LAUSR

I read with great interest the article entitled: “Endoscopic transcanal versus conventional microscopic tympanoplasty in treatment of anterior tympanic membrane perforations” by Gülşen et al. [1]. The authors retrospectively analyzed the surgical outcomes of endoscopic transcanal tympanoplasty (ETT) and conventional microscopic tympanoplasty (CMT) in repairing anterior tympanic membrane perforations (ATMPs). The graft uptake rates in ETT and CMT group were 93.7% and 91.4%, respectively (p = 0.640). Furthermore, there was no significant relationship between anterior canal wall protrusion (ACWP) and graft success rates in either the endoscopic (p = 0.685) or microscopic (p = 0.894) group. The authors believed that ETT offering fewer complication rates and shorter duration of surgery may serve as a reasonable alternative to CMT in repairing ATMPs, with comparable graft success rates [1]. This is an interesting study, however, I had some comments for the description of procedure detail. The authors described “the endomeatal incisions were performed for tympanomeatal flap elevation. After the tympanomeatal flap was elevated, the middle ear structures inspected, and the ossicular chain integrity and mobility assessed in the EIT group. In addition, a mucosal flap was created in a retrograde manner from tympanic sulcus in patients with anterior marginal perforation, where the tympanic membrane remnant is not sufficient, to secure the graft anteriorly,” in surgical technique section [1]. In this technique, a mucosal flap was created in a retrograde manner from tympanic sulcus in patients with anterior marginal perforation to secure the graft anteriorly [1]. The authors did not describe the extent of creating mucosal flap. In our department, a mucosal flap was also created in patients with anterior marginal perforation when the tympanic membrane remnant is not sufficient, the mucosal flap was created from tympanic sulcus to the skin of external auditory canal in a retrograde manner and down-to-up direction, the mucosal flap was elevated at least 2 mm off the bone (Fig. 1).The elevated mucosal flap enlarged the area of the anterior perforation edges, thereby increasing the area of contact between the graft and the annulus and remnant tympanic membrane. The cartilage graft comprising one-side perichondrium was harvested and fashioned based on the size of the perforation. The lateral perichondrium on one end was peeled and rolled up, keeping the pedicle on the other side of the cartilage, and at least 2 mm of free perichondrium was preserved. The cartilage graft was placed medial to the anterior annulus, the free perichondrium was elevated and placed medially under the mucosal flap. Thus, no additional anterior canal wall incisions were involved in our technique. Some other scholars also recently reported the endoscopic cartilage myringoplasty without the elevation of tympanomeatal skin flap [2–5].