Endoscopic Double-Flap Tympanoplasty Versus Classical Underlay Technique for Anterior Quadrant Perforations: A Prospective Comparative Study

Abstract

Introduction: Anterior quadrant tympanic membrane perforations continue to pose a surgical challenge due to limited annular support, shallow anterior canal anatomy, and reduced vascularity, all of which predispose to graft instability and higher failure rates. Conventional underlay tympanoplasty often struggles to achieve consistent closure in this region. The double-flap tympanoplasty technique, incorporating both anterior and posterior tympanomeatal flaps, aims to strengthen anterior graft anchorage and improve surgical outcomes.

Study: This prospective comparative study included 62 patients with anterior quadrant perforations, randomly assigned into Group A (Classical Tympanoplasty, n = 31) and Group B (Double Flap Tympanoplasty, n = 31). All surgeries were performed endoscopically using temporalis fascia grafts. Preoperative assessment included otoscopy, HRCT temporal bone, and pure tone audiometry. Patients were followed for three months, evaluating graft uptake, residual perforation, graft lateralisation, anterior blunting, and hearing improvement. Statistical analysis included chi-square and t-tests.

Results: Graft uptake was higher in the double-flap group (96.7%) compared to the classical group (87.1%). Residual perforation occurred in 12.9% of Group A and 3.2% of Group B. Graft lateralisation was noted exclusively in Group A (9.7%). Hearing outcomes favoured the double-flap technique, showing greater audiological gain at three months (12.84 ± 1.73 dB versus 10.24 ± 0.95 dB) and better air–bone gap closure (10.94 ± 2.98 dB versus 12.70 ± 2.49 dB), both statistically significant.

Conclusion: Double Flap Tympanoplasty offers improved graft stability, reduced residual perforation, and superior hearing outcomes compared to Classical Tympanoplasty in anterior quadrant perforations. It represents a safe, effective, and advantageous modification for challenging anterior defects, especially larger perforations requiring enhanced anterior support.