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Audiological Outcome Following Type III Tympanoplasty in Canal Wall Down Mastoidectomy
*Corresponding author: Roopashree Selvan, Department of Otorhinolaryngology, Silchar Medical College and Hospital, Silchar, 788014, Assam, India. rupaselvan4@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Selvan R, Bhattacharjee A, Dutta SR. Audiological Outcome Following Type III Tympanoplasty in Canal Wall Down Mastoidectomy. Ann Otol Neurotol. 2026;7:4. doi: 10.25259/AONO_21_2025
Abstract
Objectives:
Chronic suppurative otitis media (CSOM) is a condition that gets worse over time and is triggered by persistent damage to the middle ear mucosa as well as mastoid air cells. The common surgical approach in chronic otitis media with cholesteatoma is “canal wall-down mastoidectomy”. Our study's objective is to determine the extent to which patients undergoing type III Tympanoplasty can improve their hearing. To assess audiological outcome in patients undergoing “canal wall-down mastoidectomy” with type III Tympanoplasty and Ossicular reconstruction.
Material and Methods:
This is a prospective study of patients attending the outpatient department of Otorhinolaryngology at Silchar Medical College and Hospital for surgical treatment of CSOM over a period of 1year. A total of 60 cases of CSOM who underwent “canal wall-down mastoidectomy” with type III Tympanoplasty were included in our study. Depending on the ossicular status, we used autologous grafts for ossicular reconstruction. Pure tone audiometry evaluated the post-operative hearing improvement in patients on average 3 months after surgery.
Results:
In 60 patients, the mean preoperative air conduction (AC) threshold, bone conduction (BC) threshold, and air bone gap (ABG) were 58.91 (±9.45) decibel (dB), 16.58 (±5.54) dB, and 42 (≤72) dB, respectively. The mean postoperative AC threshold was 405.8 (±11.29) dB, the mean postoperative BC was 16.58 (±5.52) dB, and the mean postoperative ABG was 24 (±10.96) dB. A statistically significant increase in hearing was observed (p = 0.001).
Conclusion:
Type III Tympanoplasty with “canal wall-down mastoidectomy” helps in the eradication of the disease and enables hearing reconstruction.
Keywords
Chronic otitis media
Canal wall down mastoidectomy
Type III tympanoplasty
INTRODUCTION
Chronic suppurative otitis media (CSOM) is a serious global health concern that persists in the modern day, despite the introduction of various antimicrobials and improvements in knowledge about the pathophysiology of the disease. Hearing impairment, especially in children, is the major factor that makes CSOM a significant global problem. This is due to its enduring negative impact on language and speech, communication skills, and intelligence development. CSOM is a condition that gets worse over time and is triggered by persistent damage to the middle ear mucosa as well as mastoid air cells.1
It is one of the most common diseases dealt with by ear, nose, throat (ENT) surgeons; the prevalence in India ranges between 4 and 33%.2
Overcrowding, inadequate housing, inadequate health care, poor hygiene, and extreme climatic conditions have all contributed to the disease's high rates.3
CSOM is divided into tubotympanic (or safe type) and atticoantral (or unsafe type), and both lead to significant hearing loss.4
The main pathology associated with the atticoantral type is cholesteatoma, which is usually seen in cases with attic or posterosuperior marginal perforation. The middle ear cleft is typically lined with ciliated columnar epithelium in the anterior and inferior regions, while it is cuboidal in the middle region and pavement-like in the attic region. However, cholesteatoma is lined by stratified squamous epithelium containing keratin debris resting on a fibrous stroma of varying thickness, potentially causing life-threatening complications due to its bone-eroding nature.5
The main goal of the operation for CSOM is to clear the infection and reestablish auditory function. One of the most difficult surgical procedures in the field of otology still remains the clearing of middle-ear cholesteatomas. The common surgical approach to attain this goal in CSOM with cholesteatoma is “canal wall-down mastoidectomy.” This procedure allows for excellent disease visualization and complete removal with minimal recurrence. The common indications are recurrent cholesteatoma, extensive attic cholesteatoma, and localized chronic otitis media. In addition to this, procedures like tympanoplasty and ossiculoplasty enable hearing reconstruction with good hearing outcomes.
