Chronic otitis media remains a significant cause of conductive hearing loss worldwide, particularly in developing regions. Tympanoplasty is the cornerstone surgical procedure for restoring tympanic membrane integrity and middle ear function. Traditionally performed using an operating microscope, tympanoplasty has evolved with advancements in endoscopic otologic surgery [1,2]. Microscopic tympanoplasty provides binocular vision, depth perception, and ergonomic stability; however, its straight-line visualization limits access to hidden recesses such as the anterior epitympanum and hypotympanum [3]. Endoscopic tympanoplasty, using angled rigid endoscopes, offers panoramic visualization, allowing surgeons to inspect middle ear anatomy without canaloplasty or extensive bone removal [4]. Precision in tympanoplasty encompasses accurate graft placement, atraumatic handling of middle ear structures, complete perforation closure, and avoidance of residual disease. Even minor inaccuracies may lead to graft failure or persistent hearing impairment [5]. While several studies have compared outcomes between endoscopic and microscopic approaches, fewer have systematically evaluated surgical precision parameters [6–8]. This study aimed to compare endoscopic and microscopic tympanoplasty with respect to operative precision, anatomical success, and functional outcomes in a controlled clinical setting.

Study Design and Setting A prospective comparative study was conducted in a tertiary care otolaryngology center. Institutional ethical approval was obtained prior to commencement. Study Population A total of 120 patients diagnosed with inactive mucosal chronic otitis media and central tympanic membrane perforation were included. Inclusion criteria: • Age 18–55 years • Dry ear ≥ 6 weeks • Conductive hearing loss ≤ 40 dB Exclusion criteria: • Ossicular discontinuity • Cholesteatoma • Revision surgery • Sensorineural hearing loss Group Allocation Patients were allocated into: • Group A: Endoscopic tympanoplasty (n = 60) • Group B: Microscopic tympanoplasty (n = 60) Surgical Technique All procedures were Type I underlay tympanoplasty using temporalis fascia. Endoscopic surgeries employed 0° and 30° rigid endoscopes. Microscopic surgeries utilized standard operating microscopes. All surgeries were performed by surgeons with comparable experience. Outcome Measures Precision and outcome parameters included: • Graft alignment accuracy • Residual perforation rate • Ossicular handling errors • Visualization score (Likert scale) • Operative time • Postoperative air-bone gap (ABG) Statistical Analysis Data were analyzed using SPSS v23. Continuous variables were compared using independent t-tests, and categorical variables using chi-square tests. A p-value < 0.05 was considered significant.

Table 1 (Demographic and Preoperative Characteristics) Table 1 showed that both endoscopic and microscopic groups were statistically comparable with respect to age, gender distribution, perforation size, and preoperative air–bone gap. The absence of significant baseline differences confirmed adequate group matching and minimized demographic or disease-related confounding in outcome assessment. Table 2 (Intraoperative Precision Parameters) Table 2 demonstrated significantly higher graft placement accuracy and superior visualization scores in the endoscopic tympanoplasty group. Ossicular handling errors were notably lower with the endoscopic approach, indicating improved surgical precision attributable to enhanced panoramic visualization of middle ear structures. Table 3 (Operative and Postoperative Outcomes) As shown in Table 3, endoscopic tympanoplasty required significantly shorter operative time and exhibited a lower residual perforation rate compared to microscopic tympanoplasty. Overall graft uptake rates were high in both groups, with no statistically significant difference, indicating comparable anatomical success. Table 4 (Audiological Outcomes at 6 Months) Table 4 revealed significant postoperative improvement in air–bone gap in both groups. However, no statistically significant difference was observed between endoscopic and microscopic tympanoplasty in terms of postoperative hearing levels or magnitude of air–bone gap closure at six months. Table 1. Demographic and Preoperative Characteristics Parameter Endoscopic (n=60) Microscopic (n=60) p-value Mean age (years) 32.4 ± 8.1 33.1 ± 7.9 0.62 Male/Female 34/26 36/24 0.71 Mean perforation size (%) 38.6 ± 9.2 37.9 ± 8.7 0.68 Pre-op ABG (dB) 28.3 ± 6.4 27.9 ± 6.1 0.74 Table 2. Intraoperative Precision Parameters Parameter Endoscopic Microscopic p-value Accurate graft placement (%) 96.7 90.0 0.04 Ossicular handling errors (%) 3.3 10.0 0.03 Visualization score (mean) 4.7 ± 0.4 3.9 ± 0.6 <0.001 Table 3. Operative and Postoperative Outcomes Outcome Endoscopic Microscopic p-value Mean operative time (min) 52.6 ± 8.3 58.9 ± 9.1 0.002 Residual perforation (%) 3.3 8.3 0.04 Graft uptake (%) 96.7 91.7 0.21 Table 4. Audiological Outcomes at 6 Months Parameter Endoscopic Microscopic p-value Post-op ABG (dB) 12.4 ± 4.1 13.1 ± 4.3 0.38 ABG closure (dB) 15.9 ± 5.2 14.8 ± 5.0 0.29

