OtolaryngologyHead and Neck Surgery (2008) 138, 353-356

ORIGINAL RESEARCHOTOLOGY AND NEUROTOLOGY

Comparison of paper-patch, fat, and perichondrium

myringoplasty n repair of small tympanic
membrane perforations
Engin Dursun, MD, Salim Dogru, MD, Atila Gungor, MD,
Hakan Cincik, MD, Ethem Poyrazoglu, MD, and Taner Ozdemir, MD,
Istanbul, Turkey
OBJECTIVE: To compare the effectiveness of paper-patch, fat,
and perichondrium myringoplasty in the treatment of chronic tympanic membrane perforations smaller than 3 mm.
SUBJECTS AND METHODS: This investigation included 45
patients with chronic tympanic membrane perforations smaller than 3
mm. The patients were equally divided into 3 main groups according
to surgical procedures. Each group consisted of 3 subgroups, which
had 1-mm, 2-mm, and 3-mm perforations. The patients underwent
paper-patch, fat, or perichondrium myringoplasty via transcanal approach under local anesthesia. Healing of perforation, hearing improvement, and complications were investigated.
RESULTS: Closure rates of the perforations in the paper-patch,
fat, and perichondrium myringoplasty groups were 66.7%, 86.7%,
and 86.7%, respectively. There were no statistically significant
differences in tympanic membrane closure rates between techniques with regard to size.
CONCLUSION: Three techniques were found to be feasible for
tympanic membrane perforations smaller than 3 mm.
2008 American Academy of OtolaryngologyHead and Neck
Surgery Foundation. All rights reserved.

ongstanding tympanic membrane (TM) perforations

may cause hearing loss and middle ear infection even if
they are small in size. Further, the patients have to observe
water restrictions. The purpose of myringoplasty is to repair
such perforations and thus improve hearing and eliminate
the susceptibility to middle ear infections.1 Various tissues
and materials have been used with a variety of surgical
procedures and success rates. While large perforations require a relatively expensive microsurgical procedure, one
may prefer to use conservative operative techniques for
smaller perforations as they reduce cost, surgical risks, and
hospitalization period. However, it is sometimes hard to
determine which technique would be the best choice for
smaller perforations. The purpose of this study is to compare the results of paper-patch, fat, and perichondrium myringoplasties, performed as an outpatient procedure, in pa-

tients with longstanding dry perforations of the TM smaller

than 3 mm.

METHODS AND MATERIALS

This prospective, randomized study was conducted between
January and September 2006. The investigation included 45
patients with longstanding TM perforations smaller than 3
mm. The patients were selected consecutively as they were
admitted to the otology clinic and were included in the study
after careful selection as follows: presence of dry central
TM perforation not exceeding 3 mm in size; TM perforation
present for at least 6 months; absence of ossicular or mastoid pathology.
The patients were divided equally into 3 groups (n 15).
Each group was divided into 3 subgroups, based on the size
of tympanic membrane perforations: 1-mm (n 5), 2-mm
(n 5), and 3-mm (n 5); that is, the total sample size of
45 was equally allocated to 9 subgroups. Incoming subjects
were grouped according to the perforation size. Once the
predetermined sample size for a subgroup (n 5) had been
achieved, even if new patients satisfied the eligibility criteria, they were not included in the study. The staff who
randomized the subjects to groups were blinded to which
procedure would be performed. The groups were then allocated by another staff member according to the procedures.
The patients underwent paper-patch, fat, and perichondrium
myringoplasty via transcanal approach under local anesthesia. All patients were fully informed about the procedure
and gave their informed consent after a discussion of the
alternatives that included doing nothing or performing a
formal myringoplasty. This study was approved by the
institutional review board of Haydarpasa Training Hospital.
Healing of perforation, hearing improvement, and complications were investigated by microscopic otoscopy and

Received October 7, 2007; revised December 5, 2007; accepted January 7, 2008.

0194-5998/$34.00 2008 American Academy of OtolaryngologyHead and Neck Surgery Foundation. All rights reserved.
doi:10.1016/j.otohns.2008.01.003
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OtolaryngologyHead and Neck Surgery, Vol 138, No 3, March 2008

pure-tone audiometry. Data were analyzed using SPSS 11.0

for Windows. Difference testing between groups was performed using Mann-Whitney U test. A P value less than
0.05 was considered statistically significant. Ears were examined with otomicroscope before the procedure and the
sizes of perforations were documented. The size of the
perforation was determined using a specially designed
hook. Pure-tone audiograms were performed for all patients.