In our study, type III tympanoplasty was done for hearing improvement. The outcome of type III tympanoplasty is dependent on variables such as the condition of the ossicles and the extent of the disease's pathology. In “canal wall-down mastoidectomy” without reconstruction, along with complete disease clearance, there is loss of ossicles that leads to postoperative hearing loss. The type of ossicular reconstruction is determined during the procedure based on the extent of ossicular loss and the condition of the middle ear. Type III tympanoplasty, also known as myringo-stapidopexy, provides a shallow middle ear and a columella effect.6
The outcome of tympanoplasty is dependent upon the degree of hearing improvement and the success of graft-take. The type of ossicular reconstruction depends on the presence of the stapes superstructure.
As canal wall-down mastoidectomy gives a better chance of complete disease clearance, hearing improvement using different ossicular reconstruction techniques assumes importance. The objective of our study is to assess the audiological outcome in patients undergoing “canal wall-down mastoidectomy” with type III tympanoplasty and ossicular reconstruction.
MATERIAL AND METHODS
This was a prospective study of patients attending the outpatient department of Otorhinolaryngology, Silchar Medical College, and Hospital for surgical treatment of CSOM during the period from March 2023 to February 2024.
A total of 60 cases of CSOM who underwent “canal wall-down mastoidectomy” with type III tympanoplasty were included in our study.
Study design: “Prospective Observational Study.”
Inclusion Criteria
Patients aged >15 years and <60 years, and patients with a history of ear discharge diagnosed with CSOM requiring “canal wall-down mastoidectomy” with type III tympanoplasty were included in the study.
Exclusion Criteria
Patients presenting with pure sensorineural deafness, ear malignancy, revision surgery, patients with congenital ear disease, patients unfit for surgery and general anaesthesia (GA), and patients who refused postoperative follow-up as per protocol were excluded from the study.
A detailed history and ENT examination were done in all cases, and findings were recorded. pure tone audiometry (PTA) was done for all patients. We recorded the air conduction threshold, bone conduction threshold, and air-bone gap at 500Hz, 1000Hz, and 2000Hz, both preoperatively and post-operatively, at three months. After the relevant pre-operative investigations and confirmation of the diagnosis, a “canal wall-down mastoidectomy” with type III tympanoplasty was planned accordingly. The decision to perform a “canal wall-down mastoidectomy” with tympanoplasty was taken by the operating surgeon based on the intraoperative findings. Depending on the ossicular status, we used autografts for ossicular reconstruction. We used the underlay technique to reconstruct the tympanic membrane using a temporalis fascia graft.
Mean air conduction, mean bone conduction, and mean air-bone gap were calculated by taking the average of three frequencies (500,1000,2000 Hz). The mean air-bone improvement was calculated by deducting the mean preoperative air-bone gap from the mean postoperative air-bone gap. The audiometry categorized the post-operative hearing assessment as good, mild improvement, or no improvement compared to the pre-operative values. We categorized those patients with an AB gap of >20 dB as having good improvement, 10-20 dB as having mild improvement in hearing, and <10 dB as having no improvement. Both mild and good improvements in hearing were considered to be a success in the hearing outcome. We collected data using a proforma sheet and used statistical software (IBM SPSS version 26) for our statistical analysis. Descriptive analysis was done using percentages. We obtained the p-value between proportions using the Z test. A comparison of preoperative and postoperative values was done using the “unpaired t-test.” A p-value less than 0.05 was considered significant. We included all patients in the study after obtaining their informed consent. The ethical clearance for the study was approved vide No. 12.429.
RESULTS
Age-wise distribution of study population
Sex wise distribution of the study population
Males were more commonly affected in our study population, with a male-to- female ratio of 2:1.
Reconstruction technique using various autologous grafts in our study population. (Type III Tympanoplasty)
Postoperative mastoid cavity status in the study population
At 3 weeks, the majority of cases had mucoid discharge (80%), and at 6 weeks, the majority had a dry cavity (85%), and at 3 months, it further increased to 90% of dry cavity.
Postoperative findings of neo tympanic membrane in our study population
Postoperative condition of Meatoplasty in our study population.
Pure Tone Audiometry preoperatively and postoperatively in our study population.
The mean air conduction preoperatively was 58.91, which has been reduced postoperatively to 40.58, which is statistically significant. Meanwhile, there was not much difference in bone conduction readings on PTA preoperatively and postoperatively. The mean AB gap among our study group has definitely improved postoperatively with a statistically significant reduction in PTA readings. The mean AB improvement postoperatively is 18 dB, which was also statistically significant.
Postoperative hearing improvement and success outcome in our study population.
The p-value for improvement and no improvement was
0.003, which was also significant.
Successful outcome in postoperative hearing improvement.
In our study, satisfactory hearing improvement was seen in 85% of patients.
