International Journal of Otorhinolaryngology and Head and Neck Surgery

Rathi A et al. Int J Otorhinolaryngol Head Neck Surg. 2018 Mar;4(2):432-439

http://www.ijorl.com pISSN 2454-5929 | eISSN 2454-5937

DOI: http://dx.doi.org/10.18203/issn.2454-5929.ijohns20180703
Original Research Article

A comparative study of superiorly based circumferential

tympanomeatal flap tympanoplasty with anteriorly anchoring flap
tympanoplasty in large, subtotal, and anterior tympanic membrane
central perforations in chronic suppurative otitis media of mucosal type
Amitkumar Rathi, Vinod Gite*, Sameer Bhargava, Neeraj Shetty

Department of ENT, HBTMCH and Dr. R.N. Cooper Hospital, Mumbai, Maharashtra, India

Received: 11 November 2017

Revised: 23 December 2017
Accepted: 25 December 2017

*Correspondence:
Dr. Vinod Gite,
E-mail: [email protected]

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: The main objective of the study was to assess and compare the graft uptake, hearing improvement,
complications in large, subtotal, and anterior moderate perforations by each technique viz; superiorly based
circumferential tympanomeatal flap tympanoplasty (STT)/full cuff and anterior anchoring flap tympanoplasty
(AAT)/anterior tucking.
Methods: In our study of 30 cases age group in the range of 10 years to 60 years. The mean air bone gap for the 8
patients with anterior moderate perforation was 31.75 db, for 17 patients with large central perforations was 38.75 db
and for 5 patients with subtotal perforations was 41.4 db.
Results: Mean air bone gap closure after 3 months of surgery in the STT group was 21.4 db while that after 6months
of the surgery for the same group was 22.06 db. Mean air bone gap closure after 3 months of surgery in the AAT
group was 18.2 db while that after 6months of the surgery for the same group was 18.73 db.
Conclusions: Comparing the air bone gap closure in patients who underwent surgery by AAT and STT technique we
found that there is no statistical difference. Both techniques (viz: superiorly based circumferential tympanomeatal flap
tympanoplasty and anteriorly anchoring flap tympanoplasty) can be used for the repair of large, subtotal, and anterior
tympanic membrane central perforations in chronic suppurative otitis media of mucosal type.

Keywords: CSOM, Full cuff, Anterior tucking

INTRODUCTION tympanoplasty type I, where peroperatively middle ear

structures are exposed and are checked for functional
Otitis media is an important and a highly prevalent integrity.3 Three main approaches are used in
disease of the middle ear and poses serious health tympanoplasty: transcanal, endaural, and postauricular.
problem worldwide especially in developing countries Two classic methods for reconstruction of a TM
where large percentage of the population lack specialized perforation have been used: the underlay and the overlay
medical care, suffer from malnutrition and live in poor graft techniques. Each of these approaches and
hygienic environmental conditions.1 techniques has its advantages and disadvantages.4,5

Myringoplasty, is an operation performed to repair or Underlay technique is widely used and relatively simple
reconstruct the tympanic membrane.2 It is also known as to perform as the graft is placed entirely medial to the

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remaining drum and malleus. In the overlay technique, Sample size

