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\begin{document}

\title{Comparative Analysis of Per-meatal and Post-Aural Approaches in
Tympanoplasty: Patient Perspectives and Quality of Life}



\author[1]{Waqas Jamil}%
\author[2]{Haissan Iftikhar}%
\author[3]{Farah Naz}%
\author[1]{Sanjiv Kumar Bhimrao}%
\affil[1]{University Hospitals of North Midlands NHS Trust}%
\affil[2]{University Hospitals Birmingham NHS Foundation Trust}%
\affil[3]{Dow University of Health Sciences}%


\vspace{-1em}



  
  \date{May 26, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Objectives: This study aimed to compare patient perspectives and
experiences between per-meatal and post-aural tympanoplasty techniques,
focusing on scar perception, postoperative symptoms, return to work, and
quality of life (QOL). Design: Retrospective comparative study. Setting:
Secondary care hospital. Participants: Fifty-four patients who underwent
tympanoplasty via either per-meatal or post-aural methods. Main Outcome
Measures: Patient-reported scar perception, postoperative symptoms and
quality of life reported using validated patient reported outcome
measure- The Chronic Otitis Media Benefit Inventory (COMBI) score,
patient reported return time off work. Results: Scar perception was
favourable in both groups. Most patients in the post-aural group (96\%)
were content with their scar, while 83\% of the per-meatal group
patients were not bothered by the possibility of a scar behind the ear.
Long term postoperative symptoms, return to work, and quality of life
(QOL) measures were comparable between the two groups. The Chronic
Otitis Media Benefit Inventory (COMBI) scores showed no statistically
significant difference between the two surgical techniques. Conclusion:
Patient experiences and outcomes were similar between per-meatal and
post-aural tympanoplasty techniques. Clinicians should consider
individual patient factors and expectations when choosing a surgical
approach.%
\end{abstract}%



\sloppy


\textbf{Comparative Analysis of Per-meatal and Post-Aural Approaches in
Tympanoplasty: Patient Perspectives and Quality of Life}

\textbf{Abstract:}

\emph{Objectives} : This study aimed to compare patient perspectives and
experiences between per-meatal and post-aural tympanoplasty techniques,
focusing on scar perception, postoperative symptoms, return to work, and
quality of life (QOL).

\emph{Design} : Retrospective comparative study.

\emph{Setting} : Secondary care hospital.

\emph{Participants} : Fifty-four patients who underwent tympanoplasty
via either per-meatal or post-aural methods.

\emph{Main Outcome Measures} : Patient-reported scar perception,
postoperative symptoms and quality of life reported using validated
patient reported outcome measure- The Chronic Otitis Media Benefit
Inventory (COMBI) score, patient reported return time off work.

\emph{Results} : Scar perception was favourable in both groups. Most
patients in the post-aural group (96\%) were content with their scar,
while 83\% of the per-meatal group patients were not bothered by the
possibility of a scar behind the ear. Long term postoperative symptoms,
return to work, and quality of life (QOL) measures were comparable
between the two groups. The Chronic Otitis Media Benefit Inventory
(COMBI) scores showed no statistically significant difference between
the two surgical techniques.

\emph{Conclusion} : Patient experiences and outcomes were similar
between per-meatal and post-aural tympanoplasty techniques. Clinicians
should consider individual patient factors and expectations when
choosing a surgical approach.

Key words: Tympanoplasty, per-meatal, post-aural, scar perception,
postoperative symptoms, return to work, quality of life (QOL), patient
perspectives.

\textbf{Key Points:}

1. Having a post aural scar did not seem to be a big concern among
patients undergoing tympanoplasty surgery.

2. Comparable time off work, long term postoperative symptoms and
quality of life measures were observed between the two surgical
approaches i.e., per-meatal approach and post aural approach.

3. The Chronic Otitis Media Benefit Inventory (COMBI) scores revealed no
statistically significant difference in patient-reported outcomes
between the two groups.

4. Clinicians can use the findings of this study within its limitations
in future decision making for patients for tympanoplasty surgery.

5. This study could serve as the initial groundwork for future large
scale studies seeking patient's perspectives and quality of life (QOL)
for tympanoplasty surgery.

\textbf{Introduction:}

\emph{Background:} Tympanoplasties have conventionally been performed
through three primary techniques, namely post-aural, endaural, and
permeatal approaches\textsuperscript{1}. Although research has
scrutinized auditory outcomes and closure rates of perforations, limited
information is available about patient preferences and experiences
specific to each distinct surgical approach\textsuperscript{2}. This
study offers insight into the patient viewpoints concerning the
prevalent tympanoplasty approaches---per-meatal versus post-aural
methods.

