Otologic surgeries are   usually done using an operating microscope. In many surgical fields, there is also a trend and need   towards minimally invasive intervention in the field of otology. Smaller incisions and with the guidance of endoscopes are preferred over conventional large incisions. Previously, Endoscopic Unit was used for sinus surgeries only. It was only later that they were applied in the area of otology. In otologic surgeries, 0 degree and angled endoscopes were used to visualize epitympanum and retrotympanum, before being used to assist with visualization of instruments during cholesteatoma surgeries. Now a days Limited Otologic surgeries are been performed using Endoscopes. Using the endoscopic approach, similar or improved outcomes can be achieved as compared to the microscopic approach and postoperative recovery period can be reduced. Therefore, endoscopic ear surgery implementations are becoming increasingly popular. The endoscopic approach can also be preferred in procedures such as ventilation tube insertion, myringoplasty, tympanoplasty, ossicular reconstruction for malformation and ossicle trauma, cholesteatoma surgeries, otosclerosis surgeries and cochlear implantation.

It has been reported in that the final results of Microscopic Tympanoplasty in terms of uptake rate of the graft ranges from 74% to 96 %. (Large central perforation – 86%, subtotal perforation – 78%). hence the hearing outcome has been 85%-90% with minor complications of post auricular scar, postoperative pain, EAC Narrowing. Hence In this era of Minimally Invasive surgeries, Endoscopic Ear Surgeries has been practised recently to overcome complications.

Advantage

1. Endoscopes gives us wide angled view of the structures.
2. Hidden deep areas ,i.e the anterior tympanic perforation, facial recess and
3. hypotympanum can be visualized.
4. Smaller Incisions can be used. (postauricular incisions),hence better cosmetic outcomes
5. Need for canalplasty is minimal .
6. Relatively shorter duration for surgery.
7. Postoperative pain is less and faster
8. Monitor used during endoscopic surgery helpful for teaching purposes.

Hence, we would like to study outcomes of Endoscopic tympanoplasty and microscopic tympanoplasty, in terms of hearing and graft uptake outcomes.

Study Design and Setting:

This prospective randomized controlled trial was conducted at the Department of Otorhinolaryngology, ESIC Medical College PGIMSR and Model Hospital, Bengaluru, between November 2024 and  November 2025. The study protocol received approval from the Institutional Ethics Committee (No 532/L/11/12/Ethics/ESICMC&PGIMSR/Estt.Vol.IV/184-B/2024).

Study Design:  Prospective randomized controlled trial

 Setting:  Tertiary care teaching hospital.                    

Study Population: All patients diagnosed Tubotympanic Disease with Subtotal perforation attending ENT department in ESI MC PGIMSR Rajajinagar

Inclusion Criteria           

 All patients above 10 years of age with:

1. Inactive Tubotympanic disease having subtotal perforations of the tympanic membrane
2. Intact ossicular chain
3. Conductive hearing loss < 50dBHL

Exclusion Criteria

1. Patients who were diagnosed with CSOM tubotympanic type with complications.
2. Patients with sensory neural hearing loss. patients in whom hearing loss >50dBHL
3. (suggestive of ossicular discontinuity),
4. Patients undergoing revision Tympanoplasty,
5. Patients with congenital anomalies.

Sample size- is calculated using the study conducted in India in the year 2017 by

With an Calculated Effect size of (d) 0.564 , at 95%confidence Level and 80% Power, with an allocation Rate 1:1 , the sample size is calculated using G*power 3.1: the study needs ----- patients in each group with a total sample size of------ .

SAMPLE COLLECTION

The patients who fulfilled the above inclusion criteria will be selected. - Total  of 102 patients will be included and selected randomly into two groups - anterior tucking and Interlay technique. Patients will be allotted in each group by lottery method.

Randomization: Simple randomization sampling

Detailed pre operative and post-operative clinical including otoscopy and audiometric findings will be compiled.

Surgical Procedure

In Microscopic approach, All the cases will be operated under general anaesthesia , post aural Incision is given, temporalis fascia as a graft is harvested. After meatotomy, Using Microscope, tympanomeatal flap was elevated circumferentially. Canalplasty was done in cases with Narrow External Auditory canal or bony overhang obscuring the view of annulus.