the graft is placed lateral to the annulus and any
remaining fibrous middle layer. The overlay technique is In the literature of all the prospective studies reviewed,
more challenging and typically reserved for total we found that the sample sizes varied from a minimum of
perforations, anterior perforations, or failed underlay 20 to a maximum of 110. Hence, we (based on
surgery.6 The anterior and subtotal tympanic membrane feasibility) decided to study a total of 30 cases.
perforation continues to be one of the greatest problems
in middle ear surgery. It has been shown that one of the Study population
most important factors in the success of myringoplasty is
the size and position of the perforation and it has been The study population comprised of 30 subjects (15
noted that the repair of anterior and subtotal perforations subjects of each group viz STT and AAT respectively).
is less likely to be successful compared with the repair of
small posterior perforations. It is generally accepted that Inclusion criteria
the method used for the repair of posterior perforations
may not be appropriate for either anterior or subtotal Inclusion criteria were chronic suppurative otitis media of
perforations. If the perforation is in the anterior half of tubotympanic type with anterior, large and subtotal
the tympanic membrane or if the perforation is subtotal, perforations; age group of patients between 10 to 60
then underlay tympanoplasty may fail because the years of both the sexes.
anterior edge of the graft falls away from and fails to
adhere to the anterior remnant of the tympanic Exclusion criteria
membrane. Although overlay technique has higher
success rate for the reconstruction of anterior large or Exclusion criteria were cases of chronic suppurative otitis
subtotal tympanic membrane perforations, serious media of atticoantral type; cases of chronic suppurative
complications including anterior angle blunting, graft otitis media with ossicular discontinuity; cases of chronic
lateralization, epithelial pearls and delayed healing may suppurative otitis media with extensive disease
occur. The most common area of tympanoplasty failure (cholesteatoma) requiring exteriorizing procedure like
when repairing total perforations is the anterosuperior modified radical mastoidectomy; cases with sensory
area for several reasons including lack of graft support neural hearing loss.
and less vascularity, with a greater risk of reperforation.7
Added to these cases are marginal perforations, causing After the approval from ethics committee, patients
the closure rates to drop even further. undergoing surgery for chronic suppurative otitis media –
mucosal type at Dr. R. N. Cooper Municipal General
In order to achieve greater success with graft uptake, Hospital, Vile Parle (west), Mumbai and falling into the
hearing improvement, and prevention of complications, inclusion criteria were chosen for the study. Patients with
there are many modifications in underlay technique. In ear discharge were initially treated conservatively and
this study we have taken two of the modified techniques were included in the study when their ear became dry for
for correcting anterior moderate, large and subtotal at least 6 weeks.8
tympanic membrane central perforations in chronic otitis
media of mucosal type. The selected techniques are 1) The cases of chronic suppurative otitis media with
Superiorly based circumferential tympanomeatal flap hearing loss were first diagnosed by examination
tympanoplasty; 2) Anteriorly anchoring flap (otomicroscopy) and investigations (Tuning fork test and
tympanoplasty. pure tone audiometry). All patients participating in the
study underwent an audiometric assessment before
Aims and objectives surgery and at 3 months and 6 months after surgery. In
accordance with 1995 guidelines of American academy
1. To assess and compare the graft uptake in large, of otolaryngology- head and neck surgery (AAO-HNS)
subtotal, and anterior moderate perforations by each pure tone audiometry using the frequencies 500 Hz, 1000
technique (viz; superiorly based circumferential Hz, 2000 Hz, and 4000 Hz were plotted and air bone gap
tympanomeatal flap tympanoplasty and anterior was calculated with a pure tone-bone conduction
anchoring flap tympanoplasty). averages at 500 Hz, 1000 Hz, and 2000 Hz.9 Hearing
2. To assess and compare the hearing improvement by results were assessed by comparing pre-operative and
each of the technique. post-operative pure tone averages over the above three
3. To assess and compare the complications produced frequencies as well as closure of the air-bone gap at 3
by each of the technique. months and 6 months of surgery.

METHODS The study subjects/subject‟s guardians or parents (in

cases of minor) were first administered an informed
Study design: Prospective comparative study consent form (Annexure 1). After explaining the
treatment options to the subjects in detail written consent
Study period : October 2013 – June 2015

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 Rathi A et al. Int J Otorhinolaryngol Head Neck Surg. 2018 Mar;4(2):432-439

were obtained from those who agreed to participate in the Categorical variables were studied with a chi-square test
study. on open epi software.

