Abstract

Background
Tympanoplasty is a surgical procedure to repair perforated tympanic
membranes, with endoscopic and microscopic approaches being widely used.
Despite both approaches having high success rates, recovery times and
postoperative discomfort may differ.

Aim
This study aims to compare the impact of endoscopic versus microscopic
surgical approaches on recovery time and postoperative outcomes in
tympanoplasty patients.

Method
A total of 60 patients, aged 15-55 years, were divided into two groups: Group
A (endoscopic) and Group B (microscopic). Patients were selected randomly
based on their assigned number sequence. Data were collected on graft
uptake, hearing improvement, recovery time, postoperative pain, and
complications. Statistical analysis was conducted to determine the
significance of observed differences.

Result
Graft uptake success was 83.3% in the endoscopic group and 90% in the
microscopic group, with no statistically significant difference (p > 0.05). Both
groups exhibited comparable hearing gains. However, the endoscopic group
experienced a faster recovery time and lower mean pain scores, showing
statistical significance (p < 0.05). Minor postoperative complications were
slightly more common in the microscopic group.

Conclusion
Endoscopic tympanoplasty may be associated with faster recovery and
reduced postoperative discomfort compared to the microscopic approach,
suggesting a beneficial alternative for patient comfort.

Introduction
Tympanoplasty is a common surgical procedure aimed at reconstructing the tympanic
membrane and restoring hearing function, especially for patients with chronic otitis media
(COM). COM, characterized by recurrent ear discharge, hearing impairment, and
inflammation of the middle ear and mastoid cavity, is a significant health concern worldwide,
affecting both pediatric and adult populations, particularly in developing countries. The
condition’s impact on speech, cognitive, educational, and psychological development
underscores the need for effective and accessible treatments (WHO, 2023).
Traditionally, type 1 tympanoplasty, also known as myringoplasty, has been performed using
a surgical microscope, allowing precise visualization and use of both hands. However, this
approach has limitations, particularly in accessing hard-to-reach areas like the anterior
epitympanum and retrotympanum. In recent years, the introduction of endoscopic methods
has provided an alternative with several advantages, including a wider field of view and
greater magnification, enhancing visibility and potentially improving surgical outcomes
(Bonali et al., 2017). Unlike the microscope, the endoscope allows close-up and wide-angle
views and enables angled visualization, making it easier to access hidden areas in the
middle ear.

Endoscopic tympanoplasty is also more feasible in resource-limited settings. Endoscopes

are relatively affordable and mobile, allowing surgeons to provide diagnostic and therapeutic
care in rural or underserved regions where maintenance of complex medical equipment like
microscopes may be challenging. While the endoscope introduces benefits such as
minimized soft tissue dissection and an angled view, it also has its limitations, including one-
handed operation, frequent cleaning requirements, and a lack of depth perception, which
may affect surgical precision (Mahmud et al., 2020).

Despite the advantages of both approaches, there is limited research comparing their impact
on patient recovery time, a critical measure of postoperative success. This study aims to
investigate and compare the recovery time associated with endoscopic and microscopic type
1 tympanoplasty, with a focus on pain levels, healing rate, and post-surgical complications.
Findings from this research may provide valuable insights into the optimal surgical approach,
particularly in settings where resource constraints affect the choice of surgical technique.

Methodology:

This study was conducted at the Department of Otolaryngology-Head & Neck Surgery, Sir
Salimullah Medical College, Mitford Hospital, Dhaka, Bangladesh, between July 2022 and
June 2023. It used a prospective cohort design to examine the impact of surgical approach
on recovery time in tympanoplasty procedures, comparing endoscopic and microscopic
techniques.

The study population consisted of patients with the inactive mucosal type of chronic otitis
media (COM) admitted for type 1 tympanoplasty. A purposive sampling technique divided
the sample into two groups. Odd-numbered patients were allocated to the endoscopic
approach group, labeled as Group A, and even-numbered patients to the microscopic
approach group, labeled as Group B. Based on statistical calculations, a minimum sample
size was determined, accounting for a 20% expected dropout rate. However, due to time
limitations, 30 patients were ultimately included in each group, totaling 60 participants.

