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\begin{document}

\title{Endoscopic Versus Microscopic Type I Cartilage Tympanoplasty for
Anterior Perforation-A Prospective Comparative Study}



\author[1]{Dipesh Shakya}%
\author[2]{Ajit Nepal}%
\affil[1]{Civil Service Hospital}%
\affil[2]{Patan Academy of Health Sciences School of Medicine}%


\vspace{-1em}



  
  \date{May 25, 2024}


\begingroup
\let\center\flushleft
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\selectlanguage{english}
\begin{abstract}
Objective Chronic otitis media with anterior perforation is a
challenging condition to treat with a microscope especially if the canal
is narrow or has overhang. The endoscope provides the advantage of
wide-angle view and transcanal access avoiding postaural approach and
canaloplasty. The aim of this study was to compare the anatomical,
functional outcomes, and surgical duration between endoscopic and
microscopic type I tympanoplasty performed for anterior perforation
Design Prospective comparative study Setting Tertiary Referral Hospital
Participants A total of 100 cases with anterior perforations were
enrolled which was divide into two groups, the microscopic (MT) and the
endoscopic (ET) with 50 cases in each group. Main outcome measures Graft
uptake rate, hearing outcomes and surgical durations were compared
between the two groups. Results The graft uptake in MT and ET was 81.8\%
and 91.3\% respectively, statistically not significant. The mean
operative time for MT and ET was 68.68\selectlanguage{ngerman}±18.79 minutes and 61.24 ± 11.18
minutes respectively with statistically significant difference
(p-0.003). Hearing outcomes were improved after the surgery within the
groups. However, there was no significant difference in the hearing
between the groups. Conclusions The endoscopic tympanoplasty for
anterior perforation provides superior visualization avoiding postaural
incision and canaloplasty, with good graft closure rate, improved
hearing. It also offers significantly faster completion of surgery than
a microscope. Thus, with the endoscope, minimally invasive surgery can
be performed. Key points \selectlanguage{english}* Anterior perforations are challenging
condition and difficult to treat, carrying poor prognosis than central
or posterior perforations. \selectlanguage{english}* Microscope provide straight line of vision,
making it difficult to access anterior perforations. \selectlanguage{english}* Endoscope
provides wide angle view, high magnification and high definition image
which avoids postaural incision or canaloplasty for anterior perforation
repair. \selectlanguage{english}* Transcanal Endoscopic ear surgery provides advantage of
performing minimally invasive surgery. \selectlanguage{english}* It indirectly lessens the
financial burden to the patient which is significant in the developing
countries.%
\end{abstract}\selectlanguage{ngerman}%



\sloppy


\textbf{ABSTRACT}

\textbf{Objective}

Chronic otitis media with anterior perforation is a challenging
condition to treat with a microscope especially if the canal is narrow
or has overhang. The endoscope provides the advantage of wide-angle view
and transcanal access avoiding postaural approach and canaloplasty.~The
aim of this study was to compare the anatomical, functional outcomes,
and surgical duration between endoscopic and microscopic type I
tympanoplasty performed for anterior perforation

\textbf{Design}

Prospective comparative study

\textbf{Setting}

Tertiary Referral Hospital

\textbf{Participants}

A total of 100 cases with anterior perforations were enrolled which was
divide into two groups, the microscopic (MT) and the endoscopic (ET)
with 50 cases in each group.

\textbf{Main outcome measures}

Graft uptake rate, hearing outcomes and surgical durations were compared
between the two groups.

\textbf{Results~}

The graft uptake in MT and ET was 81.8\% and 91.3\% respectively,
statistically not significant. The mean operative time for MT and ET was
68.68\selectlanguage{ngerman}±18.79 minutes and 61.24 ± 11.18 minutes respectively with
statistically significant difference (p-0.003). Hearing outcomes were
improved after the surgery within the groups. However, there was no
significant difference in the hearing between the groups.

