Indian Journal of Otology

: 2019  |  Volume : 25  |  Issue : 3  |  Page : 135--140

Long-term hearing results in endoscopic sandwich myringoplasty: An innovative Dhulikhel hospital technique

Bikash Lal Shrestha, Ashish Dhakal, K C Abha Kiran, Krishna Sundar Shrestha, Aakash Pradhan 
 Department of ENT-HNS, Dhulikhel Hospital, Kathmandu University Hospital, Kavre, Nepal

Correspondence Address:
Dr. Bikash Lal Shrestha
Department of ENT-HNS, Dhulikhel Hospital, Kathmandu University Hospital, Kavre


Background: The endoscope has diagnostic and therapeutic role in different otological surgeries. It has excellent view of images where there are difficult nooks and corners. The use of sandwich cartilage perichondrium in the repair of tympanic membrane peroration has its own benefit in graft uptake and hearing results whether long term or short term. The main purpose of the present study was to evaluate the long-term hearing results in patients who underwent endoscopic sandwich myringoplasty with Dhulikhel Hospital (D-HOS) technique. Materials and Methodology: This was a prospective, cohort study performed among 45 patients who underwent endoscopic sandwich myringoplasty with D-HOS technique using tragal cartilage and perichondrium. The hearing was assessed by comparing pre- with post-operative air-bone gap (ABG) and ABG closure in speech frequencies (0.5 kHz, 1 kHz, 2 kHz, and 4 kHz). Results: Among forty-five patients, 42 (93.3%) had graft uptake in 12 months of follow-up. The postoperative ABG (17.0 ± 8.5 dB) was lesser than preoperative ABG (27.3 ± 12.5 dB) with statistically significant results. Conclusion: Endoscopic sandwich myringoplasty with D-HOS technique is a safe procedure with high-graft uptake rate and good long-term hearing results.

How to cite this article:
Shrestha BL, Dhakal A, Kiran K C, Shrestha KS, Pradhan A. Long-term hearing results in endoscopic sandwich myringoplasty: An innovative Dhulikhel hospital technique.Indian J Otol 2019;25:135-140

How to cite this URL:
Shrestha BL, Dhakal A, Kiran K C, Shrestha KS, Pradhan A. Long-term hearing results in endoscopic sandwich myringoplasty: An innovative Dhulikhel hospital technique. Indian J Otol [serial online] 2019 [cited 2021 May 13 ];25:135-140
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Full Text


Endoscopes have better optics and magnification with wide angle of view, and hence certain advantages in otological surgeries like; it can visualize anteroinferior recess of the external auditory canal, middle ear cavity, and sinus tympani.[1],[2],[3],[4]

Eavey was the first to advocate butterfly cartilage myringoplasty in children.[5],[6]

There is still scarcity of study on endoscopic cartilage myringoplasty with long-term results, and hence, we had performed this study and followed the technique performed by Rourke et al. but with our own modification, named it as Dhulikhel Hospital (D-HOS) technique.[7]

The main purpose of this study was to evaluate the long-term hearing results in patients who underwent endoscopic sandwich myringoplasty with D-HOS technique.

 Materials And Methodology

This was a prospective, cohort study conducted from July 1, 2017 to February 1, 2018. The ethical clearance was obtained from the Institutional Review Board. Informed consent was obtained from the patient before conducting the study. The inclusion criteria were as follows: chronic otitis media mucosal inactive type, age ≥18 years, and both gender. Exclusion criteria were as follows: graft failure, revision cases, mentally retarded, medical or surgical conditions, or treatment having a chance to influence the outcome.

From the patients included in the study, data collection was done preoperatively and then 12 months postoperatively. Clinical examinations (general ear, nose, and throat [ENT] examination, microscopic examination of the ear, and tuning fork tests) also performed preoperatively.

Hearing assessment

For the hearing assessment, pure-tone audiogram performed by MAICO MA 41 diagnostic audiometer (Germany) in sound-treated double room setup was done within 7 days before the operation and then 12 months after the operation. The audiological results were reported according to the American Academy of Otolaryngology-Head-and-Neck Surgery guidelines.[8] The hearing was assessed by comparing pre- with postoperative air-bone gap (ABG) and ABG closure in speech frequencies (500 Hz, 1 KHz, 2 KHz, and 4 KHz).

For the surgery

Patient preoperative preparation

The patient was given oral ciprofloxacin 500 mg 12 hourly from 1 day before surgery and continued till the 7th postoperative day. Since the surgery was performed under local anesthesia, the patient was sedated with pethidine and promethazine intramuscularly as per body weight.

