Traumatic Tympanic Membrane Perforation in Children: A Descriptive Cross-sectional Study.

INTRODUCTION:   TTraumatic perforation of the tympanic membrane in pediatric population is often encountered in primary  otolaryngologic clinics or in the emergency department. The objective of the  study was to find out the clinical presentation of traumatic tympanic membrane perforation in the pediatric population. METHODS: A cross-sectional study was done from February, 2023 to February, 2024 after obtaining the ethical approval from the Institutional Review Board (2023/114). All the patients aged less than 18 years and presenting with traumatic tympanic membrane perforation were included in the study. Collected data was entered and analysed using Microsoft Excel. Patients were evaluated for demographics, mechanism of trauma and clinical characteristics of ear drum perforation in children. RESULTS: A total of 384 children aged less than 18 years were included in the study among which 267 (69.53%) were males. Physical assault 109 (28.39%) was the most common cause of tympanic membrane perforation. The most common symptom at the time of presentation was ear block/hearing loss 208 (54.16%). Conductive hearing loss was present in 214 (55.73%) children. CONCLUSION: Traumatic perforation of the tympanic membrane resulted mostly from the blunt force trauma especially in male children.

Chronic suppurative otitis media.

Chronic suppurative otitis media (CSOM) is a leading global cause of potentially preventable hearing loss in children and adults, associated with socioeconomic deprivation. There is an absence of consensus on the definition of CSOM, which complicates efforts for prevention, treatment, and monitoring. CSOM occurs when perforation of the tympanic membrane is associated with severe or persistent inflammation in the middle ear, leading to hearing loss and recurrent or persistent ear discharge (otorrhoea). Cholesteatoma, caused by the inward growth of the squamous epithelium of the tympanic membrane into the middle ear, can also occur. The optimal treatment of discharge in CSOM is topical antibiotics. In resource-limited settings where topical antibiotics might not be available, topical antiseptics are an alternative. For persistent disease, surgery to repair the tympanic membrane or remove cholesteatoma might offer long-term resolution of otorrhoea and potential improvement to hearing. Recent developments in self-fitted air-conduction and bone-conduction hearing aids offer promise as new options for rehabilitation.

Surgical management of secondary acquired cholesteatoma depends on its characteristics.

OBJECTIVE: Cholesteatoma secondary to tympanic perforation, known as "secondary acquired cholesteatoma" may progress slower than a retraction pocket cholesteatoma, with less bone destruction and fewer intracranial complications. However, complete surgical removal remains difficult because the pathological epithelium on the marginal side of the extension is not covered by the subepithelial layer of the cholesteatoma matrix, making the boundary with the middle ear mucosa difficult to identify. Therefore, considering the pathophysiology of secondary acquired cholesteatoma, suitable preoperative evaluation and surgical techniques are required. In this study, we aimed to evaluate (i) the extension of secondary acquired cholesteatoma according to the size and location of tympanic membrane perforation; and (ii) the microscopic surgical outcomes, including the rate of residual cholesteatoma, requirement for specialized surgical management, and changes in hearing. METHODS: This retrospective study included data of cases with secondary acquired cholesteatoma (n = 66; 66 ears of 64 patients, 2 patients had bilateral ear involvement), including those who underwent a staged operation (n = 25). RESULTS: The perforation level of the tympanic membrane was associated with the cholesteatoma extension. When the cholesteatoma extended around the stapes, staged operation was chosen. Six cases of spontaneous resolution of stapes lesions at the time of staged surgery were observed. A significant postoperative improvement in hearing was observed; however, five cases experienced sensorineural hearing loss. CONCLUSION: Surgery, including staged surgery of the stapes lesions, along with careful observation of the perforation, is required in secondary acquired cholesteatoma. For lesions that are visible yet challenging to remove, it is imperative to exercise prudent judgment, taking into account the possibility of spontaneous resolution.

Does the Location of a Small Tympanic Membrane Perforation Affect the Degree of Hearing Loss in Adult Patients with Inactive Mucosal Chronic Suppurative Otitis Media?

