Original Research
Otolaryngology–
Endoscopic Type 1 Tympanoplasty in
Chronic Otitis Media: Comparative Study
with a Postauricular Microscopic
Approach
Masafumi Ohki, MD1, Shigeru Kikuchi, MD, PhD1,
and Sunao Tanaka, MD, PhD1
No sponsorships or competing interests have been disclosed for this article.
Abstract
Objective. To compare surgical outcomes after tympanoplasty
without ossiculoplasty for chronic otitis media between
transcanal endoscopic ear surgery (TEES) and postauricular
microscopic ear surgery (PAMES).
Study Design. Case-control study.
Setting. Tertiary care university hospital.
Subjects and Methods. Consecutive patients (N = 122) who
had undergone tympanoplasty without ossiculoplasty for
chronic otitis media were enrolled in this retrospective
study and divided into 2 groups: TEES (n = 47) and PAMES
(n = 75). Middle ear condition was graded with the middle
ear risk index. Hearing, repair of tympanic membrane per-
foration, and surgical time were assessed.
Results. The surgical success rate for hearing (air-bone gap
20 dB) was 95.7% in the TEES group and 84.0% in the
PAMES group. Lower middle ear risk resulted in similar
mean (95% CI) closure of air-bone gaps (TEES: 9.6, 6.5-12.6;
PAMES: 8.0, 6.4-9.7; P = .333), whereas higher middle ear
risk demonstrated significantly larger closure of air-bone
gaps for the TEES group (10.1, 3.3-16.9) than the PAMES
group (–0.2, –4.5 to 4.2; P = .009). The surgical success rate
for repair of tympanic membrane perforation and surgical
time were equivalent between TEES and PAMES.
Conclusion. Under favorable conditions of the middle ear,
TEES and PAMES resulted in similar hearing improvement by
tympanoplasty without ossiculoplasty. However, under
adverse conditions of the middle ear, TEES was a more ben-
eficial approach for hearing improvement than PAMES.
Keywords
endoscopic ear surgery, microscopic surgery, tympanoplasty,
transcanal, middle ear risk index
Received December 1, 2018; revised February 14, 2019; accepted
February 28, 2019.
Head and Neck Surgery
1–9
Ó American Academy of
Otolaryngology–Head and Neck
Surgery Foundation 2019
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/0194599819838778
http://otojournal.org
E
ndoscope-assisted microscopic ear surgery has been
developed1 since McKennan2 introduced endoscopy
for second-look ear surgery in 1993 and Thomassin
et al used endoscopy combined with microscopic ear sur-
gery in 1993.3 The recent rapid improvements in endoscopic
imaging technology have enabled endoscopic ear surgery
without microscopy, such as endoscopic myringoplasty by
El-Guindy4 in 1992, endoscopic tympanoplasty (TP) with
ossiculoplasty for chronic otitis media (COM) by Tarabichi5
in 1999, and acquired cholesteatoma by Tarabichi in 1997.6
Previous comparative studies between endoscopy and
microscopy reported hearing results by type 1 TP and/or
myringoplasty.7-16 However, these previous comparative
studies were confined to pediatric patients9-11 or showed
short-term results (6 months).7,8,13,14,16 Only 1 report, by
Jyothi et al, contained all generations (ie, adult and pediatric
patients) and discussed the hearing results 1 year after sur-
gery (enough time to evaluate surgical results).12 This report
demonstrated no significant difference in hearing success
rate. Subjects in most reported comparative studies are
defined as having good middle ear conditions. Cohen et al
showed a significant improvement in hearing in type 1 tym-
panoplasty but not in ossiculoplasty among pediatric
patients.11 This report enrolled patients under various condi-
tions of the middle ear. At the moment, there are no com-
parative studies of hearing and tympanic membrane (TM)
closure with respect to different middle ear conditions
between endoscopic and microscopic ear surgery. This
study stratified middle ear condition and assessed the results
of transcanal endoscopic ear surgery (TEES) and postauricu-
lar microscopic ear surgery (PAMES) for COM 1 year after
the surgery.
1
Department of Otolaryngology, Saitama Medical Center, Saitama Medical
University, Kawagoe-shi, Japan
Corresponding Author:
Masafumi Ohki, MD, Department of Otolaryngology, Saitama Medical
Center, Saitama Medical University, 1981 Kamoda, Kawagoe-shi, Saitama
350-8550, Japan.
Email: m-ohki@umin.ac.jp
2 Otolaryngology–Head and Neck Surgery
Patients and Methods
We retrospectively reviewed the medical records of 122
consecutive patients (58 men and 64 women; mean age,
50.4 years; range, 6-81 years) who had undergone tympano-
plasty without ossiculoplasty for COM in the Department of
Otolaryngology at our institution between January 2011 and
August 2016. Patients with cholesteatomas, narrow external
ear canal, or active suppurative infections were excluded.
Endoscopic ear surgery was performed with 2 types of
endoscopes with visual direction (0° and 30°; view angle,
71° and 68°, respectively). Each endoscope had a diameter
of 2.7 mm, an effective length of 158 mm, and a total
length of 231 mm. The patients included in this study