Operative Technique
Under the operative microscope, the external auditory canal
was cleansed of cerumen, and a classic quadratic injection was
made using a dental syringe with 2% lidocaine (Jetocaine amp,
Adeka, Turkey) with 0.125 epinephrine. The rim of the perforation was carefully excised and freshened, using a perforator
and a cup forceps, to encourage migration of the mucosal layer
and the epithelium.
Paper patching. A small piece of ordinary thin carbon
paper was trimmed to provide a 1-mm overlapping margin around the perimeter of the perforation. The paper
patch was moistened with 10% polyvinylpyrrolidone iodine (Batticon, Adeka, Turkey) and laid over perforation
with the help of an ear forceps under microscopic guidance. No packing of the external ear canal was used.
Fat myringoplasty. A skin incision was made on the medial
side of the ear lobule and a large fat swab was then taken for
use in closing the perforation. It was inserted through the
perforation with a micropoint and then inserted into the half
with a champagne cork aspect. No packing of the external
ear canal was used.
Perichondrium myringoplasty. A skin incision was made
on the posterior side of the tragus. The skin and subcutaneous tissues were dissected off and the posterior tragal
perichondrium was elevated. Small squares of gelfoam
were placed in the middle ear cavity through the perforation to form a bed for the graft. The perichondrial graft
was then removed and placed on gelfoam bed by using
underlay technique. The ear canal was then packed with
compressed gelfoam.
All patients were discharged after the procedure with
instruction to avoid nose blowing and avoid getting water in
the ear canal. They were prescribed a course of cefuroxime
axetil 500 mg twice a day and acetaminophen 500 mg 3
times a day for 7 days. Follow-up studies were performed
with otomicroscope, at 7 days, 1 month, and 3 months after
the procedure. Main outcome measures were graft closure
rates (no perforation, atelectasis, or lateralization on microscopic otoscopy), improvement of hearing by means of
audiometric evaluation, and incidence of complications.
Hearing improvement was assessed using the audiogram
results obtained at the end of third month, postoperatively.
Hearing parameters were the change in airbone gap. Airbone gap was calculated as the average difference between

Figure 1

Closure rates with regard to myringoplasty technique.

air conduction and bone conduction at 0.5, 1, 2, and 4 kHz.

This study was funded by departmental sources.

RESULTS
There were 37 males and 2 females. The ages ranged from
18 to 30 years (mean 21.4 years). The procedures were well
tolerated by all patients without any major side effect or
complication. There were 9 unsuccessful repairs of tympanic membranes, of which 5 belong to the paper-patch
group, 2 to the fat group, and 2 to the perichondrium group
(Fig 1). Closure rates of the perforations in the paper-patch,
fat, and perichondrium myringoplasty groups were 66.7%,
86.7%, and 86.7%, respectively. There was no statistically
significant difference between the 3 groups with regard to
closure rates (P 0.05).
The numbers of healed tympanic membranes with regard
to perforation size are shown in Figure 2. The closure rates of
paper patch according to perforation size were 100% for 1-mm
perforations, 60% for 2-mm perforations, and 40% for 3-mm
perforations. In fat subgroups, the closure rates were 100%,
80%, and 80% for 1-mm, 2-mm, and 3-mm perforations,
respectively. The closure rates of the perichondrium graft were
80%, 80%, and 100% for 1-mm, 2-mm, and 3-mm perforations, respectively. There were, however, no statistically significant differences in tympanic membrane closure rates between techniques with regard to perforation size (P 0.05).
The assessment of hearing improvement rates was performed only for healed ears. Mean hearing improvements were

Figure 2 Closure rates between techniques with regard to perforation size.

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Dursun et al

Comparison of paper-patch, fat, and perichondrium . . .

Table 1
Minor complications of paper-patch, fat, and
perichondrium myringoplasty

Otorrhea
Hematoma
Laceration
Hemorrhage
Otitis externa
Otomycosis

Paper-patch

Fat

Perichondrium

1
2

3
2

1
1

5.4 dB (0.83 dB) in the paper-patch group, 8.4 dB (2.15

dB) in the fat group, and 10.2 dB (2.03 dB) in the perichondrium group. Differences in hearing improvement rates between techniques were not statistically significant (P 0.05).
No serious complication was encountered in the present study.
Some minor complications are listed in Table 1.

