Type I Tympanoplasty in Large Tympanic Membrane Perforations: Comparative Outcomes of Temporalis Fascia, Partial-Thickness, And Full-Thickness Composite Cartilage–Perichondrium Grafts

Abstract

Background: Large tympanic membrane (TM) perforations represent a persistent surgical challenge in Type I tympanoplasty, with graft failure and suboptimal hearing outcomes remaining concerns. Although temporalis fascia continues to be widely used, cartilage-perichondrium grafts have gained increasing acceptance for their superior mechanical stability, particularly in large and high-risk perforations. However, comparative evidence regarding the influence of cartilage thickness on anatomical reliability and audiological outcomes remains limited, and consensus on optimal graft selection for large central TM perforations is lacking. Objective: To compare anatomical and functional outcomes of Type I tympanoplasty using temporalis fascia, partial-thickness composite cartilage-perichondrium, and full-thickness composite cartilage-perichondrium grafts in patients with large central TM perforations. Methods: This prospective observational study was conducted at a tertiary care teaching hospital between August 2023 and March 2025. Ninety patients with inactive mucosal chronic otitis media and large TM perforations (>50%) were equally allocated to three groups of 30 patients each (n=30 per group) based on graft material used: temporalis fascia (Group 1), partial-thickness cartilage-perichondrium (Group 2), and full-thickness cartilage-perichondrium (Group 3). All patients underwent Type I tympanoplasty via a postauricular approach. Audiological outcomes were assessed using pure tone audiometry, and air-bone gap (ABG) was calculated preoperatively and at 1, 2, and 6 months postoperatively. Anatomical success was defined as an intact graft with a dry ear, and functional success as postoperative ABG <20 dB. Results: All three groups demonstrated significant postoperative hearing improvement at six months. Temporalis fascia showed earlier functional recovery, with significant ABG improvement from the second postoperative month (n=30, p = 0.046), sustained to six months (p = 0.016). Partial-thickness cartilage demonstrated delayed but sustained audiological improvement (six-month ABG, p < 0.001), while full-thickness cartilage achieved significant ABG reduction only at six months (p = 0.003). Graft uptake rates were highest in the full-thickness cartilage group (26/30, 86.7%), followed by partial-thickness cartilage (24/30, 80.0%) and temporalis fascia (22/30, 73.3%), although intergroup differences were not statistically significant (all p>0.05, chi-square test). Functional success (postoperative ABG <20 dB) was achieved most frequently with temporalis fascia (22/30, 73.3%), followed by partial-thickness cartilage (21/30, 70.0%) and full-thickness cartilage (16/30, 53.3%). Conclusion: Temporalis fascia offers superior early hearing outcomes in favourable middle ear conditions, while cartilage-perichondrium grafts provide enhanced anatomical reliability in large perforations. Partial-thickness cartilage achieves a favourable balance between structural stability and auditory gain, supporting individualized graft selection in contemporary tympanoplasty practice.