\textbf{Conclusions} The endoscopic tympanoplasty for anterior
perforation provides superior visualization avoiding postaural incision
and canaloplasty, with good graft closure rate, improved hearing. It
also offers significantly faster completion of surgery than a
microscope. Thus, with the endoscope, minimally invasive surgery can be
performed.

\textbf{Key words:}

Tympanoplasty, anterior perforation, cartilage, endoscope, microscope

\textbf{Key points}

\begin{itemize}
\tightlist
\item
  Anterior perforations are challenging condition and difficult to
  treat, carrying poor prognosis than central or posterior perforations.
\item
  Microscope provide straight line of vision, making it difficult to
  access anterior perforations.
\item
  Endoscope provides wide angle view, high magnification and high
  definition image which avoids postaural incision or canaloplasty for
  anterior perforation repair.
\item
  Endoscope provides advantage of performing minimally invasive surgery.
\item
  It indirectly lessens the financial burden to the patient which is
  significant in the developing countries.
\end{itemize}



\textbf{Introduction}

An endoscope is a relatively new tool in the field of otology which is
gradually gaining its acceptance in the community. After the development
of Hopkins rod endoscope by Harrold Hopkins\textsuperscript{1} in 1966,
it was only in 1992, when El Guindy \textsuperscript{2} from Egypt
published the first paper on total endoscopic ear surgery i.e.
myringoplasty using a fat graft. Between 1966 to 1992, most of the
studies published were based on secondary endoscopic ear surgery i.e.
endoscopic assisted microscopic ear
surgery.\textsuperscript{1,3}However, the microscope is still considered
as a gold standard tool in otology.\textsuperscript{3} Tympanoplasty is
considered one of the most common procedures done by otologists to
repair tympanic membrane (TM) and to restore hearing.\textsuperscript{4}
Graft material commonly used is temporalis fascia, but it has recently
been replaced by cartilage, especially for anterior and subtotal
perforation because of stability and long-term uptake
results.\textsuperscript{5} Different techniques are described in the
literature for doing tympanoplasty which includes overlay, underlay, and
over-underlay techniques with each having pros and
cons.\textsuperscript{6,7,8} The most commonly used technique worldwide
seems to be an underlay technique because it is easier to perform and
less time-consuming.\textsuperscript{6,2}

Chronic otitis media (COM) with large perforation, subtotal perforation,
atelectasis, adhesive otitis media, cholesteatoma, tympanosclerotic
cases, revision cases are considered as high-risk cases with poor uptake
results.\textsuperscript{9} Among them anterior perforation is also
considered as the poor prognostic factor for the graft uptake because of
its difficult access, reduced vascularity, and graft
instability.\textsuperscript{10,} \textsuperscript{11}

Microscopy has been the most commonly used tool for ear surgery;
however, due to its straight-line vision, it limits the exposure of
anterior quadrant or marginal perforations.\textsuperscript{12} To
overcome this, more invasive procedures that enlarge the surgical field
are needed, such as canaloplasty or a postaural
approach.\textsuperscript{13} Because of these limitations, the use of
an endoscope is rapidly increasing in the past two decades. The main
advantage of endoscopes in tympanoplasty is its wider field of view,
magnification, high definition image, and superior visualization,
including anterior margins avoiding postaural approach and
canaloplasty.\textsuperscript{13,14} In this study, we evaluated the
difference between the graft uptake rate, surgical duration, and hearing
evaluation between endoscopic and microscopic type I tympanoplasty in
COM with anterior perforation.

\textbf{Materials and Methods}

This is a comparative study of prospectively obtained data carried out
in our center from February 2016 to October 2017. We analyzed the 100
patients who underwent surgery for COM with anterior perforation. The
subjects were classified into two groups. The first group comprised of
the first fifty cases with anterior perforation underwent microscopic
tympanoplasty and assigned as MT. The second group was the next fifty
cases who had undergone endoscopic tympanoplasty and was assigned as ET.
Out of 100 cases enrolled, 6 patients in MT and 4 patients in ET lost to
follow up, thus 44 and 46 patients were included in MT and ET
respectively. All the data of the cases used for the study are
available.

