High-risk Perforation Research Articles

Comparison of Results of Myringoplasty with Temporalis Fascia and Perichondrial: Cartilage Composite Graft in High Risk Perforations

Background: The objectives of this study were to compare the graft uptake and post-operative hearing results of underlay myringoplasty with temporalis fascia and perichondrial-cartilage composite graft in high risk perforations. Materials & Methods: Patients of ages of 13 years and above with diagnosis of chronic otitis media – mucosal type with high risk perforations undergoing myringoplasty were included. Criteria of high risk were >50% perforation of tympanic membrane, revision cases, absent/eroded handle of malleus, oedematous/unhealthy middle ear mucosa and marginal perforation of any size. Pure tone audiometry was done within 1 week before surgery. Seventy cases included for myringoplasty were randomly allocated by lottery method into two groups with 35 cases each in temporalis fascia group and perichondrial - cartilage composite graft group. After 6 weeks graft uptake results were assessed and post-operative hearing was evaluated and compared within and between the groups. Results: Graft uptake rates in temporalis fascia group and perichodrial - cartilage composite graft group were 88.57% and 91.43%, respectively with no statistically significant difference between the groups (p = 0.69). The mean pre- and post-operative air bone gaps in temporalis fascia group were 31.81 ± 10.49 dB and 17.87 ± 7.96 dB. The mean pre- and post-operative air bone gaps in perichondrial - cartilage composite group were 35.19 ±7.26 dB and 22.62 ± 8.77 dB. These differences in both the groups were statistically highly significant (p < 0.001) showing improvement in the hearing after surgery. The mean post-operative ABG gains were 13.94 ± 8.36 dB and 12.57 ± 8.21 dB in temporalis fascia and perichondrial - cartilage composite groups respectively.
 Conclusion: The graft uptake rates and hearing results after perichondrial - cartilage composite graft are similar to those of temporalis fascia graft. Perichondrial- cartilage composite graft even though more rigid and thicker than temporalis fascia did not affect post-operative hearing results adversely

Role of cartilage graft in type 1 tympanoplasty: audiological and otologic outcomes

<p class="abstract"><strong>Background:</strong> Temporalis fascia is the most commonly used graft material for the tympanic membrane perforations. Due to high failure rate of temporalis fascia in adhesive otitis media, large perforations and advanced middle ear pathology alternate graft materials which are more rigid and resistant to infection are being used. Cartilage graft has shown to be a promising graft material in such cases. The purpose of this study was to evaluate the functional and anatomic results with cartilage graft in type 1 tympanoplasty.</p><p class="abstract"><strong>Methods:</strong> The present prospective study was conducted among 40 patients of chronic otitis media between 11-60 years of age requiring tympanoplasty in department of ear, nose and throat (ENT) in Government Medical College and Rajindra Hospital, Patiala. </p><p class="abstract"><strong>Results:</strong> The overall success rate of type 1 cartilage tympanoplasty was 85% in terms of perforation closure and post operative pure tone audiometry (PTA) at 6 weeks was 37.24 and at 12 weeks PTA was 34.27 The p value was <0.001 which was found to be significant. The AB gap closure at 6 weeks post op was 6.79 and at 12 weeks 9.76±2.12 dB.</p><p class="abstract"><strong>Conclusions:</strong> Based on the results of this study, it can be concluded that cartilage is more effective graft material in high-risk perforations, chronic ET dysfunction than fascia and audiological improvement with cartilage is found to be comparable with temporalis fascia.</p>

Tympanoplasty in high-risk perforation and atelectatic ear using perichondrium-cartilage island graft and temporalis fascia: A comparative analysis

