treatment of Large Tympanic Membrane Perforations: Medial to Malleus Versus Lateral to Malleus

Abstract

The perforation size affects the success of tympanic membrane (TM) reconstruction, in addition to the surgical technique used. Large TM perforations present a surgical challenge. The perforation size has been reported to be a prognostic factor, and poorer results are obtained with large versus small perforations. We aimed to evaluate patients who had undergone tympanoplasty for large perforations at our clinic using either the underlay or overunderlay technique and to compare the results in terms of re-perforation, retraction, lateralization, and improvement of hearing. Of 302 patients with chronic otitis media, 114 who had a perforation that involved over 50 % of the pars tensa were enrolled in the study. The underlay technique was used in 61 patients, and the over-underlay technique in 53 patients. In the underlay group, the preoperative mean perforation size was 30.11 ± 5.35 mm 2 (range 20.00-52.00 mm 2 ) (n = 61). In the over-underlay group, the preoperative mean perforation size was 31.41 ± 8.65 mm 2 (range 22.00-48.00 mm 2 ) (n = 53). The graft success rate of tympanoplasty performed using the underlay technique was 89.1 % in 61 patients. Seven (10.9 %) patients had graft failure. The graft success rate with the over-underlay technique in 53 patients was 90.5 %. Five (9.5 %) patients had graft failure in this group. Three graft lateralizations (5.6 %) and two retractions (3.8 %) were observed at 12 months postoperatively in the over-underlay group. However, in the underlay group, no graft lateralization but five retractions (8.2 %) were observed at 12 months. The graft-take rates and hearing improvement results in both groups were successful and compatible with those in the literature.

Correlation of Status of Mastoid with Outcomes of Myringoplasty with Cortical Mastoidectomy in Mucosal Otitis Media with High Risk Perforation

“…These perforations are at high risk of re-perforation, retraction pockets, revision surgeries and are more difficult to treat due to less extensive tympanic membrane margins to support graft survival and less tension to resist tympanic retraction postoperatively. 17 Dangol et al 2 found the graft uptake 83.7% in dry ear, 81.2% in quiescent ear and 75% in actively discharging ear although the result was statistically not significant. The persistent discharge may lead to the displacement of graft, infection of graft material resulting in failure.…”

Myringoplasty Outcomes From a 5-Year Single Surgeon’s Experience and Important Surgical Technical Aspects

“…The underlay technique positions the graft medial to the tympanic membrane remnant and to the handle of the malleus. It thought to be more suited to posterior perforation and technically easier to perform [9]. The overlay technique is thought to be more suitable for anterior and subtotal perforations, but technically challenging [10].…”

Diagnostic accuracy of intra-operative assessment of de-epithelisation of the malleus by the surgeon in type 1 tympanoplasty compared to histopathological examination

“…The over-underlay tympanoplasty technique was introduced as a means of incorporating the advantages of both overlay and underlay techniques, whilst avoiding the disadvantages. 12 It is relatively simple and straightforward, with a good success rate. 1 The handle of the malleus remains an asset in this technique and prevents atelectasis.…”