Inclusion criteria for the study were adult patients, age more than 18
years old, suffering from COM with anterior perforation who required
primary type I tympanoplasty with patients having minimum follow up of
12 months. Patients having cholesteatoma, revision cases, retraction
pockets, atelectasis, ossicular discontinuity, middle ear discharge, and
the perforation involving posterior quadrants were excluded from the
study. All cases were done under local anesthesia as a daycare basis.
Ethical clearance was obtained from the Institutional Review Board of
the (removed for blind peer review). Informed consent was obtained from
all the participants of the study.

All surgeries were performed by the first author. Tragal cartilage was
used as a graft in the cases that were carried out via a transcanal
approach whereas conchal cartilage was used in cases that were done by
postaural approach. The shield graft technique using barred cartilage
with perichondrium reinforcement technique was used in all cases.
Demographic data including age, sex, perforation site, operation time,
approach, and graft success rate were evaluated.

For the endoscopic group, all cases were performed transcanally, whereas
the microscopic group had approached as permeatal and postaural. Nine
cases of the microscopic group needed a postaural approach due to the
lack of vision of the anterior margin.

\textbf{Surgical Procedure}

A local antibiotic was given in case of preoperative inflammation of the
tympanic cavity. The surgery was only performed was the middle ear
cavity was dry clinically. A tragal cartilage graft was harvested in the
case of a transcanal approach and conchal cartilage was obtained in case
of a postaural approach. The perichondrium was removed on both sides in
both grafts tragal and conchal.

The margin of perforation was freshened. Two vertical incisions were
given at 12 o'clock and 5 o'clock, which related to a horizontal
incision about 10mm lateral to the annulus. Tympanomeatal flap was
elevated from the posterior canal wall. The posterior annulus was
elevated out of the sulcus and the mobility of the ossicular chain was
checked.

Gelfoams (SPONGOSTAN\selectlanguage{english} Special, Ferrosan Medical Devices A/S, Soeborg,
Denmark) were kept in the middle ear accordingly. The barred cartilage
shaped according to the size needed was negotiated under the malleus
handle (underlay technique). If the middle ear space was compromised due
to a medialized handle of malleus, the cartilage was notched to fit the
handle of malleus. Then the perichondrium was placed as reinforcement
using the underlay technique under the handle of malleus and pushed
anteriorly up to anterior margin. The tympanomeatal flap was placed back
in the posterior canal wall. The perichondrium was adjusted to fit and
tug around the anterior margin of perforation. Thus, perichondrium
reinforced barred cartilage graft technique was used in both MT and ET
groups. A Final check was done to ensure there was a touch of
perichondrium cartilage graft with anterior margin and annulus (Figure).

The EAC was packed with gelfoam and then with ear pack (Osseous Ear

Pack, EonMeditech Pvt ltd.), which was removed after 7 days. No suture
was applied in the graft site in case of a transcanal approach. For the
postaural approach, the incision site was sutured, and the mastoid
bandage was applied.

Patients were followed up at 6 weeks, 12 weeks, 6 months, and with a
minimum of 12 months, and thereafter as needed. The average on four
frequencies (0.5, 1, 2, and 3 kHz) of hearing thresholds in air and bone
conduction and the Air Bone Gap (ABG) was evaluated 7 days before
surgery and 12 weeks after.

\textbf{Statistical Tools}

Data were analyzed for graft uptake rate, the difference in operation
time and change in pre- and postoperative hearing status using the
Fisher exact test, and the dependent and independent t-test in IBM SPSS
Statistics for Windows, Version 23.0 (IBM Corp., Armonk, NY, USA). The
level of statistical significance was set at p\textless{}0.05.