BACKGROUND: Tympanic membrane perforation due to inactive mucosal chronic suppurative otitis media is a common problem in otolaryngology, with consequent conductive hearing loss. Still, there is controversy about the relationship between the location of the tympanic membrane perforation and the degree of hearing impairment. AIM OF THE STUDY: To assess the correlation between the location of a small tympanic membrane perforation and the degree of conductive hearing loss in adult patients with inactive mucosal chronic suppurative otitis media. PATIENTS AND METHODS: A prospective cross-sectional study enrolled 74 adult patients with small tympanic membrane perforations (perforation involves less than one quadrant of the tympanic membrane) and conductive hearing loss (airbone gap ≥ 20 dB HL) due to inactive mucosal chronic suppurative otitis media for at least 3 months. The locations of the tympanic membrane perforations were classified as anterosuperior, anteroinferior, posterosuperior, and poster inferior perforations. Audiometric analysis and a CT scan of the temporal bone were done for all patients. The means of the air and bone conduction pure tone hearing threshold averages at frequencies 500, 1000, 2000, and 4000 Hz were calculated, and consequently, the air-bone gaps were calculated and presented as means. The ANOVA test was used to compare the means of the air-bone gaps, and the Scheffe test was used to determine if there were statistically significant differences regarding the degree of conductive hearing loss in relation to different locations of the tympanic membrane perforation. RESULTS: The ages of the patients ranged from 20 to 43 years (mean = 31.9 ± 6.5 years), of whom 43 (58%) were females and 31 (42%) were males. The means of the air-bone gaps were 32.29 ± 5.41 dB HL, 31.34 ± 4.12 dB HL, 29.87 ± 3.48 dB HL, and 29.30 ± 4.60 dB HL in the posteroinferior, posterosuperior, anteroinferior, and anterosuperior perforations, respectively. Although the air-bone gap's mean was greater in the posteroinferior perforation, statistical analysis showed that it was insignificant (P-value=0.168). CONCLUSION: In adult patients with inactive chronic suppurative otitis media, the anteroinferior quadrant is the most common location of the tympanic membrane perforation, and there was an insignificant correlation between the location of a small tympanic membrane perforation and the degree of conductive hearing loss.

A systematic review of otologic injuries sustained in civilian terrorist explosions.

PURPOSE: Determine the prevalence of otological symptoms and tympanic membrane perforation, healing rates of tympanic membrane perforation with surgical and conservative management, and hearing function in civilian victims of terrorist explosions. METHODS: A systematic review was conducted with searches on Medline, Embase, EMCare and CINAHL for publications between the 1st January 1945 and 26th May 2023. Studies with quantitative data addressing our aims were included. This review is registered with PROSPERO: CRD42020166768. Among 2611 studies screened, 18 studies comprising prospective and retrospective cohort studies were included. RESULTS: The percentage of eardrums perforated in patients admitted to hospital, under ENT follow up and attending the emergency department is 69.0% (CI 55.5-80.5%), 38.7% (CI 19.0-63.0%, I2 0.715%) and 21.0% (CI 11.9-34.3%, I2 0.718%) respectively. Perforated eardrums heal spontaneously in 62.9% (CI 50.4-73.8%, I2 0.687%) of cases and in 88.8% (CI 75.9-96.3%, I2 0.500%) of cases after surgery. Common symptoms present within one month of bombings are tinnitus 84.7% (CI 70.0-92.9%, I2 0.506%), hearing loss 83.0% (CI 64.5-92.9%, I2 0.505%) and ear fullness 59.7% (CI 13.4-93.4%, I2 0.719). Symptomatic status between one and six months commonly include no symptoms 57.5% (CI 46.0-68.3%), hearing loss 35.4% (CI 21.8-51.8%, I2 0.673%) and tinnitus 15.6% (CI 4.9-40.0%, I2 0.500%). Within one month of bombings, the most common hearing abnormality is sensorineural hearing loss affecting 26.9% (CI 16.9-40.1%, I2 0.689%) of ears 43.5% (CI 33.4-54.2%, I2 0.500) of people. CONCLUSION: Tympanic membrane perforation, subjective hearing loss, tinnitus, ear fullness and sensorineural hearing loss are common sequelae of civilian terrorist explosions.

Comparison of perichondrium-cartilage button technique and traditional over-underlay technique for repairing large perforations.