underwent TEES or PAMES under general anesthesia.
Representative Procedure of TEES
A knife was used to scratch the edges of the perforation cir-
cumferentially. The external auditory canal skin was incised
with a round knife and dissected with an elevator. The tym-
panomeatal flap was elevated. The tympanic cavity was
visualized, and the condition of the ossicles was surveyed.
If pathologic lesions were found (eg, tympanosclerotic
lesions, granulation, or fibrosis), they were removed to
mobilize the ossicles. The cases with poor ossicle mobility,
for which ossiculoplasty was a better indication, were
excluded (3 cases each for TEES and PAMES). The TM
perforation was closed with a medial-to-malleus underlay
technique with the tragal perichondrium or temporalis
fascia. The tympanomeatal flap was repositioned over the
graft, and the flap and graft were fixed with fibrin glue.
Representative Procedure of PAMES
A postauricular incision was made, and the tympanomeatal
flap was elevated. The tympanic cavity was explored, and the
condition of the ossicles was surveyed. Mobilization of the
ossicles and closure of perforations were performed in
the same manner as TEES.
Grading with Middle Ear Risk Index
COM was graded with the middle ear risk (MER) index of
Kartush.17 The MER index is composed of risk factors such
as otorrhea (Bulluci grade18), perforation, cholesteatoma,
ossicular status (Austin/Kartush19), granulation or suffusion
in the middle ear, and previous surgery. The MER index is
based on the following categories: mild (1-3), moderate (4-
6), and severe (7-12). The characteristics of patients are sum-
marized in Table 1. TM perforation was classified according
to the number of quadrants involved by the perforation.
Pure tone audiometry was performed prior to and 1 year
following ear surgery. Hearing improvement was
assessed with the guidelines of American Academy of
Otolaryngology—Head and Neck Surgery.20 Hearing levels
were the average of dB readings at 500, 1000, 2000, and
3000 Hz. We interpolated a 3000-Hz threshold by averaging
the thresholds at 2000 Hz and 4000 Hz when 3000-Hz
thresholds were not available, according to the guidelines.21
The word recognition scores (WRSs) and scattergrams21
were also assessed for the 12 patients of the TEES group
whose MER index was mild. For the other patients, the
WRSs were missing. To assess the inner ear damage, high-
tone bone conduction (HT-BC) hearing levels were also cal-
culated (average of thresholds at 1000, 2000, 4000 Hz).
Improvement in pure tone averages, air-bone (AB) gaps,
closure of AB gaps, and HT-BC hearing levels was com-
pared between the TEES and PAMES groups before and 1
year after ear surgery. A successful hearing result was
defined as a postoperative AB gap 20 dB 1 year after sur-
gery, as used in many published reports.22,23 A successful
TM closure was defined as a dry TM without perforation 1
year after surgery.
All surgeons had extensive experience (.15 years of ear
surgery with PAMES and endoscopic sinus surgery) and
transitioned from PAMES to TEES at a certain point in
their practice. Therefore, we did not make decisions to
select endoscope versus microscope. There were no cases
that started as TEES and were converted to microscope in
this study, and vice versa. The surgeons were all right-
handed.
The ethics committee approved the study protocol
(Institutional Review Board for Ethics in Clinical Study of
Saitama Medical Center, Saitama Medical University),
which was performed in accordance with the ethical stan-
dards of the Helsinki Declaration. The requirement for
informed consent was waived. The results were expressed
as means with 95% CIs. Statistical analyses were performed
with Ekuseru-Toukei 2012 software (Social Survey
Research Information Co Ltd, Tokyo, Japan) and included
the t test, paired t test, Fisher’s exact probability test, and
Cochran-Armitage test for assessments of differences
between groups. All reported P values were 2-tailed.
Results
Patient Characteristics
The characteristics of patients are summarized in Table 1.
The proportion of patients with 1, 2, 3, and 4 quadrants
involved in the perforation was similar between the TEES
and PAMES groups (P = .315). Regarding the perforation
location, the anterior perforation seemed to be more in the
TEES group than in the PAMES group, but the distributions
of the anterior, posterior, and central perforations did not
differ significantly (P = .093). With respect to middle ear
condition, MER index ratings of mild, moderate, and severe
in the TEES group (83.0%, 17.0%, and none, respectively)
were similar to the ratings in the PAMES group (89.3%,
10.7%, and none).
Pre- and Postoperative Hearing
The mean (95% CI) preoperative air conductive (AC) thresh-
olds (TEES: 43.4, 37.6-49.2; PAMES: 42.3, 38.6-45.9; P =
.728) and AB gaps (TEES: 19.7, 17.4-22.0; PAMES: 20.3,
18.4-22.2; P = .699) were equivalent between the groups
(Table 2). After surgery, both groups exhibited significant
decreases (P \ .001) in AC thresholds (TEES: 32.7,
Ohki et al 3

