Clinical Study

Ear, Nose & Throat Journal

1–6
Comparison of Endoscopic Cartilage ª The Author(s) 2021
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Myringoplasty in Dry and Wet Ears DOI: 10.1177/0145561321999263
journals.sagepub.com/home/ear
With Chronic Suppurative Otitis Media

Juanmei Yang, MD1,2, Jihan Lyu, MD1,2, Yanmei Wang, MD1,2, Binjun Chen, MD1,2,
Jianghong Xu, MD1,2, and Dongdong Ren, MD1,2

Abstract
Objectives: This study compared the rate of graft success, as well as hearing improvement and dry ear time between dry ears
and wet ears with otomycosis or without otomycosis in patients with chronic suppurative otitis media (CSOM) after endoscopic
cartilage myringoplasty. Methods: This retrospective study was conducted in a tertiary hospital in Shanghai. In total, 83 patients
with CSOM (43 with dry ears and 40 with wet ears) were included. Among the 40 patients with CSOM and wet ears, 25 exhibited
otomycosis. All patients underwent endoscopic myringoplasty, and perforations were repaired using tragal cartilage with a single-
sided perichondrium. Patients were followed up for at least 6 months. Pure-tone hearing was examined preoperatively and at
3 months postoperatively. The graft uptake rate, hearing improvement, and dry ear time were compared between the groups.
Results: The graft success rate did not differ significantly between the dry-ear and wet-ear groups (95.35% and 90.00%,
respectively). Furthermore, the graft success rate also did not differ significantly between patients with wet ears and otomycosis
and those with wet ears without otomycosis (92.00% and 86.67%, respectively). Hearing gain did not differ significantly between
the dry-ear and wet-ear groups. No significant difference in hearing gain was also found in patients with wet ears with or without
otomycosis. However, the time to dry ear was significantly longer in the wet-ear group than in the dry-ear group. Conclusion:
Patients with CSOM and wet ears required more time to achieve a completely healthy status. However, the graft success rate and
hearing improvement were not affected by a wet middle ear and otomycosis. Thus, endoscopic myringoplasty using tragus
cartilage is an effective treatment for refractory CSOM in patients with wet ears and otomycosis.

Keywords
otitis media, myringoplasty, dry ear, wet ear, otomycosis

Introduction
Chronic suppurative otitis media (CSOM) is characterized by
repeated otorrhea through perforated tympanic membrane.
Chronic suppurative otitis media often leads to conductive
hearing loss. Myringoplasty is the standard, well-established
procedure for closure of tympanic membrane perforations.
Typically, ears that have been dry for at least 3 months are
presumed to be most suitable for myringoplasty. Active ear
discharge is considered a contraindication for myringoplasty
due to the widespread belief that this discharge causes graft
rejection. To avoid graft failure, a course of antibiotic ear drops
is often administered, and the ear is allowed to become dry
before surgery. However, for some patients with recurrent
CSOM, extensive use of topical antibiotic ear drops and ster-
oids can lead to otomycosis or multidrug-resistant bacterial
1
ENT Institute and Otorhinolaryngology Department, Affiliated Eye and ENT
Hospital, Fudan University, Shanghai, People’s Republic of China
2
Key Laboratory of Hearing Medicine of National Health Commission,
Shanghai, People’s Republic of China
Received: January 30, 2021; revised: January 30, 2021; accepted: February 6,
2021
Corresponding Authors:
Dongdong Ren, MD, ENT Institute and Otorhinolaryngology Department and
Key Laboratory of Hearing Medicine of National Health Commission, Affiliated
Eye and ENT Hospital, Fudan University, 83 Fenyang Road, Shanghai, People’s
Republic of China.
Email: dongdongren@fudan.edu.cn
Jianghong Xu, MD, ENT Institute and Otorhinolaryngology Department and
Key Laboratory of Hearing Medicine of National Health Commission, Affiliated
Eye and ENT Hospital, Fudan University, 83 Fenyang Road, Shanghai, People’s
Republic of China.
Email: hongdou2012@139.com

