Tympanoplasty With or Without Total Annular Excision in Chronic Suppurative Otitis Media

Abstract

Background: Type I tympanoplasty is the standard reconstructive operation for inactive mucosal chronic suppurative otitis media (CSOM) with tympanic membrane perforation. Total annular excision (TAE) tympanoplasty removes the residual tympanic membrane and annulus circumferentially before graft placement. It has been proposed to create a uniformly vascular graft bed, reduce epithelial remnants and postoperative granular myringitis, and produce a near-anatomic neotympanum.
Objective: To critically review comparative evidence on tympanoplasty with versus without TAE in patients with mucosal CSOM, emphasizing graft uptake, hearing outcomes, postoperative otorrhea or myringitis, complications, and limitations of the available literature.
Methods: A focused narrative synthesis of peer-reviewed comparative trials and relevant institutional studies was undertaken. Total annular excision was treated as distinct from simple freshening or trimming of the perforation margin. Findings were interpreted according to study design, perforation characteristics, graft material, surgical approach, follow-up, and outcome definitions.
Results: A double-blind randomized trial of 56 patients reported complete graft uptake in 28 of 28 TAE ears versus 27 of 28 conventional ears, no postoperative discharge after TAE versus discharge in 14.3% after conventional tympanoplasty, and greater improvement in air-conduction thresholds. Air-bone-gap improvement was similar (15.43 vs 14.12 dB). A later randomized endoscopic study of 60 patients with large or subtotal perforations found comparable intact-neotympanum rates (83.3% vs 80.0%) but greater median air-bone-gap reduction after TAE (12.5 vs 8.0 dB). A larger institutional comparison found no clear advantage in graft uptake, hearing, or complications, while suggesting a possible role in preventing granular myringitis. Heterogeneity and small samples prevent firm claims of superiority.
Conclusion: TAE appears feasible and safe in selected mucosal CSOM, with a possible advantage for postoperative ear dryness and selected audiometric outcomes. Current evidence does not establish a reproducible improvement in graft uptake over conventional tympanoplasty. Conventional underlay or interlay repair remains appropriate for most routine central perforations; TAE may be considered for large or subtotal perforations, inflamed or unreliable annular remnants, or concern for postoperative myringitis, provided meticulous graft support and follow-up are available.