Inclusion criteria covered patients aged 15 to 55 with inactive mucosal COM, verified
eustachian tube patency via impedance audiometry, and hearing loss between 20–55 dB.
Patients were excluded if they presented with sensorineural hearing loss (SNHL), mixed
hearing loss, active ear disease, prior surgery, narrow ear canals, or conditions such as
chronic respiratory infections, nasal polyps, or deviated septum.

Demographic information (age, sex, residence, socioeconomic status) and specific

perforation-related details (side and size of perforation) were collected. Postoperative
outcomes were assessed in terms of graft success at 30 days, hearing improvement at six
weeks, and any complications, including chorda tympani nerve injury, postoperative pain
(evaluated on days 1 and 7 using a 1-10 pain scale), and wound infection on the seventh
postoperative day.

All tympanoplasty procedures were performed under general anesthesia with endotracheal
intubation. The surgeries were conducted by assistant, associate, or full professors. The
temporalis fascia was used as graft material in both groups. In the microscopic group, the
procedure was performed postaurally, while in the endoscopic group, a transcanal approach
was used. Graft placement followed an underlay technique, with anterior graft anchoring
achieved by creating a tunnel at the three o'clock position. Gel foam was used in both
groups to secure the graft and control bleeding, while the postauricular incision was closed
with Prolene 3-0 sutures in the microscopic group. All patients received prophylactic
antibiotics, and postoperative care included analgesics.

Data collection included preoperative pure-tone audiometry, intraoperative records, and

postoperative assessments. Patients were followed up on the 7th and 15th postoperative
days for pack and stitch removal and at six weeks for audiometric evaluation. Data were
processed using Microsoft Office 365 (2023 version), with statistical analyses performed
using chi-square, Fisher's exact, and independent t-tests, considering p-values below 0.05
as statistically significant.

Ethical approval was obtained from the Institutional Ethics Committee at Sir Salimullah
Medical College Mitford Hospital. Informed written consent was obtained from all
participants, with confidentiality and voluntary participation emphasized throughout the
study.

Result:

In our study on the "Impact of Surgical Approach on Recovery Time in Tympanoplasty:

Endoscopic vs. Microscopic," we analyzed 60 patients with chronic otitis media undergoing
tympanoplasty, divided into two groups: 30 patients undergoing endoscopic tympanoplasty
and 30 undergoing microscopic tympanoplasty. The average age was similar across both
groups, with the majority of patients aged 15-24 years, followed by the 25-34 age group.

Gender and Residential Distribution

Male participants were more common in the endoscopic group (Group A) at 60%, whereas
females were slightly more prevalent in the microscopic group (Group B) at 56%. In both
groups, a higher proportion of patients resided in urban areas, with 14 in Group A and 11 in
Group B.

Socioeconomic Background
Most participants came from lower socioeconomic backgrounds, with 20 out of 30 patients in
Group A and 16 in Group B. This may reflect the higher prevalence of chronic otitis media in
populations with limited access to healthcare and resources.

Perforation Side and Size

The majority of patients in both groups had perforations on the right side (46.67% in Group A
and 56.67% in Group B). Perforation size varied, with medium-sized perforations being the
most common.
Graft Uptake Rate
At 30 days postoperatively, graft uptake rates were slightly higher in the microscopic group
(90%) compared to the endoscopic group (83.33%), though this difference was not
statistically significant (p = 0.45).

Postoperative Hearing Gain

For patients with smaller perforations, there was no significant difference in hearing gain
between the two groups. Similarly, for medium, large, and subtotal perforations, hearing
improvement was comparable across both surgical approaches, with p-values consistently
greater than 0.05.

Complications and Pain

Complications were relatively low in both groups, with a slightly higher rate in the
microscopic group (10%) compared to the endoscopic group (3.33%), though this was not
statistically significant (p > 0.05). Pain scores on the first postoperative day were significantly
lower in the endoscopic group (mean score 4.3 ± 0.87) compared to the microscopic group
(mean score 6.1 ± 0.81), indicating a statistically significant reduction in immediate
postoperative pain for the endoscopic approach (p < 0.05). By the seventh day, however,
pain scores were similar between the two groups, with no significant difference (p > 0.05).