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2 Ear, Nose & Throat Journal
infection, eventually resulting in refractory CSOM. Some stud-
ies have found that the effectiveness of myringoplasty is not
affected by the presence of ear discharge during surgery.1-5
Otomycosis is a superficial fungal infection of the external
auditory canal and is particularly frequent in hot and humid
regions. It remains controversial whether patients with CSOM
and otomycosis are good candidates for surgery. Some studies
have found that fungal infections are common in patients with
CSOM.6-8One study showed that external auditory canal status
was an important factor affecting the success of myringo-
plasty. 9 To determine whether actively discharging ears
(ie, wet ears) and otomycosis in patients with CSOM were
suitable for myringoplasty, this retrospective study compared
the treatment efficacy, hearing improvement, and dry ear time
after endoscopic cartilage myringoplasty surgery between dry
ears and wet ears with otomycosis or without otomycosis in
patients with CSOM.
Materials and Methods
This retrospective study was conducted in a tertiary hospital in
Shanghai (China) from January to December 2019. Two groups
of patients with CSOM were selected according to their clinical
status at the time of surgery: those with dry ears and those with wet
ears. Each selected patient met the following inclusion criteria:
(1) age 16 years, (2) tympanic membrane perforation caused by
otitis media, (3) endoscopic myringoplasty (over-underlay tech-
nique) using cartilage with a single-sided perichondrium, (4) pri-
mary ear surgery, and (5) at least follow-up duration of 6 months.
The exclusion criteria were (1) ossicular chain abnormalities, (2)
cholesteatoma, and (3) revision surgery. Preoperative temporal
high-resolution computer tomography (HRCT) was performed in
all patients to exclude ossicular chain abnormalities and choles-
teatoma. Diffusion-weighted magnetic resonance imaging was
done when cholesteatoma could not be excluded by HRCT.
Patients with mucoid or mucopurulent discharge or only
edematous middle ear mucosa were considered wet ears, as
described in a previous study.10 Meanwhile, patients with both
wet middle ear and otomycosis belonged to the wet-ear group
in our study. The discharge sampled at 1 day preoperatively
was cultured to identify the causative pathogens. Patient age,
patient sex, perforation size and site, opposite ear status (uni-
lateral/bilateral CSOM), and preoperative hearing level were
recorded. The tympanic membrane perforation less than 1 quad-
rant of the tympanic membrane is considered as small perfora-
tion; perforation of tympanic membrane between 1 and
2 quadrants is considered medium perforation and more than
3 quadrants of the tympanic membrane is considered large.
The perforation locations were classified as anterior, posterior,
or central. Air–bone conduction pure-tone threshold at 500,
1000, 2000, and 4000 Hz was performed in all patients both
preoperatively and at 3 months postoperatively. The results
were used to calculate the mean air–bone gap (ABG).
Unhealed tympanic membrane, reperforation of the graft, and
persistent ear discharge at 6 months postoperatively were
considered to indicate graft failure.
Surgical Technique
All surgeries were performed by an experienced surgeon who has
focused on the ear surgery for 10 years and completed more than
200 endoscopic tympanoplasty cases each year. The ear canal and
middle ear cavity were irrigated 3 times with povidone-iodine
(5 minutes each time) after general anesthesia induction and
before the initiation of surgery. The perforation margin was
treated for fresh wounds with an angled knife. For the right ear,
this incision was made 5 mm posteriorly from the tympanic annu-
lus and extended from the 1 o’clock to the 6 o’clock position.
For the left ear, an incision was and extended from the 11 o’clock
to the 6 o’clock position. Then, the tympanomeatal flap was
gently elevated to the level of the fibrous annulus. Residual tym-
panic membrane was removed from the malleus handle. The
mobility of ossicular chain was checked. Tragal cartilage was
harvested with a single-sided perichondrium. The autograft was
placed on the inner surface of the residual tympanic membrane,
lateral to the malleus. A notch was made in the cartilage to accom-
modate the malleus handle. Gelfoam was placed in the middle ear
cavity to prevent the graft collapse. The tympanomeatal flap was
subsequently returned to its original position. The external ear
canal was packed with Gelfoam and antibiotic-soaked gauze up
to the tragus incision. The tragus incision was then sutured.
Patients were discharged on postoperative day 2.
Postoperative Follow-Up
The packing gauze soaked in antibiotic ointment was removed
from the external auditory canal on postoperative day 2.
Any remaining Gelfoam fragments were aspirated from the
external auditory canal at 2 weeks postoperatively if they had
not broken down, thus allowing the graft to be visualized.
All patients were followed up in our outpatient clinic at
2 weeks, 1 month, 3 months, and 6 months postoperatively.
Graft status and the time to dry ear were recorded during endo-
scopic examinations. Pure-tone hearing was examined preo-
peratively and at 3 months postoperatively. Complete healing
of the tympanic membrane graft at least 6 months postopera-
tively was considered successful. Graft success and hearing
improvement rates were compared between the 2 groups.
Statistical Analysis
All categorical data were compared between groups using the
w2 test. Quantitative data with a normal distribution were ana-
lyzed using a t test .Quantitative data with a non-normal dis-
tribution were analyzed using the Mann-Whitney U test. Paired
t tests were used to compare preoperative and postoperative
pure-tone audiometry values within groups. The P value <.05
was the threshold for statistical significance.
Results
In total, 83 patients were enrolled in this study (43 in the dry-ear
group and 40 in the wet-ear group). The dry-ear group comprised
31 women and 12 men (mean age, 46 + 12.67 years), whereas the
Yang et al 3

Table 1. Patients’ Characters. Table 2. Distribution of All Isolated Organism.

