We use a 0 degree 1.9mm endoscope for patients with smaller and/or tortuous ear canals or 3mm for older children and teenagers. The edges of the tympanic membrane are freshened with a pick or another sharp instrument and then suctioned or removed with an alligator forceps. The diameter of the tympanic membrane perforation is then measured with a fenestrometer. A piece of tragal cartilage is dissected and the incision closed with 5-0 fast absorbing sutures. A biopsy punch with diameter 1mm larger than the diameter of the perforation is used to create a circular cartilage graft. A 15 blade is used to create a groove on the sides of the circular cartilage graft. That is then placed in the tympanic membrane perforation lodging the cartilage graft into the anterior portion of the tympanic membrane perforation. A pick is used to put pressure in the posterior portion of the graft in order to make it fit nicely into the tympanic membrane perforation. Gelfoam soaked in Ciprofloxacin or Ofloxacin ear drops is placed lateral to the graft and tympanic membrane.

This procedure is indicated for round tympanic membrane perforations that are smaller than 25%.

There should not be any chronic or acute middle ear disease or concerns for disease or abnormalities of the ossicular chain.
Contraindications include oval or irregular tympanic membrane perforations (unless they can be trimmed into a circular perforation that is smaller than 25%), perforations larger than 25%, acute otorrhea, cholesteatoma or ossicular chain abnormalities.

Similar to any smaller ear procedures, prep and drape the entire ear.

Audiogram, pre-operative visit to ascertain that the middle ear is clear and dry.

The advantages of using endoscopes for cartilage myringoplasty are:
- Improved visualization of the entire tympanic membrane by the endoscope (including hard to reach areas)
- Easier procedure in smaller ear canals and tortuous ear canals
- Better magnification and detail by getting the endoscope closer to the surgical area
The disadvantage is that you can only use the instruments in one hand.

Closure rate with this technique is about 80-90% (so there is a 10-20% risk of residual perforation). The risks are the usual for any myringoplasty, including hearing loss and cholesteatoma.

Closure rate with this technique is about 80-90% (so there is a 10-20% risk of residual perforation). The risks are the usual for any myringoplasty, including hearing loss and cholesteatoma.

N/A

1. Celik, H., Samim, E. & Oztuna, D., 2015. Endoscopic �Push-Trough� Technique Cartilage Myringoplasty in Anterior Tympanic Membrane Perforations. Clinical and Experimental Otorhinolaryngology Vol., 8(3), pp.224�229.

2. Abdelghany, A.M., 2013. The button graft technique for perforations affecting less than 25% of the tympanic membrane: A non-randomised comparison of a new modification to cartilage tympanoplasty with underlay and overlay grafts. Clinical Otolaryngology, 38(3), pp.208�216.

3. James, A.L. & Papsin, B.C., 2012. Ten top considerations in pediatric tympanoplasty. Otolaryngology--head and neck surgery�: official journal of American Academy of Otolaryngology-Head and Neck Surgery, 147(6), pp.992�8.