Background: The prevalence of chronic otitis media in the Armed Forces is high. Moreover, management of high-risk perforation and atelectatic ear is an even greater challenge. It is necessary to assess the most viable management approach to achieve an optimal outcome. Aims and Objectives: We aimed to compare anatomical and audiological results in tympanoplasty for high-risk perforation and atelectasis using perichondrium-cartilage island (PCI) graft with temporalis fascia (TF) graft. Materials and Methods: A retrospective study was carried on 110 patients. Fifty-four patients and 56 patients underwent PCI graft and TF tympanoplasty, respectively. Postoperative graft integration rates and hearing outcomes were compared. Chi-square test was carried out to compare postoperative graft uptake. Postoperative audiological outcomes were compared using t-tests. Results: At 2-year follow-up, the graft take-up rate for PCI graft and TF graft was 96.29% and 82.14%, respectively (statistically significant). In the TF group, 17.86% had reperforation and recurrence of retraction pockets. In the PCI group, 3.71% had recurrent perforation. Furthermore, there was a statistically significant in the postoperative long-term improvement in pure-tone average air-bone gap in the cartilage island graft group (15.01 ± 3.53 db vs. 21.96 ± 4.09 db, P < 0.05). Conclusion: PCI graft achieves better morphological and audiological results in comparison to TF graft in high-risk perforation and atelectatic ears. It has a higher graft integration rate and better long-term audiological outcomes.

Correlation of Status of Mastoid with Outcomes of Myringoplasty with Cortical Mastoidectomy in Mucosal Otitis Media with High Risk Perforation

Introduction: Chronic mucosal otitis media is one of the common disease prevalent in our society. This study was done to correlate the status of mastoid with outcomes of myringoplasty with cortical mastoidectomy in mucosal otitis media with high risk perforation. Methods: This prospective, observational study was done at Department of Otorhinolaryngology and Head and Neck Surgery, Tribhuvan University Teaching Hospital. Thirty-four patients of ag|e 15 and above with chronic mucosal otitis media having high-risk perforation undergoing cortical mastoidectomy with myringoplasty were included. The status of middle ear, aditus, and mastoid air cells were assessed. Post-operatively, patients were assessed for graft uptake and hearing after three months. The post-operative graft uptake and hearing results were correlated with the peroperative status. Four patients who had preoperative sensorineural hearing loss were studied in terms of graft uptake only. Results: The graft success rate in patients with normal mastoid air cells was 90% whereas in diseased cases was 71.4% which was statistically not significant with p value 0.20. The success rate in terms of hearing was 68.8% in normal mastoid whereas it was 64.3% in diseased mastoid which was statistically not significant with p-value of 1. Conclusion: In correlation with the status of mastoid air cells with graft uptake and hearing result, the observed differences were not statistically significant. However, averages of post-operative air conduction threshold and air-bone gap of all cases were better as compared to preoperative levels.

Correlation of Status of Mastoid with Outcomes of Myringoplasty with Cortical Mastoidectomy in Mucosal Otitis Media with High Risk Perforation

Introduction Chronic mucosal otitis media is one of the common disease prevalent in our society. This study was done to correlate the status of mastoid with outcomes of myringoplasty with cortical mastoidectomy in mucosal otitis media with high risk perforation.&#x0D; MethodsThis prospective, observational study was done at Department of Otorhinolaryngology and Head and Neck Surgery, Tribhuvan University Teaching Hospital. Thirty-four patients of ag|e 15 and above with chronic mucosal otitis media having high-risk perforation undergoing cortical mastoidectomy with myringoplasty were included. The status of middle ear, aditus, and mastoid air cells were assessed. Post-operatively, patients were assessed for graft uptake and hearing after three months. The post-operative graft uptake and hearing results were correlated with the peroperative status. Four patients who had preoperative sensorineural hearing loss were studied in terms of graft uptake only.&#x0D; ResultsThe graft success rate in patients with normal mastoid air cells was 90% whereas in diseased cases was 71.4% which was statistically not significant with p value 0.20. The success rate in terms of hearing was 68.8% in normal mastoid whereas it was 64.3% in diseased mastoid which was statistically not significant with p-value of 1.&#x0D; ConclusionIn correlation with the status of mastoid air cells with graft uptake and hearing result, the observed differences were not statistically significant. However, averages of post-operative air conduction threshold and air-bone gap of all cases were better as compared to preoperative levels.

Endaural Over-Underlay Cartilage Tympanoplasty for Repair of Dry Subtotal Perforations.