OBJECTIVE: This study was performed to compare the operation time, graft outcomes and complications between the endoscopic cartilage-perichondrium button technique and over-under technique for repairing large perforations. METHODS: A total of 52 chronic large perforations were randomly allocated to receive treatment using the endoscopic cartilage-perichondrium button technique (n = 26) or over-under technique (n = 26). The graft outcomes, mean operation time and post-operative complications were compared between the two groups at 12 months. RESULTS: The study population consisted of 52 patients with unilateral chronic large perforations. All patients completed 12 months of follow up. The mean operation time was 32.3 ± 4.2 minutes in the button technique group and 51.6 ± 2.8 minutes in the over-underlay technique group (p < 0.01). The graft success rate at 12 months was 92.3 per cent (24 out of 26) in the button technique group and 96.2 per cent (25 out of 26) in the over-underlay group (p = 0.552). CONCLUSION: The endoscopic cartilage-perichondrium button technique had similar graft success rates and hearing outcomes for large chronic perforations to the over-under technique, but significantly shortened the mean operation time.

Comparison of two endoscopic perichondrium-cartilage graft underlay myringoplasty for large perforations: a randomized controlled trial.

OBJECTIVE: The objective of this study was to compare the graft outcomes and complications of two endoscopic perichondrium-cartilage graft techniques for repairing large perforations. STUDY DESIGN: Single center blinded randomized controlled trial. MATERIALS AND METHODS: 61 large perforations more than 50% of TM area were prospectively randomized to undergo the free perichondrium and free cartilage graft group (FPFC, n = 31) or perichondrium partial attachment the cartilage graft group (PPAC, n = 30). The primary outcome measures were the operation time; secondary outcome measures were the graft success rate and hearing gain at 12 months postoperatively and postoperative complications. RESULTS: All patients completed follow-up of 12 months. The mean operation time was 38.2 ± 2.3 min in the FPFC group and 37.4 ± 5.6 min in the PPAC group (P = 0.658). At postoperative 3 months, the graft success rates were 96.7% in the FPFC group and 93.3% in the PPAC group (P = 0.976). At postoperative 12 months, the graft success rates were 96.7% in the FPFC group and 83.3% in the PPAC group (P = 0.182). However, the residual and re-perforation rate with no infection was 0.0% (0/31) in the FPFC group and 16.7% (5/30) in the PPAC group (P = 0.056). No significant between-group differences were observed pre- (P = 0.842) or post- (P = 0.759) operative air bone gap (ABG) values or mean ABG gain (P = 0.886). However, granular myringitis has been noted in 6.5% in the FPFC group and in 3.3% in the PPAC group. CONCLUSIONS: This study suggested that 12-month graft success and hearing gain were comparable between the perichondrium free and partial attachment the cartilage graft techniques, nevertheless, partial attachment technique could increase residual and re-perforations.

Outcomes of perichondrium graft covering the epithelium of the tympanic membrane for large-sized perforations: A 3-5-year follow-up study.

OBJECTIVE: The objective of this study was to evaluate the graft outcomes and iatrogenic cholesteatomas for 3 years following cartilage-perichondrium over-underlay technique with perichondrial graft covering the epithelium for large-sized tympanic membrane (TM) perforations. MATERIALS AND METHODS: This prospective case series enrolled patients with large-sized perforation who underwent endoscopic cartilage-perichondrium over-underlay technique. The graft success rate, hearing outcomes, and development of iatrogenic middle ear cholesteatomas and graft cholesteatomas were assessed at 3 years postoperatively. RESULTS: This study included 62 ears of 62 patients. The mean follow-up duration was 47.3 ± 10.8 (38-64) months. Neovascularization was observed in the lateral perichondrium graft in 55 (88.7 %) patients, which inosculated into the TM remnant at 4-5 weeks. However, graft neovascularization was not observed in the four patients with excessive perichondrium graft that migrated into the external auditory canal and the three patients with middle ear infections. The graft failure rate was 6.5 % at 6 months, 11.3 % at 12 months, 6.5 % at 24 months, and the overall graft success rate was 91.8 % at the last follow-up. Granular myringitis developed in 11.3 % (7/62) of the patients. High-resolution computed tomography revealed well-pneumatized mastoids and middle ear at the final follow-up. However, graft cholesteatomas were observed in 3 (4.8 %) patients at 7-24 months postoperatively. CONCLUSIONS: The cartilage-perichondrium over-underlay technique with perichondrial graft covering TM epithelium is safe and effective for the repair of large perforations, with good short- and long-term graft outcomes, minimal risk of graft cholesteatoma development, and no risk of iatrogenic middle ear cholesteatomas.

Comparative study of fibroblast growth factor 2 and ofloxacin ear drops for repairing large traumatic perforations: A randomized controlled study.

