Endoscopic Tympanoplasty: Single Versus Double Flap Technique
Phase: NA
Conditions: Tympanic Membrane Perforation
Sponsor: Mansoura University

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           Mansoura University 
                            Faculty of Medicine 
                              ORL Department 
Endoscopic tympanoplasty: single versus double flap 
technique 
By 
Noha Ahmed Abdo El-Kholy 
M.B.B.Ch. 
Resident of Otorhinolaryngology , 
Mansoura University Hospitals 
Supervisors 
Dr. Abdelwahab M. Rakha 
Professor of  Otorhinolaryngology , 
Faculty of Medicine , Mansoura University  
Dr. Mohammed Abdelbadie Salem 
Lecturer of Otorhinolaryngology , 
Faculty of Medicine , Mansoura University 
 
IRB approval date: 20 August 2017, Code: MS/17.07.100 
 
2017 

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Introduction: 
The aims of tympanoplasty are elimination of disease and restoration of function. 
Restoration of function requires a healthy tympanic membrane, an air-containing, 
mucosal-lined middle ear and a connection between the tympanic membrane and 
the inner ear fluids (Harris et al., 2016) 
Underlay (medial) and overlay (lateral) techniques are two traditional 
methods for repair of TM perforations. The underlay technique is easier to perform 
and less time consuming (Fayad and Sheehy, 2009) , thus it is often preferred by 
otologists (Harris et al., 2016) 
The graft is placed medial to the entire TM remnant and the malleus handle 
and is suitable for posterior perforations (Jackson et al., 2010) 
Some of the commonly faced problems in underlay technique include 
decreased mesotympanic space and a lesser success rate in anterior perforations 
(Gerlinger et al., 2006) 
 In the overlay technique, which is frequently applied to anterior 
perforations, the epithelial layer is elevated precisely, and the graft is placed lateral 
to the fibrous layer of TM remnant and annulus (Fayad and Sheehy, 2009) 
Although the overlay technique has a higher success rate in repairing 
anterior perforations, it is more technically demanding, and specific potential 
complications may occur such as graft lateralization, anterior blunting, slower 
healing, stenosis of the external auditory canal, epithelial pearls, and iatrogenic 
cholesteatoma (Gersdorff et al., 2002) 
Therefore, repairing anterior perforations remain a challenge, especially 
when using the underlay technique. Factors influencing failure of the underlay 
technique in those cases include inadequate blood supply lack of residual TM as a 
source of epithelium, lack of support for the graft anteriorly, and poor exposure 
(Applebaum and Deutsch, 1986),. 
 

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Underlay and overlay technique of myringoplasty have been used for several 
years, and both have their advantages and disadvantages. When the underlay 
technique is used to repair the subtotal tympanic membrane perforation, the 
anterior portion of graft may fall away resulting in reperforation, and obliteration 
of the anterior part of middle ear cavity. The overlay technique has a higher 
success rate for the reconstruction of the subtotal tympanic membrane perforation, 
but lateralization of the graft may occur (Kartush et al., 2002). 
These problems have been managed by a variety of surgical techniques such 
as the use of William’s microclip, sandwich graft tympanoplasty, loop overlay 
tympanoplasty, and over-underlay tympanoplasty (Lee et al., 2010). 
Over-underlay tympanoplasty is a safe, simple and easy procedure with low 
rate of graft failure and better hearing improvement (Prakas et al., 2014). 
Yet, a still better method is needed to repair anterior tympanic membrane 
perforations (Kartush et al., 2002) 
As a solution, this study aims to apply a modification of several previously 
reported techniques by using endoscopic double anterior and posterior 
tympanomeatal flaps and compare it with single posterior tympanomeatal flap as 
regard success rate in the challenging total and subtotal perforations.  
 
 
 
 
 
 
 
 
 

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Hypothesis: 
To test the role of graft placement under the anterior flap in success rate of 
tympanoplasty. 
Aim of work 
            The aim of this work is to compare outcome between endoscopic single and 
double flap technique in repairing total and subtotal tympanic membrane 
perforations. 
Outcomes: 
Primary outcome:the difference in graft taking rate between the two techniques. 
Secondary outcomes:1-Post operative hearing results. 
                                   2-Benefits of endoscope in tympanoplasty. 
  
Patients and methods: 
A prospective randomized controlled clinical study will be conducted in 
Otorhinolaryngology Department, Mansoura University Main Hospital, on 40 
patients with total and subtotal tympanic membrane perforations attending in the 
department. 
Period of study: 
1 year from July 2017 to July 2018. 
 Method of randomization: 
Randomized according to random table design. 
 

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Patients will be divided randomly into 2 groups A and B: 
Group A:will undergo single posterior tympanomeatal flap. 
Group B:will undergo double anterior and posterior tympanomeatal flaps. 
 