We explored the auditory and anatomical success of grafting when the cartilage perichondrium (CP) was prepared using two different methods. Patients with subtotal or total perforation underwent tympanoplasty with a CP graft. A V-shaped groove for the handle of the malleus was prepared for CP grafts in patients in group 1. Patients in group 2 did not have a groove on the graft. The anatomical success of the graft was evaluated as success, partial success, or failure. Results of auditory evaluations were compared between the two groups. A total of 195 patients were included in the study. The total CP graft integration rate was 96% for both groups. Significant changes were detected in all hearing criteria evaluated 12 months after surgery compared to the preoperative period (P < .05). There were no significant differences between the groups in terms of the relationship between graft technique and postoperative hearing results. However, rates of partial success were significantly higher for group 1 than group 2 (P = .033). Cartilage slice support offers an extremely reliable method for reconstruction of tympanic membrane in cases of high-risk perforation. Partial failures are rare, but when they occur, they most often involved anterior graft medialization. When a piece of cartilage is removed at the malleus interface there may be a higher rate of partial failure.

Comparative study of outcomes of type-1 tympanoplasty with temporalis fascia only and with cartilage slice reinforcement

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Tympanoplasty is a surgical procedure performed to eradicate infection and restore the function of middle ear. Cartilage slice support offers an extremely reliable method for reconstruction of tympanic membrane in cases of high-risk perforation. The purpose of this study was to evaluate the graft uptake and auditory outcomes of type I tympanoplasty using temporalis muscle fascia only and with cartilage slice reinforcement.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; This prospective study was conducted at the Department of Otorhinolaryngology, Government Medical College, Jalaun, Uttar Pradesh, India from November 2016 to November 2019. There were total of 100 patients, divided in two groups, 50 patients in each group, tympanoplasty type-1 using only temporalis fascia (group-A) and tympanoplasty type-1 using temporalis fascia with cartilage slice reinforcement (group-B). The result was measured on graft uptake and hearing outcome at 6 months postoperatively. &lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Overall graft uptake rate in group-A was 94%, whereas that in group-B was 100%. The age and sex had no significant effect on the success rate of surgery (p&amp;gt;0.05) in group-A. The average air bone gap (ABG) decreased from 28.3 dB to 10 dB, in group-B, the average ABG was 28.3 dB preoperatively and reached 16.6 dB after surgery. The difference between the rates of ABG improvement in the two groups was significant (p&amp;lt;0.01).&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Hearing improvements is better in tympanoplasty type-1 with a temporalis graft only then with cartilage slice reinforcement. However, the graft uptake rate is higher in cartilage reinforcement compare with temporalis muscle fascia only.&lt;/p&gt;&lt;p class="abstract"&gt; &lt;/p&gt;

Tri-layer Tympanoplasty as a New Technique in High-risk Tympanic Membrane Perforations.

The eradication of the middle ear disease is mentioned as the fundamental principle of tympanoplasty. The presence of some factors related to patient or disease itself forces the physician to classify the chronic ear disease as high-risk perforations. The aim of this study was to present a tri-layer tympanoplasty technique and its otological and audiological outcomes in the ears with high-risk perforations. This retrospective study was carried out on a total of 46 eligible ears that had chronic otitis media with high-risk perforations. Preoperatively, 17, 15, and 14 ears were reported with Sade classification grade 4 pars tensa retraction (Group 1), total or near-total tympanic membrane perforation (Group 2), and a history of ear surgery (Group 3), respectively. All the cases had tympanoplasty using the tri-layer technique at a tertiary center during 2008 and 2014. A review of the patients' chart showed that 46 patients underwent tri-layer tympanoplasty. Regarding the audiological outcomes, the comparison of pre- and post-operative results revealed mean air conduction level and mean air-bone gap (ABG) of 4 different frequencies in dB according to a new standardized format for reporting hearing outcome in clinical trials. The mean value of the follow-up period was reported as 29.22±3.23 months. Graft take rate was 93.4 % in all the cases, as well as 94.1%, 100%, and 85.7% in Group 1, Group 2, and Group 3, respectively. The mean values of ABG were improved from 35.17±6.64 to 23.52±10.4, 30.46±5.89 to 17.20±8.04, and 29.14±8.37 to 16.14±5.02 dB in Group 1, Group 2, and Group 3, respectively (P<0.05). Tri-layer tympanoplasty is a reliable procedure in the surgical treatment of the chronic otitis media with high-risk re-perforations.