These findings suggest that while both surgical approaches are effective for tympanoplasty,
the endoscopic approach may offer benefits in terms of immediate postoperative pain.
However, long-term outcomes, including hearing gain and graft success, were comparable
between both techniques.

Discussion

In our study, patients aged 15-55 were evaluated to compare recovery times in
tympanoplasty using endoscopic and microscopic approaches. Patients were divided into
two groups using an odd-even allocation method: Group A for endoscopic tympanoplasty
and Group B for microscopic tympanoplasty. Both groups consisted of 30 patients, totaling
60 participants. The mean age was 26.5 years in Group A and 29.8 years in Group B, with
the majority falling within the 15-24 age range. The younger age distribution may reflect
higher awareness among younger individuals, where hearing difficulties can impact
academic and work performance, prompting early medical consultation. Studies indicate that
younger patients are more prone to upper respiratory infections, potentially affecting
eustachian tube function and contributing to chronic otitis media (COM) (Biswas et al.,
1970).

Gender distribution was fairly balanced, with Group A having a male-to-female ratio of 3:2
and Group B showing a similar trend. Notably, urban patients were predominant in both
groups, which aligns with findings that urban populations with better healthcare access are
more likely to pursue surgical treatment (Vahdat et al., 2014). Socioeconomic factors also
played a role, as the majority of patients came from lower socioeconomic backgrounds,
consistent with previous research indicating that lower-income individuals often experience
more frequent respiratory infections, increasing susceptibility to COM (Adoga et al., 2010).

In terms of surgical outcomes, graft uptake was slightly higher in the microscopic group
(90%) compared to the endoscopic group (83.33%). However, our findings align with studies
indicating that the endoscopic approach may yield marginally lower graft success rates,
though without statistical significance (Choi et al., 2017; Ravi et al., 2021). Graft uptake
appeared to correlate with perforation size, with larger perforations demonstrating higher
failure rates. This aligns with findings by Smyth et al. (1976) and Ahmed & Palliyalippadi
(2016), who noted a decrease in graft success as perforation size increases.

Post-operative hearing improvements were evaluated by analyzing pre- and post-operative

air-bone gap (A-B gap) closure. Both groups showed improvements, with Group B
demonstrating a slightly higher mean hearing gain across various perforation sizes.
However, statistical analysis revealed no significant difference between the two groups.
These results corroborate previous studies by Harugop et al. (2008) and Kawale et al.
(2023), indicating similar hearing improvement in both surgical approaches.

A key area of difference was the postoperative pain and recovery experience. Patients in the
endoscopic group reported lower mean pain scores immediately after surgery (mean
4.3±0.87) compared to the microscopic group (mean 6.1±0.81), possibly due to reduced
tissue trauma in the endoscopic approach. By the 7th post-operative day, pain scores
between the two groups were comparable, suggesting that the initial advantage of the
endoscopic approach may be short-lived. This finding supports prior research indicating that
endoscopic procedures can reduce early post-operative discomfort (Choi et al., 2017).

In terms of complications, the endoscopic group exhibited fewer postoperative complications

(13.3%) than the microscopic group (23.33%), although the difference was not statistically
significant. This aligns with Mahmud et al. (2020), who found no significant complication
differences between these two techniques.

Overall, our study suggests that while both endoscopic and microscopic approaches are
effective for tympanoplasty, the endoscopic approach may offer benefits in terms of initial
postoperative pain and slightly fewer complications, contributing to potentially faster recovery
times. However, further research with larger sample sizes is warranted to validate these
findings and explore the long-term impact of each approach on recovery and surgical
outcomes.

Conclusion
Endoscopic tympanoplasty may offer faster recovery and reduced pain compared to the
microscopic approach, though both methods showed similar graft success and hearing
improvement. Endoscopic techniques could thus enhance patient comfort.

Limitations
The study’s small sample size and limited follow-up period may affect the generalizability of
results, underscoring the need for further large-scale studies.

