Underlay Versus Over-Underlay Myringoplasty Regarding Hearing and Surgical Outcomes

Hend Zakzouk; Abdulselam Daif; Khalid Elgogary; Abdelrahman Ezzat

doi:10.25259/AONO_2024_2_(210)

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Original Article

2025

:6;

e016

doi:

10.25259/AONO_2024_2_(210)

Underlay Versus Over-Underlay Myringoplasty Regarding Hearing and Surgical Outcomes

Hend Zakzouk¹, Abdulselam Daif², Khalid Elgogary², Abdelrahman Ezzat²

1Department of Otolaryngology, Faculty of Medicine, Al-Azhar University Cairo, Cairo, Egypt

2Department of ENT, United Lincolnshire Hospital Trust, Lincoln, UK

*Corresponding author: Hend Zakzouk, Department of Otolaryngology, Faculty of Medicine, Al-Azhar University Cairo, Cairo, Egypt. hend.zakzouk@azhar.edu.eg

Received: 2024-02-25, Accepted: 2024-05-15, Published: 2025-08-14

Licence

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Zakzouk H, Daif A, Elgogary K, Ezzat A. Underlay Versus Over-Underlay Myringoplasty Regarding Hearing and Surgical Outcomes. Ann Otol Neurotol. 2025;6:e016 doi: 10.25259/AONO_2024_2_(210)

Abstract

Objectives

Closure of tympanic membrane perforation aimed to restore the vibratory mechanism of the tympanic membrane and improve hearing. The graft material usually used is temporalis fascia, perichondrium, or cartilage. There are three classic techniques of myringoplasty: overlay, underlay, and over-underlay. Compare underlay and over-underlay myringoplasty and its effect on the sealing of the TM perforation and hearing improvement.

Material and Methods

A randomized prospective comparative study was done on 60 patients with chronic otitis media with dry central perforation of the tympanic membrane from February 2022 to June 2023 at Al Zahraa University Hospital. All patients underwent endoscopic myringoplasty using a tragal perichondrium graft. Patients were divided into two groups; each group included 30 patients; group A: graft was inserted medial to the handle of the malleus; group B: graft was inserted lateral to the handle of the malleus. All patients had preoperative otoscopy and PTA and were 3 months postoperative. The success of surgery is defined as a completely sealed TM without lateralization, atelectasis, or retraction pocket.

Results

The overall success rate was 91.66%, which was 90.0% and 93.3% in Groups A and B, respectively. Mean air-bone gap (ABG) closure is 8.02±2.92 and 9.57±3.99 in Groups A and B, with significant improvement in hearing between each group (P = 0.054).

Conclusion

Both techniques (underlay and over-underlay myringoplasty) are effective, with success rates of 90.0% and 93.3%, respectively, and the differences in ABC closure were statistically insignificant in both techniques.

Keywords

Endoscopic myringoplasty

Over-underlay myringoplasty

Underlay myringoplasty

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INTRODUCTION

Chronic otitis media (COM) surgery is a common procedure worldwide to reconstruct tympanic membrane (TM) perforation and establish a functional sound-conducting structure in a well-aerated middle ear.¹ Surgical treatment for COM with perforation is safe and effective in improving symptoms, such as preventing recurrent infection and maintaining or improving hearing.^2,3

There are two classic techniques used in tympanoplasty, which include underlay and overlay tympanoplasty.⁴ In the most common underlay technique, the graft is inserted medial to the malleus and residual of the tympanic membrane [Figure 1]. It is recommended for posterior perforations, and it carries the risk of graft medialization and subsequently decreases the middle ear volume. However, it has a high success rate even in less expert surgeons.⁵ In the overlay technique, the graft is inserted lateral to the tympanic annulus and medial to the squamous layer of the tympanic membrane after its elevation. It is recommended in large and anterior perforation, and it carries the risk of graft lateralization and requires an expert surgeon.⁶ A modified technique has been introduced to carry the advantage of the underlay technique, easy procedure, and decrease its risk, medialization, and decreased middle ear space. It is an over-underlay technique in which the graft is inserted medial to the tympanic annulus and lateral to the handle of the malleus [Figure 2].⁴ The over-underlay tympanoplasty technique, first described by Kartush et al., combines the advantages of overlay and underlay techniques while minimizing their disadvantages.^4,7 This method aims to provide a fine, conically formed, vibrating membrane to replace the original TM and restore auditory function.⁸

Aim of the work

Comparison between the underlay (graft medial to the handle of malleus) and over-underlay technique (graft lateral to the handle of malleus) regarding graft taking and closure of the air-bone gap in patients who had endoscopic tympanoplasty using a tragal perichondral graft.