Outcome of Myringoplasty with Temporalis Fascia and Perichondrial-Cartilage Composite Graft in High Risk Perforations

The objective of this study was to compare the graft uptake results and postoperative hearing of myringoplasty with temporalis fascia and cartilage-perichondrial composite graft in high risk perforations. Patients of age 13 years and above with diagnosis of chronic otitis media – mucosal type with high risk perforation that is &gt;50% perforation of tympanic membrane, revision cases, absent/ eroded handle of malleus, oedematous/unhealthy middle ear mucosa and marginal involvement cases were included for myringoplasty. Pure Tone Audiometry was done within 1 week before surgery. 80 cases were included for myringoplasty which were randomly allocated by lottery method with 40 cases each in temporalis fascia group and cartilage perichondrial composite graft group. Graft uptake results were assessed after 6 weeks and postoperative hearing was evaluated and compared within and between the groups. Graft uptake rate in temporalis fascia group and cartilage perichondrial composite graft group was 90% and 92.5%, respectively with no significance difference in the graft uptake rate (p = 0.692) between the groups. The mean pre and post-operative air bone gap in temporalis fascia group and cartilage perichondrial composite group were 30.69dB±10.19,16.36±8.37dB and 33.73±8.07dB, 20.76±9.47dB, respectively with highly significant difference in both groups (p &lt; 0.001) showing improvement in the hearing after surgery in both groups. The mean air bone gain were 14.33dB and 12.97dB in temporalis fascia and cartilage perichondrial composite group respectively with no significant difference between the groups (p=0.469). The graft uptake rate and hearing results after cartilage perichondrial composite graft are comparable to those of temporalis fascia graft. Furthermore, the cartilage perichondrial composite graft is more rigid and thick so it is more resistant than fascia to anatomic deformation and necrosis. Therefore, we recommend the use of cartilage perichondrial composite graft for tympanic membrane reconstruction in high risk perforation without concern about affecting audiometric results.

Maximising Graft Take-Up in Type1 Tympanoplasty Using Peripheral Cartilage Ring and Perichondrium.

The aim of this study is to evaluate the results of closure of big central and subtotal perforation by Tympanoplasty using underlay technique with Composite graft of tragal perichondrium supported by a ring of cartilage peripherally. Our hypothesis was that the cartilage support offers an extremely reliable method for reconstruction of the tympanic membrane in cases of advanced middle ear pathology and Eustachian tube dysfunction and also revision cases. Prospective study of patients undergoing tympanoplasty in big central and subtotal perforation with graft supported by a ring of cartilage peripherally between June 2016 and August 2016. Hearing results were reported using four frequency (500, 1000, 2000 and 3000) pure tone average air-bone gap. During the study period, composite graft comprising of tragal perichondrium and peripheral ring of cartilage prepared from ipsilateral tragus was used for tympanic membrane reconstruction in 30 patients. Overall graft take rate was 93.33%. Complications included residual perforation in 6.67%. Cartilage ring support offers an extremely reliable method for reconstruction of tympanic membrane in cases of high-risk perforation (big central perforation, subtotal perforation, anterior perforation of tympanic membrane, revision cases).

薄切しない軟骨膜/軟骨島状弁を用いた鼓室形成術

Grafting of cartilage has been recognized as useful for tympanoplasty of retracted ear drums or ear drums with high-risk perforation.

Percutaneous drain for high risk cases of perforative peritonitis

Background: Perforative peritonitis is most common general surgery emergency encountered. It is also associated with high operative mortality and morbidity. Most cases present late on second and third day with severe peritonitis and hemodynamic instability. Resulting in hypotension and circulatory shock due to septicaemia and third space fluid loss. In these patients conventional immediate laparotomy and perforation closure was associated with high mortality. Henceforth we managed those high risk patients with percutaneous drain and conservative Taylor’s regimen was followed. Methods: Aim of this study was to analyse series of high risk perforation cases managed with percutaneous drain under local anesthesia for whom conventional surgery of immediate laparotomy were associated with high mortality rates. Those conservatively managed patients were serially monitored and put on Taylor’s regimen previously used for sealed early perforation. Results: Retrospectively 9 cases of high risk perforative peritonitis managed with percutaneous drain were studied and we found that mortality rate was 22% compared to more than 60% in cases taken up for immediate laparotomy. Conclusions: High risk patients for whom conventional surgery is associated with increased mortality, percutaneous drain under local anaesthesia and improving the hemodynamic status by non-operative Taylor’s regimen seems to be associated with decreased mortality and morbidity.

