Comparison of Endoscopic Versus Microscopic Tympanoplasty: A Prospective Randomised Study

Abstract

Aim

To compare endoscopic versus microscopic method for tympanoplasty in terms of Graft uptake and hearing outcome.

Material and methods

A randomized prospective observational study was done. 60 patients who came to ENT outpatient of tertiary care teaching hospital requiring operative intervention for inactive mucosal chronic otitis media. Randomization was done and patients divided into two groups with Group A undergoing endoscopic tympanoplasty and Group B undergoing microscopic tympanoplasty. Post operative graft uptake and hearing improvement were compared between both groups. Intraoperatively visualization of middle ear structures, surgeon’s comfort, duration of surgery, post operative pain, giddiness was compared. in both the groups.

Results

Total 60 patients got randomly divided in the two groups. There was no difference in terms post op graft success rate and post operative hearing improvement in both the groups Intra operative visualization of middle ear structures better in the endoscopic group and also the surgical time was significantly less in endoscopic group.

Conclusion

On comparing endoscopic versus microscopic tympanoplasty in patients of mucosal chronic otitis media, success rate in terms of graft acceptance and hearing improvement was equal between both groups. However, visualisation of middle ear structures was better in endoscopic method. Operating time was shorter in endoscopic tympanoplasty.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-024-04585-z.

Introduction

Tympanoplasty and myringoplasty are commonly used surgeries for treatment of chronic otitis media ( [1]) Traditionally tympanoplasty was performed using a microscope with the advantage of desired magnification, binocular vision, manoeuvrability of microscope and use of both hands for surgery. However, there was a limitation with microscope especially to visualize the areas like sinus tympani, facial recess, epitympanum which are hidden spaces of middle ear [2], Microscopes also required frequent adjustment. In 1967, Mer and colleagues introduced use of endoscopes in middle ear ( [3]). Later on endoscopes were used in addition to microscopes for all surgical procedures involving the middle ear and eventually now a days they are used as standalone instruments ( [4, 5]). Certain perceived advantages of using endoscopes are its without suture, lesser operative time and better and wide-angle visualization of middle ear ( [2]). It does have disadvantages which are lack of depth perception, one handed technique and probable thermal injury from light source that can be overcome with practice ( [6]). There are different schools of thought regarding microscopic and endoscopic tympanoplasty surgery to understand if any on is better this study is aimed to compare endoscopic versus microscopic tympanoplasty.

Methodology

Institutional ethical clearance was taken and a prospective randomised study was conducted at this tertiary care teaching hospital, over a period over two years. All patients more than 15 years of age, presenting to ENT OPD and after evaluation, posted for tympanoplasty were included in this study. Written informed consent was obtained from these patients about the study. Patients with active discharging ear were or those with squamosal disease were not included in the study.

Simple randomisation was done using computer generated sequences. A Total of 60 patients were included in this study, who were randomised into two groups-Group-A (Endoscopic Tympanoplasty), Group–B (Microscopic Tympanoplasty).

Thorough preoperative evaluation was done for all patients with included hearing evaluation using pure tone audiometry.

Surgery

In both the groups the surgeries were performed under general anaesthesia and tragal cartilage was used as the graft material. In both groups underlay technique of graft placement was used.

Both the groups had similar steps of surgery except for the fact that microscopic was done through post aural approach which required suturing at the end of surgery. Povidone Iodine-soaked gel foam was placed in the external auditory canal following the surgery. Both the groups were kept on same antibiotics and analgesics in the post operative period, Intraoperative photographs of endoscopic and microscopic tympanoplasty is as per Figs. 1 and 2.

Fig. 1.

Endoscopic Tympanoplasty

Fig. 2.

Microscopic Tympanoplasty

Intraoperative findings, duration of surgery, post operative complications, post operative graft uptake and hearing improvement were documented in both groups A and B.

Post-operatively comfort was assessed on post operative day 1 and day 7 in terms of pain (using visual analogue scale), giddiness (using visual analogue scale). Note was made of any operative site infection/wound dehiscence. On follow up at 2 weeks and 4 weeks, status of graft uptake noted and post-operative audiometry was done after one month.

All the above data was noted for the groups and comparison of endoscopic versus microscopic tympanoplasty group was done.

Results

60 cases were included in this study divided in both the groups.

Mean age group in the present study was 35.1 years in Group A and 36.5 years in Group B.In Group A 64% were female and 36% were male and in Group B 60% were female and 40% were male.

In this study visualisation of middle ear structures was noted in the two groups and compared and analysed. Table 1.

Table 1.

Visualisation of middle ear structures

	Group A(n = 30)			Group B(n = 30)			P –Value
	RWN	ST	FR	RWN	ST	FR	RWN	ST	FR
Visualised	26	17	14	21	0	0	0.489	0.00*	0.00*
Not visualised	4	13	16	9	30	30

P-Value by chi-square test *Statistically significant for ST and FR (P-Value < 0.05)

RWN- Round Window niche ST- Sinus Tympani FR- Facial Recess

It was observed that visualisation of round window area, sinus tympani and facial recess was better in endoscopic method. This difference was statistically significant for visualization of Sinus tympany and facial recess area.