 Incision is given from 10 clock to 30 clock through 60 clock in the right Ear and from 110 clock to 90 clock through 60 clock in the Left Ear.  The flap will be elevated at posteroinferior region and annulus lifted and mesotympanum will be reached, ossicles will be inspected for continuity and the mobility was checked, Temporalis Fascia graft was placed in such a fashion that it rested on the mucosal layer and bony canal all around and below the handle of malleus. The Tympanomeatal flap will be repositioned carefully, gel foam will be kept in external auditory canal and the incision sutured in two layers. Patients will be discharged on 2nd post operative day with oral antibiotics and Day 7 sutures will be removed.

Figure 1 Microscopic Tympanoplasty showing Tympanomeatal flap elevation and and post graft placement

In Endoscopic Approach,

In this approach, temporalis fascia harvested after giving small supratemporal region,

Incision is given from 10 clock to 30 clock through 60 clock in the right Ear and from 110 clock to 90 clock through 60 clock in the Left Ear.  The flap will be elevated at posteroinferior region will be elevated and annulus lifted and mesotympanum will be reached. Ossicles will be inspected for continuity and the mobility was checked, Temporalis Fascia graft was placed in such a fashion that it rested on the mucosal layer and bony canal all around and below the handle of malleus. The Tympanomeatal flap will be repositioned carefully, gel foam will be kept in external auditory canal.

After 4 weeks Patients will undergo otoscopy to assess the graft uptake and complications (if any) at every follow up visit and a pure tone audiometry at the end of 3rd month to evaluate the hearing improvement. Results will be tabulated and statistical analysis will be done using statistical software.

Figure 2: Endoscopic Tympanoplasty showing Underlay with Anterior Tucking with Post graft placement

Pie chart 1

Statistical methods employed for analysis of data

Graphs

Sex

DIAGNOSIS

Age and Gender

Microscopic and Endoscopic( independent sample t test is used)

There is significant difference in AB_gap_closure in procedure  with Microscopic and  Endoscopic

PRE_OP_PTA and POST_OP_PTA comparison for Microscopic procedure (Paired t test )

There is significant difference in pre and post op pta in patients undergo with Microscopic procedure

PRE_OP_PTA and POST_OP_PTA comparison for Endoscopic procedure (Paired t test )

There is significant difference in pre and post op pta in patients undergo with Endoscopic procedure.

In this study, it was found that mean air‐conduction threshold preoperatively in the endoscopic  group was 39 ± 4.45 decibel (dB) and 41.86 ± 8.85 dB in microscopic preoperatively. Preoperative mean air‐conduction threshold comparison between the endoscopic and microscopic group was statistically not significant (P > 0.140) .

The mean air‐conduction threshold postoperatively in endoscopic  group was 28.40 ± 4.94 dB, whereas in microscopic , it was 27.96 ± 4.62 dB. Data were statistically not significant (P > 0.416) .

The mean air–bone gap postoperatively in endoscopic  group was 10.66 and 13.1 dB in microscopic group . Postoperative mean air–bone gap comparison between the endoscopic and microscopic group was statistically not significant (P > 0.272).

 Hearing gain postoperatively was 10.2dB in the endoscopic group and 13.9dB in microscopic group, respectively, with P = 0.132 (not significant).

Duration of surgery

In endoscopic tympanoplasty, the mean duration of surgery was 36 min, and in microscopic tympanoplasty, the mean duration of surgery was 48 min. Duration of surgery in endoscopic tympanoplasty was significantly lower than microscopic tympanoplasty with P < 0.001 which was statistically significant.

Graft uptake

Postoperatively at the 6th month, temporalis fascia graft uptake was seen in 91.30% of patients who underwent endoscopic tympanoplasty with residual perforation in 8.70% of patients and in 93.40% of patients who underwent microscopic tympanoplasty with residual perforation in 7.60% of patients.