\emph{Objectives} : Our study primarily seeks to capture patient's
experiential perspectives and opinions in relation to the contrasting
per-meatal and post-aural techniques. This study encompasses patient
perceptions of scar Vs scar-less surgical procedures, as well as any
associated scar-related complications. Furthermore, we explore potential
dissimilarities observed by patients in postoperative symptoms,
particularly related to ear discharge and auditory function. Lastly, we
examine variations in patients' recovery times and their ability to
resume work after undergoing each distinct surgical approach.

\textbf{Methodology:}

\emph{Reporting Guideline} : This study followed the Strobe guidelines
for reporting the study findings.

\emph{Study design} : A retrospective study was undertaken concerning
patients who underwent either post-aural or per-meatal tympanoplasty
surgery. Patients were contacted via telephonic consultation to gather
insights into their experiences with the respective approaches.

\emph{Setting and Participant Cohort} : This study was performed in a
secondary care hospital, catering to a population exceeding 900,000
individuals\textsuperscript{3}. Study approval was obtained from the
hospital's clinical audit department. The study encompassed 54
consecutive patients who provided consent and demonstrated the ability
to be able to participate. Exclusions were attributed due to the factors
such as non-consent, communication challenges, language barriers, and
health-related impediments. Encompassed within this group were
individuals who underwent tympanoplasty via either the post-aural or
per-meatal method. Procedures spanned simple myringoplasty,
ossiculoplasty (performed in cases where the ossicular chain was not in
continuity), and limited atticotomy (4 cases of atticotomy out of total
of 54 cases). Mastoid surgeries were excluded. Predominantly, the
permeatal subgroup underwent microscopic procedures, with a sole
instance of endoscopic tympanoplasty. General anaesthesia was
administered, with a solitary exception of local anaesthesia. Primary
and revision cases were included. The study spanned a 3 year window,
commencing from November 2019 to April 2022, encapsulating patients who
had undergone surgery within the prior 1 to 3 years. This temporal scope
facilitated a comprehensive long-term assessment of the postoperative
outcomes. Out of the 90 patients contacted for telephonic survey
participation, 54 responded and were included in the analysis.

\emph{Data collected} : Utilising the validated patient reported outcome
measure, denoted as The Chronic Otitis Media Benefit Inventory
(COMBI)\textsuperscript{4,5} (Figure 1), data was collected from both
cohorts. Additional inquiries encompassed work absence and return to
work details. Post-aural patients underwent supplementary questioning
concerning the post aural scar, which has been used in research articles
before\textsuperscript{6,7} (See figure 3 below).

The data collected included demographic specifics (age, gender). In the
post-aural subset, scar related queries are shown in figure 3.
Per-meatal patients were queried on post-aural scar inclination (See
figure 3 below).

The validated COMBI patient reported scoring system (See Figure 1 below)
facilitated a comparison between the two cohorts.

\textbf{Symptom severity:}

Since your operation/intervention, has the discharge or drainage from
your ear been better or worse?\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
5\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
4\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
1\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{Much Better}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{A little} or \emph{somewhat} \emph{better}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{No Change}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{A little} or \emph{somewhat} \emph{worse}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{Mluch worse}\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

2. Since your operation/intervention, how would you define the change
the having a ``smelly ear'' Has this become better or worse?\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
5\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
4\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
1\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{Much Better}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{A little} or \emph{somewhat} \emph{better}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{No Change}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{A little} or \emph{somewhat} \emph{worse}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{Mluch worse}\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

3. Since your operation/intervention, has your hearing at home (e.g.
requiring the volume of the TV or Radio to be turned up) got better or
worse?\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
5\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
4\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
1\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{Much Better}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{A little} or \emph{somewhat} \emph{better}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{No Change}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{A little} or \emph{somewhat} \emph{worse}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{Mluch worse}\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

4. Since your operation/intervention, has your hearing when talking to
people in groups (or when there are noisy surroundings) got better or
worse?\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
5\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
4\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
1\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{Much Better}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{A little} or \emph{somewhat} \emph{better}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{No Change}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{A little} or \emph{somewhat} \emph{worse}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{Mluch worse}\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

5. Since your operation/intervention, has the discomfort and/or around
the ear got better or worse?\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
5\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
4\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
1\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{Much Better}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{A little} or \emph{somewhat} \emph{better}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{No Change}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{A little} or \emph{somewhat} \emph{worse}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{Mluch worse}\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

6. Since your operation/intervention, has your dizziness or feeling off
balance got better or worse?\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
5\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
4\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
1\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{Much Better}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{A little} or \emph{somewhat} \emph{better}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{No Change}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{A little} or \emph{somewhat} \emph{worse}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{Mluch worse}\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

7. Since your operation/intervention, has your tinnitus or noises in the
ear got better or worse?\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
5\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
4\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
1\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{Much Better}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{A little} or \emph{somewhat} \emph{better}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{No Change}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{A little} or \emph{somewhat} \emph{worse}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{Mluch worse}\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{Lifestyle, work and health service impact:}