DISCUSSION
One of the most significant issues with public health, especially in developing nations, is CSOM.7 It is imperative to promptly detect these patients and administer proper treatment, particularly to mitigate the harmful consequences of the disease. According to the World Health Organization (WHO) estimates, between 65 and 330 million individuals worldwide suffer from CSOM; of those, over 50% have hearing loss, and about 28,000 lives are lost annually. In recent years, we have seen a breakthrough in CSOM surgery along with increased access to technical resources, yet the surgical management of cholesteatoma in CSOM is still a controversial topic. The surgical modality called “canal wall-down mastoidectomy” is more popular in contemporary clinical practice, especially in cases of cholesteatoma.
We conducted a prospective study on all patients attending the outpatient department of Otorhinolaryngology at Silchar Medical College and Hospital for surgical treatment of CSOM. A total of 60 cases of CSOM who underwent canal wall down mastoidectomy with type III tympanoplasty were included in our study.”
I Demographic characteristics
Within our research group, consisting of 60 individuals, most patients were under 20 years old, accounting for 54% of the population, with the next highest age group being 21–30 years old [Figure 1 and Table 1]. Correspondingly, Abraham ZS et al.'s study indicated that the prevalence of CSOM was greatest among individuals aged 11–15 years (3%) and lowest among those over 40 years old (0.6%).8 Another study by Fliss DM et al. found that the 11–20 age group accounted for the largest proportion of patients (42.5%).3 Similarly, Yash D. Lavana et al. reported that most patients fell within the age range of 11 to 20, with the next largest group being those between the ages of 21 and 30.9 Their comparatively undeveloped immune system, causing repeated upper respiratory tract infections, small and horizontal eustachian tubes, and cellular mastoid, as supported by other studies, could be the contributing factors for CSOM in this age group [Table 2]. “The male-to-female ratio in our study population was 2:1, indicating a higher frequency of impact on men compared to women [Figure 2].” There was also a 54.4% male predominance. A male predominance may have been due to random subject selection, and there are currently no documented anatomical or genetic differences between males and females regarding the ear. Similarly, Fliss DM et al. found a higher proportion of males compared to females, with a ratio of 1.5:1.3
| Age in years | No of patients (N=60) | Percentage |
|---|---|---|
| Less than 20 | 32 | 54% |
| 21-30 | 12 | 20% |
| 31-40 | 5 | 8% |
| More than 40 | 11 | 18% |
| Sex | No of patients (N=60) | Percentage |
|---|---|---|
| Male | 40 | 67% |
| Female | 20 | 33% |
- Bar Diagram showing age distribution.
- Pie-diagram showing sex wise distribution of cases.
II Pure tone audiometry findings (Preoperative)
In our study, the pre-operative mean bone conduction threshold was 16.58 (±5.54) dB, the mean air-bone gap was 42 (±7.2) dB, and the mean air conduction threshold was 58.91 (±9.45) dB. These values have a statistically significant p-value of 0.001. In contrast, Lavana YD et al. reported the pre-operative mean bone conduction threshold as 8.96 (7.85) dB, the pre-operative air-bone gap as 40.11 (12.92) dB, and the mean air conduction threshold as 48.16 15.15) dB.9 In our study, all 60 patients had conductive hearing loss [Table 3 and Figure 3].
| Autologous graft used | No of patients (N=60) | Percentage |
|---|---|---|
| Only incus (reshaped) | 17 | 28% |
| Only incus (without reshape) | 20 | 33% |
| Only malleus | 10 | 17% |
| Incus + malleus | 7 | 12% |
| Tragal cartilage | 2 | 3% |
| Conchal cartilage | 4 | 7% |
- Bar diagram showing various autologous graft used for reconstruction techniques.
III Surgical outcome
Mastoid cavity status
In our study, approximately 48 patients showed mucoid discharge 3 weeks after surgery, while 12 patients showed purulent discharge [Table 4]. After three months, 54 (90%) patients had a dry, well-epithelialized mastoid cavity, and only 4 cases had purulent discharge [Figure 4]. Two patients showed granulation, while no residual cholesteatoma was visible after 3 months. In a study done by Thakur K et al.10, 35 out of 43 patients showed a well-epithelialized cavity, and 3 had a discharging cavity. In a retrospective study done by Zhang Linasheng et al.11, almost all the ears were dry by the end of 6 weeks. Thapa et al.12 found that out of 299 patients who had undergone “canal wall-down mastoidectomy,” 96.39% experienced dry ears. The surgeons' extensive expertise and competence in the field of otology, along with appropriate pre-operative management, can be the reason for this high success rate.