Characters Dry ear Wet ear P value Percentage of

Type of organism Organism Isolates all isolates
Gender
F 31 26 .49 Fungus Aspergillus niger 17 41.5
M 12 14 Candida albicans 4 9.8
Age (years, mean + SD) 46 + 12.67 44.3 + 14.48 .67 Aspergillus flavus 2 4.9
Duration of illness 12.68 + 15.63 12.75 + 14.13 .82 Aspergillus fumigatus 2 4.9
(years, mean + SD) Bacteria Staphylococcus aureus 8 19.5
Smoking history Pseudomonas aeruginosa 5 12.2
Yes 3 3 .93 Coagulase-negative 1 2.4
No 40 37 Staphylococcus
Status of contralateral Staphylococcus lugdunensis 1 2.4
Normal 32 31 .74 Staphylococcus intermedius 1 2.4
Otitis media 11 9 No organism 3
Size of perforation
Small 12 4 .11
Medium 18 23 Table 3. Comparison of Graft Success Between the Dry-Ear and
Large 13 13 Wet-Ear Group.
Position of perforation
Anterior 19 15 .72 Graft Graft
Posterior 3 2 Group success failure Total
Central 21 23
Dry ear 41 (95.35%) 2 (4.65%) 43 (100%)
Abbreviations: F, female; M, male. Wet ear 36 (90%) 4 (10%) 40 (100%)
Wet ear with otomycosis 23 (92%) 2 (8%) 25 (100%)
Wet ear without 13 (86.67%) 2 (13.33%) 15 (100%)
otomycosis
wet-ear group comprised 26 women and 14 men (mean age, 44.3
+ 14.48 years). The duration of illness was 12.68 + 15.63 years
in the dry-ear group and 12.75 + 14.13 years in the wet-ear group.
Most patients (18 in the dry-ear group and 23 in the wet-ear group) postoperative multidrug-resistant infection with S. aureus or
had medium-sized perforations. Perforations were most com- P. aeruginosa led to graft failure in 2 of 15 patients with wet
monly centrally located (21 patients in the dry-ear group and 23 ears but without otomycosis.
patients in the wet-ear group). Table 1 summarizes the detailed In the dry-ear group, the preoperative mean ABG was 17.34
patient characteristics. There were no significant differences in + 8.71 dB and the postoperative mean ABG was 10.97 +
age, sex, duration of illness, smoking history, perforation size, or 7.91 dB, with an ABG closure of 6.38 + 4.71 dB. In the wet-
perforation position between the 2 groups (P > .05). Twenty-five ear group, the preoperative ABG was 19.09 + 5.85 dB and
patients in the wet-ear group were diagnosed with CSOM and the postoperative ABG was 11.38 + 4.68 dB, with an ABG
otomycosis, based on their clinical symptoms and signs. Fungi closure of 8.12 + 6.11 dB (Table 4). Postoperative ABGs
were identified in 25 patients, consistent with their clinical man- were significantly reduced in both the dry-ear and wet-ear
ifestations. Bacteria were identified in 16 patients. Four patients groups, compared with preoperative ABGs. However, there
had mixed fungal and bacterial infections. No fungi or bacteria was no significant difference in hearing gain between the
were observed in the ears of 3 patients. The most common fungi 2 groups (P ¼ .39). Furthermore, the preoperative ABG was
were Aspergillus niger and Candida albicans. The most common 18.75 + 6.32 dB and the postoperative ABG was 10.79 +
bacteria were Staphylococcus aureus and Pseudomonas aerugi- 4.13 dB, with an ABG closure of 8.13 + 6.31 dB in the wet
nosa (Table 2). ears with otomycosis. The preoperative ABG was 20.55 +
The graft success rate was 95.35% for the dry-ear group 4.99 dB and the postoperative ABG was 11.64 + 6.71 dB,
(2 patients with graft failure) and 90.00% for the wet-ear with an ABG closure of 8.10 + 5.93 dB in the wet ears
group (4 patients with graft failure; Table 3). These rates did without otomycosis. No significant difference in hearing gain
not differ significantly. In the wet-ear group, 25 patients was found in patients with wet ears with or without otomy-
exhibited otomycosis. The graft success rate was 92.00% cosis (P ¼ .86).
(23/25) for patients with wet ears and otomycosis and The time to achieve a dry ear was 2.93 + 0.70 weeks post-
86.67% (13/15) for those with wet ears without otomycosis. operatively in the dry-ear group and 4.56 + 3.96 weeks post-
Although the rates were different, the difference was not operatively in the wet-ear group. It took significantly longer to
statistically significant (P ¼ .62). Figure 1 shows a represen- achieve a dry ear in the wet-ear group than in the dry-ear group
tative tympanic membrane preoperatively and at 3 months (P ¼ .0005; Table 5). However, no significant difference in the
postoperatively. Notably, postoperative fungal infection led time to achieve a dry ear was observed in patients with wet ears
to graft failure in 2 of 25 patients with otomycosis, whereas with or without otomycosis (P ¼ .67).
4 Ear, Nose & Throat Journal