Surgical procedure

The patient was given 5–10 ml of 2% Xylocaine with 1:200,000 adrenalin as per the approach selected for four-quadrant canal wall block and on the tragus. The rigid Hopkins II endoscope (Karl Storz) 0° and 30° with 4-mm diameter and 18 cm in length was passed through the transcanal route to observe and assess the perforation, ossicular chain status, middle ear mucosa, and also the eustachian tube orifice. The margin of perforation was refreshened with the straight needle as shown in [Figure 1].{Figure 1}

When the handle of the malleus was visible, it was well skeletonized. The size of the graft was measured with a round knife. For harvesting the graft, about 2 cm vertical incision was given by number 15 scalpel from the incisura terminalis up to the intratragal notch which was around 5 mm medial to the tip of the tragus as shown in [Figure 2]. The single stroke skin incision was given up to the tragus cartilage. The assistant held the tissue of the tip of the tragus by nontooth forceps and cleared the surgical field from blood by suction. Whereas the operating surgeon held the skin with nontooth forceps, and then, the canal side cartilage along with the perichondrium was dissected with tympanoplasty scissor taking precaution of not penetrating the canal skin. Similarly, cartilage along with the perichondrium from the anterior aspect of tragal cartilage was dissected and made free at the incisura terminalis. The cartilage along with the perichondrium was excised with number 15 scalpel giving incision from the incisura terminalis. The skin was closed with 4/0 prolene interrupted suture.{Figure 2}

The graft was then kept on the silastic block. The perichondrium on the lateral side of the graft was elevated with part of the perichondrium left intact on the central part of cartilage, whereas the medial perichondrium was left as such to avoid curling of cartilage as shown in [Figure 3].{Figure 3}

Apart from that, the area of cartilage was removed to make place for the handle of the malleus and incudostapedial joint. The cartilage graft was then placed around the perforated tympanic membrane by first inserting on the anterior end of perforation by mounting on the crocodile forceps as shown in [Figure 4].{Figure 4}

Then, the rest of the cartilage was placed in the middle ear with a straight needle. The elevated perichondrium covers the later end of the tympanic membrane around the perforation thus making the tympanic membrane sandwich between the perichondrium laterally and cartilage with perichondrium medially as shown in [Figure 5] and [Figure 6]. The canal was then packed with wet gelatin sponge soaked in ciprofloxacin ear drops and followed by the ribbon pack medicated with Soframycin was kept in the canal, and the bandage was applied on the canal only.{Figure 5}{Figure 6}

Surgical video = fh5uRhkjWD4.

Postoperative care and follow -up

The patient was prescribed tablet ciprofloxacin 500 mg 12 hourly for 7 days. The ribbon gauge pack and the stitch were removed on the 7th postoperative day. The remaining gelatin sponge was also suctioned on the 7th postoperative day. Then, the patient was prescribed chloramphenicol and dexamethasone ear drops for 6 weeks. The patient was again followed up after 6 weeks and 12 months [Figure 7]. The hearing results and graft uptake rate noted on 12 months of follow-up.{Figure 7}

Statistical analysis

For the statistical data analysis, ENT statistics (Otology Module) software Client Version:, Pro edition, normal model with DB version: ENT statistics DBIII-3. 0-492 from INNOFORCE creative solutions, Liechtenstein, 2019, was used. The significance of difference between two groups was evaluated using the Student's t-test. The significance level for all tests was set at P < 0.05.


There were a total of 45 patients with 45 ears enrolled in the study. Among them, three cases had perforated tympanic membrane because of infection, and hence, only 42 patients were included in the study.

The graft uptake rate was 93.3% in a 1-year follow-up period. We had not found any cholesteatoma or myringitis of graft during the follow-up period.

Regarding the age distribution, it ranges from 18 to 55 years with 26.1 ± 10.7 years. Regarding the gender distribution, 22 were female and 20 were male with a male-to-female ratio of 1:1.1.

Comparison of pre- and post-operative ABG is shown in [Table 1], with a statistically significant improvement in the postoperative period.{Table 1}

The ABG closure is more within 0–20 dB as shown in [Table 2].{Table 2}


This study mainly focuses on the surgical outcome and audiological results following endoscopic sandwich myringoplasty with our own D-HOS technique in 42 patients.

In this sandwich myringoplasty, we did the modification with elevated perichondrium cover the later end of the tympanic membrane, whereas intact cartilage with perichondrium lies medial to perforation thus making the tympanic membrane sandwich between perichondrium laterally and cartilage with perichondrium medially.