Table 1. Characteristics of Patients: TEES and PAMES.

Patients, n (%)

Overall TEES PAMES

Patients 122 47 75
Age, ya 50.4 6 21.5 50.5 6 22.1 50.4 6 21.2
Male:female 58:64 28:19 30:45
TM perforation size
1 quadrant 37 (30.3) 18 (38.3) 19 (25.3)
2 quadrants 50 (41.0) 16 (34.0) 34 (45.3)
3 quadrants 14 (11.5) 5 (10.6) 9 (12.0)
All quadrants 21 (17.2) 8 (17.0) 13 (17.3)
Perforation side, right:left 51:71 22:25 29:46
Perforation location
Anterior only 37 (30.3) 20 (42.6) 17 (22.7)
Posterior only 9 (7.4) 1 (2.1) 8 (10.7)
Central (anteroposterior) 76 (62.3) 26 (55.3) 50 (66.7)
Primary/revision 114:8 43:4 71:4
TM graft
Fascia 99 (81.1) 27 (57.4) 72 (96.0)
Perichondrium 23 (18.9) 20 (42.6) 3 (4.0)
Mucosa (pathologic) 52 (42.6) 18 (38.3) 34 (45.3)
Otorrheab
Dry 65 (53.3) 26 (55.3) 39 (52.0)
Occasionally wet 44 (36.1) 17 (36.2) 27 (36.0)
Persistently wet 13 (10.7) 4 (8.5) 9 (12.0)
Wet, cleft palate — — —
Ossicular statusc
M1I1S1 112 (91.8) 40 (85.1) 72 (96.0)
M1S1 — — —
M1S2 — — —
M2S1 — — —
M2S2 — — —
Ossicular head fixations 10 (8.2) 7 (14.9) 3 (4.0)
Stapes fixation — — —
Middle ear risk index17
Mild (1-3) 106 (86.9) 39 (83.0) 67 (89.3)
Moderate (4-6) 16 (13.1) 8 (17.0) 8 (10.7)
Severe (7-12) — — —
Abbreviations: I, incus; M, malleus; PAMES, postauricular microscopic ear surgery; S, stapes; TEES, transcanal endoscopic ear surgery; TM, tympanic membrane.
a
Mean 6 SD.
b
Bullucci grade.18
c
Austin/Kartush classification.19