___________________________

Abstract

Background
Tympanoplasty is a surgical intervention for the repair of perforated tympanic
membranes. Some of the current popular approaches include endoscopic and
microscopic approaches. While both approaches tend to have high success
rates, recovery times and postoperative discomfort may vary.

Objective

The paper compares the impacts of using an endoscopic and microscopic

surgical approach on recovery time and postoperative outcomes in patients with
tympanoplasty.

Method

Patients aged from 15 to 55 years were divided into two groups: Group A, or the
endoscopic group, and Group B, or the microscopic group. Patients were
selected with a view on the number sequence. Data regarding graft uptake,
hearing improvement, recovery time, postoperative pain, and complications
were documented. The results of the tests were tabulated and analyzed
statistically to determine the observed differences.

Results

The graft uptake success rate in the endoscopic group was 83.3%, compared to
90% for the microscopic group. This was statistically insignificant, p > 0.05. A
similar hearing gain was seen in both groups. However, the endoscopic group
had a slightly earlier recovery time and demonstrated less mean pain scores,
which is statistically significant, p < 0.05. Minor postoperative complications were
more frequent in the microscopic group.

Conclusion :

Endoscopic tympanoplasty may offer a promising alternative to the microscopic

approach due to its association with quicker recovery and less postoperative
discomfort. However, it has also been associated with serious complications.

Introduction

Tympanoplasty is one of the most frequently performed surgeries meant to

restore the tympanic membrane and improve hearing in patients, especially
those suffering from COM. COM is a major health problem worldwide, affecting
all age groups of populations, from pediatric to adult ones, and is more common
in developing countries. It includes recurring ear discharge, hearing loss, and
inflammation of the middle ear and mastoid cavity; therefore, the demand for
effective and easily accessible treatments is underlined, since such conditions
affect the speech, cognitive, educational, and psychological development of an
individual.

Conventionally, Type 1 tympanoplasty, also termed myringoplasty, has been

performed with the assistance of the surgical microscope for clear vision and the
use of both hands. With the use of this modality, especially when accessing
hidden areas such as the anterior epitympanum and the retrotympanum, there
is a limitation. Recently, the introduction of endoscopic techniques offered an
alternative that provided a few advantages in terms of wide field of view and
greater magnification of the image, thus potentially enhanced visibility with
improved surgical outcome. Unlike the microscope, the endoscope can provide
close-up and wide-angle views and allows angled views to better visualize hidden
areas in the middle ear.

Another important advantage of endoscopic tympanoplasty is that this seems

more feasible in resource-constrained settings. These devices are relatively
inexpensive and portable, enabling surgeons to conduct diagnosis and offer
treatments even in rural areas or underdeveloped parts of the world where it
may be challenging to maintain such highly complicated medical devices as
microscopes. While the endoscope also confers advantages in terms of limited
soft tissue dissection and angled view of the operating area, there is also its own
disadvantages which include the need for one-handed operation, constant
cleaning of the endoscope, lack of depth perception that may place surgical
accuracy at risk.

Despite these two approaches having their advantages, few studies have been
designed comparing these two techniques in terms of the recovery time of the
patients, the most critical criterion for postoperative success.

http://wwwAJOL.info /index.php/og/article/view/72869/64067

►. The current study will investigate the differences in the time of

recovery between endoscopic and microscopic type 1 tympanoplasty
through the evaluation of postoperative pain, rates of healing, and
complications. The outcome of this study might be quite useful in
recommending a choice surgical type based on such variables, especially
for resource-poor countries where the choice of surgical technique could
be inspired by available resources.

Methodology:
This study was carried out at the Department of Otolaryngology-Head & Neck
Surgery, Sir Salimullah Medical College, Mitford Hospital, Dhaka, Bangladesh,
from July 2022 to June 2023. It was a prospective cohort study investigating the
effect of the surgical approach on the recovery time of patients undergoing
tympanoplasty, comparing both endoscopic and microscopic techniques.

It included patients with the COM's inactive mucosal type who were to be
admitted for type 1 tympanoplasty. A sample obtained by a purposive sampling
technique was divided into two groups. Odd-numbered patients were put in the
endoscopic approach group, Group A, and even-numbered patients in the
microscopic approach group, Group B. The sample size was calculated using the
formula, adding 20% for expected dropouts. Since there was not much time, the
minimum sample was taken as 30 patients for each group, adding up to 60
patients in all.

