Chronic otitis media (COM) is one of the most common otological disorders worldwide and remains a significant cause of preventable hearing impairment, particularly in developing countries. It is characterized by persistent inflammation of the middle ear cleft, tympanic membrane (TM) perforation, recurrent otorrhoea, and conductive hearing loss. Persistent TM perforation can adversely affect communication, social functioning, and quality of life. Surgical repair through myringoplasty or tympanoplasty aims to achieve a dry, safe ear and restore hearing function [1].Tympanoplasty is the established surgical procedure for reconstruction of the tympanic membrane, with or without ossicular chain repair. Microscopic ear surgery (MES) has traditionally been considered the gold standard approach due to its excellent magnification, binocular vision, depth perception, and precise handling of middle ear structures. However, the microscope provides a limited straight-line field of view, which may restrict visualization of hidden areas such as the anterior tympanic membrane, sinus tympani, and epitympanic recess, particularly in anatomically challenging cases [2,3].The success of tympanoplasty depends on various factors, including perforation characteristics, middle ear status, graft material, surgical technique, and surgeon expertise. Different graft materials and techniques, including temporalis fascia, cartilage grafts, underlay, and overlay techniques, have been developed to improve graft stability and closure rates [4,5].The introduction of endoscopic ear surgery (EES) has transformed middle ear surgery by providing a minimally invasive alternative to conventional microscopic techniques. Endoscopes offer a wide-angle, panoramic, and magnified view of the middle ear cavity, allowing improved visualization of anatomical regions that are difficult to access with microscopy. The transcanal endoscopic approach reduces the need for extensive surgical exposure, postauricular incision, and canaloplasty, thereby potentially decreasing surgical morbidity [6,7].Endoscopic tympanoplasty provides several advantages, including better visualization of hidden recesses, reduced tissue trauma, shorter operative time, improved cosmetic outcomes, and decreased postoperative discomfort. Its application has expanded to challenging situations such as anterior tympanic membrane perforations and narrow external auditory canals, where microscopic visualization may be limited [7,8]. However, endoscopic surgery also has limitations, including single-handed instrumentation, lack of binocular depth perception, and a significant learning curve. Surgical outcomes may vary depending on surgeon experience and disease complexity [6,9].Recent comparative studies and meta-analyses have demonstrated that endoscopic tympanoplasty provides comparable graft uptake rates and hearing outcomes to microscopic tympanoplasty. Endoscopic techniques may offer additional benefits, including shorter operative duration, reduced postoperative pain, and improved access to difficult anatomical regions. However, variations in surgical methods, graft materials, patient selection, and follow-up periods highlight the need for further prospective comparative studies [10-12].Advances in endoscopic technology, including high-definition imaging systems, smaller diameter endoscopes, and improved instrumentation, have further expanded the role of endoscopic tympanoplasty. Nevertheless, whether endoscopic tympanoplasty can completely replace microscopic tympanoplasty remains an area of ongoing investigation [11,12]. Therefore, the present prospective clinical study titled “Comparative Evaluation of Endoscopic and Microscopic Tympanoplasty: A Prospective Clinical Study” aims to compare endoscopic and microscopic tympanoplasty with respect to graft success, hearing outcomes, operative parameters, and postoperative complications.

