Dear Editor,

Different surgical techniques and variations are seen in the literature in every stage of endoscopic tympanoplasty surgery. These differences are graft preparation, tympanomeatal flap methods, graft insertion (underlay–overlay–inlay–butterfly–push through), tampons placed in the outer ear canal (EAC) and tragal area, etc. [1,2,3,4].

We use tympanomeatal flap elevation technique (underlay) in endoscopic tympanoplasty surgeries in our clinic. In cases where we are planning inlay or overlay surgery, we do not consider flap elevation necessary. Our main goal in tympanomeatal flap elevation is, we think it is better to graft feeding with vascular strip. Also, the graft placed receives mechanical support from EAC and flap elevation allows us to better evaluate the middle ear. In addition to the limitation of evaluating the middle ear with angled and straight telescopes through perforation, the middle ear structures and ossicular system can be evaluated better under the elevated flap.

The placement of the graft prepared after flap elevation differs according to surgeons [2]. At this stage, we place the perichondrial tragal graft for the right ear on the malleus (over) in the posterior, under the anulus in the anterior (under), and the outer ear canal in the lateral. Thus, our graft also get supports from malleus and EAC. Different techniques have been reported, the flap of which is not elevated [3]. In our clinic, there are cases that we performed without flap elevating in appropriate cases. The main purpose here is to choose the most suitable technique for the patient and the most suitable technique for the surgeon’s experience.

Because of the place where the graft is taken from, the tragus is usually small and without bleeding, it is the surgeon’s preference not to sut. Tampons can be placed on the grafted area [4]. We make a single stitch with rapid absorbabl sutures to prevent postoperative leakage bleeding. Thus, we think that it provides extra comfort to the patient by taking the tampons placed in the tragal region early. Also, we do not use the ‘packing geuze’ you use for EAC. We have no experience of protecting against infections.