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Figure.
Representative Images of Endoscopic Transcanal Myringoplasty
Representative Images of Endoscopic Transcanal Myringoplasty

A, An anterior marginal perforation with partial visualization of the margin (arrowheads) is seen. B, The graft is pushed through the perforation. C, Image at the 6-month follow-up shows complete repair.

Table 1.  
Preoperative and Postoperative Air-Bone Gaps
Preoperative and Postoperative Air-Bone Gaps
Table 2.  
Association Between Rates of Graft Success and Prognostic Factors
Association Between Rates of Graft Success and Prognostic Factors
1.
Zollner  F.  The principles of plastic surgery of the sound-conducting apparatus.  J Laryngol Otol. 1955;69(10):637-652.PubMedGoogle ScholarCrossref
2.
Sheehy  JL, Anderson  RG.  Myringoplasty: a review of 472 cases.  Ann Otol Rhinol Laryngol. 1980;89(4, pt 1):331-334.PubMedGoogle ScholarCrossref
3.
Rizer  FM.  Overlay versus underlay tympanoplasty, II: the study.  Laryngoscope. 1997;107(12, pt 2):26-36.PubMedGoogle ScholarCrossref
4.
Applebaum  EL, Deutsch  EC.  An endoscopic method of tympanic membrane fluorescein angiography.  Ann Otol Rhinol Laryngol. 1986;95(5, pt 1):439-443.PubMedGoogle ScholarCrossref
5.
Schraff  S, Dash  N, Strasnick  B.  “Window shade” tympanoplasty for anterior marginal perforations.  Laryngoscope. 2005;115(9):1655-1659.PubMedGoogle ScholarCrossref
6.
Peng  R, Lalwani  AK.  Efficacy of “hammock” tympanoplasty in the treatment of anterior perforations.  Laryngoscope. 2013;123(5):1236-1240.PubMedGoogle ScholarCrossref
7.
Jung  TT, Park  SK.  Mediolateral graft tympanoplasty for anterior or subtotal tympanic membrane perforation.  Otolaryngol Head Neck Surg. 2005;132(4):532-536.PubMedGoogle ScholarCrossref
8.
Seidman  MD.  Anterior transcanal tympanoplasty: a novel technique to repair anterior perforations.  Otolaryngol Head Neck Surg. 2008;138(2):242-245.PubMedGoogle ScholarCrossref
9.
Lee  HY, Auo  HJ, Kang  JM.  Loop overlay tympanoplasty for anterior or subtotal perforations.  Auris Nasus Larynx. 2010;37(2):162-166.PubMedGoogle ScholarCrossref
10.
el-Guindy  A.  Endoscopic transcanal myringoplasty.  J Laryngol Otol. 1992;106(6):493-495.PubMedGoogle ScholarCrossref
11.
Raj  A, Meher  R.  Endoscopic transcanal myringoplasty: a study.  Indian J Otolaryngol Head Neck Surg. 2001;53(1):47-49.PubMedGoogle ScholarCrossref
12.
Usami  S, Iijima  N, Fujita  S, Takumi  Y.  Endoscopic-assisted myringoplasty.  ORL J Otorhinolaryngol Relat Spec. 2001;63(5):287-290.PubMedGoogle ScholarCrossref
13.
Karhuketo  TS, Ilomäki  JH, Puhakka  HJ.  Tympanoscope-assisted myringoplasty.  ORL J Otorhinolaryngol Relat Spec. 2001;63(6):353-357.PubMedGoogle ScholarCrossref
14.