For every individual consenting to participate in the RESULTS

study, a case record form was filled as (Annexure 2).
Randomization was done by draw of lots. Age

The surgery was done under local or general anaesthesia

by postaural route. After raising the tympanomeatal flap 41-60 2
by either of the technique, status of the ossicular chain

age in years
was assessed. Temporalis fascia was used to close the 21-40
16
perforation by underlay technique.
>20
12
Surgical technique 0 5
10
15
The surgical techniques used by us in our study are as 20
follows; no. of patients

A. superiorly based circumferential tympanomeatal flap Figure 1: Showing age distribution for the whole
tympanoplasty study.
• Canal incision given radially from 12 „O clock from Gender
medial to lateral, while a second circumferential
incision from 1 „O clock lateral to the annulus Male outnumbered females in our study, total of 16 males
(approximately 6mm lateral to annulus) extending (53%) and 14 females (47%) participated in the study
circumferentially and joining 5‟O clock radially. (Figure 2).
• Elevation of circumferential tympanomeatal flap,
which is superiorly based.
• Temporalis fascia graft is anchored under the handle
of Malleus and reposited all around the bony
8
number of patients

annulus. 7 8
8 7
B. Anteriorly anchoring flap tympanoplasty

• Canal incisions: 12‟O clock incision radially from 0

medial to lateral over the canal other incision is taken STT
from 6‟O clock radially from medial to lateral these Surgery AAT
two incisions creates a posteriorly based male female
tympanomeatal flap. Another incision
circumferentially just lateral to the annulus
Figure 2: Showing gender distribution in the
(approximately 6mm lateral to annulus) on the
individual groups.
anterior canal wall from 1‟ O clock to 5‟O clock
creating an anterior canal flap taken.
• Posterior flap elevated and ossicles mobility Chief complaints
checked.
• Temporalis fascia graft placed in an underlay fashion
below the handle of malleus while the anterior edge 15
of the graft is tucked under the anterior flap made 4
4
initially tympanomeatal flap reposited. 10

11
Statistical analysis 5 11

0
Data was collected using case record forms and were
STT
entered on Microsoft excel spreadsheet. Given the normal
AAT
distribution of values, differences between patients of two
ear discharge with decreased hearing exclusive ear discharge
groups were assessed using a two-tailed, two-sample
Student's t-test on Microsoft excel 2007. Differences
between postoperative and preoperative results were Figure 3: Showing distribution of the chief complaints
analyzed with a paired t-test Microsoft excel 2007. in the individual groups.

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Side of the diseased ear The mean air bone gap closure of the patients operated by
STT and AAT technique at 6 months of surgery shows no
Involvement of right side of the ear was seen in statistical difference (Table 2).
10patients (33%) and left side in 20 patients (67%).

Comorbidity

mean AB gap in db
20
Out of all the patients 4 patients had co- morbities as 17.47 16.87
15
hypertension and diabetes mellitus and HIV infection was
seen in one patient. 10

5
Mean air bone gap
0
post sx (STT)@ post sx (AAT) @
Comparing the mean air bone gap preoperatively of both 6months 6months
the groups (AAT and STT) separately showed no Post surgery 6 months
statistical difference between both (Table 1).
Mean air bone gap in db
Table 1: Showing pre surgery mean air bone gap in
the individual groups.
Figure 5: Comparison between post-surgery mean air
Pre surgery Pre surgery bone gaps at 6 months between individual groups.
(STT) (AAT)
Mean AB gap in db 38.87 35.6 Table 2: Showing mean air bone gap closure post
Standard deviation 4.88 6.31 surgery at 6 months of individual groups.
P value 0.124059993
(Values: mean±S.D., p<0.05: significant, P>0.05 : not
Post surgery Post surgery
significant). STT (6months) AAT (6months)
Mean AB gap
22.07 18.73
Comparison between the mean air bone gaps of the closure in db
patients operated by both the techniques at 3 months Standard
4.15 5.05
showed no statistically significant difference (Figure 4). deviation
P value 0.058138
(Values: mean±S.D., p<0.05: significant, P>0.05 : not
significant).