\textbf{Results}

During the study period, 100 patients were included, out of which 6 and
4 patients had lost to follow up in MT and ET group, and thus, only 90
patients were assessed. The demographic profile including age, sex, site
of perforation, graft uptake rate and follow up range has been shown in
table 1. In the MT group, the mean age of patients was 30.89 +- 11.78,
and the age ranged from 18 to 60 years old, and in the ET group, the
mean age of the patients was 30.43+-10.18 ranged from 18 to 57. There was
no statistical difference between the two age groups (p-0.285).

There were 20 males and 24 females in the MT group and 27 males and 19
females in the ET group which was not statistically different (p-0.291).

Based on the laterality of disease, in the MT group, 19 cases were on
the right side and 25 on the left side. In the ET group, 26 cases were
on the right side, and 20 on the left side. Both were statistically
insignificant (p-0.292).

The graft success rate at a minimum of 12 months post-operative period
in the MT group was 81.8\% with follow up range of 16.09+- 5.071 months
and in ET was 91.3\% with a followup of 14.67+-4.02 months. Three cases
in MT and one case in ET which had initial graft uptake seen at 6 months
later failed during follow up of 12 months period. There seem to be
improved graft uptake percentage seen in ET then MT however, the data
was not statistically significant between the two groups. (p-0.225).

Mean surgical duration was defined as the time of margin freshening up
to the time where the ear pack was kept. The mean operative time for MT
and ET was 68.68+-18.79 minutes and 61.24 +- 11.18 minutes respectively.
The difference obtained was statistically significant (p-0.003).
Endoscopic tympanoplasty significantly saved time than the microscopic
tympanoplasty.

Hearing outcomes were as shown in table 2. There was a highly
statistically significant hearing outcome within the group before and
after the surgery in both groups, endoscopic and microscopic. But there
was no change in hearing outcomes between the two groups. Thus, the
hearing outcome didn't change with either use of an endoscope or a
microscope.

\textbf{Discussion}

The microscope has been a widely used tool for the otological procedure
and still considered as the gold standard in this field. It provides the
main advantage of bimanual handling along with stereoscopic vision,
better depth perception, and excellent
magnification.\textsuperscript{15} However, due to its straight line of
vision, it has a drawback of the inability to look around the nooks and
corners of the middle ear cavity like sinus tympani, retrotympanum,
epitympanum and tensor fold area.\textsuperscript{3,13,16} Anterior
perforation especially in cases with narrow canal or bony overhang needs
postaural approach and/or canaloplasty to perform the tympanoplasty.
Nevertheless, microscopic tympanoplasty for anterior perforation is
still considered as a high-risk case. The reasons for the lower success
rate in the closure of anterior TM perforation are insufficient
visualization, technically challenging procedure, decreased graft
viability due to poor vascularization, inadequate anterior membrane
remnant, and poor stabilization. \textsuperscript{17}

An endoscope, on the other hand, is a newly emerging tool in the town,
which is gaining popularity in our community. More and more surgeons are
now accepting it to be used for the surgery. Though it was first used by
Mer et al in 1967 as a tool to study the middle ear in cadavers and
animals, it became only famous when Tarabichi et al started to publish
widely and exclusively on transcanal endoscopic ear surgery especially
on myringoplasty and cholesteatoma.\textsuperscript{1} The scope of the
endoscope in ear surgery is expanding since then, not only limited to
cholesteatoma but ossicular reconstruction, stapes surgery, facial nerve
decompression, and even to excision of vestibular
schwannoma.\textsuperscript{3} We still need to wait what future brings
us more with the expansion of the use of the endoscope in otology.