Surgeon’s comfort in terms of intraoperative visualization, ease of instrumentation and need for external auditory canal widening procedures was assessed and compared between two groups. The difference between the two groups were not significant statistically.

The time required for surgery was also compared between the two groups. In endoscopic group 87% cases required 60–90 min and 13% required > 90 min. In microscopic group, 53% (60–90 min) and 47%(> 90 min). This difference was statistically significant, duration of surgery was less in endoscopic compared to microscopic(P < 0.04) Table 2.

Table 2.

Visualisation of middle ear structures

	Group A (n = 30)		Group B (n = 30)
	60-90 min	> 90 min	60-90 min	> 90 min	P VALUE
Duration of surgery	26	4	16	14	0.04*

P-Value is by sample t test *Statistically significant (P-Value < 0.05)

Post op pain on Day 1(P = 0.00) and Day 7(P < 0.002) was less in endoscopic than microscopic which was statistically significant.

In terms of Post Op giddiness on Day 1 and Day 7 results between the two groups were statistically non-significant.

On comparison of the success rate of the acceptance of graft in the two groups it was found that in group A, success rate was 80% on DAY 14 and 87% on day 30, and in group B it was 90% on Day 14 and 93% on Day 30.This difference between the two groups was non-significant.

Post operative Air–bone gap improvement for group A and B on Day 30 was 7.82dB and 7.79dB respectively. It showed no significant difference between two groups.

Thus, the results showed that on comparing the endoscopic versus microscopic group, there was no statistical difference between the graft uptake rate and the hearing improvement. However, there was a statistical difference for the time taken which was less in endoscopic and post operative pain was also less in the endoscopic group.

Discussion

Chronic otitis media (COM) is defined as persistent inflammation of the middle ear or mastoid cavity, with recurrent or persistent otorrhoea over two to six weeks through a tympanic membrane perforation or a permanent abnormality in pars tensa ( [7]).Tympanoplasty and myringoplasty by endoscopic or microscopic approach with their said advantages and disadvantages are commonly used surgeries for treatment of mucosal type of chronic otitis media.

In this study 60 patients with mucosal chronic otitis media planned for tympanoplasty were divided in either endoscopic group or microscopic group and the results were compared.

This study was aimed to compare endoscopic versus microscopic technique to treat mucosal chronic otitis media. to compare the visualisation of middle ear structures, Surgeon’s comfort, postoperative improvement in hearing and assessment of graft uptake at the end of 1 month.

Group A underwent endoscopic tympanoplasty and Group B underwent microscopic tympanoplasty. In this study visualisation of middle ear structures like round window, Stapedius tendon and Facial recess area was visualised better in endoscopic this could be well compared with study by Tarabichi M et al. ( [8]) which also showed better visualization of middle ear structures like facial recess, sinus tympani, hypotympanum.

Surgeon’s comfort in terms of operating, ease of instrumentation and need for any external auditory canal widening procedures was also assessed and the results was statistically non-significant. This result is comparable to Choi N et al. ( [9]) et al. and Harugop et al. ( [10]) studies.

There was significant difference between the duration of surgery where time for surgery was lesser in the endoscopic technique compared to microscopic. This result is comparable to Choi N et al. ( [9]). Study by Harugop et al. ( [10]) have shown duration of surgery was less in microscopic compared to endoscopic surgery and probably this may be due to the learning curve for endoscopic surgery.

In this study post op pain on Day 1 and Day 7 was less in endoscopic than microscopic which was statistically significant. Choi N et al. ( [9]) had similar results in their study. In terms of Post Op giddiness on Day 1 and Day 7 results were comparable in both the groups and difference was non-significant. This result is comparable to Kaya I etal [11].

The graft acceptance rate in both the groups was similar and the difference was not significant. Graft success rate was 80% on DAY 14 and 87% on Day 30 in Group A, 90% on Day 14 and 93% on Day 30 in Group B.

Also, the hearing improvement in terms of improved AB gap was similar in both the groups and difference was not significant Post operative Air–bone gap improvement for group A and B on Day 30 was 7.82 and 7.79 dB respectively. Harugop et al. ( [10]) Kaya I et al. ( [11]) and Choi N et al. [9] also showed comparable results .

Conclusion

On comparing endoscopic versus microscopic technique in tympanoplasty it is concluded that graft uptake rate and hearing improvement in both the groups are comparable. Endoscope was better in terms of visualization of middle ear structures and the time taken for surgery was lesser in endoscopic technique. Thus, endoscopic tympanoplasty could be a good alternative for microscopic tympanoplasty. A multicentric study with larger sample size will be a way forward to make this conclusion more robust.

Electronic Supplementary Material

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Declarations

Ethical Approval

Institutional Ethical Clearance taken.

Financial Implication

Not applicable.