Yadav  SP, Aggarwal  N, Julaha  M, Goel  A.  Endoscope-assisted myringoplasty.  Singapore Med J. 2009;50(5):510-512.PubMedGoogle Scholar
15.
Mohindra  S, Panda  NK.  Ear surgery without microscope: is it possible.  Indian J Otolaryngol Head Neck Surg. 2010;62(2):138-141.PubMedGoogle ScholarCrossref
16.
Ayache  S.  Cartilaginous myringoplasty: the endoscopic transcanal procedure.  Eur Arch Otorhinolaryngol. 2013;270(3):853-860.PubMedGoogle ScholarCrossref
17.
Furukawa  T, Watanabe  T, Ito  T, Kubota  T, Kakehata  S.  Feasibility and advantages of transcanal endoscopic myringoplasty.  Otol Neurotol. 2014;35(4):e140-e145.PubMedGoogle ScholarCrossref
18.
Dundar  R, Kulduk  E, Soy  FK,  et al.  Endoscopic versus microscopic approach to type I tympanoplasty.  Int J Pediatr Otorhinolaryngol. 2014;78(7):1084-1089.PubMedGoogle ScholarCrossref
19.
Migirov  L, Wolf  M.  Transcanal microscope-assisted endoscopic myringoplasty in children.  BMC Pediatr. 2015;15:32.PubMedGoogle ScholarCrossref
20.
Awad  OG, Hamid  KA.  Endoscopic type 1 tympanoplasty in pediatric patients using tragal cartilage.  JAMA Otolaryngol Head Neck Surg. 2015;141(6):532-538.PubMedGoogle ScholarCrossref
21.
Tarabichi  M.  Endoscopic middle ear surgery.  Ann Otol Rhinol Laryngol. 1999;108(1):39-46.PubMedGoogle ScholarCrossref
22.
Tarabichi  M, Ayache  S, Nogueira  JF, Al Qahtani  M, Pothier  DD.  Endoscopic management of chronic otitis media and tympanoplasty.  Otolaryngol Clin North Am. 2013;46(2):155-163.PubMedGoogle ScholarCrossref
23.
Eren  SB, Tugrul  S, Ozucer  B, Veyseller  B, Aksoy  F, Ozturan  O.  Endoscopic transcanal inlay myringoplasty: alternative approach for anterior perforations.  Otolaryngol Head Neck Surg. 2015;153(5):891-893.PubMedGoogle ScholarCrossref
24.
Harugop  AS, Mudhol  RS, Godhi  RA.  A comparative study of endoscope assisted myringoplasty and micrsoscope assisted myringoplasty.  Indian J Otolaryngol Head Neck Surg. 2008;60(4):298-302.PubMedGoogle ScholarCrossref
25.
Lade  H, Choudhary  SR, Vashishth  A.  Endoscopic vs microscopic myringoplasty: a different perspective.  Eur Arch Otorhinolaryngol. 2014;271(7):1897-1902.PubMedGoogle ScholarCrossref
26.
Pinar  E, Sadullahoglu  K, Calli  C, Oncel  S.  Evaluation of prognostic factors and middle ear risk index in tympanoplasty.  Otolaryngol Head Neck Surg. 2008;139(3):386-390.PubMedGoogle ScholarCrossref
27.
Salviz  M, Bayram  O, Bayram  AA,  et al.  Prognostic factors in type I tympanoplasty.  Auris Nasus Larynx. 2015;42(1):20-23.PubMedGoogle ScholarCrossref
28.
Nardone  M, Sommerville  R, Bowman  J, Danesi  G.  Myringoplasty in simple chronic otitis media: critical analysis of long-term results in a 1000-adult patient series.  Otol Neurotol. 2012;33(1):48-53.PubMedGoogle ScholarCrossref
Original Investigation
November 2016