27.3-38.2; PAMES: 33.8, 29.9-37.7) and AB gaps (TEES:
10.1, 8.3-11.8; PAMES: 13.1, 11.0-15.3). AC threshold
improvement of the TEES and PAMES groups was 10.7
(7.6-13.7) and 8.5 (6.3-10.7), respectively (P = .234). The
postoperative AB gaps of the TEES group were smaller than
those of the PAMES group (P = .048), while the closure of
AB gaps was not significantly different (P = .092).
The mean (95% CI) preoperative WRS of the TEES
group was 95.8% (92.6%-99.1%; Figure 1). The mean
postoperative WRS of the TEES group was 93.3% (90.5%-
96.2%), equivalent to the preoperative one (P = .111).
Figure 2 shows the postoperative scattergram of changes in
AC threshold and WRS.
With respect to the condition of the middle ear, in the
mild category, mean (95% CI) AC threshold improvement
was similar (TEES: 10.9, 7.6-14.3; PAMES: 9.9, 7.9-11.8;
P = .545); postoperative AB gaps were 9.5 (7.6-11.4) in the
TEES group and 11.5 (9.6-13.5) in the PAMES group (P =
.081); and closure of AB gaps was 9.6 (6.5-12.6) in the
TEES group and 8.0 (6.4-9.7) in the PAMES group (P =
.333; Table 3). These factors were all equivalent between
groups.
4 Otolaryngology–Head and Neck Surgery

Table 2. Pre- and Postoperative Hearing Results and TM Closure.

Mean (95% CI) or n (%)

TEES PAMES P Valuea

AC threshold, dB
Preoperative 43.4 (37.6 to 49.2) 42.3 (38.6 to 45.9) .728
Postoperative 32.7 (27.3 to 38.2) 33.8 (29.9 to 37.7) .745
Improvement 10.7 (7.6 to 13.7) 8.5 (6.3 to 10.7) .234
BC threshold, dB
Preoperative 23.7 (18.9 to 28.5) 22.0 (19.2 to 24.8) .508
Postoperative 22.7 (17.8 to 27.5) 20.7 (17.9 to 23.4) .436
Improvement 1.0 (–0.2 to 2.3) 1.3 (0.2 to 2.5) .741
AB gap, dB
Preoperative 19.7 (17.4 to 22.0) 20.3 (18.4 to 22.2) .699
Postoperative 10.1 (8.3 to 11.8) 13.1 (11.0 to 15.3) .048b
Closure 9.6 (7.0 to 12.3) 7.1 (5.5 to 8.8) .092
HT-BC threshold, dB
Preoperative 25.0 (19.9 to 30.1) 23.3 (20.2 to 26.5) .559
Postoperative 24.4 (19.2 to 29.6) 22.9 (19.8 to 26.1) .599
Closure 0.6 (–0.6 to 1.7) 0.4 (–0.9 to 1.7) .864
Success for hearing 45 of 47 (95.7) 63 of 75 (84.0) .077
Postoperative air-bone gap, dB
10 24 (51.1) 35 (46.7)
10.1-20 21 (44.7) 28 (37.3)
20.1-30 2 (4.3) 7 (9.3)
.30 0 (0.0) 5 (6.7)
Success for TM closure 44 of 47 (93.6) 64 of 75 (85.3) .244
1 quadrant 17 of 18 (94.4) 18 of 19 (94.7) ..999
2 quadrants 15 of 16 (93.8) 30 of 34 (88.2) ..999
3 quadrants 5 of 5 (100) 6 of 9 (66.7) .26
All quadrants 7 of 8 (87.5) 10 of 13 (76.9) ..999
Abbreviations: AB, air-bone; AC, air conductive; BC, bone conduction; HT-BC, high-tone bone conduction; PAMES, postauricular microscopic ear surgery;
TEES, transcanal endoscopic ear surgery; TM, tympanic membrane.
a
P values: t test for AC threshold, BC threshold, AB gap, and HT-BC threshold; Fisher’s exact test for success for hearing and success for TM closure.
b
P \.05.