Technique and results of cartilage shield tympanoplasty

Aim: Use of cartilage for repair of tympanic membrane is recommended by many otologists. The current study aims at evaluating results of cartilage shield tympanoplasty in terms of graft take up and hearing outcomes. Material and Methods: In the current study, cartilage shield tympanoplasty(CST) is used in ears with high risk perforations of the tympanic membrane. A total of 40 ears were selected where type I CST was done in 30 ears and type III CST was done in 10 ears. Results: An average of 37.08 dB air bone gap(ABG) was present in pre operative time and an average of 19.15 dB of ABG was observed at 6 months after the surgery with hearing gain of 17.28 dB on average was observed. Graft take up rate of 97.5% was observed. The technique is modified to make it easier and to minimize chances of lateralization of graft. Conclusion: The hearing results of this technique are comparable to other methods of tympanic membrane repair.

Tympanoplasty in Subtotal Perforation with Graft Supported by a Slice of Cartilage: A Study with Near 100 % Results

The aim of this study is to evaluate the results of closure of subtotal perforation by tympanoplasty using underlay technique with the perichondrium/temporalis fascia graft supported by single cartilage slice anteriorly. Our hypothesis was that the cartilage support, single slice, offers an extremely reliable method for reconstruction of the tympanic membrane in cases of advanced middle ear pathology and Eustachian tube dysfunction. Retrospective and prospective study of patient undergoing tympanoplasty in subtotal perforation with graft supported by a slice of cartilage between March 2000 and October 2005. Intact perichondrium/temporalis fascia was placed as graft in subtotal perforation, supported by a slice of cartilage. Slice was placed anteriorly from hypotympanum to anterior part of attic. It does not obstruct Eustachian tube opening, as it is curved with concavity facing towards medial wall and lined by perichondrium without any raw area, which prevents adhesion formation. Hearing results were reported using four frequency (500, 1,000, 2,000 and 3,000) pure tone average air-bone gap. During the study period, perichondrium/temporalis fascia graft with support of cartilage slice was used for tympanic membrane reconstruction in 94 patients. Overall graft take rate was 98.94%. In 95.74% of patients of different types of tympanoplasty achieved hearing level of 30dB or less. Complications included residual perforation in (1.06%), infection or gaping of wound in 2 (2.13%). Cartilage slice support offers an extremely reliable method for reconstruction of tympanic membrane in cases of high-risk perforation (subtotal perforation, retraction pocket, cholesteatoma, anterior perforation of tympanic membrane).

Audiological and graft take results of cartilage reinforcement tympanoplasty (a new technique) versus fascia

Our objective is to compare hearing and graft take results of temporal muscle fascia tympanoplasty and cartilage reinforcement tympanoplasty. Seventy seven patients are classified into two groups: Group 1 included 37 patients for whom cartilage graft, harvested from symba concha, is used as reinforcement under temporalis muscle fascia anteriorly and Group 2 included 40 patients for whom only temporalis muscle fascia is used in type 1 tympanoplasty. A pure-tone audiometry is done within 1 week prior to surgery and at 6 months postoperatively. There is statistically significant difference between postoperative graft take results among groups. In both groups postoperative anterior TM perforation is encountered most commonly. Success rate of cartilage reinforcement tympanoplasty in revision patients is 100% but temporal muscle fascia tympanoplasty's is 66%. There is no statistically significant difference between preoperative and postoperative air conduction gain of TM intact patients. The results indicated that Cartilage reinforcement myringoplasty technique under anterior of the temporal muscle fascia significantly increases the graft take ratios in high-risk perforations and it also does not affect hearing levels. Therefore, the authors suggest usage of cartilage reinforcement tympanoplasty technique under anterior of the temporal muscle fascia which is an easy and applicable technique to increase graft take ratios, particularly in patients with preoperative anterior and subtotal TM perforations.