Endoscopic Transcanal Myringoplasty for Anterior Perforations of the Tympanic Membrane

Author Affiliations
  • 1Department of Otolaryngology, Wan Fang Medical Center, Taipei Medical University, Taipei, Taiwan
  • 2Department of Otolaryngology, PoJen General Hospital, Taipei, Taiwan
  • 3Department of Otolaryngology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
 

Copyright 2016 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.

JAMA Otolaryngol Head Neck Surg. 2016;142(11):1088-1093. doi:10.1001/jamaoto.2016.2114
Key Points

Question  What are the results of endoscopic transcanal myringoplasty for repairing anterior perforations of the tympanic membrane?

Findings  In this medical record review that included 59 patients undergoing endoscopic transcanal myringoplasty, 55 (93%) had successful graft repair at 6 postoperative months.

Meaning  Endoscopic transcanal myringoplasty should be considered for repairing anterior perforations of the tympanic membrane.

Abstract

Importance  Repairing anterior perforations of the tympanic membrane has been challenging for otolaryngologists. Therefore, devising a simple and effective technique for performing the repair is crucial.

Objective  To assess the results of endoscopic transcanal myringoplasty for repairing anterior perforations of the tympanic membrane.

Design, Setting, and Participants  This medical record review included 59 patients who underwent endoscopic transcanal myringoplasty from January 1, 2013, to June 1, 2015, at PoJen General Hospital, Taipei, Taiwan. Patients with ossicular chain disease and cholesteatoma or inadequate follow-up were excluded. Patients were followed up for 6 months, and final follow-up was completed on January 1, 2016.

Main Outcomes and Measures  The main outcome was the rate of overall graft success after endoscopic transcanal myringoplasty. Secondary outcomes included hearing results and prognostic factors.

Results  The study sample included the medical records of 59 patients (30 men [51%]; 29 women [49%]; mean [SD] age, 49.5 [13.1] years) who underwent endoscopic transcanal myringoplasty. Overall, 55 patients (93%) had a successful graft at 6 postoperative months. The mean (SD) preoperative and postoperative air-bone gaps were 15.9 (9.4) and 5.4 (7.0) dB, respectively, revealing a significant mean (SD) improvement of 10.3 (7.6) dB (Cohen d, 1.27; 95% CI, 0.90-1.63; P < .001, paired t test) in the gap. The postoperative air-bone gap in 46 patients (78%) was less than 10 dB; in 12 patients (20%), 10 to 20 dB; and in 1 patient (2%), more than 20 dB. Postoperative otorrhea significantly affected the graft success rate (odds ratio, 52.00; 95% CI, 4.08-662.55; P < .01, χ2 test). The visualization of the perforation margin (complete or partial) was not significantly associated with the graft success rate. However, partial visualization of the perforation margin significantly prolonged the mean (SD) operative time (complete vs partial, 59.2 [13.7] vs 68.1 [14.1] minutes; Cohen d, 0.64; 95% CI, 0.12-1.18; P = .02, t test).

Conclusions and Relevance  The rate of graft success and hearing outcomes for endoscopic transcanal myringoplasty are comparable with those of microscopic myringoplasty for repairing anterior perforations of the tympanic membrane. However, the present technique is simpler because postauricular incision, canalplasty, and general anesthesia are not required. Thus, endoscopic transcanal myringoplasty should be considered for repairing anterior perforations of the tympanic membrane.

Introduction

Since the 1950s, microscopic tympanoplasty has become the standard treatment of a perforated tympanic membrane.1 The operation can be performed using 2 classic techniques, including underlay and overlay graft tympanoplasty.2,3 In the underlay technique, the graft is placed medial to the remaining tympanic membrane and malleus. In the overlay technique, the graft is placed lateral to the anulus and remaining fibrous middle layer.

Tympanoplasty for closing anterior perforations of the tympanic membrane is considered challenging. The reasons for poor surgical outcomes include a reduced vascular supply, limited anterior margin, poor visualization, and inadequate graft stabilization.4-6 Overlay tympanoplasty has a high success rate in treating anterior perforations of the tympanic membrane, but it is surgically difficult.2,3 The modifications of underlay tympanoplasty for repairing anterior perforations of the tympanic membrane include mediolateral graft, window-shade, anterior transcanal, loop overlay, and hammock techniques.5-9 Although effective, these techniques require advanced surgical skills, postauricular incision, and general anesthesia.

In addition to microscopic tympanoplasty, endoscopic tympanoplasty has been performed increasingly since the 1990s.10-23 Compared with microscopy, endoscopy provides a wider surgical view, which can avoid postauricular incision and canalplasty for treating tympanic perforations through the narrow external auditory canal.24,25

Few studies have described endoscopic transcanal myringoplasty for repair of anterior perforations of the tympanic membrane.23 The present study aimed to evaluate the rate of graft success, hearing outcomes, and prognostic factors for endoscopic transcanal myringoplasty in repairing anterior perforations of the tympanic membrane.

Methods
Patients

The present study was a retrospective review of the medical records of patients who underwent endoscopic transcanal myringoplasty from January 1, 2013, to June 1, 2015, at the PoJen General Hospital, Taipei, Taiwan. The patients with anterior perforations of the tympanic membrane were enrolled; these patients were followed up for at least 6 months. Final follow-up was completed on January 1, 2016. Patients with ossicular chain disease and cholesteatoma were excluded. The same surgeon (C.-C.T.) performed all the procedures. The joint institutional review board of the Taipei Medical University approved our study protocol. All patients provided oral informed consent.