Although there are different methods of performing myringoplasty (either microscopic or endoscopic), the endoscope provide good visualization of the anterior end of perforation and 360° view of perforated tympanic membrane as compared to the microscope, and hence the graft can be easily placed using endoscope in our D-HOS technique.[9],[10]

The main disadvantages with the use of endoscope are; one hand technique, absence of stereoscopic view, potential risk of mechanical and thermal trauma, and along with that the learning curve is also an important factor as seen in sinonasal and skull base surgery.[10],[11],[12],[13],[14]

Regarding the hearing outcome after myringoplasty, the study showed that it depends largely on the incorporation of the graft to the tympanic membrane, the integrity of the ossicular chain, absence of any residual perforation and also the absence of graft medialization or lateralization. Hence, it is irrespective of either endoscopic or microscopic method.[9]

We have used the tragal cartilage graft, as the clinical and experimental study showed that the cartilage is well tolerated with minimal resorption time and survives for a long period with good hearing outcome.[15],[16],[17],[18],[19]

There were different methods of cartilage tympanoplasty popular for the grafting procedure such as island technique, wheel technique, inlay butterfly technique, shield technique, and palisade technique.[20],[21] This butterfly cartilage technique was first described by Eavey for small-to-medium perforation.[6] Similarly, Rourke et al. and Ghanem et al. modified this technique to repair the large perforation.[7],[22]

We did the same technique but with the modification keeping both sides of perichondrium intact and named it as a sandwich myringoplasty D-HOS technique. We had kept the perichondrium intact on both sides because the study showed that cartilage with perichondrium on one or both sides had better viability (better metabolism and strong enzymatic reaction) than naked cartilage.[23]

The main advantages of endoscopic sandwich myringoplasty are less time-consuming, more comfortable technique as no need to raise the tympanomeatal flap, the sandwiching of perforated tympanic membrane margin maintained the graft position without support from the middle or the external ear canal and the oozing practically nonexistent.[23]

The disadvantage of the technique is relatively difficult for beginners, endoscopic sandwich myringoplasty requires precise evaluation of the perforation size and shape, meticulous preparation of the edges, and exact sizing of the graft with precisely raise the perichondrium flap to make island at the center of cartilage, learning curve while using the endoscope as it is a one-hand technique; furthermore, if there are not any enough membrane remnants in the edges of perforation such as annular perforations, it is difficult to perform the procedure; and finally, theoretical disadvantages of cartilage is that it makes an opaque tympanic membrane, which could potentially hide disease in the middle ear.[22]

Another theoretical disadvantage could be the possibility of a superficial layer of the tympanic membrane to migrate to the middle ear through the medial side of the perichondrial layer which covers the perforated rim of the tympanic membrane, but we did not observe any iatrogenic cholesteatoma in the present study during 12 months follow-up period. Similarly, previous studies did not report any cholesteatoma related with butterfly tympanoplasty.[6],[23],[24] Hence, it is a reliable method in this regard. However, long-term follow-up (5–10 years) may be required to know about the clue regarding the appearance and generation of cholesteatoma.

The graft uptake rate in this study is comparable to the results in the literature as shown in [Table 3]. The graft uptake rate in this study was 93.3%, which is comparable to another study performed by endoscopically which showed success rate from 73% to 96% as shown in [Table 3].[25],[26],[27],[28],[29],[30],[31],[32]{Table 3}

Regarding the audiological results, different studies reported postsurgical decrease in the air-bone gap in butterfly cartilage tympanoplasty. Özgür et al. reported that mean air-bone gain was 9.4 dB on postoperative 6th month for an adult group who had endoscopic butterfly inlay myringoplasty.[30] Likewise, Kaya et al. studied long-term results of microscopic butterfly cartilage tympanoplasty group and showed that mean air conduction differed between the postoperative 6th month and postoperative 24th month.[33] A study performed by Karabulut et al. showed that the mean preoperative ABG was 24.2 ± 3.8 dB, the mean ABG on the 12th postoperative month was 17.1 ± 3.5 dB, and the mean ABG on the 24th postoperative month was 12.4 ± 3.1 dB.[34]

In this study, the mean preoperative ABG was 27.3 ± 12.5 dB, the mean postoperative ABG on the 12th month follow-up was 17.1 ± 8.5 dB with statistically significant results. Hence, our audiological results are comparable with the above studies and also with other different studies.[25],[26],[27],[28],[29],[30],[31],[32],[33],[34]

This study showed that the ABG closure within 30 dB in 100% of cases and within 20 dB in 71.4% of cases which is also comparable with different studies.[25],[26],[27],[28],[29],[30],[31],[32]

The good hearing results in this study could be because of; a modification in such a way that only perichondrium lies at the handle of the malleus and at incudostapedial joint whenever visible, this could be the reason for good hearing because of better conduction of sound.

The main limitation of this study is as follows:

Sample sizeDuration of study.


Endoscopic sandwich myringoplasty with D-HOS technique is a safe procedure with the high-graft uptake rate and good long-term hearing results. Apart from that, the cosmesis is good as there is no retroauricular or endaural incision. Hence, it is advised to perform our technique without any difficulty.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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