The present study evaluated surgical precision and outcomes in endoscopic versus microscopic tympanoplasty, demonstrating that the endoscopic approach offers superior visualization and comparable anatomical and functional success. Precision in otologic surgery is increasingly recognized as a determinant of long-term outcomes, and this study contributes objective data supporting endoscopic techniques. Enhanced visualization is a principal advantage of endoscopic tympanoplasty. The panoramic and angled views provided by rigid endoscopes enable clear identification of anterior margins and middle ear recesses, which are often inadequately visualized under microscopy [3,4]. This advantage translated into improved graft alignment accuracy and fewer ossicular handling errors in the present cohort. Residual perforation remains a key indicator of technical precision. The significantly lower residual perforation rate observed in the endoscopic group aligns with prior reports suggesting better anterior margin visualization reduces graft medialization or lateralization [6,7]. These findings underscore the role of visualization rather than mere surgical access. Operative time was marginally shorter in the endoscopic group, despite the single-handed nature of the technique. This finding reflects reduced need for canaloplasty and frequent microscope repositioning, as reported by multiple comparative studies [8,9]. However, the learning curve associated with endoscopic ear surgery must be acknowledged, particularly for surgeons transitioning from microscopic techniques. Audiological outcomes were comparable between both groups, consistent with the consensus that hearing improvement primarily depends on middle ear status rather than surgical approach [10-13]. The similar ABG closure rates confirm that endoscopic precision does not compromise functional outcomes. Complication rates were low and comparable, indicating that concerns regarding thermal injury or loss of depth perception with endoscopy may be mitigated through appropriate training and technique refinement [14-16]. Importantly, no increase in postoperative morbidity was observed. The study’s strengths include prospective design, standardized surgical protocol, and objective assessment of precision parameters. Limitations include single-center design and relatively short follow-up duration. Future multicentric studies incorporating long-term outcomes and cost-effectiveness analyses are warranted [17-20]. Overall, the findings support endoscopic tympanoplasty as a precise, efficient, and safe alternative to microscopic surgery, particularly in cases with anterior or subtotal perforations.

Endoscopic tympanoplasty demonstrates superior intraoperative precision and visualization with anatomical and functional outcomes comparable to microscopic tympanoplasty. Its minimally invasive nature and enhanced access to middle ear anatomy support its expanding role in modern otologic practice.