The main outcome was the rate of overall graft success of endoscopic transcanal myringoplasty. Postoperative complications of recurrent perforations, infections, hemorrhage, and hearing loss were examined. We performed preoperative and postoperative audiograms at frequencies of 500, 1000, 2000, and 4000 Hz to access the closure of the air-bone gap.

We used an otoscope to evaluate the visualization of the perforation margin preoperatively. If this margin could be completely observed, visualization was defined as complete; any other visualization was defined as partial. Anterior perforations were defined as anterior to the malleus handle. The tympanic membrane was divided into 4 quadrants according to the position of the malleus handle, with each quadrant accounting for 25% of the size of the tympanic membrane. If the perforation size was smaller than 2 quadrants, then it was defined as less than 50%. Otherwise, the perforation was 50% or greater. A similar method was used in the report by Pinar et al.26 We defined the operative time as the duration from the start of local anesthesia to the end of wound dressing.

We analyzed the association between the rate of graft success and prognostic factors. The prognostic factors included age (<50 or ≥50 years), sex, cause of the perforation, the perforation size (<50% or ≥50%), marginal perforation, hearing level, primary or revision surgery, visualization of the perforation margin, operative time, and postoperative otorrhea.

Surgical Techniques

Two rigid endoscopes (Karl Storz) were used in our surgical techniques (4.0-mm, 0°, 18-cm-long lens and 3.0-mm, 0°, 14-cm-long lens). Patient ears were prepared and draped under sterile conditions without hair shaving. Each patient was administered intravenous sedation (50 mg of meperidine hydrochloride and 5 mg of midazolam hydrochloride) 10 minutes preoperatively by an anesthesiologist. The periaural area and external ear canal were infiltrated with 2% lidocaine hydrochloride and 1:100 000 epinephrine. Transcanal injections were administered in all 4 quadrants using a 26-gauge needle under direct endoscopic visualization. Meanwhile, blanching of the canal skin was observed, and hemorrhagic bulbs were prevented by slowly and carefully injecting local anesthesia.

We used the temporalis fascia or the tragal perichondrium as graft material. For harvesting of the temporalis fascia graft, a 2.5-cm incision near the hairline superior and posterior to the helix was made to expose the areolar tissue or temporalis fascia; this connective tissue was harvested and then pressed using a fascia clamp. After achieving hemostasis, the postauricular incision was closed with absorbable sutures. For harvesting of the tragal perichondrial graft, a 1-cm incision was made 2 to 3 mm medial to the free border of the tragal cartilage by cutting through the skin and cartilage. The perichondrium was freed of the cartilage and prepared as a graft. The incision was sutured with absorbable material. Surgical techniques included endoscopic simple underlay myringoplasty (without elevation of the tympanomeatal flap) and endoscopic type 1 tympanoplasty (with elevation of the tympanomeatal flap), as described by Furukawa et al.17

Endoscopic Simple Underlay Myringoplasty

For endoscopic simple underlay myringoplasty, the perforation margin and anterior anulus were visualized through endoscopy. The perforation margin was circumferentially freshened using a pick or a sickle knife. The middle ear cavity was tightly packed with an absorbable gelatin sponge (Gelfoam; Pfizer, Inc) through the perforation. Furthermore, the tubal orifice was packed to prevent medialization because of negative pressure produced by sniffing. After being prepared 2 mm larger than the perforation size, the graft was pushed through the perforation and placed in an underlay manner (Figure). Absorbable gelatin sponge pledgets soaked with antibiotic drops (ofloxacin ear solution, 0.3%) were placed lateral to the graft in the external auditory canal.

Endoscopic Type 1 Tympanoplasty

When large perforations were observed, we performed endoscopic type 1 tympanoplasty with elevation of the tympanomeatal flap. First, the perforation margin and anterior anulus were visualized through endoscopy. The perforation margin was circumferentially freshened with a pick or a sickle knife. An incision was made 5 mm away from the tympanic anulus posteriorly and extended from the 12-o’clock to the 7-o’clock positions. The tympanomeatal flap was subsequently elevated to the level of the fibrous anulus. Cottonoid pledgets soaked with epinephrine were applied to reduce bleeding from the cut edges of the flap. After the middle ear cavity was exposed, the integrity and mobility of the ossicular chain were examined. A graft trimmed to an appropriate size was placed medial to the malleus handle to prevent graft lateralization. Absorbable gelatin sponges were packed in the middle ear cavity to support the graft from medialization. The tympanomeatal flap was subsequently replaced to its original position. The external auditory canal was packed with absorbable gelatin sponge pledgets to the level of the isthmus.

