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Diagnostic accuracy of intra-operative assessment of de-epithelisation of the malleus by the surgeon in type 1 tympanoplasty compared to histopathological examination

  • A P Azeez (a1) and V Letha (a2)



This study was undertaken to determine the accuracy of the surgeon's assessment in detecting epithelial remnants over the malleus after de-epithelisation in tympanoplasty.


Intra-operatively, the umbo was assessed for epithelial remnants with the microscope. The umbo was then resected and sent for histopathological examination to detect epithelial remnants.


Out of 42 cases, microscopic examination findings for epithelium were positive in 16 cases and negative in 26 cases. Histopathology findings were positive in 13 cases. The surgeons’ assessment was accurate only in two cases.


Residents, with their limited experience, are more likely to leave residual epithelium. When the chance of residual epithelium over the umbo is significant, the surgeon has two choices: to place the graft medial to the umbo or to resect the umbo. It is our opinion that the malleus exteriorisation should be incorporated into tympanoplasty training, with the aim of preventing epithelial entrapment in the middle ear.


Corresponding author

Author for correspondence: Dr V Letha, Dept of Pathology, Government Medical College, Kottayam, Kerala, India, PIN 686008 E-mail: Fax: +91 481 259 7284


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Dr V Letha takes responsibility for the integrity of the content of the paper



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1Sarkar, S. A review on the history of tympanoplasty. Indian J Otolaryngol Head Neck Surg 2012;65:455–60
2Rizer, FM. Overlay versus underlay tympanoplasty. Part I: historical review of the literature. Laryngoscope 1997;107(12 Pt 2):125
3Vijayendra, H, Mahadeviah, A, Surendran, K, Sangeetha, R. Micro ear surgery – its purpose and procedure for tubo tympanic pathology. Indian J Otolaryngol Head Neck Surg 2005;57:360–3
4Ryan, JE, Briggs, RJ. Outcomes of the overlay graft technique in tympanoplasty. ANZ J Surg 2010;80:624–9
5Sanna, M, Sunose, H, Mancini, F, Russo, A, Taibah, A. Middle Ear and Mastoid Microsurgery, 2nd edn. New York: Thieme, 2012
6Mahadevaiah, A, Parikh, B. Surgical Techniques in Chronic Otitis Media and Otosclerosis. New Delhi: CBS Publishers & Distributors, 2008
7Benzer, M. Talk of the hearing impaired [in Italian]. Trans Am Acad Ophthalmol Otolaryngol 1963;67:233–59
8Toynbee, J. On the Use of Artificial Membrana Tympani in Cases of Deafness, Dependent upon Perforation or Destruction of the Natural Organ. London: J Churchill and Sons, 1853
9Blake, CJ. Transactions of the First Congress of the International Otological Society. New York: D Appleton & Company, 1887
10Berthold, E. Overlay myringoplasty [in German]. Wier Med Bull 1878;1:627
11Helmholtz, H. The mechanism of the ossicles of the ear and the membrane tympani [in German]. Pfluger Archiv für Physiologie 1868;1:160
12Kulduk, E, Dundar, R, Soy, FK, Guler, OK, Yukkaldiran, A, Iynen, I et al. Treatment of large tympanic membrane perforations: medial to malleus versus lateral to malleus. Indian J Otolaryngol Head Neck Surg 2015;67:173–9
13Kartush, JM, Michaelides, EM, Becvarovski, Z, Larouere, MJ. Over-under tympanoplasty. Laryngoscope 2002;112:802–7
14Hough, JVD. Tympanoplasty. Indian J Otolaryngol Head Neck Surg 1994;3:63–6
15Nejadkazem, M, Totonchi, J, Naderpour, M, Lenarz, M. Intratympanic membrane cholesteatoma after tympanoplasty with the underlay technique. Arch Otolaryngol Head Neck Surg 2008;134:501–2
16Gulya, A. Anatomy of the Temporal Bone with Surgical Implications, 2nd edn. New York: Parthenon Publishing Group, 1995
17Tos, M. Manual of Middle Ear Surgery. New York: Thieme, 1993
18Graham, MD, Reams, C, Perkins, R. Human tympanic membrane – malleus attachment. Preliminary study. Ann Otol Rhinol Laryngol 1978;87:426–31
19Van der Jeught, S, Dirckx, JJ, Aerts, JR, Bradu, A, Podoleanu, AG, Buytaert, JA. Full-field thickness distribution of human tympanic membrane obtained with optical coherence tomography. J Assoc Res Otolaryngol 2013;14:483–94
20El-Seifi, A, Fouad, B. The fibrous annulus in myringoplasty. J Laryngol Otol 1992;106:116–19
21Emir, H, Ceylan, K, Kizilkaya, Z, Gocmen, H, Uzunkulaoglu, H. Success is a matter of experience: influencing factors on type 1 tympanoplasty. Eur Arch Otorhinolaryngol 2007;264:595–9
22Kutluhan, A, Yalçıner, G, Güler, G, Kösemehmetoğlu, K, Bozdemir, K, Bilgen, AS. Shall we resect the tip of manubrium mallei in tympanoplasty? Clin Exp Otorhinolaryngol 2011;4:24–6
23Khalifa, MC, Khalifa, BC. Over-under myringoplasty. Med J Cairo Univ 2011;79:165–8
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