MATERIAL AND METHODS

A randomized prospective comparative study was done at Al Zahraa University Hospital from February 2022 to June 2023 on 60 patients.

Inclusion Criteria

All patients have a chronic dry central tubo-tympanic perforation.

Exclusion Criteria

Patients who have ossicular abnormality
Attic-antral COM
Neoplastic perforation

All patients underwent endoscopic myringoplasty under general anesthesia and grafting using tragal perichondrium.

Patients were divided into two groups; group A included 30 patients managed by tragal perichondrium grafting medial to fibrous tympanic annulus and lateral to handle of the malleus (underlay method), and group B included 30 patients managed by tragal perichondrium grafting medial to the fibrous tympanic annulus and lateral to handle of the malleus (over-underlay method). All patients underwent complete preoperative ear nose throat (ENT) assessment and preoperative audiometry and 3 months postoperative to calculate air-bone gap (ABG), detect ABG closure in each group, and compare both techniques. Additionally, compare the success rate in each group. The success of myringoplasty is defined as complete sealing of the tympanic membrane without lateralization or retraction pocket.

An informed consent was taken from all patients. There was no financial conflict of interest.

Statistical Analysis

Recorded data were analyzed using the statistical package for social sciences, version 23.0 (SPSS Inc., Chicago, Illinois, USA).

RESULTS

Table 1 displays the demographic characteristics of the study participants, allowing for a comparative analysis between the underlay method (N = 30) and the over-underlay method (N = 30) groups. The underlay method group showed a narrower age range (16–48 years) compared to the over-underlay method group (18–52 years), with a slightly lower mean age. In terms of gender distribution, the underlay method group had a higher proportion of females (70%) compared to males (30%), while the over-underlay method group exhibited a more balanced gender distribution, with 40% males and 60% females. These findings highlight demographic disparities between the two groups.

Table 1: Demographic characteristics of the study population.

Variable	Total (N = 60)	Underlay method (N = 30)	Over-underlay method (N = 30)	Test value	P-value^*
Age (years)
Range	16–52	16–48	18–52	1.914	0.061
Mean ± SD**	40.12 ± 7.26	37.76 ± 6.83	41.30 ± 7.48	1.914	0.061
Gender
Male	21 (35.0%)	9 (30.0%)	12 (40.0%)	0.293	0.588
Female	39 (65.0%)	21 (70.0%)	18 (60.0%)	0.293	0.588

^*Using: x²: Chi-square test for number (%) or Fisher’s exact test, when appropriate, **Using: t-independent sample t-test for Mean ± SD. SD: Standard deviation.

Table 2 demonstrates the overall success rate in both groups was 91.66%, which was 90.0% in group A with 3 patients who had residual perforation and 93.3% in group B with 2 patients who had residual perforation. Subsequently, there is no statistically significant difference between each group (P = 0.647).

Table 2: Comparison between group A grafting medial to malleus and group B grafting lateral to malleus according to success rate.

Outcome	Group 1		Group II		Chi-square test
Outcome	No.	%	No.	%	x²	P-value
Successful	27	90.0	28	93.3	0.210	0.647
Failed	3	10.0	2	6.7
Total	30	100.0	30	100.0

Table 3, 4 shows mean ABG preoperative in group A and group B were 15.32 ± 2.69 and 16.40 ± 2.68, which decreased 3 months postoperatively to be 7.31 ± 2.20 and 6.82 ± 2.25, respectively, which indicates a high statistically significant improvement P < 0.001 in both groups.

Table 3: Comparison between preoperative ABG and postoperative ABG in group A graft medial to malleus.

Group 1 medial to malleus	Preoperative ABG	Postoperative ABG	Paired sample t-test
Group 1 medial to malleus	Preoperative ABG	Postoperative ABG	Mean ± SD	t-test	P-value
Mean ± SD	15.32 ± 2.69	7.31 ± 2.20	8.02 ± 2.92	23.376	<0.001**
Range	10.75–19.75	4.5–11.75	8.02 ± 2.92	23.376	<0.001**

^“**”: Statistically significant, ABG: Air-bone gap, SD: Standard deviation.

Table 4: Comparison between preoperative ABG and postoperative ABG in group 2 graft lateral to malleus.

Group 2 lateral to malleus	Preoperative ABG	Postoperative ABG	Paired sample t-test
Group 2 lateral to malleus	Preoperative ABG	Postoperative ABG	Mean ± SD	t-test	P-value
Mean ± SD	16.40 ± 2.68	6.82 ± 2.25	9.57 ± 3.99	14.68	<0.001**
Range	11.75–21	3.5–11	9.57 ± 3.99	14.68	<0.001**

^“**”:Statistically significant, ABG: Air-bone gap, SD: Standard deviation.