The postauricular incision was covered with a gauze dressing, whereas the tragal incision was packed with a cottonoid ball placed in the orifice of the external auditory canal. No mastoid dressing was required. The patients were discharged on the day of the surgery. The packing and stitches were removed 1 week postoperatively. Hearing tests were performed at 3, 6, and 12 months postoperatively.

Statistical Analysis

Statistical analysis was performed using SPSS software (version 16 for Windows; SPSS Inc/IBM). The study results were expressed as mean (SD) for continuous variables and as percentages for categorical variables. We compared the study data using the paired t, χ2, and univariate logistic regression tests. Effect sizes were reported as Cohen d and odds ratios (ORs) with 95% CIs. The differences between groups were considered significant at P < .05.

Results
Patient Characteristics

We reviewed the medical records of 69 patients who underwent endoscopic transcanal myringoplasty. Of these patients, 10 were excluded because of an inadequate follow-up period of less than 6 months, and the remaining 59 (30 men [51%]; 29 women [49%]; mean [SD] age, 49.5 [13.1] years ) were included in the analysis.

The mean operative time was 62.1 (13.1) minutes. The mean operative time for complete visualization of the perforation margin was 59.2 (13.7) minutes, whereas that for partial visualization was 68.1 (14.1) minutes (Cohen d, 0.64; 95% CI, 0.12-1.18; P = .02, t test). Overall graft success was determined at 6 postoperative months in 55 of 59 patients (93%), and the mean follow-up was 11.7 (8.1) months. Moreover, the mean preoperative and postoperative air-bone gaps were 15.9 (9.4) and 5.4 (7.0) dB, respectively, revealing a significant improvement of 10.3 (7.6) dB (Cohen d, 1.27; 95% CI, 0.90-1.63; P < .001, paired t test) in the air-bone gap. Table 1 displays the changes from preoperative to postoperative air-bone gaps. Forty patients (68%) had preoperative air-bone gaps of less than 20 dB, whereas 58 patients (98%) had postoperative air-bone gaps of less than 20 dB. Table 2 lists the association between the rate of graft success and prognostic factors. The success rate among patients with postoperative otorrhea was significantly lower than that among patients without postoperative otorrhea (3 of 6 patients [50%] vs 52 of 53 patients [98%]; OR, 52.00; 95% CI, 4.08-662.55; P < .01, χ2 test). Notably, the success rate with partial visualization of the perforation was comparable to that with complete visualization of the perforation (20 of 22 patients [91%] vs 35 of 37 patients [95%]; OR, 1.75; 95% CI, 0.23-13.40; P = .59, χ2 test). No significant differences were seen for larger and marginal perforations.

Complications

Anterior perforations of the tympanic membrane could not be closed postoperatively in 4 patients; 2 of them had smaller residual perforations. The remaining 2 patients underwent later revision procedures that repaired the previous perforations. One patient had postoperative hemorrhage because of a postauricular incision; however, the bleeding stopped after direct compression. Furthermore, 6 patients developed postoperative otorrhea, which resolved after they received otic and oral antibiotic treatments. No patients reported sensorineural hearing loss.

Discussion

The major difference between microscopy and endoscopy is the surgical view. Tarabichi et al21,22 reported that the view during microscopic surgery is defined and limited by the narrowest segment of the ear canal. By contrast, transcanal endoscopy bypasses the narrow segment of the ear canal and provides a wide view, even when a 0° endoscope is used. Furukawa et al,17 Lade et al,25 and Harugop et al24 conducted studies to compare the microscopic and endoscopic views in tympanoplasty. They reported that in the microscopy groups, the tympanic anulus was not completely visualized in 17% to 20% of patients, thus requiring canalplasty. However, in the endoscopy groups, the tympanic anulus was completely visualized; hence, no patient required canalplasty. Ayache16 reported an even higher rate of 73% of patients in whom anterior perforations of the tympanic membrane were poorly visualized. Our study showed partial visualization of the perforation margin through otoscopy in 22 patients (37%); however, none of them required canalplasty. All of these reports reveal that endoscopy provides a wider surgical view than microscopy, particularly in the cases of anterior bony overhangs of the external auditory canal and anterior perforations of the tympanic membrane.