OBJECTIVE: The objective of this study was to compare the healing outcome of fibroblast growth factor 2 (FGF2), ofloxacin ear drops (OFLX) and spontaneous healing for repairing large traumatic tympanic membrane (TM) perforations. MATERIAL AND METHODS: A total of 75 traumatic large perforations with >1/4 of TM were randomly divided into FGF2 (n = 25), OFLX (n = 25), and spontaneous healing (n = 25) groups. The closure rates, closure times, and hearing gains were compared at 3 months. RESULTS: At 2 weeks after treatment, the closure rate was 95.8 % in the FGF2 group, 96.0 % in the ofloxacin ear drops group, and 14.3 % in the spontaneous healing group (P < 0.01), respectively. At 3 months after treatment, the closure rate was 100 % in the FGF2 group, 100 % in the OFLX group, and 85.7 % in the spontaneous healing group, no among-group differences were significant (P > 0.05). The mean closure time was 9.69 ± 2.46 days in the FGF2 group, 9.45 ± 2.32 days in the OFLX group, and 30.94 ± 8.95 days in the spontaneous healing group (P < 0.01). The mean ABG was 10.37 ± 2.51 dB for the FGF2 group, 11.01 ± 1.31 dB for the OFLX group, and 10.86 ± 1.94 dB for the spontaneous healing group, no significant difference was found among three groups (P > 0.05). CONCLUSIONS: This study suggested that both FGF2 and OFLX significantly shortened the mean closure time and improved the closure rate compared with spontaneous healing for repairing large traumatic perforations, while the healing outcome wasn't significantly different among FGF2 and OFLX groups.

Comparison of perichondrium-cartilage double and single underlay myringoplasty for subtotal perforations: a randomized controlled trial.

OBJECTIVE: The objective of this study was to compare graft outcome, operation time and surgical complications of the double and single perichondrium-cartilage underlay techniques for repairing subtotal tympanic membrane (TM) perforations. MATERIALS AND METHODS: Patients with unilateral subtotal perforations undergoing myringoplasty were prospectively randomized to undergo DPCN or SPCN. The operation time, graft success rate, audiometric outcomes, and complications were compared between these groups. RESULTS: In total, 53 patients with unilateral subtotal perforations were included (DPCN group, 27; SPCN group, 26).All patients completed 6 months of follow-up. The mean operation time was 41.2 ± 1.8 min in the DPCN group and 37.2 ± 5.4 min in the SPCN group, the difference was not significant (p = 0.613).The graft success rates were 96.3% (26/27) in the DPCN group and 73.1% (19/26) in the SPCN group, the difference was significant (p = 0.048). During the period of follow-up, residual perforation was found at postoperative in one (3.7%) in the DPCN group, while cartilage graft slipped (graft lateralization) in 2 (7.7%) and residual perforation in 5 (19.2%) were found in the SPCN group, the difference of residual perforation was not significant among two group (p = 0.177).In addition, no significant between-group differences were observed pre- (p = 0.741) or post- (p = 0.687) operative ABG values or mean ABG gain (p = 0.659) (Table 2).The functional success rates (postoperative ABG ≤ 20 dB) were 85.2% (23/27) in the DPCN group and 73.1% (19/26) in the SPCN group (p = 0.454). CONCLUSION: Although similar functional result and operation time can be obtained with double perichondrium-cartilage underlay technique compared to the single perichondrium-cartilage underlay technique for endoscopic closure of subtotal perforations, double unerlay technique offers better anatomical result with minimum complications.

Inhibition of TGF-ß signaling enables long-term proliferation of mouse primary epithelial stem/progenitor cells of the tympanic membrane and the middle ear mucosa.

The surface of the middle ear is composed of the tympanic membrane (TM) and the middle ear mucosa (MEM). A number of diseases and conditions such as otitis media, middle ear cholesteatoma, and perforation of the TM have been reported to cause dysfunction of the middle ear, ultimately leading to high-frequency hearing loss. Despite its importance in repairing the damaged tissues, the stem/progenitor cells of the TM and the MEM epithelia remains largely uncharacterized due, in part, to the lack of an optimal methodology to expand and maintain stem/progenitor cells long-term. Here, we show that suppression of TGF-ß signaling in a low Ca2+ condition enables long-term proliferation of p63-positive epithelial stem/progenitor cells of the TM and the MEM while avoiding their malignant transformation. Indeed, our data show that the expanded TM and MEM stem/progenitor cells respond to Ca2+ stimulation and differentiate into the mature epithelial cell lineages marked by cytokeratin (CK) 1/8/18 or Bpifa1, respectively. These results will allow us to expand epithelial stem/progenitor cells of the TM and MEM in quantity for large-scale analyses and will enhance the use of mouse models in developing stem cell-mediated therapeutic strategies for the treatment of middle ear diseases and conditions.

