Air bone closure and graft uptake, vis a vis tympanic reconstitution


  • Manish Munjal Department of ENT-HNS, Dayanand Medical College, Ludhiana, Punjab, India
  • Nitin Mathur Department of ENT-HNS, Dayanand Medical College, Ludhiana, Punjab, India
  • Parth Chopra Department of ENT-HNS, Dayanand Medical College, Ludhiana, Punjab, India
  • Shubham Munjal Department of Physiology, Dayanand Medical College, Ludhiana, Punjab, India
  • Hemant Chopra Department of ENT-HNS, Dayanand Medical College, Ludhiana, Punjab, India
  • Ayushi Garg Department of ENT-HNS, Dayanand Medical College, Ludhiana, Punjab, India
  • Anurima Arora Department of ENT-HNS, Dayanand Medical College, Ludhiana, Punjab, India



Perforation, Tympanoplasty, Overlay, Underlay


Background: Tympanoplasty involves reconstitution of the tympano-ossicular system with commonly. fascia of the temporalis muscle, situated in its proximity. The fascia is grafted on the residual tympanic membrane by placing it either over it or below it, after creating a raw surface. The former is the overlay and latter, the underlay technique. In this study on restitution of the ear drum utilizing the overlay and underlay techniques, an exhaustive analysis of the two modalities has been done, taking into consideration various variables individually. The surgical outcome wrt to graft uptake and hearing gain has been compared in "depth" with extensive studies undertaken in India and abroad. The unbiased tabulated comparison of each aspect is unique and would guide future researchers to opt the ideal modality.

Methods: Tympanoplasty was undertaken in chronic safe suppurative otitis media with the underlay and overlay techniques in a study group of 40 patients in this prospective study. The patients were randomly divided into equal groups for either procedure.  

Results: In the cohort of 40 subjects successful graft uptake was observed in 16 (80%) with overlay technique and 17 (85%) with underlay technique. Graft rejection was reported in 4 (20%) and 3 (15%) cases with overlay and underlay techniques respectively. Hearing improvement was 56.25% in 10-20 dB range in Overlay. Whereas, with underlay it was 47.05% in 10-2 dB.

Conclusions: Overlay technique is ideal for anterior and central perforations while underlay for subtotal and posterior perforations. In terms of hearing improvement, the fibrosis during graft uptake makes the results of either technique unpredictable.

Author Biography

Manish Munjal, Department of ENT-HNS, Dayanand Medical College, Ludhiana, Punjab, India

Professor and Head, Deptt of ENTHNS


Shenoi M. Management of CSOM. Scott Brown. Edition V. 1987;(3).

Podoshin L. and Fradis M. Tympanoplasty in Adults. ENT J. 1966;75:149-52.

Wang WH, Lin YC, Minimally invasive inlay and underlay myringoplasty. Am J Otolarngol 2008;29;363-6

Doyle PJ. Schleuning AJH, Echevarna J. Tympanoplasty should graft be placed medial or lateral to tympanic membrane. Laryngosc. 1972;82;1425-30

Glasscock ME IIOI, Tympanic membrane grafting with fascia; overlay vs under surface technique. Laryngosc. 1973;83:754-70.

Rizer FM. Overlay versus underlay tympanoplasty part I: Historical review of the literatre. Laryngosco. 1997;107;1-25.

Packer P, Mackendrick A, Solar M. What’s best in myringoplasty underlay or overlay, dura or fascia. J Laryngol Otol. 1982;96:25-41.

Sergi B, Galll J, De Corso E, Pari, Paludeffi G. Overlay versus underlay myringoplasty, Report of outcomes considering closure of perforation and hearing function. Acta Otorhinolaryngol Ital. 2011;31:366-71.

Singh M, Rai A, Bandhyopadhyay S, Gupta SC, Comparative study of the underlay and overlay techniques of myringoplasty in large and subtotal perforations of the tympanic membrane. J Lryngol Otol. 2003;117:444-8.

Kalsotra P, Gupta R, Gupta N, kotwal S, Suri A, Kanotra S, Overlay versus Underlay myringoplasty, A comparative study. Ind J Otol. 2014;20:183-8

Fadi FA. Outcome of type -1 tympanoplasty. Saudi Med J. 2003;24;58-61.

Brown CY, McCarty DJ, Briggs RJ. Success rate following myringoplasty at the Royal Victoria Eye and Ear Hospital. Aust J Otolaryngol. 2002;29;606-11.

Mahesh SG, Pai VK, Pavithran P, Nithin PS. Myringoplasty underlay versus overlay –a comparative study. Int. J Otorhinolaryngol Head Neck Surg. 2018;4:381-6.

Sheehy JL and Anderson RG. Myringoplasty: A review of 472 cases. Ann. Otol Rhino Laryngol. 1980;89(4):331-4.

Gupta SC. Myringoplasty with a single flap. Ear, Nose, Throat L. 2000;79:946-8.

Ferraro V, Albera R, Canale G. Annular wedge tympanoplasty-a variation of overlay myringoplasty. Acta Otorhinolaryngol Ital. 1997;17;15-21.

Rodriguez GL, Landa M, Rivas A, Navarro J, Camacho J, Algaba J. Myringoplasty Onlay vs Overlay. Review of 460 cases. Acta Otolaryngologol Exp. 1996;47;21-5.

Yung MW. Myringoplasty for subtotal perforation. Clin Otolaryngol Allied Sci. 1995;20;241-5.

Gibbs AG, Chang SK. Myringoplasty, A review of 365 operations. J Laryngol Otol. 1982;96;915-30.

Ashfaq M, Aasim MU, Khan N Myringoplasty; Anatomical and functional results, pak Armed Forces Med J. 2004,54;155-B.

Khan IZ Khan Tympanoplasty of combined military hospital Rawalpindi. Pak Armed Force Med J. 1995;45;33-5.

Black JH, Wormald PJ. Myringoplasty effects on hearing and contributing factors. S Afr Med J. 1995;85;41-3.

Perkins R, Bui HT, Tympanic membrane reconstruction using formaldehyde-formed autogenous temporalls fascia;twenty years experience, Otolaryngol Head Neck Surg. 1996;114;366-79.

Seifie AEL Myringoplasty, Repair of total of sub-total drum perforations. J Laryngol Otol. 1974,88;731-40.

Strauss P, Kress M. Medial or Lateral Placement of the graft in Myringoplasty. Laryngol Rhinol Otol. 1975;54;183-90.

Smyth GDL. Tympanic reconstruction - Fifteen year report tympanoplasty Part II. J Laryngol Otol. 1976; 70;713-40.

Koch WM. Friedman EM, McGill TJI, Healy GB. Tympanoplasty in Children: The Boston Children's Hospital Experience. Arch Otolaryngol Head Neck Surg. 1990;116(1):35-40.

Wyne M. Tympanoplasty in children. Arch Otolaryngol Head Neck Surg. 1990116 :35-40.

Vartiainen E, Karja J Failures in myringoplasty. Archiv Otorhinolaryngol. 1985;242;27-33.






Original Research Articles