Comparing the success rates of microscopic and endoscopic tympanoplasty is often the main concern. Success rates of 90% to 95% for microscopic myringoplasty have been reported.2,3 Similar success rates of 80% to 100% have also been reported for endoscopic myringoplasty.10,13,14 Harugop et al24 and Lade et al25 compared the success rates of microscopic and endoscopic myringoplasty and reported no difference. For anterior perforations of the tympanic membrane, the rates of graft success for microscopic overlay and modified underlay tympanoplasty ranged from 88% to 98%.5-9 Our results reveal a rate of graft success of 93%. Our air-bone gap closure rates were also comparable with those previously reported.5-9 However, our technique is less invasive because postauricular incision, canalplasty, and general anesthesia were not required. Moreover, the operative time was reduced to approximately 1 hour, and all patients were discharged on the day after surgery.

Various factors influence the success rate of myringoplasty, such as age, the perforation portion, the perforation size, postoperative otorrhea, revision surgery, and poor visualization of the perforation margin.9,26-28 As displayed in Table 2, the graft success rate of the patients with postoperative otorrhea was significantly lower than that of the patients without postoperative otorrhea, which could have been caused by uncontrolled preoperative or postoperative infections. The operative time with partial visualization of the perforation margin was longer than that with complete visualization. However, visualization of the perforation margin, whether complete or partial, had no significant association with the rate of graft success. This finding indicates that the wider endoscopic visualization neglected the effect of partial visualization of the perforation margin on the rate of graft success in anterior perforations of the tympanic membrane. The larger perforation (≥50%) and marginal perforation type had no significant differences for these 2 factors, which is different from the findings in the previous report.26

Endoscopy has several disadvantages in ear surgery compared with microscopy. First, the endoscope must be held in one hand, and only the other hand is free to operate; this procedure is particularly cumbersome when bleeding obscures the view of the operating field. In addition, endoscopy provides a monocular view, which causes the loss of depth perception compared with the binocular view provided through microscopy. Moreover, endoscopic myringoplasty still requires more training experience.13,21,22

The present study has 2 limitations. First, this study included a relatively small sample size, resulting in a lack of generalizability of the findings. Second, this study was a retrospective medical record review, and the patients who were lost to or unavailable for follow-up might have caused recall and selection bias. A prospective study with a larger patient sample is recommended.

Conclusions

Our study revealed that wider endoscopic visualization can neglect the factor of partial visualization of the perforation margin through otoscopy, which increases the rate of graft success in anterior perforations of the tympanic membrane. Therefore, the rate of graft success and hearing results are comparable with those of microscopic myringoplasty for repairing anterior perforations of the tympanic membrane. However, our technique is simpler because postauricular incision, canalplasty, and general anesthesia are not required. Thus, endoscopic transcanal myringoplasty should be considered for repairing anterior perforations of the tympanic membrane.

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Article Information

Corresponding Author: Chih-Chieh Tseng, MD, MPH, Department of Otolaryngology, Wan Fang Medical Center, Taipei Medical University, Building 111, Section 3, Xinglong Road, Taipei 11696, Taiwan (doctseng@yahoo.com.tw).

Accepted for Publication: June 20, 2016.

Published Online: August 18, 2016. doi:10.1001/jamaoto.2016.2114.

Author Contributions: Dr Tseng had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Tseng.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Tseng.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Tseng.

Obtaining funding: Tseng.

Administrative, technical, or material support: Tseng.

Study supervision: All authors.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Additional Contributions: Winston W. Shen, MD, Department of Psychology, Wan Fang Medical Center, Taipei Medical University, provided constructive criticism of the manuscript. He was not compensated for this contribution.