DISCUSSION

Conventionally most ontological surgeries are  performed under the guidance of a microscope. thoughit provides a linear view, deep recesses visualisation  is difficult.

If the external ear canal is narrow or blocked by  bony overhang, a microscopic surgeries should be done after canaloplasty. The main advantage of the microscopic approach is that it provides a stereo-view and allows bimanual operation.

Endoscopes  provide us  magnification of the surgical field. Microscopes require image adjustment during operation, whereas back-and-forth movements of the endoscope can easily produce close-up and angled images when needed. Moreover, rotational movement of angled endoscopes can provide panoramic images of the deep and hidden regions of the middle ear. An endoscopic approach ,during surgery  improves visualization of retrotympanum. Advantages of the endoscopic approach include shorter operation time, reduced exposure to anesthetic agents and associated side effects, and improved surgeon concentration (Huang et al., 2016)[1]

The endoscopic approach is less invasive, as it does not require large post auricular incision or canaloplasty. Compared with the microscopic approach, an endoscopic approach is associated with less postoperative bleeding and pain, and it provides improved cosmetic outcomes

Huang et al. (2016) reported that the mean operation times were 50 min and 75 min in patients undergoing endoscopic and microscopic tympanoplasty, respectively[1]. In our study , endoscopic tympanoplasty, the mean duration of surgery was 36 min, and in microscopic tympanoplasty, the mean duration of surgery was 48 min.In the study of Patel et al. (2015), mean time of endoscopic and microscopic tympanoplasty operations was found to be 75 min and 90 min, respectively.[3]

Huang et al. (2016) performed type 1 tympanoplasty in 50 patients by microscopic approach and in another 50 patients by endoscopic approach. Similar hearing recovery and rate of perforation closure were found between the two patient groups. Moreover, shorter operation times, better views of surgical field, improved outcomes, reduced tissue injury and particularly lower rate of postoperative nausea were noted in patients undergoing endoscopic surgeries[1].

 Karhuketo et al. (2001) stated that canaloplasty and outer ear curettage became necessary in some of their patients undergoing microscopic tympanoplasty. Conversely, none of their patients who underwent endoscopic tympanoplasty required interventions such as canaloplasty or curettage [6].

Advantages of Endoscopic Tympanoplasty are:

1. The enhanced visual acuity, wide angled Imaging and superior illumination ,allows us to visualise better quality images of Middle Ear .
2. Deep Hidden areas can be visualised easily – Posterior tympanic sinus, sinus tympani, anterior epitympanic recess,
3. Eluminates the need for changing position of patient head frequently.
4. Requires small incisions, helps us to preserve normal tissue .better cosmetic outcome
5. less post-operative pain and faster recovery
6. Requirement of canaloplasty and curettage is very minimal
7. Time duration of surgery is reduced, shorter hospital stay and low financial burden .
8. Recording purpose, teaching students , training for junior colleges .

Disadvantages are

1. Surgical manipulations are performed using one hand
2. Monitor provides only Two – Dimensional views, as depth perception is absent
3. Frequent Defogging is required.
4. Requires good Hemostasis.
5. Limited Field of Magnification
6. Requires a longer learning curve.

CONCLUSION

Endoscopic tympanoplasty is an alternative to the conventional microscopic technique in terms of duration of surgery and graft uptake, the endoscopic approach provides better postoperative cosmesis, post op pain, and early mobilization. Further research involving a larger sample sized randomized trials could find its place as a common daycare procedure.

Compliance with Ethical stantards

Disclosure of potential conflits of interest

1. The authors did not receive support from any organization for the submitted work.
2. All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject or materials discussed in this manuscript.

Research involving Human Participants and/or Animals

This study was performed in line with the principles of the Declaration of Helsinki.The study was approved by the Institutional Ethics committee of ESIC Medical college and PGIMSR Rajajinagar, Bengaluru. (No 532/L/11/12/Ethics/ESICMC&PGIMSR/Estt.Vol.IV/184-B/2024).

Informed consent

Consent to participate – Informed consent was obtained from all individual participants included in the study.

Consent to publish – The participants have consented to submission of the study to the journal

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