Figure 1. Preoperative and postoperative endoscopic images of the tympanic membrane. Panels 1A and 1B: Preoperative and postoperative
images of the tympanic membrane in a dry ear. Panels 2A and 2B: Preoperative and postoperative images of the tympanic membrane in a wet ear
without otomycosis. Panels 3A, 3B, 4A, and 4B: Preoperative and postoperative images of the tympanic membrane in a wet ear with otomycosis.

Table 4. Comparison of Hearing Improvement Between the Dry-Ear and Wet-Ear Group Preoperatively and Postoperatively.a

Mean preoperative Mean postoperative Mean

Group ABG + SD (dB) ABG + SD (dB) ABG closure + SD (dB) P value

Dry ear 17.34 + 8.71 10.97 + 7.91 6.38 + 4.71 <.0001

Wet ear 19.09 + 5.85 11.38 + 4.68 8.12 + 6.11 <.0001
Wet ear with otomycosis 18.75 + 6.32 10.79 + 4.13 8.13 + 6.31 <.0001
Wet ear without otomycosis 20.55 + 4.99 11.64 + 6.71 8.10 + 5.93 .003
Abbreviation: ABG, air–bone gap.
a
No significant difference of mean ABG closure between the dry-ear and wet-ear groups (P ¼ .39); No significant difference of mean ABG closure between the wet
ear with otomycosis and without otomycosis (P ¼ .86).