Complications
20
mean ab gap in db

In the entire study out of 30 patients 2 patients developed

15 complication, this was a residual perforation after
6months of surgery (Table 3).
10 18.13 17.4
Table 3: Showing distribution of the complications in
5
the individual groups.
0
Post sx (STT) @ post sx (AAT)@ Complications
3months 3months (residual perforation)
surgery Present Absent Total
Surgery STT 1 14 15
Mean air bone gap in db of both groups @ 3 months
(type) AAT 1 14 15
total 2 28 30
Figure 4: Comparison between post-surgery mean air P value 1
bone gaps at 3months between individual groups. (p<0.05: significant, P>0.05 : not significant).

Comparing the mean air bone gap of the patients who got Comparing the complications developed in the patients
operated by STT technique and by AAT technique after 6 who underwent surgery by AAT and STT technique we
months shows no significant difference statistically found that there is no statistical difference in the
(Figure 5). development of complication.

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DISCUSSION hearing impairment which is very well with the view of

many authors.1 Unilateral involvement of ears in the
The main objective of myringoplasty has traditionally entire study group was seen in 72% cases while bilateral
been the closure of the tympanic membrane perforation to involvement was seen in 28% of patients. Out of the
prevent chronic infections and to make the ear safe.10 unilaterally involved ears, it was seen that left ear was
Consequently; the second objective is to improve the more commonly involved in their study (58.33%); in our
hearing loss which resulted due to perforation of the study also the commonest complaint was ear discharge
tympanic membrane. There is still no consensus about the and the second common complaint being hearing
optimal technique, which is often employed on the basis impairment. Similarly in our study 70% patients had
of the surgeon's preference and skills, and not on the type unilateral disease and 30% had bilateral ear disease which
of the tympanic membrane perforation.11 In our study we is comparable with their study. While in our study left ear
compared two techniques of raising the tympanomeatal was involved in 67% which is also comparable with their
flaps in tympanoplasty viz superiorly based study.
circumferential tympanomeatal flap, anterior anchoring
flap. In our study these two modified techniques were In our study the mean air bone gap of 8 patients with
used to close the anterior moderate, large and subtotal anterior moderate perforation was 31.75±7 db, for 17
perforations of tympanic membrane in csom of mucosal patients with large central perforations was 38.75±4.88
type. db and for 5 patients with subtotal perforations was
41.4±3.30 db. The mean air bone gap of patients with
For this purpose, a prospective randomized study was anterior moderate perforation was significantly low
done in which 30 patients with chronic suppurative otitis compared to the large and subtotal perforations
media (mucosal type) who were randomly allocated two statistically with p value of 0.004147 and 0.01051
groups– Group I (i.e. STT) comprising of 15 patients in respectively. While the mean air bone gap when
whom superiorly based tympanomeatal flap compared between patients with large and subtotal
tympanoplasty was done, Group II (i.e. ATT) comprised perforation showed no statistical difference (p value of
of 15 patients in whom anteriorly anchoring flap 0.17923 which is more than 0.05). Terkildsen stated that
tympanoplasty was done. “There is no general agreement among clinicians about
the magnitude and the configuration of the hearing loss
Mean age of patients in our study over all was that is caused by various types of tympanic-membrane
25.17±11.47 years. CSOM is prevalent in all age groups; perforations.”16 Shambaugh observed that seemingly
however, patients in the paediatric and younger age identical perforations in size and location produce
groups are most commonly affected (WHO, 2004). In a different degrees of hearing loss.18 The reasons for the
study by Yaor et al, age of patients undergoing variations in the hearing effects of simple perforations are
myringoplasty ranged from 9 to 84 years with a mean age not easily defined. Mehta et al in their study concluded
of 37 years and 24% of their patients being children aged that the hearing loss increases with increasing size of a
9 to15 years.12 In present study, mean age was slightly perforation; the hearing loss does not vary substantially
lower which might mainly be attributed to the inclusion with location of the perforation.18 Effects of location, if
criteria where the age range was restricted only between any, are small. Kumar et al also concluded that hearing
10 and 60 years. Yoon et al in their series of 111 patients loss increases with the increase in the size of tympanic
undergoing myringoplasty had all the patients aged 15 membrane perforation.1 In our study also patients with
years or less.13 Magsi et al reported a study in which anterior moderate perforations had less hearing loss than
patients were aged 5 to 50 years and had maximum the large and subtotal perforations which is in accordance
number of patients aged 11-20 years as against present with Kumar et al and Mehta et al study.
study in which maximum number of patients were aged
21 to 30 years.14 Age has been identified as a possible Technique of underlay tympanoplasty was preferred by
confounding factor having an impact on the outcome us, as it has many advantages, that there is no risk of
(Webb and Chang) in present study both extreme ends as blunting, lateralization of graft and epithelial cyst
mentioned in the above studies, were excluded from the formation, as elaborated by Doyle.19 Our results and
study to rule out any such confounding effect.15 observations about underlay tympanoplasty matches with
that of Doyle and Glasscock, where underlay
In present study, majority of patients irrespective of the tympanoplasty is justified as a technique with better
group to which they were allocated were males. Although results.20 These findings are in contrast to the results of
some western studies (Webb and Chang) have reported a Rizer, who attained drum healing in 95.6% in overlay, as
higher prevalence amongst females yet gender wise compared to 88.8% in underlay tympanoplasty.21 In our
differences could be purely incidental and could study over all we attained drum healing in 90% with
generally be attributed to gender biased healthcare underlay tympanoplasty. While in the individual groups
seeking practices in our settings.15 viz STT and AAT we attained drum healing in 93.33%
and 86.67% respectively. Mishra et al in their study
In the study conducted by Kumar et al commonest attained drum healing 97% by doing superiorly based
complaint was observed to be otorrhoea, followed by circumferential tympanomeatal flap tympanoplasty (i.e.

