Introduction
Background
Tympanoplasty can be performed through post-aural, endaural or permeatal approaches.Reference Brar, Watters and Winters1 While previous research has focused on auditory outcomes and perforation closure rates,Reference Rahman and Atikuzzaman2 patient perspectives on these approaches remain underexplored. This study investigates patient experiences with permeatal and post-aural tympanoplasty.
Objectives
The study aimed to evaluate patient preferences, post-operative symptoms and recovery times associated with permeatal versus post-aural tympanoplasty, with a focus on scar-related concerns and complications.
Methodology
Reporting guideline
Strobe guidelines were used for reporting the study findings.
Study design
This was a retrospective study involving patients (telephonic consultation) who underwent tympanoplasty (permeatal or post-aural) at a secondary care hospital between 2019 and 2022.
Setting and participant cohort
The study took place and was registered in a UK secondary care hospital. It encompassed 54 consecutive patients who provided consent and demonstrated the ability to be able to participate. Exclusions were attributed to factors such as non-consent, communication challenges, language barriers and health-related impediments. Included in this group were individuals who underwent tympanoplasty via either the post-aural or the permeatal method.
Procedures spanned tympanoplasty (ossicular reconstruction was performed as part of the tympanoplasty procedure in 5 cases in the permeatal group and in 6 cases in the post-aural group) and limited atticotomy (4 cases of atticotomy out of total of 54 cases). Mastoid surgical procedures were excluded. Predominantly, the permeatal subgroup underwent microscopic procedures, with a sole instance of endoscopic tympanoplasty. In the permeatal group, a tragal cartilage graft was used, harvested through a small incision on the medial aspect of the tragus. In our experience, such an incision does not result in many wound or scar-related problems. The incision was subsequently closed with absorbable interrupted sutures.
In contrast, in the post-aural group, an incision was made 5–10 mm behind the post-auricular sulcus. A small anteriorly based muscle flap was raised, with chonchal cartilage primarily used as graft material. In some cases, an additional layer of temporalis fascia was used as a composite cartilage fascia graft. Closure of the post-auricular skin wound was achieved using Vicryl 4.0 vertical mattress sutures. General anaesthesia was administered, with a solitary exception of local anaesthesia.
The majority of cases involved primary surgery, with only three cases requiring revision surgery via the post-auricular approach. The study spanned a three-year window, from November 2019 to April 2022, encapsulating patients who had undergone surgery within the prior one to three years. This temporal scope facilitated a comprehensive long-term assessment of the post-operative outcomes. Out of the 90 patients contacted for telephonic survey participation, 54 responded and were included in the analysis.
Data collected
Utilising the validated patient-reported outcome measure of the Chronic Otitis Media Benefit InventoryReference Phillips, Haggard, Spencer and Yung3, Reference Kara, Doruk, Celik, Polat, Topsakal and Orhan4 (see Figure 1), data were collected from both cohorts. Additional inquiries encompassed work absence and return to work details. Post-aural patients underwent supplementary questioning concerning the post-aural scar, which has been used in research articles beforeReference Barrett, Koecher, Ronan and Whinney5, Reference Inwood, Wallace and Clarke6 (see Table 1).
The validated Chronic Otitis Media Benefit Inventory scoring system.
Patient responses to scar perception questions
NA = not applicable.
The data collected included demographic specifics (age and gender). For the post-aural subset, scar-related queries are shown in Table 1. Permeatal patients were queried on post-aural scar inclination (see Table 1).
The validated Chronic Otitis Media Benefit Inventory patient-reported scoring system (Figure 1) facilitated a comparison between the two cohorts.
The principal author gathered data and made phone contact. Verbal consent was obtained and responses were documented in an Excel spreadsheet.
Statistical analysis
Data were assessed for normality of data distribution with the Shapiro–Wilk test. Continuous variables were reported as mean and standard deviation whereas categorical variables were reported as frequencies and percentages. An independent sample t-test was used to compare means between the two groups, whereas the chi-square test was used to compare categorical variables. A type I error of less than 0.05 was taken as significant. All individual Chronic Otitis Media Benefit Inventory questions were compared between the two groups. The responses to each question were reported with the mean and standard deviation.
Results
Of the 90 patients contacted to participate in the study, 54 responded: 30 in the post-aural group and 24 in the permeatal group (Table 2). The participants were all adults, with a mean age of 48 years (range, 18–79 years).
Participant characteristics
Patient scar perception
In the permeatal group 20 out of 24 patients (83 per cent) were not bothered about a scar if it was behind the ear but 4 patients (mostly females, 3 out of 4, 75 per cent) were happy not to have a scar (Table 1).
In the post-aural group, 96 per cent of patients (29 out of 30) were satisfied with their scar. Of these, 77 per cent (n = 23) were unconcerned about having a scar, while 23 per cent (7 patients) preferred no scar. No patients changed their hairstyle because of the scar and none reported the scar being visible to others. Only 7 per cent of patients (n = 2) experienced mild scar discomfort, while 17 per cent (n = 5 patients) had slight but non-intrusive numbness. Ear position changes were reported by 3 patients, with 2 unsure and 25 reporting no change. Of the 11 patients using hearing aids, 1 had minor issues, while 91 per cent (n = 10) had no problems. Lastly, 6 patients could move their ears before the surgical procedure, but 50 per cent (n = 3) lost this ability after the surgical procedure (Table 1).