However, in the moderate category, mean (95% CI) post-
operative AB gaps (12.9, 7.6-18.2) in the TEES group were
significantly smaller than the gaps (26.6, 17.7-35.4) in the
PAMES group (P = .007), and closure of AB gaps (10.1,
3.3-16.9) in the TEES group was significantly larger than
the closure (–0.2, –4.5 to 4.2) in the PAMES group (P =
.009; Table 4).
Surgical Results for Hearing
The surgical success rate for hearing (AB gap 20 dB) was
95.7% for the TEES group and 84.0% for the PAMES
group (P = .077).
With respect to the condition of the middle ear, in the
mild category, the success rate for hearing was 97.4% in the
TEES group and 88.1% in the PAMES group (P = .150). In
the moderate category, the hearing success rate was 87.5%
in the TEES group and 50.0% in the PAMES group (P =
.282).
Inner Ear Damage
The HT-BC hearing levels were assessed (Tables 2-4).
The HT-BC thresholds of the TEES and PAMES groups
were not significantly changed after the surgery (TEES:
P = .336, PAMES: P = .540). Mean (95% CI) closure of
the HT-BC hearing levels in the TEES and PAMES
groups were equivalent: 0.6 dB (–0.6 to 1.7) and 0.4 dB
(–0.9 to 1.7), respectively (P = .864). With respect to the
condition of the middle ear, closure of the HT-BC hearing
levels of TEES and PAMES groups was not significantly
different in the mild (P = .499) and moderate (P = .210)
categories.
Surgical Results for TM Repair
The surgical success rates for TM closure were 93.6% for
the TEES group and 85.3% for the PAMES group, which
were not significantly different (P = .244; Table 2). The
success rates for TM closure of perforation were stratified
Ohki et al
Figure 1. Scattergram of preoperative hearing results among the
12 patients of the transcanal endoscopic ear surgery group whose
middle ear risk index was mild.
Figure 2. A posttreatment scattergram for the patients whose
preoperative hearing results are presented in Figure 1.
by perforation sizes (1, 2, 3, and 4 quadrants). There was no
significant difference in the categories of each perforation
size between the TEES and PAMES groups. The success
rates for TM closure were also stratified with the MER
index (Tables 3 and 4). No significant difference was
found in the mild and moderate categories.
5
Surgical Time
The TEES group took a mean (95% CI) 77.2 minutes (69.9-
84.5) for surgery, whereas the PAMES group took 86.9
minutes (79.6-94.2, P = .077). In the mild category, the sur-
gical times were similar: 78.1 minutes (70.2-86.0) and 84.6
minutes (76.9-92.4), respectively (P = .270). However, in
the moderate category, the TEES group took a significantly
shorter time (72.9 minutes, 49.5-96.3) than the PAMES
group (105.9 minutes, 85.8-125.9; P = .024).
Influence of Surgeon Handedness on the TEES Side
All the surgeons were right-handed. The TEES group
showed similar mean (95% CI) postoperative AB gaps of
10.5 (7.8-13.3) on the right-side perforation and 9.7 (7.2-
12.1) on the left side (P = .619). The surgical time of the
TEES group was 71.5 minutes (60.6-82.5) on the right and
82.2 minutes (72.2-92.1) min on the left, with no significant
difference (P = .144).
Discussion
The TEES group of our study exhibited the following
results: mean postoperative AB gap, 10.1 dB; occurrence
rate of a postoperative AB gap 20 dB, 95.7%; success rate
for TM closure, 93.6% (Table 2). Several authors reported
endoscopic myringoplasty4,8,12,24-35 and endoscopic type 1
tympanoplasty.* The mean postoperative AB gap was 4.0 to
18.1 dB (median, 10.8 dB) in these studies,y and the occur-
rence rate of a postoperative AB gap 20 dB was 77% to
100% (median, 90.8%).z Success rates for TM closure were
69% to 100% (median, 88%).4,5,7,9-16,24-36,38 Similar results
were obtained from the data of the current study.
The present study demonstrated that the postoperative
AB gap was significantly smaller in the TEES group in TP
without ossiculoplasty (Table 2). However, it may not be
clinically significant and may be due to a few outliers
because the closure of AB gaps was not significantly differ-
ent. Previous comparative studies of TEES and microscopic
ear surgery demonstrated equivalent hearing results between
groups.7-10,12-14,16 However in the studies limited to normal
mucosae9,12 or normal ossicles,7,8,10,12 subjects were defined
as patients with good conditions of the middle ear, and mar-
ginal perforation was excluded.7,8 Therefore, the middle ear
condition of patients in these previous comparative studies
was good and advantageous (ie, MER 1); treatment around
ossicles was not necessary; and closing of the TM perfora-
tion was sufficient. However, subjects in the present study
were not limited to patients with normal mucosae or normal
ossicles. We included patients with pathologic mucosae and
ossicles. In a study of pediatric patients, Cohen et al11
reported that TEES showed significantly better hearing
results in type 1 TP but not in ossiculoplasty. This study
was not limited to patients with normal mucosae or normal
*
References 5, 7, 9-11, 13, 15, 16, 34, 36-38
y
References 7, 9, 10, 12, 13, 16, 24-28, 32-38
z
References 8, 12, 24, 29, 30, 33, 34, 36, 38
6 Otolaryngology–Head and Neck Surgery