The inclusion criteria were patients aged 15 to 55 years with inactive mucosal
COM. Eustachian tube patency was determined by impedance audiometry, and
hearing loss was between 20 and 55 dB. Exclusions included SNHL, mixed
hearing loss, active ear disease, previous surgery, narrow external ear canals,
chronic infections of the upper respiratory system, nasal polyps, or deviated
septum.

The demographic data regarding age, sex, residence, and socioeconomic status
were recorded along with the specific details of perforation such as side and size
of perforation. The postoperative outcomes were evaluated regarding graft
uptake at 30 days, hearing gain after six weeks, and complications such as
chorda tympani nerve damage, postoperative pain, and wound infection after
the seventh day of the operation.

All the tympanoplasty operations were done under general anesthesia with
endotracheal intubation. The operations were performed by assistant, associate,
or full professors. In both groups, graft material used was temporalis fascia. The
operation was performed postaurally in the microscopic group, while in the
endoscopic group, a transcanal approach was used. The graft was positioned by
using an underlay technique. An anterior anchoring of the graft was made by
creating a tunnel at the position of three o'clock in the tympanic membrane
remnant. The graft in both groups was secured in its position with gel foam, thus
it also helped in assisting hemostasis. Now, the microscopic group postauricular
incision was closed with Prolene 3-0 sutures. Prophylactic antibiotics were given
to the patients. Analgesics were prescribed on demand during the postoperative
period of the patients.
Preoperative data of pure-tone audiometry, intraoperative data, and
postoperative results were recorded. The patients were followed up on the 7th
and 15th postoperative day for pack and stitch removal, respectively, and at six
weeks for audiometric assessment. Data were analyzed with the help of
Microsoft Office 365 (2023 version). Statistical analysis was done by using chi-
square test, Fisher's exact test, and independent t-test, considering p-value
below 0.05 as significant.

Ethical approval was obtained from Institutional Ethics Committee, Sir Salimullah
Medical College Mitford Hospital. Informed written consent was obtained from
all participants; confidentiality and voluntary participation were assured
throughout the research.

Results:

Materials and Methods: Our study "Impact of Surgical Approach on Recovery

Time in Tympanoplasty: Endoscopic vs. Microscopic" involved 60 patients with
chronic otitis media undergoing tympanoplasty, which we divided into two
groups, with 30 patients undergoing endoscopic tympanoplasty and 30
undergoing microscopic tympanoplasty. The mean age for both the groups was
quite similar. The majority of the patients belonged to the age group of 15-24
years, followed by the 25-34 age group.

Gender and Residential Distribution

In the endoscopic group, Group A, 60% were males and the rest in the
microscopic group, Group B represented a slight majority of females at 56%. In
both groups, urban background patients dominated 14 in Group A and 11 in
Group B.

Socio-economic Background

The participants were mostly from the lower socioeconomic classes. 20 in Group
A and 16 in Group B indicated this aspect, which may reflect the higher
prevalence of chronic otitis media in populations where access to healthcare
and facilities is limited.

Perforation Side and Size

Most of the patients from both the groups presented with right-sided
perforations: 46.67% in Group A versus 56.67% in Group B. The size of the
perforation was variable; however, most of the patients had medium-sized
perforations.

Graft Uptake Rate

Postoperative day 30 graft uptake was better, though not significant, for the
microscopic group as compared to the endoscopic group: 90% versus 83.33%,
p=0.45.

Postoperative Hearing Gain

However there was no significant difference in hearing gain between the two
groups in cases of small perforations. For medium, large, and subtotal
perforations, improvement in hearing following both the surgical approaches
has no significant difference, as all the p-values were >0.05.

Complications and Pain

Complications in both groups are relatively low, higher in the microscopic group
at about 10% versus 3.33% in the endoscopic group, though not of statistical
significance. Accordingly, the mean pain scores in the first postoperative day
were 4.3 ± 0.87 in the endoscopic group, as opposed to the scores of 6.1 ± 0.81
in the microscopic group. This reflects a statistically significant reduction in the
immediate postoperative pain for the endoscopic approach, with p < 0.05. The
pain scores became similar in both groups on the seventh day, without
significant difference, with a p-value of > 0.05.