Time off work after ear surgery
Standard hospital advice recommends two weeks off work after ear surgery. In the permeatal group, 14 of 24 patients reported an average leave of 13.7 days (ranging from 1 day to 6 weeks), with 5 taking the full 2 weeks, 5 returning sooner and 4 requiring more time off. In the post-aural group, 23 of 30 patients took an average of 13.4 days off, with 7 taking the full 2 weeks, 8 returning early and 8 needing more than 2 weeks off. Some patients did not report leave due to its insignificance because they were housewives, retirees or remote workers, or as a result of memory lapse.
Comparison of permeatal versus post-aural approaches using the Chronic Otitis Media Benefit Inventory questionnaire
Overall, the statistical analysis indicated that there are variations in patient perceptions and experiences between the permeatal and post-aural tympanoplasty techniques across different dimensions assessed by the Chronic Otitis Media Benefit Inventory questionnaire. However, these variations appear to be relatively subtle, and in all cases (12 questions) the differences between the two groups are not statistically significant. (Anonymised patient response data are available from the corresponding author on reasonable request.)
Discussion
Key findings
In line with our research, no notable contrast emerged between the permeatal and post-aural groups based on patient responses after tympanoplasty surgery. The scar behind the ear posed a minimal concern for the majority of patients in both groups. The post-aural approach was well-tolerated, with negligible scar-related problems. Work absence and resumption were similar between groups. The Chronic Otitis Media Benefit Inventory questionnaire revealed no statistically significant difference in post-operative quality of life or symptoms. To the best of our knowledge, this is the first study comparing patient viewpoints, symptomatology and quality of life tied to these two surgical approaches.
Limitations
Some patients underwent meatoplasty with the post-aural approach, which could theoretically affect post-operative results, particularly with hearing aids. However, our study found no evidence of this. The graft materials used included cartilage, temporalis fascia and fat, but because most patients received cartilage (with some using composite cartilage and fascia), the high success rates minimised result disparities. Procedures were performed or supervised by two experienced otologists. Surgical approach selection, based on perforation size, site and ear canal characteristics, could introduce selection bias. Despite a significant age difference between approaches, this likely did not affect the overall conclusions. Confounding factors, including revision cases and ossiculoplasty, could influence outcomes such as hearing and dry ear status.
Comparison with prior literature
The three recognised methods for tympanoplasty are post-aural, endaural and permeatal.Reference Brar, Watters and Winters1 The literature extensively covers these approaches, discussing indications, techniques, outcomes and complications.Reference Rahman and Atikuzzaman2 Studies have compared permeatal and post-aural approaches, examining graft uptake, hearing, surgery duration, recovery and complications.Reference Rahman and Atikuzzaman2, Reference Khan, Rana and Malik7, Reference Shinwari, Ali, Mustafa, Mushahid, Jamil and Khan8 The literature presents varying findings regarding graft uptake associated with different approaches. Some studies indicate higher graft uptake with the permeatal approach,Reference Shinwari, Ali, Mustafa, Mushahid, Jamil and Khan8 while others suggest higher rates with the post-aural approach.Reference Rahman and Atikuzzaman2 In addition, certain studies report comparable graft uptake rates with both approaches.Reference Khan, Rana and Malik7 Similarly, disparities exist regarding hearing outcomes, with some studies indicating improvement in hearing with the permeatal approachReference Rahman and Atikuzzaman2 and others showing no significant difference between the two approaches.Reference Khan, Rana and Malik7 While our study did not directly assess graft uptake or provide objective measurements of hearing via audiometry, patient-reported outcomes reveal similar outcomes between the two approaches in terms of hearing and ear discharge, as assessed by the Chronic Otitis Media Benefit Inventory questionnaire (questions 1, 2, 3 and 4). Notably, our study contributes a unique patient perspective on the experiences associated with these surgical methods, distinguishing it from previous research.
Clinical and research implications
This study offers preliminary data that could guide future research with more rigorous methods and larger samples. Clinicians can apply the findings, considering the study’s limitations.
• This study provides useful data to support patient-centred care in selecting tympanoplasty surgical approaches.
• Patient experiences between permeatal and post-aural tympanoplasty techniques were compared
• It was concluded that these techniques offer comparable results in terms of patient preferences, quality of life and post-operative recovery
• This study provides groundwork for further research on quality of life in tympanoplasty surgical approaches
Conclusion
Our study suggests comparable long-term outcomes in terms of quality of life between permeatal and post-aural approaches. No significant disparity was observed in ongoing ear symptoms, impact on quality of life, scar perception or return to work. Clinicians should consider individual patient factors, outcomes and preferences when selecting a surgical approach.
Competing interests
None declared.