Study Design and Setting The present prospective comparative clinical study was conducted in the Department of ENT in collabaration with surgery. The study included 90 patients with tympanic membrane perforation undergoing tympanoplasty. Study Population and Selection Criteria Patients presenting to the ENT outpatient department with chronic tympanic membrane perforation and conductive hearing loss were evaluated. A detailed history, otological examination, and audiological assessment were performed. Eligible patients were allocated into two groups: • Group I: Endoscopic tympanoplasty • Group II: Microscopic tympanoplasty Inclusion Criteria Patients aged 15–60 years with central tympanic membrane perforation secondary to chronic otitis media or trauma, associated conductive hearing loss, and inactive/quiescent middle ear disease were included. Exclusion Criteria Patients with active ear discharge, mastoiditis, cholesteatoma, sensorineural hearing loss, or unwillingness to participate were excluded. Preoperative Assessment All patients underwent clinical and audiological evaluation, including: • Otoscopic examination for assessment of perforation site and size. • Tuning fork tests for hearing assessment. • Pure tone audiometry (PTA) for evaluation of hearing thresholds and calculation of air–bone gap (ABG). • Routine preoperative investigations as per institutional protocol. Surgical Procedure and Outcome Assessment Patients underwent tympanoplasty using either an endoscopic or microscopic approach. Postoperative follow-up was performed at scheduled intervals to assess anatomical and functional outcomes. The following parameters were evaluated and compared between groups: • Graft uptake rate. • Improvement in hearing thresholds. • Postoperative air–bone gap closure. • Duration of hospital stay. • Postoperative complications. Statistical Analysis Statistical analysis was performed using SPSS version 25.0. Continuous variables were expressed as mean ± standard deviation (SD), while categorical variables were presented as frequencies and percentages. Normality was assessed using the Shapiro–Wilk test.The independent sample t-test or Mann–Whitney U test was used for comparison of continuous variables between groups. Pre- and postoperative hearing parameters were analyzed using the paired t-test or Wilcoxon signed-rank test as appropriate. Categorical variables were compared using the Chi-square test or Fisher’s exact test. A p-value <0.05 was considered statistically significant.

The present prospective comparative study included 90 patients, with 45 patients each undergoing endoscopic and microscopic tympanoplasty. Baseline demographic characteristics were comparable between both groups. Age distribution was similar (p=0.941), with the majority of patients belonging to the 41–50 years age group. Gender distribution was also comparable (p=0.522). A significant difference was observed in residence distribution, with more urban patients in the endoscopic group and more rural patients in the microscopic group (p=0.001) (Table 1; Figure 1).Clinical characteristics, including duration of ear discharge, duration of dry ear, and site of tympanic membrane perforation, were comparable between the two groups. The most common perforation site was the anterosuperior quadrant in both groups (46.7% vs 42.2%; p=0.814) (Table 2).The choice of graft material was similar, with temporalis fascia being used in the majority of cases (80.0% vs 84.4%; p=0.602). All patients in the endoscopic group underwent a transcanal approach, whereas the microscopic group underwent postauricular/transcanal microscopic tympanoplasty (Table 3; Figure 2).Postoperative outcomes showed comparable graft uptake rates between groups, with successful graft uptake achieved in 95.6% of endoscopic and 91.1% of microscopic tympanoplasty cases (p=0.678). Postoperative complications were also similar between groups (p=0.284), with lower frequencies of pain, fever, discharge, and TMJ discomfort observed in the endoscopic group (Table 4). Both