Factors influencing successful reconstruction of tympanic membrane perforations: a systematic review and meta-analysis.

PURPOSE: Based on a systematic review and meta-analysis, our study aimed to provide information about the factors that influence the success of tympanic membrane reconstruction. METHODS: Our systematic search was conducted on November 24, 2021, using the CENTRAL, Embase, and MEDLINE databases. Observational studies with a minimum of 12 months of follow-up on type I tympanoplasty or myringoplasty were included, while non-English articles, patients with cholesteatoma or specific inflammatory diseases, and ossiculoplasty cases were excluded. The protocol was registered on PROSPERO (registration number: CRD42021289240) and PRISMA reporting guideline was used. Risk of bias was evaluated with the QUIPS tool. A random effect model was used in the analyses. Primary outcome was the rate of closed tympanic cavities. RESULTS: After duplicate removal, 9454 articles were found, of which 39 cohort studies were included. Results of four analyses showed significant effects: age (OR: 0.62, CI 0.50; 0.78, p value: 0.0002), size of the perforation (OR: 0.52, CI 0.29; 0.94, p value: 0.033), opposite ear condition (OR: 0.32, CI 0.12; 0.85, p value: 0.028), and the surgeon's experience (OR: 0.42, CI 0.26; 0.67, p value: 0.005), while prior adenoid surgery, smoking, the site of the perforation, and discharge of the ear did not. Four factors: etiology, Eustachian tube function, concomitant allergic rhinitis, and duration of the ear discharge were analyzed qualitatively. CONCLUSIONS: The age of the patient, the size of the perforation, the opposite ear status, and the surgeon's experience have a significant effect on the success of tympanic membrane reconstruction. Further comprehensive studies are needed to analyze the interactions between the factors. LEVEL OF EVIDENCE: Not applicable.

Intratympanic membrane cholesteatoma after traumatic tympanic membrane perforation: a case report.

BACKGROUND: Intratympanic membrane cholesteatoma presents as an asymptomatic, white, round mass on the tympanic membrane, and is usually detected incidentally in children. CASE PRESENTATION: A 12-year-old Korean boy visited our otorhinolaryngology clinic for a whitish mass on the right tympanic membrane. He had a history of traumatic tympanic membrane perforation in the right ear that had occurred 1 year prior, which had healed well with a paper patch placement. The mass was completely removed under local anesthesia during surgery with a microscope. The mass was on the outer epithelial layer of the right tympanic membrane and did not invade the middle fibrous and inner mucosal layers. Cholesteatoma was diagnosed on the basis of histopathology. CONCLUSION: Intratympanic membrane cholesteatoma may not induce symptoms or invade the middle ear because it can grow outwards into the external auditory canal. However, intratympanic membrane cholesteatoma can grow over time, and then after growth, it can compress the tympanic membrane and advance into the middle ear, which can cause symptoms such as hearing loss. Intratympanic membrane cholesteatoma in children should be carefully evaluated and followed, and surgical removal should be considered, even for asymptomatic cases, to minimize potential damage and hearing loss.

[Blast and explosion traumas-effects on the middle and inner ear based on the example of Bundeswehr foreign missions]. / Knall- und Explosionstraumata ­ Auswirkungen auf Mittel- und Innenohr am Beispiel von Auslandseinsätzen der Bundeswehr.

Despite all protective measures, blast and explosion traumas are a frequent pattern of injury in Bundeswehr missions abroad. Due to body protection measures, head injuries, particularly of the ears, are higher in number compared to injuries in other regions of the body. Perforations of the tympanic membrane are the most frequent lesions of the middle ear, acute sensorineural hearing loss is the most frequent lesion of the inner ear, often accompanied by tinnitus and dizziness. With a high spontaneous recovery rate, prompt specialist care for these injuries is provided according to medical standards comparable to those in the home country.