Table 5. Comparison of Time to Dry Ear Postoperatively Between microscopic myringoplasty with respect to tympanic mem-
the Dry-Ear and Wet-Ear Group. brane, closure rates, as well as hearing improvement. 12
The endoscopic approach provides a much larger field of view
Time to dry ear and enables better cosmetic outcomes. Cartilage graft is the
Group (weeks, mean + SD) P value grafting material of choice for endoscopic myringoplasty.
Dry ear 2.93 + 0.70 It is easy to harvest and suitable for one-handed operation
Wet ear 4.56 + 3.96 .0005 under the endoscope due to its hardness. It has reported in many
Wet ear with otomycosis 3.75 + 1.45 previous studies.13,14 In our study, all patients underwent trans-
Wet ear without otomycosis 5.87 + 6.01 .67 canal endoscopic myringoplasty and achieved repair of a per-
forated tympanic membrane using tragal cartilage with a
single-sided perichondrium. The results showed that the total
graft success rate was 92.80%. Significant improvements in
Discussion hearing were observed within the groups, based on preopera-
Myringoplasty is a surgical procedure performed solely to tive versus postoperative measurements, similar to the results
repair a perforated tympanic membrane, without manipulation of other studies.15,16
of the middle ear or ossicles. Recently, transcanal endoscopic The timing of myringoplasty surgery has been controversial.
myringoplasty has become popular due to the availability of Gersdorff et al17 found that the state of the middle ear at the
high-resolution endoscopy technology.11 Endoscopic myringo- time of surgery influenced the clinical outcomes—wet ears
plasty results in treatment outcomes comparable to those of were associated with higher rates of perforation, myringitis,
Yang et al
and retraction pockets. Another study by Zwierz et al18 indi-
cated that a better surgical outcome could be achieved in chil-
dren with a dry ear, thus facilitating better middle ear
conditions. In a multivariate analysis of otological, surgical,
and patient-related factors involved in myringoplasty success,
Onal et al19 showed that a longer dry-ear period was a signif-
icant prognostic factor, positively influencing the rate of myr-
ingoplasty success. Moreover, the success rate was higher in
dry ears than in wet ears. By contrast, Caylan et al20 indicated
that better healing was observed in discharging ears (100%)
compared to dry ears (75%). In a prospective study, Hosny
et al21 reported that mucoid ear discharge has no adverse effect
on the outcome of the operation as regard to graft uptake and
hearing gain. Other studies1-5,22-25 have reported similar graft
success rates between dry and wet ears. Notably, graft success
and hearing improvement rates did not differ significantly
between the dry-ear and wet-ear groups in our study.
Preoperative pathogen investigations provided important
information concerning the reason for ear discharge (ie, bacter-
ial infection, fungal infection, or both). Although some studies
showed that otomycosis can lead to tympanic membrane per-
foration,26,27 the history of otomycosis was shorter than that of
CSOM in most patients in our study. Recurrent middle ear
discharge and the use or abuse of topical antibiotics and ster-
oids in patients with CSOM are more likely to cause fungal
infection in the external auditory canal. Furthermore, the graft
success rate did not differ significantly between patients with
wet ears and otomycosis and those with wet ears without oto-
mycosis in our study. To the best of our knowledge, there has
been limited research concerning graft success rates in patients
with CSOM according to otomycosis status. One study
reported that fungal otitis externa and a mucopurulent wet ear
were factors influencing tympanic membrane closure.9 How-
ever, that study only included a small number of patients.
Among the 25 patients with otomycosis in our study, 2 expe-
rienced graft failure due to postoperative fungal infection.
Graft failure occurred in 2 other patients in the wet-ear group
because of multidrug-resistant S. aureus or P. aeruginosa
(1 patient each). Among the remaining 36 patients with CSOM
and wet ears, no postoperative infections were observed. No
patient in the dry-ear group experienced postoperative infec-
tion. An important reason for these low rates of postoperative
infection may be the use of povidone-iodine. In our study,
povidone-iodine was used to irrigate the external auditory canal
and middle ear at least 3 times during surgery. Some studies28-30
have shown that topical povidone-iodine can effectively kill
bacteria and fungi in patients with otomycosis or CSOM. The
discharge from all patients in the wet-ear group at 1 day pre-
operatively was cultured to identify causative pathogens.
Multidrug-resistant S. aureus and P. aeruginosa were found in
2 patients and 1 patient, respectively. Graft failure occurred in
2 of the 3 patients. Therefore, patients with preoperative
multidrug-resistant bacterial infection require preoperative and
postoperative medication, as well as timely follow-up.
A notable finding was that the time to achieve dry ear was
significantly longer in the wet-ear group than in the dry-ear group
5
but did not influence the closure failure rate. Although postopera-
tive otorrhea persisted in patients in the wet-ear group, this otor-
rhea was aseptic in most patients. No specific drugs were used on
these patients. Only 4 patients exhibited persistent infection post-
operatively. Possible causes of postoperative otorrhea are nonin-
fectious, such as secretory middle ear mucosa, external auditory
canal skin exudates, eczema, or eustachian tube dysfunction.10
These results were similar to findings in a previous study.31
Occasionally, ear discharge in patients with CSOM is diffi-
cult to control with drug treatment alone and often recurs pre-
operatively. The otology center in our hospital is one of the
largest otology centers in China and receives a variety of
patients from all areas of the country. Some patients at the time
of registration may exhibit dry ears. However, at the time of
surgery, those patients may have ear discharge. Therefore, it is
difficult to ensure a dry ear status at the time of surgery. In this
study, the results showed that otomycosis and mucopurulent
discharge did not influence graft success or hearing improve-
ment. However, this does not suggest that myringoplasty can be
performed at any time. Preoperative discharge culture and anti-
biotic sensitivity tests should be performed routinely. When an
infection is caused by multidrug-resistant bacteria, myringo-
plasty should be performed with caution.
Conclusion
Patients with CSOM and wet ears required more time to achieve a
completely healthy status following endoscopic myringoplasty.
However, graft success and hearing improvement rates were not
affected by a wet middle ear or otomycosis. Thus, endoscopic
myringoplasty using tragus cartilage is an effective treatment for
refractory CSOM in patients with wet ears and otomycosis.
Authors’ Note
Juanmei Yang, MD, and Jihan Lyu, MD, contributed equally to this
work. The patients gave their informed consent, and the study protocol
was approved by the institutional review board of Hospital, and
informed consent was provided by patients enrolled in the study.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for
the research, authorship, and/or publication of this article: This study
was funded in part by the National Natural Science Foundation of
China (NSFC; Grant Nos. 81771017 and 81970880 to D.R.).
ORCID iD
Dongdong Ren https://orcid.org/0000-0002-2889-9375
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