Table 5 shows mean ABG closure 3 months postoperative, which indicates improvement of hearing (mean ± SD), was 8.02 ± 2.92 in group A and 9.57 ± 3.19 in group B. The comparison of mean postoperative ABC closure after 3 months of surgery between both groups was not statistically significant (P = 0.054).

Table 5: Comparison between ABG closures in both groups.

Amount of change (post-pre ABG)	Group 1 medial to malleus	Group 2 lateral to malleus	t-test	P-value
Mean ± SD	8.02 ± 2.92	9.57 ± 3.19	1.963	0.054

ABG: Air-bone gap, SD: Standard deviation.

DISCUSSION

This clinical study was performed to compare the underlay technique by placing the graft medial to both the tympanic annulus and handle of the malleus and the over-underlay technique by placing the graft medial to the tympanic annulus and lateral to the handle of the malleus. The success rate is higher in group B (over-underlay technique) than in group A (underlay technique) but not statistically significant. The mean ABG closure 3 months postoperatively indicated slight hearing improvement in group B but was statistically insignificant.

Several studies on these two methods have reported a comparison between the underlay and over-underlay technique regarding graft taking and closure of the air-bone gap in patients who had tympanoplasty using temporalis fascia graft.

Rogha M et al.⁹ conducted a study on 56 patients with COM with perforated TM at Alzahra and Kashani Hospitals between June 2010 and February 2012. All patients were divided into two groups. The first group included 28 patients. The temporalis fascia graft was fashioned to have a hole to fit the handle of the malleus, and the graft was placed medial to the handle of the malleus. In the second group, the graft was placed lateral to the handle of the malleus. All patients were assessed by audiometry preoperatively and 3 months postoperatively.

Overall success rate was 94.64%. The success rate was 96.42% and 92.85% for the first and second groups, respectively. Air-bone gap closure was 16.10 (±4.89) in the first group and 15.78 (±3.40) in the second group. Improvement in hearing level was statistically insignificant between the 2 surgical methods.

In another study conducted from May 2017 to August 2018 on thirty patients, patients were divided into two groups. The first group included 15 patients treated by temporalis fascia grafting medial to handle malleus. The second group included 15 patients treated by temporalis fascia grafting lateral to it.

The mean ABG closure was 33.42 ± 3.71 dB and 22.30 ± 5.56 dB in the first and second groups, respectively. The ABG closure difference between both groups was statistically insignificant (P > 0.05). The overall graft success rate was 83.33%, with 86.7% and 80.0% in the first and second groups, respectively, which was statistically insignificant (P-value = 0.624).¹⁰

A prospective study was conducted from January 2021 to June 2022 on 60 patients. All patients were divided into two groups, each one including 30 patients. Group A underwent temporalis fascia grafting lateral to the malleus, and group B underwent grafting medial to it. All patients were evaluated preoperatively by audiometry and otoscopy and 1 month and 3 months postoperatively.

The first follow-up month postoperatively showed a 93.3% success rate in each group. The second follow-up 3 months postoperatively showed success rates (83.3%) and (86.7%) in the first group and second group, respectively, which were statistically insignificant (P = 0.6711).

The mean ABG closure 3 months postoperatively (mean ± SD) was 8.3480 ± 4.4209 in group A and 8.2427 ± 4.7653 in group B, which was statistically insignificant (P = 0.3020).¹¹

The outcomes of underlay myringoplasty and the over-underlay technique were compared by Panchal et al.¹² Twenty patients had underlay myringoplasty, and another twenty had over-underlay myringoplasty. Even though the graft success rate in underlay myringoplasty was 90% compared to 95% in over-underlay myringoplasty after a follow-up period of months, the difference was not statistically significant (P = 0.5). ABG gains varied statistically significantly between the underlay and over-underlay myringoplasty (14.5 ± 7.236 dB and 18.75 ± 5.349, respectively; P = 0.04).

Our center’s overall success rate for both procedures was deemed acceptable when compared to related studies, and it is comparable to similar centers worldwide. Regarding the success rate and hearing outcomes, the statistical analysis was unable to show a significant difference between the underlay and over underlay intervention groups.

CONCLUSION

Our study, along with findings from analogous research, indicates that there exists no notable distinction in terms of success rates and hearing improvement between the underlay and over-underlay techniques. The pivotal factor influencing outcomes appears to be the proficient execution of either technique rather than a preference for one over the other. This underscores the importance of skillful application, emphasizing that success in otologic procedures hinges more on the competence of the practitioner than the specific choice of technique employed.

Ethical approval

The research/study complies with the Helsinki Declaration of 1964.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

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.

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