Table 3. Hearing Results in Middle Ear Risk Index 1-3: Mild Group.
Mean (95% CI) or n (%)

TEES PAMES P Valuea

AC threshold, dB
Preoperative 41.4 (34.7 to 48.1) 41.2 (37.6 to 44.9) .957
Postoperative 30.5 (24.3 to 36.6) 31.4 (27.8 to 34.9) .786
Improvement 10.9 (7.6 to 14.3) 9.9 (7.9 to 11.8) .545
BC threshold, dB
Preoperative 22.4 (16.8 to 27.9) 21.7 (18.8 to 24.6) .805
Postoperative 21.0 (15.5 to 26.5) 19.8 (17.0 to 22.6) .680
Improvement 1.4 (0.0 to 2.8) 1.8 (0.9 to 2.8) .581
AB gap, dB
Preoperative 19.0 (16.5 to 21.5) 19.6 (17.7 to 21.4) .738
Postoperative 9.5 (7.6 to 11.4) 11.5 (9.6 to 13.5) .081
Closure 9.6 (6.5 to 12.6) 8.0 (6.4 to 9.7) .333
HT-BC threshold, dB
Preoperative 23.2 (17.3 to 29.2) 22.9 (19.5 to 26.2) .902
Postoperative 22.7 (16.8 to 28.6) 21.8 (18.5 to 25.0) .764
Closure 0.6 (–0.7 to 1.9) 1.1 (0.1 to 2.1) .499
Success for hearing 38 of 39 (97.4) 59 of 67 (88.1) .150
Success for TM closure 37 of 39 (94.9) 58 of 67 (86.6) .322

Abbreviations: AB, air-bone; AC, air conductive; BC, bone conduction; HT-BC, high-tone bone conduction; PAMES, postauricular microscopic ear surgery;
TEES, transcanal endoscopic ear surgery; TM, tympanic membrane.
a
P values: t test for AC threshold, BC threshold, AB gap, and HT-BC threshold; Fisher’s exact test for success for hearing and success for TM closure.