groups demonstrated significant postoperative hearing improvement. Preoperative air–bone gap was comparable (28.12 ± 9.84 dB vs 29.86 ± 10.21 dB; p=0.421). Postoperative air–bone gap and hearing improvement were better in the endoscopic group, although differences were not statistically significant (p=0.067) (Table 5).Patient recovery and satisfaction outcomes significantly favored endoscopic tympanoplasty. Early return to work was higher in the endoscopic group (80.0% vs 60.0%; p=0.041), along with better cosmetic satisfaction (88.9% vs 68.9%; p=0.018), fewer postoperative visits (86.7% vs 62.2%; p=0.018), and higher overall satisfaction (91.1% vs 73.3%; p=0.032) (Table 6; Figure 3). Table 1: Baseline Demographic Characteristics of Study Participants (n=90) Parameter Endoscopic Tympanoplasty (n=45) Microscopic Tympanoplasty (n=45) p-value Age group (years), n (%) 0.941 ≤20 5 (11.1%) 4 (8.9%) 21–30 9 (20.0%) 8 (17.8%) 31–40 9 (20.0%) 11 (24.4%) 41–50 15 (33.3%) 14 (31.1%) 51–60 7 (15.6%) 8 (17.8%) Sex, n (%) 0.522 Male 23 (51.1%) 26 (57.8%) Female 22 (48.9%) 19 (42.2%) Residence, n (%) 0.001 Urban 28 (62.2%) 11 (24.4%) Rural 17 (37.8%) 34 (75.6%) Table 2: Clinical Characteristics of Patients (n=90) Clinical Parameter Endoscopic Tympanoplasty (n=45) Microscopic Tympanoplasty (n=45) p-value Duration of ear discharge, n (%) 0.622 <6 months 11 (24.4%) 12 (26.7%) 6–12 months 13 (28.9%) 16 (35.6%) >1 year 21 (46.7%) 17 (37.8%) Duration of dry ear, n (%) 0.672 <1 month 27 (60.0%) 25 (55.6%) 1–2 months 11 (24.4%) 10 (22.2%) >2 months 7 (15.6%) 10 (22.2%) Site of tympanic membrane perforation, n (%) 0.814 Anterosuperior quadrant 21 (46.7%) 19 (42.2%) Anteroinferior quadrant 11 (24.4%) 12 (26.7%) Posterosuperior quadrant 9 (20.0%) 10 (22.2%) Posteroinferior quadrant 4 (8.9%) 4 (8.9%) Statistical test applied: Chi-square test Table 3: Operative Characteristics of Study Groups (n=90) Operative Parameter Endoscopic Tympanoplasty (n=45) Microscopic Tympanoplasty (n=45) p-value Graft material used, n (%) 0.602 Temporalis fascia 36 (80.0%) 38 (84.4%) Tragal perichondrium 9 (20.0%) 7 (15.6%) Type of approach, n (%) — Transcanal 45 (100%) — Postauricular/transcanal microscopic — 45 (100%) Table 4: Comparison of Postoperative Surgical Outcomes (n=90) Outcome Parameter Endoscopic Tympanoplasty (n=45) Microscopic Tympanoplasty (n=45) p-value Graft uptake, n (%) 0.678 Successful graft uptake 43 (95.6%) 41 (91.1%) Graft failure 2 (4.4%) 4 (8.9%) Postoperative complications, n (%) 0.284 Pain 4 (8.9%) 7 (15.6%) Fever 2 (4.4%) 5 (11.1%) Postoperative ear discharge 2 (4.4%) 5 (11.1%) TMJ discomfort 1 (2.2%) 3 (6.7%) Statistical test applied: Chi-square test Table 5: Comparison of Audiological Outcomes Between Groups Hearing Parameter Endoscopic Tympanoplasty (n=45) Mean ± SD Microscopic Tympanoplasty (n=45) Mean ± SD p-value Preoperative AB gap (dB) 28.12 ± 9.84 29.86 ± 10.21 0.421 Postoperative AB gap at 12 weeks (dB) 11.82 ± 8.76 15.74 ± 9.68 0.067 Hearing improvement (dB) 16.30 ± 5.12 14.12 ± 5.46 0.067 Statistical test applied: Independent sample t-test Table 6: Patient Satisfaction and Recovery Outcomes Satisfaction Parameter Endoscopic Tympanoplasty (n=45) Microscopic Tympanoplasty (n=45) p-value Early return to work, n (%) 36 (80.0%) 27 (60.0%) 0.041 Good cosmetic satisfaction, n (%) 40 (88.9%) 31 (68.9%) 0.018 ≤3 postoperative hospital visits, n (%) 39 (86.7%) 28 (62.2%) 0.018 High overall satisfaction, n (%) 41 (91.1%) 33 (73.3%) 0.032 Statistical test applied: Chi-square test

