Comparison between overlay and underlay primary myringoplasty: retrospective analysis on anatomical and functional results in 497 adult patients

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Filippo Ricciardiello
Davide Pisani
Gerardo Petruzzi
Pasquale Viola
Remo Palladino
Giulio Sequino
Aldo Falco Raucci
Giovanni Motta
Ciro Coppola
Michele Cavaliere
Alessia Astorina
Claudio Di Nola
Flavia Oliva
Alfonso Scarpa
Giuseppe Chiarella


Myringoplasty; Graft; Tympanic membrane perforation; Surgery; Healing; Hearing function


Purpose: Retro-auricular approach using an autologous graft is the main surgical method for myringoplasty (MPL). Endaural and transcanal or endoscopic approaches are also used. There is no definitive consensus on the best MPL surgical technique. The aim of this study is to compare the two most used technique, over and underlay MPL, to evaluate the difference in anatomical and functional outcomes. Materials and methods: We made a retrospective analysis of 497 adult patients who underwent underlay or overlay primary MPL, between 2010 and 2018, and evaluated the difference in anatomical and functional outcomes. Results: Successful functional results, evaluated 18 months after surgery, were obtained in 380 patients (76,4%); the underlay MPL obtained a successful result in 85% of patients, while the overlay technique in the 68%. We observed anatomical failure in 13.4% patients, in detail 9,8% of underlay MPL and 17,2% of overlay MPL had an anatomical failure. Conclusion: Our results show less complications related to the underlay technique. We believe that this remains the technique to prefer, except in subtotal or wide anterior perforations that could be better managed using the overlay technique.


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1. Merkus P, Kemp P, Ziylan F, Yung M. Classifications of Mastoid and Middle Ear Surgery: A Scoping Review. J Int Adv Otol 2018 Aug;14(2):227-232. doi: 10.5152/iao.2018.5570. PMID: 30100541; PMCID: PMC6354474.

2. Lagos A, Villarroel P, García-Huidobro F, Delgado V, Huidobro B, Caro J, San Martín J. Tympanoplasty: factors associated with anatomical and audiometric results. Acta Otorrinolaringol Esp 2020 Jul-Aug;71(4):219-224.

3. Van Stekelenburg BCA, Aarts MCJ. Determinants influencing success rates of myringoplasty in daily practice: a retrospective analysis. Eur Arch Otorhinolaryngol 2019 Nov;276(11):3081-3087.

4. Tan HE, Santa Maria PL, Eikelboom RH, Anandacoomaraswamy KS, Atlas MD. Type I Tympanoplasty Meta-Analysis: A Single Variable Analysis. Otol Neurotol 2016 Aug;37(7):838-46.

5. Yigit O, Alkan S, Topuz E, Uslu B, Unsal O, Dadas B. Short-term evaluation of over-under myringoplasty technique. Eur Arch Otorhinolaryngol 2005 May;262(5):400-3.

6. Committee on Hearing and Equilibrium guidelines for the evaluation of results of treatment of conductive hearing loss. AmericanAcademy of Otolaryngology-Head and Neck Surgery Foundation, Inc. Otolaryngol Head Neck Surg 1995 Sep;113(3):186-7.
7. Wullstein H. Theory and practice of tympanoplasty. Laryngoscope 1956 Aug;66(8):1076-93.

8. Merchant SN, Rosowski JJ, McKenna MJ. Tympanoplasty, Operative Techniques in Otolaryngology-Head and Neck Surgery, Volume 14, Issue 4, 2003, 14(4):224-236.

9. Nardone M, Sommerville R, Bowman J, Danesi G. Myringoplasty in simple chronic otitis media: critical analysis of long-term results in a 1,000-adult patient series. Otol Neurotol 2012 Jan;33(1):48-53.

10. Halik JJ, Smyth GD. Long-term results of tympanic membrane repair. Otolaryngol Head Neck Surg 1988 Feb;98(2):162-9.

11. Vartiainen E. Findings in revision myringoplasty. Ear Nose Throat J 1993 Mar;72(3):201-4.

12. Sadé J, Berco E, Brown M, Weinberg J, Avraham S. Myringoplasty: short and long-term results in a training program. J Laryngol Otol 1981 Jul;95(7):653-65.

13. Sheehy JL, Anderson RG. Myringoplasty. A review of 472 cases. Ann Otol Rhinol Laryngol 1980 Jul-Aug;89(4 Pt 1):331-4.

14. Packer P, Mackendrick A, Solar M. What's best in myringoplasty: underly or overlay, dura or fascia? J Laryngol Otol 1982 Jan;96(1):25-41.

15. El-Seifi A, Fouad B. Granular myringitis: is it a surgical problem? Am J Otol 2000 Jul;21(4):462-7.

16. El-Seifi A, Fouad B. The fibrous annulus in myringoplasty. J Laryngol Otol 1992 Feb;106(2):116-9.

17. Gersdorff M, Garin P, Decat M, Juantegui M. Myringoplasty: long-term results in adults and children. Am J Otol 1995 Jul;16(4):532-5.

18. Vartiainen E, Nuutinen J. Success and pitfalls in myringoplasty: follow-up study of 404 cases. Am J Otol 1993 May;14(3):301-5.

19. Perkins R, Bui HT. Tympanic membrane reconstruction using formaldehyde-formed autogenous temporalis fascia: twenty years' experience. Otolaryngol Head Neck Surg 1996 Mar;114(3):366-79.

20. Choi N, Noh Y, Park W, Lee JJ, Yook S, Choi JE, Chung WH, Cho YS, Hong SH, Moon IJ. Comparison of Endoscopic Tympanoplasty to Microscopic Tympanoplasty. Clin Exp Otorhinolaryngol 2017 Mar;10(1):44-49.

21. Sergi B, Galli J, De Corso E, Parrilla C, Paludetti G. Overlay versus underlay myringoplasty: report of outcomes considering closure of perforation and hearing function. Acta Otorhinolaryngol Ital 2011 Dec;31(6):366-71.

22. Singh M, Rai A, Bandyopadhyay S, Gupta SC. Comparative study of the underlay and overlay techniques of myringoplasty in large and subtotal perforations of the tympanic membrane. J Laryngol Otol 2003 Jun;117(6):444-8.

23. Latini G, Laudadio P. La terapia chirurgica degli esiti di otite cronica: la miringoplastica - complicanze ed insuccessi nella MPL. In: Società Italiana di Otorinolaringologia e Chirurgia Cervico-Facciale, editor. Attualità in tema di chirurgia dell’orecchio medio, relazione ufficiale XCIII Congresso Nazionale SIO, Bologna, 2006, p 155-171.

24. Bedri EH, Worku A, Redleaf M. The effect of surgeon experience on tympanic membrane closure. Laryngoscope Investig Otolaryngol 2019 Jul 27;4(5):526-531.

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