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 Rathi A et al. Int J Otorhinolaryngol Head Neck Surg. 2018 Mar;4(2):432-439

STT technique) which is comparable to our study with In the study conducted by Mishra et al 7% patients
93.33%. Hosamani et al did 33 patients with anterior suffered complications post operatively like otitis media
tagging myringoplasty (i.e. AAT) showed graft uptake with effusion (2%) retraction (2%) myringitis (2%) and
was 95.45% in anterior and subtotal and concluded with lateralization (1%).22 While in our study 2 patients out of
anterior tagging of graft material is a suitable for anterior 30 i.e. 6.67% patients suffered complications of residual
and subtotal perforations; in our study we attained drum perforation which was preceded by acute otitis media,
healing in 86.67% in the group who underwent anteriorly which are comparable to the Mishra et al study.
anchoring flap tympanoplasty which is comparable to the Complications in the individual group i.e. STT and AAT,
above study.23 Hence in our study in the individual out of 15 patients of STT group, 1 patient i.e. 6.67%
groups viz STT and AAT we attained drum healing in developed the complication and out of 15 patients of
93.33% and 86.67% respectively, which when compared AAT group 1 patient i.e. 6.67% developed the
with each other shows no statistical significant difference complication. Comparing the complications in the
(p value of 0.5428which is more than 0.05). patients who got operated by STT and AAT technique
respectively it showed no statistical significant difference
In our study the preoperative mean air bone gap of the between the two (P value of 1 which is more than 0.05).
patients was 37.23±5.79 db after surgery at 6 months
came down to 17.17±3.31 db hence after calculating the Good hearing gain in our study can be correlated with
mean air bone gap closure it came down to be expertise technique to deal with subtotal perforations
20.4±4.85.which showed a significant improvement in the with special reference to the superiorly based
hearing (p value 1.493 E-23 which is less than 0.05). circumferential tympanomeatal flap and anteriorly
While in the individual group viz STT and AAT the anchoring flap placement of the graft, maintaining the
preoperative mean AB gap was 38.87±4.88 db and conization of the grafted tympanic membrane by placing
35.6±6.31 respectively and postoperative at 6 months the graft under the handle of malleus.
mean AB gap was 17.47±1.96 db and 16.8±74.32 db
respectively. When compared with the preoperative mean Various surgeons have used different kinds of grafts to
air bone gap the postoperative mean air bone gap showed repair tympanic membrane perforations. Most popular are
significant improvement. But inter–comparison between autogenous grafts. Zollner used pedicled ear canal skin
STT and AAT of the postoperative mean AB gap at 6 graft to close perforations.26 Shea introduced vein graft to
months post-surgery showed no statistical significant close tympanic membrane perforations.27 It goes to the
difference. credit of Heermann for introducing temporalis fascia as a
grafting material in tympanoplasty.28 We used temporalis
J.F. Sharp et al did 47 cases with anterior or subtotal fascia graft to close subtotal perforations and could
perforation of pars tensa and found in kerr flap technique achieve good results both in terms of drum healing (90%)
graft uptake was 95.7% and hearing improved by an and closure of (A-B) gap– of 20.4±4.85 db.
average 8.5 dB.24 Mokhtarinejad et al did 38 cases