The impact of adding platelet-rich plasma during fat graft myringoplasty for managing medium-sized tympanic membrane perforations: A prospective randomized case-control study.

PURPOSE: This study aimed to evaluate the effect of adding platelet-rich plasma (PRP) during FGM to close medium-sized TM perforations. METHODS: This prospective randomized case-control study was conducted from February 2017 to March 2022. We included 320 patients with a medium-sized TM perforation with inactive mucosal otitis media. Transcanal FGM managed all patients under general or local anesthesia according to the patient preference. According to PRP, patients were divided into two groups: the first with PRP (170 patients) and the other without PRP (150 patients). We evaluated the closure rate of both groups one month, six months, and one year after the surgery. Also, we assessed the audiological performance before and one year after the operation for the patients with a successful closure. RESULTS: The closure rate was 87.6 % in the first group and 72.7 % in the second group, with a statistically significant difference between both groups as the P-value, was 0.001. Successful closure of the ABG to <10 dB occurred in 95.3 % of group A and 90.8 % of group B without a statistically significant difference between both groups (P-value = 0.163). CONCLUSIONS: This prospective comparative study on a relatively large number of patients revealed that FGM effectively closed medium-sized TM perforations. It also significantly improved postoperative audiological performance in both groups. Adding PRP during the FGM enhanced the closure success and the healing process without recorded complications. We recommend using the PRP in the routine FGM for closing medium-sized TM perforations.

General anaesthetic vs local anaesthetic myringoplasties: a systematic review and meta-analysis.

AIMS: To assess all available data and determine the success rates and tolerability of local anaesthetic myringoplasty in comparison with those undertaken under general anaesthetic myringoplasty. MATERIALS AND METHODS: The study was designed following a PRISMA-P protocol and registered with the PROSPERO database. MEDLINE, Cochrane Library (CDSR/Central), EMBASE and CINHAL-were directly searched for studies, which met the inclusion criteria. OBJECTIVES: Primary objective was to compare perforation closure rates between patients undergoing myringoplasty under local anaesthetic and those under general anaesthetic from all available published data. Secondary outcomes include complications, such as 'any minor complications', infection rates in the first 6 month post-op, facial nerve weakness, dysgeusia and patient satisfaction. RESULTS: 27 studies were included in the final analysis and found that myringoplasty had an overall perforation closure rate of 89%. The pooled proportion of closures after myringoplasty under local anesthesia was 87% and for myringoplasties under general anesthesia was 91%. Analysis of myringoplasty under local anaesthesia focusing on 'in-office' performed procedures only, found a closure rate of 88%. CONCLUSIONS: There is no significant difference in the success rate of myringoplasty surgery when performed under local or general anaesthetic as measured by perforation closure rates. However, there are other factors, which can drive choosing local anaesthetic surgery, such as minimising anaesthetic risks, reducing costs and reducing environmental impact.

Trans-canal tragal cartilage myringoplasty; a comparative analysis of endoscopic and microscopic approaches.

BACKGROUND: The advent of Endoscopic Ear Surgery (EES) has allowed otologists an improved view of the surgical field compared with conventional Microscopic Ear Surgery (MES). EES presents different challenges for surgeons and a learning curve is necessary. AIMS: The purpose of this study was to compare the efficacy of EES and MES for trans-canal tragal cartilage myringoplasty, an entry level EES. METHODS: We retrospectively analysed patients who underwent push through trans-canal tragal cartilage myringoplasty in our institution over 5 years (2016-2020). Exclusion criteria were: patients with prior ear surgery, non-tragal cartilage tympanic membrane graft, additional procedure at time of surgery and patients with insufficient follow up. EES and MES groups were compared using outcomes such as graft success rate, changes in pure tone audiometry (PTA), operative time and complications. RESULTS: Seventy-four patients met inclusion criteria (MES = 38, EES = 36). Mean age of included patients was 29.3 years with no significant demographic differences between groups. Graft success rate at 12 months was higher among the EES group versus MES (94.4% v 86.8%, p = 0.43). Mean operative time was reduced in the EES group (47.3 min v 53.8 min, p = 0.04). Hearing outcomes did not differ significantly between groups. No major operative complications occurred in either group. CONCLUSIONS: Outcomes were marginally better in the cohort who underwent EES. This supports that EES offers an otologic choice to complement established practice for trans-canal myringoplasty and may be used to facilitate introduction to EES for trainees and otologists wishing to learn this technique.