Though temporalis fascia is still commonly used as a graft material, it
has been largely replaced by cartilage perichondrium graft especially in
high-risk conditions such as large or subtotal perforations, retraction
pockets, atelectasis, adhesive COM, and
cholesteatoma.\textsuperscript{5} Among them anterior perforation is
also considered among high risk due to its lack of vascularization,
stability, and support for graft. For this, cartilage-perichondrium
graft is an ideal graft for the surgery due to its stability and
long-term uptake result.\textsuperscript{12}

In this study, we made an objective to evaluate if the endoscope holds
an advantage over the microscope for anterior perforation. Type I
tympanoplasty for anterior perforation using a microscope is difficult
to manage especially if the canal is narrow or the margins are not
adequately visible. We had graft uptake of 81.8\% in the microscopic
group and 91.3\% in the endoscopic group. The result revealed the
endoscopic group having better uptake outcomes than the microscopic
group however, it was not statistically significant. The mean operative
time was 68.68 +- 18.79 minutes in MT and 61.24 +- 11.18 minutes in ET.
Endoscopic tympanoplasty was faster than the microscopic group and it
was statistically significant.

Though endoscopic tympanoplasty avoids postaural incision, canaloplasty,
mastoid bandaging, it is technically challenging procedure as one must
master surgery using one hand. Even the little blood in the canal can
smudge the scope, making surgery difficult. These factors might be some
of the reasons behind the long surgical duration compared to other
studies. We experienced that with more practice the surgery got faster,
however, endoscopic surgery required a learning curve to overcome. On
the other hand, microscopic tympanoplasty gave the privilege of using
two hands for the surgery. Even if we were doing permeatal microscopic
tympanoplasty, speculum could be snugly fitted into the wide canal, and
still, two hands could easily be used for the procedure which is not
possible at all with the endoscope.

However, the postaural approach required more time to be spent on the
incision and suturing which was easily avoided in endoscopic
tympanoplasty. Thus, we could see that endoscopic ear surgery is
minimally invasive surgery decreasing the operation time, morbidity, and
complications.

A similar study but retrospective was done by Gulsen et
al.\textsuperscript{18} with an uptake rate of 93.7\% in the endoscopic
group and 91.5\% in the microscopic tympanoplasty with follow up of less
than 12 months. They had a significant difference in surgical time
between the two groups as well. The overall total surgical time in their
study is lesser than ours. Surgical time depends on the surgeon's
experience as well as the learning curve.

A retrospective comparative study was also done by Kuo et
al.\textsuperscript{19} with a graft uptake of 97.3\% in the endoscopic
group and 98.2\% in the microscopic group but for central perforation.
However, this study had very short follow up of 3 months. The study had
significant difference in surgical time as well.

We could not find other literature that compared prospectively between
microscopic and endoscopic tympanoplasty in anterior perforation. There
are few studies published on total endoscopic transcanal ear surgery for
anterior perforation.

Tseng et al.\textsuperscript{7} published a retrospective study on
endoscopic transcanal myringoplasty for anterior perforation using
temporalis fascia and/or perichondrium as the graft and had uptake rate
of 93\% among 59 patients with a follow up of a minimum of 6 months.

Another study was done by Ozdemir et al.\textsuperscript{12} on
endoscopic transcanal cartilage tympanoplasty in 104 patients, out of
which 35.6\% had anterior quadrant involvement. The graft used was a
tragal perichondrium composite graft and had an uptake rate of 93.2\% at
a minimum follow up of 6 months. A similar prospective study carried out
by Mohanty et al.\textsuperscript{10} on transcanal endoscopic cartilage
myringoplasty for anterior perforation in 87 patients had uptake result
in 91.9\% at 1 year follow up which had similar uptake rate as our
result.

A systemic review was published by Visvanathan et
al.\textsuperscript{20} on techniques of successful closure of anterior
TM perforation. They described various techniques as anterior anchoring,
anterior hitch method, anterior interlay, anterosuperior anchoring,
endoscopic push through, butterfly, lateral graft tympanoplasty, hammock
tympanoplasty, Felix tympanoplasty, and endoscopic transcanal
techniques. The success rate ranged from 87-98\% with a minimum follow
up of 6 months.