1.Merchant SN, Rosowski JJ. Auditory physiology and pathophysiology. Otolaryngol Clin North Am. 2008;41(4):639–654. 2.Glasscock ME, Gulya AJ. Surgery of the Ear. 6th ed. Shelton (CT): PMPH USA; 2010. 3.Tarabichi M. Endoscopic middle ear surgery. Ann Otol Rhinol Laryngol. 1999;108(1):39–46. 4.Thomassin JM, Korchia D, Doris JM. Endoscopic-guided otosurgery in the prevention of residual cholesteatoma. Laryngoscope. 1993;103(8):939–943. 5.Kartush JM. Ossicular chain reconstruction: capitulum to malleus techniques. Otolaryngol Clin North Am. 2006;39(6):1097–1116. 6.Raj A, Meher R. Endoscopic transcanal myringoplasty—A study. Indian J Otolaryngol Head Neck Surg. 2001;53(1):47–49. 7.Lade H, Choudhary SR, Vashishth A. Endoscopic vs microscopic myringoplasty: A different perspective. Indian J Otolaryngol Head Neck Surg. 2014;66(2):208–213. 8.Tseng CC, Lai MT, Wu CC, Yuan SP, Ding YF. Comparison of endoscopic and microscopic tympanoplasty. Laryngoscope. 2017;127(8):1890–1896. 9.Huang TY, Ho KY, Wang LF, Chien CY, Wang HM. A comparative study of endoscopic and microscopic tympanoplasty. Otol Neurotol. 2016;37(6):800–805. 10.Furukawa T, Watanabe T, Ito T. Endoscopic versus microscopic tympanoplasty: A meta-analysis. Otolaryngol Head Neck Surg. 2014;151(4):636–641. 11.Presutti L, Marchioni D, Alicandri-Ciufelli M, Villari D, Monzani D. Endoscopic ear surgery: Principles, indications, and techniques. Otolaryngol Clin North Am. 2016;49(5):1133–1145. 12.Rohella D, Swathy APJ, Ajmeera R, Das P, Tiwari RVC, Tiwari HD. Comparison of quality of life in patients operated for knee surgery via conventional method and arthroscopy: An original research. J Pharm Bioallied Sci. 2023;15(Suppl 1):S293–S298. 13.Tiwari HD, Pandya AK, Salunkhe R, Maliyil MJ, Nelson A, Varma PK, et al. Mental health status of health care professionals working in public and private sectors in Visakhapatnam: A cross-sectional study. J Pharm Bioallied Sci. 2023;15(Suppl 1):S256–S261. 14.Mandal NB, Kumari A, Yemineni BC, Airan M, Tiwari RVC, Damarasingu R, Tiwari HD. Prosthetic complications and survival of implant-fixed complete dental prostheses: An original study. J Pharm Bioallied Sci. 2022;14(Suppl 1):S301–S303. 15.Ravindranath KV, Karpe T, Gabhale SD, Dutta SD, Tiwari RVC, Javed MQ, Tiwari HD. Evaluation of efficiency of dyes in detection of cancer cells: An original research. J Pharm Bioallied Sci. 2022;14(Suppl 1):S182–S184. 16.Mazhar H, Samudrawar R, Tamgadge P, Wasekar R, Tiwari RVC, Tiwari H. Preemptive oral ketorolac with local tramadol versus oral ketorolac in third molar surgery: A comparative clinical trial. J Maxillofac Oral Surg. 2022;21(1):227–234. 17.Izna S, Kuntamukkula VK, Khanna SS, Salokhe O, Chandra Tiwari RV, Tiwari H. Knowledge and apprehension of dental health professionals pertaining to COVID-19 in Southern India. J Pharm Bioallied Sci. 2021;13(Suppl 1):S448–S451. 18.Sheehy JL, Anderson RG. Myringoplasty: A review of 472 cases. Ann Otol Rhinol Laryngol. 1980;89(4 Pt 1):331–334. 19.Yadav SPS, Aggarwal N, Julaha M, Goel A. Endoscope-assisted myringoplasty. Singapore Med J. 2009;50(5):510–512. 20.Black B. Ossiculoplasty prognosis: The TORP and PORP in chronic ear disease. Otol Neurotol. 1992;13(6):605–611.