8. Regarding your normal daily activities at home and at work, would you
say that you have had more problems or less problems, since your
operation/intervention?\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
4\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
5\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{Much more problems performing activities}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{More problems performing activities}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{No Change}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{Less problems performing activities}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{Much less problems performing activities}\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

9. Regarding your ability to wash or shower or bathe as you would like
to since your operation/intervention have you been more fearful or less
fearful of these activities causing an ear infection?\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
4\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
5\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{Much more problems performing activities}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{More problems performing activities}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{No Change}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{Less problems performing activities}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{Much less problems performing activities}\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

10. Since your operation/ intervention, have you seen your family doctor
more often or less often about your ear problems?\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
l\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
4\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
5\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{Much more often}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{More often}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{No Change}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{Less often}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{Much less often}\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Since your operation/Intervention, have you needed to take medicines
(including ear drops) for your ear problem more often or less often?\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
4\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
5\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{Much more often}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{More often}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{No change}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{Less often}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{Much less often}\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{General:}

12. Since your operation/intervention have your ear problems got you
down more or less than before?\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
4\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
5\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{Much more than before}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{More then before}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{No change}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{Less than before}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\emph{Much less than before}\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Figure 1: Showing Validated COMBI scoring system

The principal author gathered data and made phone contact. Verbal
consent was obtained, and responses were documented in an Excel
spreadsheet.

\emph{Statistical analysis} :

Data was assessed for normality of data distribution with Shapiro Wilk
test. Continuous variables were reported as mean and standard deviation
whereas, categorical variables were reported as frequencies and
percentages. Independent sample t-test was used to compare means between
the two groups, whereas chi-square test was used to compare categorical
variables. Type I error of \textless{}0.05 was taken as significant. All
individual COMBI questions were compared between the two groups. The
responses to each question were reported with mean and standard
deviation.

\textbf{Results:}

Among the 90 contacted patients, 54 were included - 30 in the post-aural
group and 24 in the per-meatal group (See Figure 2 below).\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
& Per-meatal Group & Post-aural group\tabularnewline
\midrule
\endhead
Number of patients included & 24 & 30\tabularnewline
Mean age in years & 42.23 & 53.79\tabularnewline
Male: Female ratio & 11:13 & 19:11\tabularnewline
\bottomrule
\end{longtable}

Figure 2: Participant Characteristics.

\emph{Patient's Scar Perception} : In the per-meatal group 20 out of 24
(83\%) were not bothered about scars if there was one behind the ear but
4 patients (mostly females 3 out of 4 i.e., 75\%), were more happy on
not having any scar (See figure 3 below).

\textbf{Patient response in numbers}\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\textbf{Permeatal group scar perception} & Yes & No &
\vtop{\hbox{\strut Don't}\hbox{\strut Care/Don't Know}}\tabularnewline
\midrule
\endhead
1. Would it matter to you if there was a scar behind the ear? & &
&\tabularnewline
Yes, No, don't care & 4 & 0 & 20\tabularnewline
\textbf{Postaural group scar perception} & & &\tabularnewline
1. Are you satisfied with the scar behind the ear? & & &\tabularnewline
Yes, No, don't care & 29 & 0 & 1\tabularnewline
2. Would you prefer no scar if you had a choice? & & &\tabularnewline
\vtop{\hbox{\strut Yes, No, don't care}\hbox{\strut 3. Hairstyle needed
changing after surgery?}} & 7 & 0 & 23\tabularnewline
Yes, No & 0 & 30 & 0\tabularnewline
4. Do other people remark or ask about the scar? & & &\tabularnewline
Yes, No, don't know & 0 & 30 & 0\tabularnewline
Does it bother you? & & &\tabularnewline
Yes, No, don't know & NA & NA & NA\tabularnewline
5. Scar causes discomfort? & & &\tabularnewline
Yes, No, don't care & 2 & 28 & 0\tabularnewline
6. Is ear/scar numb? & & &\tabularnewline
Yes, No, don't care & 5 & 24 & 1\tabularnewline
Numbness causes problems? & & &\tabularnewline
Yes, No, don't care & 0 & 5 & 0\tabularnewline
7. Ear position has changed since ear surgery? & & &\tabularnewline
Yes, No, don't know, don't care & 3 & 25 & 2\tabularnewline
8. Any problems wearing eye glasses since ear surgery? & &
&\tabularnewline
Yes, No, don't know & 1 & 24 & 0\tabularnewline
9. Any problems wearing hearing aids since surgery? & & &\tabularnewline
Yes, No, don't know & 1 & 10 & 0\tabularnewline
10. Voluntary pinna movements effected since ear surgery? & &
&\tabularnewline
Yes, No, don't know & 3 & 3 & 0\tabularnewline
\bottomrule
\end{longtable}