Status of the temporalis fascia graft
| Mastoid | At 3 weeks | At 6 weeks | At 3 months |
|---|---|---|---|
| Mucoid discharge | 48 | 0 | 0 |
| Purulent discharge | 12 | 8 | 4 |
| Dry cavity | 0 | 51 | 54 |
| Granulation | 0 | 1 | 2 |
| Residual cholesteatoma | 0 | 0 | 0 |
- Bar diagram showing postoperative mastoid cavity findings at 3 weeks, 6 weeks, and 3 months
In the study Table 5 and Figure 5 shows, 49 (81%) patients had an intact tympanic membrane at the end of 3 months, which was similar to the findings by Austin (1962), which was about 85.7%. But there were 5 cases of residual perforation, anterior blunting seen in 2 cases, and lateralization of the graft in 1 case [Figure 6 and Table 6]. Similarly, in a study by Lee HJ et al., 88% showed an intact tympanic membrane at the end of 6 months, and 12% had residual perforation, which was almost similar to what we found in our study.13
| Neo tympanic membrane | At 6 weeks | At 3 months |
|---|---|---|
| Intact | 49 | 49 |
| Perforation | 2 | 5 |
| Blunting | 0 | 2 |
| Lateralisation of graft | 1 | 1 |
| Residual cholesteatoma | 0 | 0 |
| Meatoplasty status | No of patients (N=60) | Percentage |
|---|---|---|
| Patent | 49 | 88.50% |
| Reduced | 10 | 17% |
| Stenosed | 1 | 1.50% |
- Bar diagram showing neo tympanic membrane at 6 weeks and 3 months postoperatively
- Bar diagram showing the postoperative condition of Meatoplasty.
IV Audiological outcome
The postoperative “mean air conduction threshold was 40.58 (±11.29) dB, the postoperative mean bone conduction threshold was 16.58 (±5.52) dB [Figure 7 and Table 7], and the mean air-bone gap was 24 (±10.96) dB. Using an unpaired t-test, we found both the AC and AB gap thresholds were statistically significant, with a p-value of 0.001. The” mean AB gap among our study group has definitely improved postoperatively, with a statistically significant reduction in PTA readings. The mean AB improvement postoperatively is 18 dB. An analogous investigation was conducted by Lewis A et al.14, in which the average weighted air-bone gap data for adult patients reveals a reduction from 26.5 dB HL (preoperative) to 16.1 dB HL (postoperative). After three months, no improvement has been found in six cases, while twenty-two patients have shown mild improvement. Good improvement has been observed in twelve patients. Similarly, in our study, good improvement was seen in about 16 patients, mild improvement in 35, and no improvement in about 9 patients [Table 8A and Figure 8]. “It is important to acknowledge that these surgeries are intricate procedures, and as a result, the success rates are also dependent on the surgeons' expertise and the patient's management after the operation.
| PTA (500/1000/2000 Hz) | Average air conduction threshold (In dB) | Average air conduction threshold (In dB) | Average AB gap (In dB) |
|---|---|---|---|
| Mean ± SD | Mean ± SD | Mean ± SD | |
| Pre-operative | 58.91 ± 9.45 | 16.58 ± 5.54 | 42 ± 7.2 |
| Post-operative (at 3 months) | 40.58 ± 11.29 | 16.58 ± 5.52 | 24 ± 10.96 |
| P value | 0.001* (Significant) | 0.57 | 0.001* |
SD: Standard deviation, PTA: Pure tone audiometry, AC : Air conduction, BC: Bone conduction.’’ * ‘’ is to show that the value is significant.
| Hearing improvement | No of patients (N=60) | Percentage |
|---|---|---|
| Good improvement | 16 | 27% |
| Mild improvement | 35 | 58% |
| No improvement | 9 | 15% |
- Bar diagram showing preoperative and postoperative PTA findings.
- Pie-diagram showing hearing improvement.