Cartilage reinforcement tympanoplasty: otological and audiological results

Conclusion: High risk perforations including total, subtotal, atelectatic perforations, those with cholesteatoma and revision cases can be treated efficiently with cartilage reinforcement tympanoplasty. Objective: The purpose of this study was to describe the perforation closure rates and hearing results of cartilage reinforcement tympanoplasty. Methods: This was a retrospective chart review and included 60 patients who underwent surgery with the cartilage reinforcement technique between November 2006 and October 2008 at the Department of Otorhinolaryngology of Haydarpasa Numune Research and Training Hospital, Istanbul, Turkey. The male to female ratio was 28 (46.7%)/32 (53.3%). The mean age of the patients was 30.10 ± 11.50 years (range 13–55). Results: Preoperatively, only one patient had a retraction pocket but not a perforation, 12 (20%) patients had perforation of < 25% of the total tympanic membrane diameter, 12 patients had perforation between 25% and 50% of the total membrane diameter, 18 patients had a perforation between 50% and 75% of total membrane diameter and 17 patients had a perforation of > 75% of the total membrane diameter. Postoperatively we achieved total closure of tympanic membrane perforations for 47 patients but the perforations of 13 patients remained in various sizes (7 patients had tympanic membrane perforation < 25% of the total membrane diameter, 3 between 25% and 50%, 2 between 50% and 75% and 1 patient had a perforation > 75% of the total membrane diameter). There was a statistically significant difference between percentages of preoperative perforation and postoperative perforations (p = 0.001). Only 1.7% of patients had no perforation preoperatively and this ratio increased to 78.3% postoperatively. Also, 30% of patients had a perforation between 50% and 75% of the total membrane diameter, 28.3% of the patients had a perforation > 75% of the total membrane diameter preoperatively and this ratio decreased to 3.3% and 1.7%, respectively. Concerning the audiological parameters, the difference between preoperative and postoperative hearing levels was statistically significant (p = 0.001).

Island cartilage myringoplasty. Anatomical and functional results in 122 cases

Introduction and objectivesIn certain situations (“high risk perforations”) such as large perforations, revision cases, middle ear pathology, eustachian tube dysfunction and atelectatic ears, the failure rate for myringoplasty is high. Some authors have suggested that the materials most frequently used for myringoplasty (fascia and perichondrium) may play a role in this failure rate. Cartilage myringoplasty, however, achieves good results in these “high risk” cases. The purpose of this study was to analyse our results and describe the technique. MethodsA retrospective study of all consecutive patient charts for cartilage myringoplasties performed in a 5-year period (2002–2007) was carried out. ResultsDuring the study period, cartilage was used in 99 patients (122 cases). More than 66% of the cases were large perforations and 26% of the cases were revision cases. Successful closure was achieved in 92% of the cases and the functional results showed improvement in the air-bone gap average with statistical significance for type I tympanoplasty. DiscussionThe reconstruction of tympanic membrane perforations with cartilage is recommended in certain cases (“high risk” perforations). The results described here show that the anatomical and functional results are good and we consider the technique easy to learn. ConclusionsWe consider cartilage myringoplasty to be a technique that can be used in “high risk” perforations where a technique using fascia or perichondrium may have a higher risk of failure.

Miringoplastia con cartílago «en isla». Resultados anatómicos y funcionales de 122 casos

Introduction and objectivesIn certain situations (“high risk perforations”) such as large perforations, revision cases, middle ear pathology, eustachian tube dysfunction and atelectatic ears, the failure rate of myringoplasty is high. Some authors have suggested that the materials most frequently used for myringoplasty (fascia and perichondrium) may have a role in this failure rate. Cartilage myringoplasty, however, achieves good results in these “high risk” cases. The purpose of this study is to analyze our results and describe the technique. MethodsA retrospective study of all consecutive patient charts for cartilage myringoplasties performed in a 5-year period (2002–2007) was carried out. ResultsDuring the study period, cartilage was used in 99 patients (122 cases). More than 66% of the cases were large perforations and 26% of the cases were revision cases. Successful closure was achieved in 92% of the cases and the functional results show an improvement in the air-bone gap average with statistical significance for type I tympanoplasties. DiscussionThe reconstruction of tympanic membrane perforations with cartilage is recommended in certain cases (“high risk” perforations). The results described here show that the anatomical and functional results are good and we consider the technique easy to learn. ConclusionsWe consider cartilage myringoplasty a technique that could be used in “high risk” perforations where a technique using fascia or perichondrium may have a higher risk of failure.