(group- A) circumferential sub annular grafting and 25 CONCLUSION
cases (group-B) of underlay tympanoplasty with
extension of anterior edge of the graft forward against the After considering the observations and results and in
lateral wall of the Eustachian tube, they found success accordance with the aims and objectives of our study
rate in 97% in group A and 100% in group B patients, regarding, „comparison between superiorly based
improvement of the air conduction thresholds in all tympanomeatal flap tympanoplasty with the anteriorly
frequencies and closure of the mean air bone gap were anchoring tympanomeatal flap tympanoplasty in large,
significant and similar among two groups -A and in group subtotal, and anterior tympanic membrane central
B patients. Mishra et al did prospective study of 100 perforations in chronic suppurative otitis media of
cases of underlay technique with superiorly based mucosal type‟, we conclude that,
circumferential flap it was found that graft take up was
97%, hearing gain of 10-30 dB was achieved in 95% of 1. The graft uptake in large, subtotal, and anterior
cases.22 In our study the mean air bone gap closure or the moderate perforations by each technique is
hearing gain with the STT and AAT technique was comparable i.e. both techniques have same results in
22.07±4.15db and 18.73±5.05db respectively which is view of graft uptake.
better than Sharp et al and comparable with the other two 2. The hearing improvement by each of the techniques
studies of Mokhtarinejad et al and Mishra et al. is comparable i.e. both techniques shows same
amount of hearing improvement with no significant
While comparing the mean air bone gap closure of the difference in patients with large, subtotal, and
patients who got operated by STT and AAT technique at anterior moderate perforations.
6months of surgery it shows that there is no statistical 3. Complications produced by each of the techniques
significant difference between both (p value of 0.058138 are comparable i.e. both the techniques have no
which is more than 0.05). significant difference in the complications produced
post-surgery.

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 Rathi A et al. Int J Otorhinolaryngol Head Neck Surg. 2018 Mar;4(2):432-439

Recommendation 11. Sergi B, Galli J, De Corso E, Parrilla C, Paludetti G.

Overlay versus underlay myringoplasty: Report of
We recommend that both techniques can be used for the outcomes considering closure of perforation and
repair of large, subtotal, and anterior tympanic membrane hearing function. Acta Otorhinolaryngol Ital.
central perforations in chronic suppurative otitis media of 2011;31:366-71.
mucosal type. 12. Yaor MA, El-Kholy A, Jafari B. Surgical
Management of Chronic Suppurative Otitis Media:
Limitations A 3-year Experience. Annals of African Medicine
2006;5(1):24-7.
Owing to limitation of sample size the trends obtained in 13. Yoon TH, Park SK, Kim JY, Pae KH, Ahn JH.
present study need further validation and verification Tympanoplasty, with or without mastoidectomy, is
highly effective for treatment of chronic otitis media
Funding: No funding sources in children. Acta Otolaryngol Suppl. 2007;558:44-8.
Conflict of interest: None declared 14. Magsi PB, Jamro B, Sangi HA. Clinical
Ethical approval: The study was approved by the presentation and outcome of mastoidectomy in
Institutional Ethics Committee of HBT medical college chronic suppurative otitis media (CSOM) at a
tertiary care hospital Sukkur, Pakistan. RMJ.
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