Inclusion criteria: 
-Age group (20-50) 
-Chronic otitis media with total or subtotal tympanic membrane perforation. 
-No active inflammation of middle ear and no epithelial invagination or 
cholesteatoma mass. 
Exclusion criteria 
-Recurrent perforation after previous myringoplasty. 
-Active inflammation of middle ear. 
-Narrow external auditory canal. 
-Ossicular disruption or fixation. 
-Immunocomromised patients including uncontrolled diabetics, chronic liver and 
kidney diseases. 
 
Preparation: 
-All patients are subjected for pre-operative pure-tone audiograms with planned 
post-operative audiograms for follow up. 
-Written consent will be obtained from patients. 
 

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Surgical technique: 
-Surgery will be applied under local or general anesthesia via endoscopic trans-
canal approach. 
 
-Group A( Single tympanomeatal flap group):- 
 The procedure begins with a transcanal endoscopic examination of the TM. 
 A temporalis fascia graft is harvested in standard fashion, pressed, and then 
dried. 
 A rim of tissue is removed from the edges of the perforation to ensure 
complete de-epithelialization of the medial surface of the TM remnant. 
 A posterior canal wall incision is made 6-8 mm from annulus from 6 to 12 
O’clock, then posterior tympanomeatal flap is elevated with the posterior 
tympanic annulus to enter middle ear space. 
 Tympanic membrane is dissected from handle of malleus.  
 The status of the middle ear and ossicular chain are examined. 
 The previously harvested fascia graft is trimmed to appropriate size for full 
coverage of the perforation and placed over handle of malleus, below 
remnant of tympanic membrane.  
 The graft is drapped properly to provide complete coverage of the TM 
perforation. 
 The tympanomeatal flap is then laid back down in native position.  
 
 
 
 
 
 
 

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-Group B( Double tympanomeatal flaps group):- 
 
 Posterior tympanomeatal flap is elevated like group A. 
 Then, the anterior tympanomeatal flap is initiated.  
 A horizontal incision is made just lateral to the anterior portion of the 
annulus . 
 The canal skin and anterior annular ring are carefully elevated medially with 
a Rosen Needle. 
 The middle ear is entered medial to the annulus using a 1mm right-angle 
hook to penetrate the middle ear mucosa until the tip of the instrument is 
visible  through TM perforation 
 Care is taken to preserve the integrity of the annular ring when making this 
anterior canal skin tunnel.  
 The previously harvested fascia graft is trimmed to appropriate size for full 
coverage of the perforation and tailored to have anterior tip that will be later 
pulled from the middle ear through the anterior tympanomeatal flap. 
 The posterior tympanomeatal flap is then moved anteriorly.  
 The trimmed fascia graft is then placed into the middle ear through the 
posterior flap. 
 The posterior tympanomeatal flap is placed back down into native position, 
and the fascia graft is drapped properly to cover TM perforation with the 
anterior tip is directly in line with the anterior canal skin tunnel.  
 The anterior tip is picked up with the right-angle hook and pulled through 
the tunnel underneath the tympanic annulus, and out through the canal skin 
incision and left as a tag which is laid up against the normal anterior canal 
skin.  
        
 
 
  

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In both groups: 
 The middle ear is then packed with dry gel foam followed by gel foam 
soaked with antibiotic solution and antibiotic soaked ribbon gauze.  
 A standard ear pressure dressing is applied for the first 24h and then 
removed. 
 The outer canal packing (ribbon gauze) is removed in 1 week at the first 
post-operative visit 
 Antibiotic drops are initiated twice a day for a week until the second post-
operative visit.  
 Endoscopic follow up evaluation will be carried out after 3 weeks & follow 
up PTA&Tympanogram will be done after 3 month. 
 The 2 groups will be compared as regard middle ear pressure, hearing 
assessment& success rate. 
 
Data collection and statistical analysis: 
 
Patients’ data including preoperative assessment, operative details and 
postoperative follow up will be recorded, tabulated, analyzed and discussed. 
 
Sample size: Based on a pilot trial, a convenient sample size was calculated 
to achieve 80% power to compare outcome between endoscopic single and double 
flap technique in repairing total and subtotal tympanic membrane perforations with 
an alpha level of 0.05. Twenty patients per arm will be included in the study. 
 
Data distribution will be analyzed by computer by SPSS program.  
 
Statistical analysis will be performed by using the suitable statistical 
methods and tests of significance and differences will be considered significant at 
P ≤ 0.05. 
 

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tympanic membrane fluorescein angiography. Ann Otol Rhinol Laryngol, 95, 
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2. FAYAD, J. N. & SHEEHY, J. 2009. Tympanoplasty—outer surface grafting 
technique. Otologic Surgery: Expert Consult-Online, 119. 
3. GERLINGER, I., RÁTH, G., SZANYI, I. & PYTEL, J. 2006. 
Myringoplasty for anterior and subtotal perforations using KTP-532 laser. 
European Archives of Oto-Rhino-Laryngology and Head & Neck, 263, 816-
819. 
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9. PRAKAS, M. D., VISWANATHA, B., KAUR, J. & SANYAL, S. 2014. 
Comparative Study of the Underlay and Over-Underlay Techniques of 
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