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Table 3. Comparisons of hearing outcomes and functional success
between groups.

Mean preoperative ABG
Mean postoperative ABG
Mean hearing gain
Functional success

Group 1

Group 2

21.1 (7.1) dB
8.1 (2.7) dB
12.5 (11.0) dB
33/40 (82.5%)

20.5 (6.7) dB
7.9 (3.0) dB
15.6 (10.1) dB
36/44 (81.8%)

.458
.254
.183
.582

Abbreviation: ABG, air-bone gap.
a
Significance level: P < .05, functional success: ABG less than <10 dB.

endoscopic approach using the tragal cartilage from one ear as
graft material.
In the literature, the graft success rates of cartilage tympanoplasty vary from 92% to 100%.9-14 It is important to emphasize that these results relate to cases in which bilaterality of the
disease is not taken into consideration. Tympanoplasty is less
successful in patients with bilateral COM; thus, bilaterality of
the disease represents a negative prognostic factor.15 In the
present study, we found success rates of 92.9%, 92.5%, and
93.2% for overall, unilateral, and bilateral same-day groups,
respectively. The 81.8% hearing success rate for bilateral
myringoplasty obtained from this study also corresponds well
to the 82.5% hearing success rate for unilateral myringoplasty.
Sakagami et al16 reported an anatomic success rate of 72%
(18 patients) and a postoperative ABG of <20 dB in 15
(60%) of 25 patients. Katsura et al17 reported an 85% success
rate for graft take with hearing improvement in 15 (88%)
patients. Caye-Thomasen et al7 found a 94% success rate for
graft take in all patients, with a closure of ABG <10 and 20 dB
postoperatively in 92% and 100% of 26 patients, respectively.
Yu et al18 recorded a 100% success rate, with an improvement
in ABG from 15.8 to 8.4 dB. Rai et al19 reported a 93% graft
take rate and an ABG of <20 dB postoperatively in 27 (90%)
patients who had undergone bilateral myringoplasty using temporalis fascia. The authors did not find a significant difference
in graft take and hearing improvement between the results of
unilateral and bilateral myringoplasty. Daneshi et al20 calculated a 94.4% success rate, with an improvement in ABG from
13.8 to 9.6 dB in patients having undergone bilateral simultaneous endoscopic transcanal cartilage tympanoplasty. Karatas¸
and Kaskalan21 performed bilateral inlay cartilage tympanoplasty using tragal cartilage from one ear and reported an
86.3% success rate, with an ABG of <20 dB and 10 dB postoperatively in 98% (65 patients) and 56% (37 patients) of 66
patients, respectively. In our study, the 93.2% (41 ears) graft
take rate in group 2 was also similar to the results of the above
studies. Furthermore, no patient had bilaterally failed TM grafting; thus, at least one TM closure was achieved at the end of 12
months. Likewise, in this study, the ABG for group 2 was <10
dB in 36 (81.8%) ears, which is also within the average
reported success rate of the previous studies in the literature.
Endoscopic transcanal middle ear surgery, which is
minimally invasive, is a practical, time-saving, and conservative technique compared with conventional surgical

techniques.2,20,21 Apart from tragal incision, this technique
does not require retroauricular skin incision, canal drilling, or
hair shaving. In our study, the average length of operation
time was 61.6 minutes for the unilateral group, which is
consistent with existing studies on the cited subject. The less
pain and decreased demand for analgesics are other advantages of this technique. Since postoperative pain is a significant factor for patient comfort after middle ear surgery, we
prefer the endoscopic approach when performing bilateral
same-day myringoplasty at our clinic. However, Rai et al
indicated that the severity of pain did not cause any greater
degree of disturbance to the patients after bilateral same-day
myringoplasty performed via a retroauricular approach, and
they found no statistically significant difference between the
unilateral and bilateral same-day myringoplasty groups in
terms of postoperative pain scores.19
Adult TM measures 9 to 10 mm vertically and 8 to 9 mm
horizontally.22 The average tragal cartilage size was reported as
21.9 mm Â 15.3 mm.23 Consequently, only one tragus provides
an adequate amount of graft even for bilateral large-sized TM
perforations. The advantage of using tragal cartilage from one
ear for both TM perforations is that it reduces the time required
to obtain another tragal graft. Furthermore, using tragal cartilage from one ear preserves the contralateral tragal cartilage,
which can subsequently be used as graft material in case of
failure of graft take or revision surgery. Therefore, we harvested tragal cartilage from one ear and used the same graft
to repair both TM perforations.
From the data collected on operation time, it is clear that by
eliminating the need for a second procedure for graft harvesting, bilateral same-day surgery (110.1 minutes) becomes less
time consuming compared to unilateral surgery (61.6 minutes) done twice. We believe that this technique will provide
substantial cost savings by reducing the number of hospital
admissions and bed occupancy. Moreover, it also eliminates
hidden costs related to the patient taking time off work and
away from home.
Some otologic surgeons are reluctant to perform bilateral
tympanoplasty because of a theoretical risk of ISNHL during
surgery. From a review of literature, it is essential to note that
such incidents occurred in patients with congenital diseases,
cholesteatoma, and granulation tissue or in cases undergoing
ossicular chain reconstruction.4-7,24 In our study, we did not
observe any cases of postoperative ISNHL. Our findings are
in agreement with those of previous studies.7,16-18,24 Moreover,
Daneshi et al20 reported that they did not encounter any case of
ISNHL, facial paralysis, or chorda tympani injury in their previous series of endoscopic stapedectomy, even though the theoretical risk for ISNHL was greater in cases of stapes surgery.
Kim et al25 reported that performing bilateral simultaneous
middle ear surgery for COM provided favorable hearing
results. They also reported reduced costs, operation time, and
number of postoperative outpatient control visits, as well as a
low incidence of complications. Therefore, the risk of developing ISNHL is negligible regardless of the nature of the graft
or technique used unless the ossicular chain is manipulated as

ENT - September 2020

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