DISCUSSION
Most patients with longstanding TM perforation choose to
have the perforation repaired by standard myringoplasty
techniques. For some patients, however, the risks, costs, and
inconvenience of an operation are significant concerns.2
These patients may benefit from a simple, inexpensive,
nonsurgical, outpatient alternative. Paper-patch, fat, and
perichondrium myringoplasty techniques are simple, quick,
and minimally invasive procedures that can be performed
on outpatients basis, and they are suitable to repair small
primary perforations of the TM.
Paper patching was not found suitable for perforations
larger than 5 mm.2 Golz et al3 designed a study to evaluate
the results of paper-patch myringoplasty in patients with
chronic perforations of the TM of different sizes and they
found the closure rate 63.2%, 43.5%, and 12.5% for small,
medium, and large perforations, respectively. The closure
rates after fat-graft myringoplasties in patients have been
previously reported in the literature, ranging between 79.2%
and 92%.4-7 Imamoglu et al8 investigated the recovery rate
in paper-patch and fat-plug myringoplasty in rats. The recovery rate was 94.7% in fat-plug myringoplasty, 94.4% in
paper-patch myringoplasty, and 66.6% in control group.
The recovery rates in large perforations were 52.9%, 56.2%,
and 26.6%, respectively.
In terms of transcanal myringoplasty (simple underlay or
transtympanic), only a few clinical series have been reported, with success rates ranging from 67.5% to 84%.9-11 A
comparative analysis of these studies may not be possible
due to varied inclusion criteria and technique. In the present
study, mean closure rates of perforations in the paper-patch,
fat, and perichondrium myringoplasty groups were 66.7%,
86.7%, and 86.7%, respectively. It depends on the surgeons
choice whether to elevate a flap or work through a perfora-

355

tion for a given perforation size. However, we believe that

transcanal myringoplasty without any skin incision reduces
the risk of surgical trauma related to injury of chorda tympany, fibrous annulus, etc.
The classic endaural and retroauricular incisions have the
disadvantages of longer healing period and dressing time
and the potential to leave a visible scar. The fat and tragal
perichondrium graft harvesting are feasible and have the advantages of a minimal visible scar and better cosmetic results.
No possible complication of a classic myringoplasty, such as
facial nerve or chorda tympani injury, hearing loss, atelectasis,
myringitis, canal stenosis, scarring, or adhesions in the middle
ear or external ear canal, were encountered in the present study.
The techniques investigated in this study are simple, time
saving, safe to perform, cost effective, and suitable as an
outpatient procedure, and they avoid the risks and morbidity of
a classic myringoplasty. They are alternative techniques to
classic myringoplasty, particularly suitable for the closure
of small-sized longstanding dry central perforations. They
should be tried in perforations smaller than 3 mm before a
patient is referred for surgery. Although no statistically
significant differences with regard to closure rates were
found between techniques, we recommend paper-patch and
fat myringoplasty for 1- and 2-mm perforations and perichondrium myringoplasty for 3-mm perforations. It should
be remembered that this study may not have adequate power
to show small but significant differences between groups,
since the sample sizes in each group are small.
The content of this study was limited to perforations
smaller than 3 mm. The upper limit of perforation size that
can be repaired successfully with a given myringoplasty
technique was not investigated. It should be remembered
that the characteristics of healing may be different for larger
perforations. It should also be noted that the results of this
study represent relatively short-term follow-up in a small
number of patients. Further studies may be performed to
evaluate the results of these procedures for larger perforations in a large number of patients.

CONCLUSION
In conclusion, all three techniques were found to be feasible
for tympanic membrane perforations smaller than 3 mm.

AUTHOR INFORMATION
From the Department of OtolaryngologyHead and Neck Surgery, GATA
Haydarpasa Training Hospital.
Presented as a poster at the Annual Meeting of the American Academy of
OtolaryngologyHead and Neck Surgery, Washington, DC, September
16-19, 2007.
Corresponding author: Salim Dogru, MD, Department of Otolaryngology
Head and Neck Surgery, GATA Haydarpasa Training Hospital, KadikoyIstanbul, Turkey.
E-mail address: salimdogru@yahoo.com.

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OtolaryngologyHead and Neck Surgery, Vol 138, No 3, March 2008

AUTHOR CONTRIBUTIONS
Salim Dogru, study design, surgery, writer; Engin Dursun, surgery, data
collection, writer; Atila Gungor, study design, controller; Hakan Cincik,
data collection, statistics; Ethem Poyrazoglu, study design, controller;
Taner Ozdemir, surgery, data collection.

FINANCIAL DISCLOSURES
None.

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