In our study, the mean air bone improvement postoperatively was 18 dB, which was statistically significant. In a study conducted by Fliss DM et al. (2020), it was found that there was a considerable AB improvement of 8.81 dB.3 In a study conducted by Vergison A et al. (2015), it was discovered that there was a postoperative rise of 21.24 dB in air conduction.2 This finding aligns with the results of our own study, which showed a similar increase of 18 dB. In their study, Lavana YD et al. (2019) found that the average closure of the air bone gap was 8.76, and this result was statistically significant.9
In a study done by Öçalan R et al. (2013)[15], “46 patients with CSOM underwent ossicle chain reconstruction with type III tympanoplasty and canal wall down mastoidectomy. 1 Pure-tone audiometry was used to compare the hearing results before and after surgery, and found the mean air-bone gaps before and after surgery to be 33.96 dB and 28.21 dB, respectively. In 26.1% and 47.8% of the cases, “preoperative and postoperative audiological results found an air-bone gap of 25 dB, respectively. In our study, the preoperative and postoperative air-bone gaps were 42 (±7.2) dB” and 24 (±10.96) dB, respectively, with a gain of 18 dB postoperatively.
In 142 patients treated with “canal wall down mastoidectomy” by De Corso et al.,[16] bone conduction had an average preoperative threshold of 22.14 dB, while air conduction had an average preoperative threshold of 50.97 dB. He reported a mean air conduction threshold of 37.62 dB and a mean bone conduction threshold of 23.37 dB with air-bone gap closure from 28.83 to 13.94 dB in the same trial, yielding a 14.89 dB hearing gain.
Averaged pure-tone audiometry (PTA) at 4 KHz, 500 Hz, 2 KHz, and 1 KHz was used to quantify the air as well as bone conduction thresholds in a study by Kalita S et al. (2018),[17] both before and after surgery.” After the operation, audiometry was performed three weeks, three months, and six months later.4 As per the “American Academy of Otolaryngology-Head and Neck Surgery,” recommendation an audiometric analysis showed, ABG 30dB were 3.3% in the CWD group and 6.67% in the ICW group in the preoperative period; 3.3% (CWD) and 20% (ICW) in the 3 and 6-month postoperative periods; and 14.81% (CWD) and 34.48% (ICW) in the 12-month postoperative period. However, these observations made it clear that the patient's ABG had shifted toward the better hearing range, ICW>CWD. At three months following surgery, a comparison of patients in the two surgical groups with an ABG of 30 dB revealed a statistically significant difference (p = 0.0461).
In a study by Fliss DM et al. (2020)[3], the results showed that “in canal wall down mastoidectomy with cartilage-enhanced tympanoplasty type III, the mean pre- and post-operative air-bone gaps were 38.5 dB and 29.69 dB, respectively, with a net gain of 8.81 dB that is statistically significant.3 The post-operative PTA-ABG varied from 25 to 36 dB, and in 40% of cases, the ABG closure was 11 to 15 dB. The mean pre- and post-operative air-bone gaps in canal wall down mastoidectomy without cartilage-enhanced tympanoplasty type III were 37.19 dB and 34.19 dB, respectively, with a statistically insignificant net gain of 3 dB. In 35% of instances, the ABG closed at 0 to 5 dB, and the post-operative PTA-ABG ranged from 26.25 to 41.75 dB. The mean pre- and postoperative air-bone gaps in our sample were 42 dB and 24 dB, respectively, with a statistically significant gain of 18 dB.” (p-value is 0.001)
Lavana YD et al. (2019) found 86 instances of CSOMattico-antral type in total. A PTA was performed at 10 and 24 weeks following surgery to compare pre- as well as postoperative hearing function.9 Of the 86 patients, the average preoperative AC threshold measured 48.16 (15.15) dB, the average preoperative BC measured 8.96 (7.85) dB, and the average preoperative air-bone gap measured 40.11 (12.92) dB. Following surgery, the average BC was 11.34 (9.44) dB, the average air-bone gap was 32.06 (11.62) dB, and the average AC threshold was 43.17 (13.72) dB. The average air-bone gap closure was 8.76 (11.86). This hearing” increase had strong statistical significance (p = 0.001). Out of 86 patients, 60 received cartilage treatment. For homologous septal cartilage, conchal cartilage, and tragal cartilage, “the mean ABG was 8.43 dB, 11.05 dB, and 8.6 dB, respectively.
Audiological Success
In our study, we got a success rate of 85%, Table 8B which includes both the good and mild improvement of hearing.” 26.7% of patients had good hearing improvement (>20 dB), 58% had mild improvement (10-20 dB), and 15% had no improvement (<10 dB) [Figure 9]. The p-value for improvement and non-improvement is 0.003, which is significant. According to Shrinivas et al.[18], ossiculoplasty had an 80% success rate and an average air-bone gap change of 15.76 dB. Additionally, he discovered that mastoidectomy was associated with worse hearing outcomes as compared to no mastoidectomy. Our findings indicate that the surgical method, the degree of mastoid cellularity, the complexity of the pre-operative ear discharge, and the existence of disease were all significant prognostic factors.
| Outcome | No of patients (N=60) | Percentage |
|---|---|---|
| Success (good + mild improvement) | 51 | 85% |
| Failure | 9 | 15% |
- Pie-diagram showing the outcome of the study.