References
1.
Zollner  F.  The principles of plastic surgery of the sound-conducting apparatus.  J Laryngol Otol. 1955;69(10):637-652.PubMedGoogle ScholarCrossref
2.
Sheehy  JL, Anderson  RG.  Myringoplasty: a review of 472 cases.  Ann Otol Rhinol Laryngol. 1980;89(4, pt 1):331-334.PubMedGoogle ScholarCrossref
3.
Rizer  FM.  Overlay versus underlay tympanoplasty, II: the study.  Laryngoscope. 1997;107(12, pt 2):26-36.PubMedGoogle ScholarCrossref
4.
Applebaum  EL, Deutsch  EC.  An endoscopic method of tympanic membrane fluorescein angiography.  Ann Otol Rhinol Laryngol. 1986;95(5, pt 1):439-443.PubMedGoogle ScholarCrossref
5.
Schraff  S, Dash  N, Strasnick  B.  “Window shade” tympanoplasty for anterior marginal perforations.  Laryngoscope. 2005;115(9):1655-1659.PubMedGoogle ScholarCrossref
6.
Peng  R, Lalwani  AK.  Efficacy of “hammock” tympanoplasty in the treatment of anterior perforations.  Laryngoscope. 2013;123(5):1236-1240.PubMedGoogle ScholarCrossref
7.
Jung  TT, Park  SK.  Mediolateral graft tympanoplasty for anterior or subtotal tympanic membrane perforation.  Otolaryngol Head Neck Surg. 2005;132(4):532-536.PubMedGoogle ScholarCrossref
8.
Seidman  MD.  Anterior transcanal tympanoplasty: a novel technique to repair anterior perforations.  Otolaryngol Head Neck Surg. 2008;138(2):242-245.PubMedGoogle ScholarCrossref
9.
Lee  HY, Auo  HJ, Kang  JM.  Loop overlay tympanoplasty for anterior or subtotal perforations.  Auris Nasus Larynx. 2010;37(2):162-166.PubMedGoogle ScholarCrossref
10.
el-Guindy  A.  Endoscopic transcanal myringoplasty.  J Laryngol Otol. 1992;106(6):493-495.PubMedGoogle ScholarCrossref
11.
Raj  A, Meher  R.  Endoscopic transcanal myringoplasty: a study.  Indian J Otolaryngol Head Neck Surg. 2001;53(1):47-49.PubMedGoogle ScholarCrossref
12.
Usami  S, Iijima  N, Fujita  S, Takumi  Y.  Endoscopic-assisted myringoplasty.  ORL J Otorhinolaryngol Relat Spec. 2001;63(5):287-290.PubMedGoogle ScholarCrossref
13.
Karhuketo  TS, Ilomäki  JH, Puhakka  HJ.  Tympanoscope-assisted myringoplasty.  ORL J Otorhinolaryngol Relat Spec. 2001;63(6):353-357.PubMedGoogle ScholarCrossref
14.
Yadav  SP, Aggarwal  N, Julaha  M, Goel  A.  Endoscope-assisted myringoplasty.  Singapore Med J. 2009;50(5):510-512.PubMedGoogle Scholar
15.
Mohindra  S, Panda  NK.  Ear surgery without microscope: is it possible.  Indian J Otolaryngol Head Neck Surg. 2010;62(2):138-141.PubMedGoogle ScholarCrossref
16.
Ayache  S.  Cartilaginous myringoplasty: the endoscopic transcanal procedure.  Eur Arch Otorhinolaryngol. 2013;270(3):853-860.PubMedGoogle ScholarCrossref
17.
Furukawa  T, Watanabe  T, Ito  T, Kubota  T, Kakehata  S.  Feasibility and advantages of transcanal endoscopic myringoplasty.  Otol Neurotol. 2014;35(4):e140-e145.PubMedGoogle ScholarCrossref
18.
Dundar  R, Kulduk  E, Soy  FK,  et al.  Endoscopic versus microscopic approach to type I tympanoplasty.  Int J Pediatr Otorhinolaryngol. 2014;78(7):1084-1089.PubMedGoogle ScholarCrossref
19.
Migirov  L, Wolf  M.  Transcanal microscope-assisted endoscopic myringoplasty in children.  BMC Pediatr. 2015;15:32.PubMedGoogle ScholarCrossref
20.
Awad  OG, Hamid  KA.  Endoscopic type 1 tympanoplasty in pediatric patients using tragal cartilage.  JAMA Otolaryngol Head Neck Surg. 2015;141(6):532-538.PubMedGoogle ScholarCrossref
21.
Tarabichi  M.  Endoscopic middle ear surgery.  Ann Otol Rhinol Laryngol. 1999;108(1):39-46.PubMedGoogle ScholarCrossref
22.
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