Flapless Endoscopic Myringoplasty in Large Perforations: Is Tympanomeatal Flap Elevation Necessary?

The role of tympanomeatal flap elevation in type I tympanoplasty remains debated, particularly in cases of large tympanic membrane perforations. We report the case of a 59-year-old patient with a long-standing right-sided otorrhea and hearing loss. Otoscopic examination revealed a large inferior perforation involving the anteroinferior and posteroinferior quadrants. Audiometry demonstrated a 15 dB air-bone gap. The patient underwent flapless endoscopic myringoplasty using a 30° 4K endoscope. A bean-shaped cartilage with attached perichondrium was sculpted and positioned beneath the malleus handle, while a second perichondrial fragment was placed above the cartilage and beneath the tympanic membrane remnant, creating a sandwich configuration around the handle. The graft was stabilized with Gelfoam® (Pfizer Inc., New York, NY, USA), without elevation of the tympanomeatal flap. At six weeks, the graft was fully integrated with neovascularization, and the air-bone gap was reduced to 5 dB. These anatomical and functional outcomes were maintained at six months of follow-up. This case illustrates that flapless endoscopic myringoplasty using a cartilage-perichondrium graft can achieve stable anatomical and functional results in large perforations, while tympanomeatal flap elevation should be reserved for cases with suspected ossicular pathology or diagnostic uncertainty.