Other studies describing the techniques for the treatment of anterior
perforation includes the procedure that does not involve raising
tympanomeatal flaps such as endoscopic butterfly-inlay, endoscopic
push-through, and endoscopic transcanal inlay with graft uptake ranging
from 87.5 to 95.5\% .\textsuperscript{11,17,21}

There are different studies found in the literature comparing the
operative time between microscopic and endoscopic tympanoplasty. Huang
et al. \textsuperscript{22}, Choi et al.\textsuperscript{23}, and kaya
el al.\textsuperscript{24}, all compared surgical duration in both
groups and reported as endoscopic tympanoplasty being faster than
microscopic surgery which was statistically significant. However, their
study was done for the central perforation and the study was not
involving exclusively for anterior perforation as in our study.

All the studies mentioned above had significant hearing improvement pre-
and postoperatively, including those studies that used perichondrium and
cartilage perichondrium composite graft. In this study, we raised the
tympanomeatal flap to check the status of the ossicular chain, other
middle ear pathologies, and to perform underlay myringoplasty. This
ensures the stability of graft to avoid lateralization. There were no
postoperative complications noted in both groups.

Nine patients in the MT group required postaural incision to perform the
surgery due to a narrow canal and lack of visualization of the anterior
margin. All the cases in the ET group were completed via a transcanal
approach. It is all because of the wide-angle view of the endoscope
where the anterior margin could easily be seen. This adds up the
advantage of endoscopic surgery to be minimally invasive surgery
preventing complications as well as a financial burden which plays a big
role in a developing country like ours.

There are few limitations of this study which include small sample size,
lack of randomization and short follow up period. This could hamper the
generalizability of the results. In our opinion, the surgeon should also
be blinded during the surgery to decrease the bias especially if the
surgical duration is also considered in the study. The learning curve
could also be the factor that affects the surgical time.

\textbf{Conclusion}

The endoscope had comparable graft uptake rate and hearing improvement
compared to the microscope. However, it had a significant difference in
surgical duration with the endoscope offering faster completion of
procedure than the microscope. The Endoscope offered the advantages of a
wide panoramic view, magnification without loss of resolution, and
superior visualization, making it a wonderful tool to perform surgery
especially for anterior perforation, avoiding postaural incision and
canaloplasty. Thus, with the endoscope, minimally invasive surgery can
be performed avoiding unnecessary tissue dissection, and retraction
decreasing the surgical duration, complications, morbidity, and
indirectly decreasing the financial burden.

\par\null



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28--31.

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Oto-Rhino-Laryngology}\textbf{274} , 3343--3349.

\textbf{Figure Legend}

Figure 1:

\begin{enumerate}
\tightlist
\item
  Preoperative anterior perforation
\item
  Middle ear and ossicles assessed after elevation of tympanomeatal flap
\item
  Barred cartilage placed in underlay fashion
\item
  Perichondrium placed over barred cartilage as reinforcement
\item
  Final position of the graft ensuring all tugged under the margin and
  anterior annulus
\item
  Final graft uptake after 12 months of surgery
\end{enumerate}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-1-combined/Figure-1-combined}

\end{center}
\end{figure}

\textbf{Hosted file}

\verb`Table 1 summary for ANL.docx`  available at \url{https://authorea.com/users/326022/articles/472404-endoscopic-versus-microscopic-type-i-cartilage-tympanoplasty-for-anterior-perforation-a-prospective-comparative-study}

\textbf{Hosted file}

\verb`Table 2 hearing results for ANL.docx`  available at \url{https://authorea.com/users/326022/articles/472404-endoscopic-versus-microscopic-type-i-cartilage-tympanoplasty-for-anterior-perforation-a-prospective-comparative-study}

\selectlanguage{english}
\FloatBarrier
\end{document}