Figure 3: Showing patient's responses to Scar perception questions (NA-
Not applicable)

In the post-aural group, 29 out of 30 (96\%) patients were satisfied
with the scar they have. Concerning scar preference in the post-aural
group, 23 patients (77\%) were not bothered about the scar while 7
patients (23\%) preferred no scar. No patient (0\%) altered hairstyle
due to post aural scar. Scar visibility to others was reported as nil
(0\%). Merely 2 patients (7\%) reported mild scar discomfort. 5 patients
(17\%) noted slight scar numbness which was non-intrusive. 3 patients
indicated a slight change in ear position post-surgery, 2 patients were
uncertain about post-surgery ear re-positioning, and 25 patients noted
no change in ear position. Hearing aids were used by 11 out of 30
patients in the post-aural group; 1 patient reported minor issues
wearing hearing aid and 10 out of 11 patients (91\%) reported no issues
with hearing aids. 6 out of 30 patients could move their ears prior to
surgery using auricular muscles; where 3 out of 6 of those patients
(50\%) lost that ability post-surgery (See figure 3).

\emph{Time off work post-ear surgery} : Standard hospital advice
suggests approximately 2 weeks of work leave after ear surgery. For some
patients, work leave was not reported due to memory lapse or either it
was insignificant due to their roles (e.g., housewives, retirees, remote
workers).

In the per-meatal group, 14 of 24 individuals had relevant work leave,
averaging 13.7 days (1 day to 6 weeks). Among them, 5 followed the
advice with 2 full weeks off, 5 returned sooner, and 4 needed more than
2 weeks off.

In the post-aural group, 23 of 30 were relevant, with an average leave
of 13.4 days. 8 returned early, 7 took full 2 weeks, and 8 needed over 2
weeks off.

\emph{Comparison of Permeatal vs. Post-aural approaches using the COMBI
questionnaire} :

Overall, the statistical analysis indicates that there are variations in
patient perceptions and experiences between the per-meatal (PA) and
post-aural (PM) tympanoplasty techniques across different dimensions
assessed by the Chronic Otitis Media Benefit Inventory (COMBI)
questionnaire. However, these variations appear to be relatively subtle,
and in all cases (12 questions), the differences between the two groups
are not statistically significant.

\textbf{Discussion:}

\emph{Key findings} : In line with our research, no notable contrast
emerged between the per-meatal and post-aural groups based on patient
responses after tympanoplasty surgery. The scar behind the ear posed a
minimal concern for the majority of patients in both groups. The
post-aural approach was well-tolerated, with negligible scar-related
problems. Work absence and resumption were akin between groups. The
COMBI questionnaire revealed no statistically significant difference in
postoperative quality of life or symptoms. To the best of our knowledge,
this is the first study comparing patient viewpoints, symptomatology,
and quality of life tied to these two surgical techniques.

\emph{Limitations} : Some patients underwent meatoplasty alongside the
post aural approach, theoretically impacting post-operative results,
particularly with hearing aid use. However, our study found no
supporting evidence of this based on patient responses. Graft materials
included cartilage, temporalis fascia, and fat graft, each could
potentially yield different success rates and subsequent ongoing
symptoms. Yet, as most patients received cartilage grafts (occasionally
composite cartilage and fascia), and in only one case used a fat plug,
generally high success rates of these graft materials mitigate
significant result disparities. Procedures were performed or supervised
by two experienced otologists. Selection criteria for choosing a
surgical approach encompassed perforation size, site, ear canal diameter
and curvature which could be a source of selection bias. While age
displayed a statistically significant difference between per-meatal and
post aural approach, this disparity would have less likely impacted the
overall conclusions of the study.

\emph{Comparison with Prior Literature} : The three recognized methods
for tympanoplasty are post-aural, endaural, and per-meatal
approaches\textsuperscript{1}. Literature extensively covers these
approaches, discussing indications, techniques, outcomes, and
complications\textsuperscript{2}. Studies compare per-meatal and
post-aural approaches, examining graft success, hearing, surgery
duration, recovery, and complications\textsuperscript{2,8}. Perhaps our
study is unique since it offers a patient perspective on experiences
with these two surgical methods.

\emph{Clinical and Research Implications} : This study provides
preliminary data, potentially paving the way for a more extensive
investigation with robust methodology and larger sample size. Clinicians
can utilise our study findings within the study's limitations.

\textbf{Conclusion:}

Our study suggests comparable long-term outcomes in quality of life
between per-meatal and post-aural approaches. No significant disparity
was observed in ongoing ear symptoms, impact on quality of life, scar
perception, or return to work. Clinicians should consider individual
patient factors and preferences when selecting a surgical approach.

\emph{Conflict of interest statement:} The authors declare no conflicts
of interest.

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