Table 4. Hearing Results in Middle Ear Risk Index 4-6: Moderate Group.
Mean (95% CI) or n (%)

TEES PAMES P Valuea

AC threshold, dB
Preoperative 53.1 (44.0 to 62.2) 51.1 (33.9 to 68.3) .808
Postoperative 43.8 (33.6 to 53.9) 54.1 (36.2 to 72.1) .252
Improvement 9.4 (–0.1 to 18.9) –3.0 (–14.7 to 8.6) .07
BC threshold, dB
Preoperative 30.2 (22.6 to 37.8) 24.7 (13.8 to 35.6) .347
Postoperative 30.9 (21.8 to 39.9) 27.6 (16.8 to 38.3) .590
Improvement –0.7 (–4.5 to 3.1) –2.9 (–11.9 to 6.1) .606
AB gap, dB
Preoperative 23.0 (16.7 to 29.2) 26.4 (17.3 to 35.5) .474
Postoperative 12.9 (7.6 to 18.2) 26.6 (17.7 to 35.4) .007b
Closure 10.1 (3.3 to 16.9) –0.2 (–4.5 to 4.2) .009b
HT-BC threshold, dB
Preoperative 33.5 (26.3 to 40.7) 27.3 (15.3 to 39.3) .308
Postoperative 32.9 (23.2 to 42.6) 32.7 (22.3 to 43.1) .973
Closure 0.6 (–2.9 to 4.1) –5.4 (–15.7 to 4.9) .210
Success for hearing 7 of 8 (87.5) 4 of 8 (50.0) .282
Success for TM closure 7 of 8 (87.5) 6 of 8 (75.0) ..999