The present prospective comparative study included 90 patients undergoing tympanoplasty, with 45 patients each in the endoscopic and microscopic tympanoplasty groups. Baseline demographic characteristics were comparable between both groups. The majority of patients belonged to the 41–50 years age group (33.3% in endoscopic group and 31.1% in microscopic group; p=0.941). Sex distribution was also comparable, with males constituting 51.1% and 57.8% in the endoscopic and microscopic groups, respectively (p=0.522). Clinical parameters including duration of ear discharge, dry ear period, and site of perforation showed no significant difference between groups. Similar findings were reported by Jyothi et al. [13], who evaluated 120 patients with tubotympanic chronic suppurative otitis media and found comparable baseline characteristics between endoscopic and microscopic myringoplasty groups, supporting reliable comparison of surgical outcomes. In the present study, successful graft uptake was achieved in 43 patients (95.6%) in the endoscopic group and 41 patients (91.1%) in the microscopic group, with no statistically significant difference (p=0.678). This indicates that endoscopic tympanoplasty provides anatomical success comparable to microscopic tympanoplasty. Jyothi et al. [13] reported graft uptake rates of 91.67% in the endoscopic group and 93.3% in the microscopic group, with no significant difference between techniques. Similarly, Harugop et al. [14] observed comparable graft success between endoscope-assisted and microscope-assisted myringoplasty, suggesting that endoscopic visualization does not compromise graft healing. Plodpai and Paje [15] also demonstrated similar outcomes between endoscopic and microscopic overlay myringoplasty, supporting the effectiveness of endoscopic techniques in achieving successful tympanic membrane closure. The high graft uptake observed in the present study may be attributed to enhanced visualization of perforation margins and middle ear anatomy provided by endoscopic systems, allowing accurate graft placement. In the present study, preoperative hearing status was comparable between groups, with mean preoperative ABG of 28.12 ± 9.84 dB in the endoscopic group and 29.86 ± 10.21 dB in the microscopic group (p=0.421). At 12 weeks postoperatively, ABG improved to 11.82 ± 8.76 dB and 15.74 ± 9.68 dB, respectively. The mean hearing improvement was higher in the endoscopic group (16.30 ± 5.12 dB) compared with the microscopic group (14.12 ± 5.46 dB), although statistically insignificant (p=0.067). These findings are consistent with Jyothi et al. [13], who reported comparable postoperative hearing improvement between endoscopic and microscopic myringoplasty. James [16], in pediatric tympanoplasty, also demonstrated similar grafting and hearing outcomes between endoscope-guided and microscope-guided procedures. Nassif et al. [17] further reported satisfactory closure rates and hearing improvement following endoscopic type I tympanoplasty in children, supporting the functional effectiveness of endoscopic techniques. The present study showed fewer postoperative complications in the endoscopic group. Pain was observed in 4 patients (8.9%) in the endoscopic group compared with 7 patients (15.6%) in the microscopic group. Other complications, including fever, postoperative discharge, and TMJ discomfort, were also more frequent in the microscopic group, although the difference was not statistically significant (p=0.284). Jyothi et al. [13] reported reduced postoperative pain and improved patient comfort following endoscopic myringoplasty. Similarly, Plodpai and Paje [15] highlighted reduced postoperative morbidity with endoscopic overlay myringoplasty, supporting the minimally invasive advantage of endoscopic approaches. In the present study, endoscopic tympanoplasty demonstrated better patient-reported recovery outcomes. Early return to work was achieved in 80.0% of patients in the endoscopic group compared with 60.0% in the microscopic group, while good cosmetic satisfaction was reported in 88.9% and 68.9%, respectively. The requirement for ≤3 postoperative hospital visits was significantly lower in the endoscopic group (86.7% vs 62.2%; p=0.018). These findings support the minimally invasive nature of endoscopic surgery. James [16] reported favourable outcomes with endoscope-guided pediatric tympanoplasty, while Nassif et al. [17] demonstrated that endoscopic type I tympanoplasty provides satisfactory results with reduced surgical morbidity.

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