The endoscopic “push-through” cartilage myringoplasty technique has many advantages: no postauricular incision, no tympanomeatal flap, no ear packing postoperatively, minimal or no pain, 1-day surgery, shorter operation time (20–35 min), and relative low costs.

The endoscope’s wide-field vision allows visualization of the entire perforation, and the undersurface of the tympanic membrane can also be assessed. This allows for repair of the perforation without any possibility of an iatrogenic cholesteatoma, unlike the conventional myringoplasty. Furthermore, endoscopic surgery gives better demonstration of the surgical steps, along with viewing of the anatomic structures in the same field, resulting in a better appreciation of their relationship [4].

In our study, the otoendoscope was utilized for inspection of medial surface of the tympanic membrane, as well as the status of ossicular chain. With the aid of the endoscope and curved instruments, removal of epithelial ingrowth from medal surface of tympanic membrane was feasible.

Endoscopic ear surgery is a one-handed technique. The rigid endoscope has to be held in the left hand having the right hand free to operate. This becomes a challenge when there is excessive bleeding. Many solutions can help to reduce the bleeding: preoperative local preparation, low and stable operative blood pressure, local adrenalin, and special instruments with suction [4].

In our series, bleeding presented as a challenge. It was due to contact of the endoscope and instruments with the canal wall. This was more evident in our first cases. Using only one hand for the surgery and suction prompted as a learning challenge. Maintaining a low stable operative blood pressure and low pulse rate helped reduce bleeding. Adrenaline-soaked cottonoids also helped stop bleeding in the operative field.

One other drawback of endoscopic myringoplasty is the difficulty to operate directly off the endoscope leading to neck strain and backache. Therefore, the camera and monitor were always used. This increased the weight of the endoscope, leading to arm fatigue.

Celik et al. in 2015 treated 32 patients with endoscopic push-through myringoplasty with graft success rate 87.5%, air-bone gap closure </=10 dB 91% [5].

El-Guindy et al. in 1992 underwent endoscopic transcanal myringoplasty on 36 patients with graft success rate 91.7%, air-bone gap closure </=10 dB 83.3% [6].

Ayache in 2013 reported an uptake rate of 96% in the 1-year follow-up period in 30 cases operated upon [3].

Huang et al. in 2016 had a success rate of 98% in 6 months follow-up period in fifty cases using endoscopic myringoplasty with cartilage graft. His study had a hearing improvement of 8.9 dB in the air-bone gap [7].

Mokbel et al. in 2015 had a graft uptake rate of 100% in type 1 cartilage tympanoplasty in forty ears with a follow-up period between 6 months and 1 year. He had a postoperative hearing improvement of the air-bone gap of 8.50 ± 1.25 dB [8].

Singh et al. in 2013 with an uptake rate of 92.85% in twenty-eight ears at 2 year follow-up. They had an average postoperative air-bone gap of 15.65 dB [9]. Özgür et al. in 2016, after 6-month follow-up, had a success rate of 92.5% in fifty-three ears with hearing improvement, with a postoperative air-bone gap of 10 ± 7 dB. All of our surgeries were performed by the endoscopic transcanal approach; none needed microscope, nor the postaural or the endaural approach [10].

Usami et al. in 2001, in their study, had twenty-two myringoplasty patients treated with endoscopy with a follow-up period of 1 year. The perforation closure rate was 81.8%, and improvement in air-bone gap after surgery was 14.8 dB [11].

Karhketo et al. in 2001 reviewed the data of twenty-nine endoscopic-assisted myringoplasty patients with a follow-up time of 1 year. The perforation closure rate was 80%, and improvement in air-bone gap after surgery was 7 dB [12].

Raj et al. in 2001 performed twenty endoscopic transcanal tympanoplasties had a closure rate of 90%, and the postoperative air-bone gap was < 10 dB in 60% of the ears [13].

In the present study, we achieved comparable results with a graft uptake rate of 85%. There was a statistically significant improvement in hearing outcome, with ABG gain of 7.75 ± 4.82.

Unlike the microscope, the endoscope can easily be transported and used in temporary ear surgery locations that take place in far less prepared places. Also, the endoscope costs less than the microscope, so it can be an efficient substitute in the healthcare facilities which cannot afford a microscope.

Drawbacks and limitations of this study

Incorporating the endoscope in ear surgery has a steep learning curve. One-handed technique poses as a challenge. External canal wall injury and bleeding could be troublesome. Availability of camera and monitor is mandatory to avoid back and arm fatigue. Operating on a larger scale for different tympanic membrane perforations regarding the size and site will give a better evaluation of the outcome using this technique.

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