CONCLUSION
When carried out by a skilled practitioner, canal wall down mastoidectomy produces the best outcomes in terms of a dry well-epithelialized cavity. Additionally, our study's audiological outcomes have improved. We can therefore presume that with type III tympanoplasty, hearing is stable. When cholesteatoma destroys the ossicle chain, tympanoplasty type III is a dependable procedure for maintaining hearing.
Ethical approval:
The research/study was approved by the Institutional Review Board at Silchar Medical College and Hospital, number 12.429, dated 01/08/2023.
CTR number:
CTRI/2023/09/057771
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Conflicts of interest:
There are no conflicts of interest
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship: Nil
References
- Epidemiology of Otitis Media During the First Seven Years of Life in Children in Greater Boston: A Prospective Cohort Study. J Infect Dis. 1989;160:83-94.
- [CrossRef] [PubMed] [Google Scholar]
- Otitis media and its consequences: beyond the earache. The Lancet infectious diseases. 2010 Mar 1;. ;10(3):195-203.
- [CrossRef] [PubMed] [Google Scholar]
- Medical Management of Chronic Suppurative Otitis Media Without Cholesteatoma in Children. J Pediatr. 1990;116:991-96.
- [CrossRef] [PubMed] [Google Scholar]
- Role of Anaerobic Bacteria in Chronic Otitis Media and Cholesteatoma. Int J Pediatr Otorhinolaryngol. 1995;31:153-57.
- [CrossRef] [PubMed] [Google Scholar]
- The Complications of Chronic Otitis Media: Report of 93 Cases. J Laryngol Otol. 2000;114:97-100.
- [CrossRef] [PubMed] [Google Scholar]
- Petrositis and Cerebellar Abscess Complicating Chronic Otitis Media. J Paediatr Child Health. 2003;39:635-36.
- [CrossRef] [PubMed] [Google Scholar]
- Chronic Suppurative Otitis Media: Burden of Illness and Management Options Geneva: World Health Organization; 2004.
- [Google Scholar]
- Prevalence and Etiological Agents for Chronic Suppurative Otitis Media in a Tertiary Hospital in Tanzania. BMC Res Notes. 2019;12:429.
- [CrossRef] [PubMed] [Google Scholar]
- Hearing results in modified radical mastoidectomy with type III tympanoplasty. Int J Otorhinolaryngol Head Neck Surg. 2019;5:1629-34.
- [CrossRef] [Google Scholar]
- Surgical and audiological outcome of canal wall down mastoidectomy in Sub Himalayan region: our experience. International Journal of Research in Medical Sciences. 2017;5:4426.
- [CrossRef] [Google Scholar]
- Predictors of Anatomical and Functional Outcomes Following Tympanoplasty: A Retrospective Study of 413 Procedures. Laryngoscope Investig Otolaryngol. 2021;6:1421-28.
- [CrossRef] [PubMed] [Google Scholar]
- Complications of canal wall down mastoidectomy. Journal of the Nepal Medical Association. 2004;43:151.
- [CrossRef] [Google Scholar]
- Canal reconstruction and mastoid obliteration using floating cartilages and musculoperiosteal flaps. The Laryngoscope. 2017 ;. ;127:1153-60.
- [CrossRef] [PubMed] [Google Scholar]
- Success rates in restoring hearing loss in patients with chronic otitis media: A systematic review. Laryngoscope investigative otolaryngology. 2021;6:522-30.
- [CrossRef] [PubMed] [Google Scholar]
- Hearing results in patients undergoing canal wall down mastoidectomy with type III tympanoplasty. ENT Updates. 2013;3:3.
- [CrossRef] [Google Scholar]
- Otitis media in children: Which phenotypes are most linked to allergy? A systematic review. Pediatric Allergy and Immunology. 2021;32:524-34.
- [CrossRef] [PubMed] [Google Scholar]
- A comparative study on the hearing outcome in canal wall down and intact canal wall mastoidectomy in chronic suppurative otitis media with special reference to atticoantral disease. Int J Res Rev. 2018;5:94-103.
- [Google Scholar]
- Factors influencing ossicular status in mucosal chronic otitis media-an observational study. Indian Journal of Otology. 2014;20:16-9.
- [CrossRef] [Google Scholar]