These findings indicated both surgical approaches were effective in the

treatment of tympanoplasty but the endoscopic approach may be more
advantageous with regards to immediate postoperative pain. Long-term results,
however included hearing gain and graft success that were similar for both
techniques.

Discussion

In our study, patients aged 15-55 were evaluated in comparing recovery times in
tympanoplasty utilizing both endoscopic and microscopic approaches. An odd-
even allocation was therefore utilized in assigning the patients into two groups,
namely: Group A. There were 30 patients in both groups, making a total of 60
participants in this study. For Group A, the average age was 26.5 years and for
Group B, the average age was 29.8 years; the highest number in both groups
was within the age bracket of 15 to 24 years. The only explanation for the
relatively younger age distribution may be a higher awareness among younger
age groups, in whom hearing difficulties can affect school and work
performance, bringing them into early medical consultation. Other studies
suggest that patients in this relatively younger age group are more susceptible
to upper respiratory infections which can affect the eustachian tube function
and thus predispose to COM.

The distribution of gender is relatively fair, with a male-to-female ratio of 3:2 in

Group A and a similar trend in Group B. Surprisingly, urban patients are
predominant in the two groups-a factor that goes in line with findings that urban
populations, because they enjoy better health care, are more likely to seek
surgical treatment. It is also due to the socioeconomic factor because most of
the patients belonged to low socio-economic groups, and also in the literature, it
is said that persons of low economic status are prone for frequent infections of
the respiratory tract which in turn provide easy access to COM, Adoga et al.,
2010.

Surgical outcome in terms of graft uptake were 90 % for microscopic and 83.33
% for endoscopic. These findings, however, do support the reports that show the
marginal reduction in the success rates of grafts with the endoscopic approach,
though the difference is not statistically significant. Choi et al. state, "Besides,
Ravi et al. also claim that the main reason for graft failure is perforation size.
This agrees with the report of Smyth et al. (1976) and Ahmed & Palliyalippadi
(2016), who found out that graft success decreases with increased perforation
size.

Ability for postoperative hearing improvement was analyzed in the A-B gap
closure both preand post-operatively. An improvement was seen in both groups;
however, the mean hearing gain seemed to be slightly higher with increasing
perforation size in Group B. There was no statistical difference among the two
groups. This further supports studies by Harugop et al., 2008, and Kawale et al.,
2023, showing no difference in the hearing improvement of either surgical
approach.

Another point related to the observed difference was postoperative pain and the
recovery experience. Immediately after surgery, patients in the endoscopic
group reported mean pain scores of 4.3±0.87 compared to the microscopic
group, with means of 6.1±0.81; this may be because of the lesser tissue trauma
with the endoscopic approach. Pain scores between the two groups by the 7th
postoperative day were essentially comparable, suggesting the initial advantage
of the endoscopic approach may be short-lived. This result follows earlier
studies, which showed that endoscopic procedures reduce early post-operative
discomforts. (Choi et al., 2017)
Concerning the complication, it has been realized that an endoscopic group
showed a low rate of post-operative complications (13.3%) compared to the
microscopic groups (23.33%), thus proving statistically insignificantly different.
This agrees with Mahmud et al. (2020), where no significant differences in the
complication between two techniques were shown.

On the whole, our investigation of both endoscopic and microscopic methods of

performing tympanoplasty would tend to indicate that while both are effective,
the endoscopic approach may offer advantages in terms of initial postoperative
pain and slightly fewer complications, therefore potentially offering shorter
convalescence times. However, further studies with larger samples are required
to confirm this and evaluate the long-term consequences of the two approaches
on patient recovery and surgical outcomes.

Conclusion

Thus, the endoscopic approach provides quicker recovery and less pain than the
microscopic one, though both techniques resulted in equal graft success and
hearing improvement. The endoscopic methods may improve the patient
comfort.

Limitations

Small sample size and short follow up period of this study could affect
generalizability of results; large-scale studies are required further.