Dear Editors,

We read with interest the paper titled ‘Results of revision myringoplasty: are they different to those of primary myringoplasty?’ by Prinsley,^{Reference Prinsley1} which describes the results of a second myringoplasty. However, we have been unable to find any recent publications describing the results for a third attempt. This prompted us to review our own data.

We have previously published our results for transmeatal myringoplasty, with a closure rate of 82.4 per cent for anterior perforations and 93.8 per cent for subtotal perforations.^{Reference de Savornin Lohman and Borgstein2} Analyses of second and (a small group of) third myringoplasty operations yielded the following results. In the group of patients undergoing second myringoplasty operations, 34 out of 40 perforations (85 per cent) were successfully closed. In the group undergoing third myringoplasty operations, 10 out of 12 ears (83 per cent) were successfully closed. The two failures had a remaining microperforation (smaller than the opening in a grommet). Nonetheless, no patients returned with persistent or recurring symptoms, or, to the extent of our registered data, were referred to other centres for further therapy.

These findings are largely in agreement with the results reported by Prinsley (the difference being non-significant (p = 0.157)) for both second and third operations. However, in our study, we did not resort to retroauricular or endomeatal incisions for any of our operations. All of our operations, including the second and third myringoplasties, were carried out transmeatally.

Tragal perichondrium was used as the first choice graft material. We found that as long as the tragal cartilage is carefully preserved while removing the perichondrium, the tragal perichondrium may be harvested a second time after 6–12 months. For the third operation, a tragal cartilage and perichondrium composite graft was frequently used (in 10 of 12 cases).

The results for the third operation then, were not markedly different to those of the first or second operation; this information is useful for the pre-operative discussion with the patient.