Abbreviations: AB, air-bone; AC, air conductive; BC, bone conduction; HT-BC, high-tone bone conduction; PAMES, postauricular microscopic ear surgery;
TEES, transcanal endoscopic ear surgery; TM, tympanic membrane.
a
P values: t test for AC threshold, BC threshold, AB gap, and HT-BC threshold; Fisher’s exact test for success for hearing and success for TM closure.
b
P \.05.
Ohki et al
ossicles. We speculated that these differences most likely
resulted in differences in hearing outcomes. When we
focused on the condition of the middle ear, in case of the
better condition (ie, a MER index of 1-3), the postoperative
AB gaps were equivalent between TEES and PAMES, as
the previous studies demonstrated. However, in the worse
condition (ie, a MER index of 4-6), the postoperative AB
gap in the TEES group was smaller than in the PAMES
group. In the worse condition, the TEES group demon-
strated the superior result to the PAMES group. We specu-
late the reason for the difference as follows. When TP
without ossiculoplasty in the PAMES group was performed,
evaluation of ossicles may have been insufficient. Pathology
in ossicles may tend to be underestimated, and removal of
the granulation or calcification interrupting ossicle mobility
may have been inadequate because of an insufficient field
of view. Some cases with poor ossicle mobility, in which
ossiculoplasty was a better indication, may have been under-
estimated as having good mobility, and ossiculoplasty was
not performed. These factors may have yielded the differ-
ences in the hearing results. We speculate that evaluations
of the condition of ossicles, removal of lesions (eg, calcifi-
cation, granulation tissue, and fibrous tissue), and a more
precise performance of ossiculoplasty may be better in
TEES than PAMES because of a better field of view.
Perforation, fixation of ossicles, loss of ossicles, aeration
of the middle ear, and condition of the mucosae are influen-
tial factors for successful surgery.17-19,39 De Vos et al40 and
Yung and Vowler41 statistically demonstrated the impor-
tance of the malleus handle, mucosa status, and otorrhea,
which is a factor of the MER index. We should evaluate
middle ear condition precisely and treat pathologic lesions
(eg, removal of calcification or granulation) around ossicles
on demand. Endoscopy is suitable for a precise examination
of the middle ear, including the attic, ossicles, and posterior
tympanum. Hidden structures, such as the anterior TM per-
foration, sinus tympani, facial recess, attic, and hypotympa-
num, may be visualized with an endoscope via a transcanal
approach.5 An endoscope is advantageous for evaluations of
ossicle mobility and condition. Tarabichi5 and Kakehata
et al37 emphasized the good visualization and minimally
invasive procedure for ossiculoplasty. A microscope is
unsuitable for accessing these areas unless an atticotomy,
atticoantrotomy, or mastoidectomy is performed.
The influence to the inner ear function was assessed by
the HT-BC hearing levels. The HT-BC thresholds were not
significantly changed after the surgery, and closure of the
HT-BC hearing levels in TEES and PAMES groups was
equivalent. The TEES technique is suggested to be safe for
inner ear function.
With respect to TM repair, it is difficult to observe the
entire perforation in a single field under microscopic ear
surgery. The anterior perforation is frequently in a blind
spot from the anterior meatal overhang, and TM repair
tends to fail in microscopic myringoplasty.42 A postauricu-
lar approach or canalplasty is often performed to observe
the entire perforation under a microscope. Myringoplasty in
7
TEES may be performed under superior visualization as
compared with a microscopic field of view.7-9 Eren et al
used endoscopic transcanal myringoplasty for anterior per-
foration and reported its advantages.27 Endoscopy enables
surgeons to perform myringoplasty and TP in a minimally
invasive manner with the transcanal approach without post-
auricular incision, even in cases with narrow ear canals or
anterior meatal overhang.4,5 TM repair with TEES is
equivalently successful to PAMES.
Surgical times were equivalent between TEES and
PAMES under the better middle ear condition. However,
under the worse middle ear condition, PAMES had a longer
surgical time as compared with TEES. The reason is consid-
ered to be that handling a pathologic lesion around ossicles
under an insufficient surgical view is laborious and takes
time.
Limitations
This study had some limitations. First, our study was a retro-
spective study, although a prospective randomized controlled
study would ideally compare TEES and PAMES. Second, the
population enrolled in this study was small, especially for
patients with moderate/severe ratings on the MER index.
Further accumulation of data and reassessment with a larger
number of patients are necessary in the future. Third, the surgi-
cal learning curve was another possible challenge. All sur-
geons switched their surgical approach from PAMES to TEES
at some date and did not choose whether TEES or PAMES
was performed. Surgeons in this study had less experience
with TEES than PAMES. Therefore, a learning curve bias is
speculated to have adversely affected the results with TEES.
All surgeons possessed sufficient skills for endonasal sinus sur-
gery and PAMES, and the use of an endoscope for ear surgery
is not difficult. Therefore, any learning curve bias for PAMES
is assumed to have been minimal in this study. Last because
MER index was not designed with an endoscope, it may miss
some important variables. As far as we examined, perforation
locations were not biased between the TEES and PAMES
groups, and influence of surgeon handedness on TEES was
not shown in AB gaps and surgical time.
Conclusions
Under the favorable condition, TEES and PAMES produced
comparable hearing outcomes. However, in surgery of TP
without ossiculoplasty under the adverse condition of the
middle ear, TEES was a more beneficial approach for hear-
ing improvement than PAMES. With respect to TM repair,
TEES and PAMES were comparably effective.
Author Contributions
Masafumi Ohki, conception and study design, conduct, acquisi-
tion of data, analysis and interpretation of the data, drafting and
revising the article, final approval of the version to be published,
and agreement on accountability for the work; Shigeru Kikuchi,
study design, acquisition of data, revising the article, final approval
of the version to be published, and agreement on accountability for
the work; Sunao Tanaka, study design, acquisition of data,
8 Otolaryngology–Head and Neck Surgery
revising the article, final approval of the version to be published,
and agreement on accountability for the work.
Disclosures
Competing interests: None.
Sponsorships: None.
Funding source: None.
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