Chronic suppurative otitis media (CSOM) is a persistent inflammatory condition of the middle ear and mastoid cavity, commonly characterized by recurrent or persistent ear discharge through a perforated tympanic membrane. It remains an important cause of preventable conductive hearing loss, particularly in developing countries, where delayed diagnosis, recurrent upper respiratory tract infections, inadequate treatment, and limited access to specialized otological care contribute to disease persistence. The tubotympanic or mucosal type of CSOM primarily involves the pars tensa of the tympanic membrane and is generally associated with a central perforation. Persistent perforations interfere with the normal sound-conduction mechanism, resulting in hearing impairment, recurrent infections, communication difficulties, and reduced quality of life. Surgical reconstruction of the tympanic membrane is therefore essential for restoring its anatomical integrity, improving hearing, and preventing recurrent middle ear infections [1]. Tympanoplasty is an established surgical procedure performed to reconstruct the tympanic membrane and restore the sound-conducting mechanism of the middle ear. Various autologous graft materials, including temporalis fascia, perichondrium, and cartilage, have been utilized for tympanic membrane repair. Although temporalis fascia has traditionally been preferred because of its availability, flexibility, and favorable acoustic properties, graft failure may occur in patients with large perforations, Eustachian tube dysfunction, and recurrent middle ear disease. Cartilage tympanoplasty has gained increasing acceptance because of its structural stability, resistance to retraction and resorption, and ability to withstand negative middle ear pressure. Nevertheless, concerns regarding the rigidity and thickness of cartilage and their potential effects on postoperative sound transmission remain clinically relevant [2]. Recent investigations have evaluated the anatomical and functional effectiveness of cartilage tympanoplasty. Emami et al. reported in a systematic review and meta-analysis that partial-thickness cartilage grafts were associated with better hearing outcomes than full-thickness cartilage grafts, highlighting the importance of graft thickness in postoperative auditory improvement [2]. Huang et al., in a systematic review of butterfly cartilage tympanoplasty, demonstrated satisfactory graft uptake and hearing improvement, with reduced operative duration and postoperative discomfort compared with conventional procedures [3]. Similarly, Lubianca Neto et al. compared endoscopic and microscopic butterfly cartilage tympanoplasty and found comparable anatomical and audiological outcomes between the two approaches [4]. Further evidence from Chen and Zhao, involving 44 studies and 4,582 patients, demonstrated superior overall morphological success with cartilage grafts compared with temporalis fascia, although hearing outcomes were generally comparable [5]. Bin Lajdam et al., in a meta-analysis of 18 randomized controlled trials involving 1,273 participants, reported significantly higher graft success rates with cartilage at 12 and 24 months without significant differences in postoperative air–bone gap closure [6]. Despite these encouraging findings, variations in surgical techniques, graft characteristics, perforation size, patient selection, and follow-up duration complicate the interpretation of postoperative outcomes. Furthermore, focused clinical evaluation of both anatomical success and early audiological improvement following cartilage tympanoplasty in patients with inactive tubotympanic CSOM remains relevant, particularly in regional hospital settings. Therefore, the present study aims to evaluate postoperative graft uptake and hearing improvement following cartilage tympanoplasty in patients with tubotympanic CSOM, by assessing the anatomical integrity of the reconstructed tympanic membrane and comparing preoperative and postoperative hearing thresholds using pure tone audiometry. These findings may contribute to understanding the short-term effectiveness of cartilage tympanoplasty in routine otological practice.

The present study was a prospective observational study conducted in the Department of Otorhinolaryngology at Kamineni Institute of Medical Sciences, Narketpally, Nalgonda District, Telangana, India, from August 2022 to May 2024. The study included 50 patients diagnosed with inactive tubotympanic type of chronic suppurative otitis media (CSOM) who underwent cartilage tympanoplasty. The primary objective was to evaluate postoperative surgical outcomes in terms of graft uptake and hearing improvement by comparing preoperative and postoperative pure tone audiometry (PTA) findings. Patients fulfilling the eligibility criteria were enrolled after obtaining informed consent. All patients underwent butterfly cartilage tympanoplasty using autologous tragal cartilage and were evaluated during postoperative follow-up. Inclusion Criteria • Patients aged 15–50 years, irrespective of gender. • Patients diagnosed with uncomplicated tubotympanic type of CSOM. • Patients with inactive CSOM and a dry ear for at least six weeks. • Patients with conductive hearing loss and an air–bone gap of less than 40 dB on pure tone audiometry. • Patients willing to undergo surgery and attend postoperative follow-up examinations. Exclusion Criteria • Patients younger than 15 years or older than 50 years. • Patients with complicated CSOM. • Patients diagnosed with atticoantral type of CSOM. • Patients with active middle ear infection or active CSOM. • Patients with mixed or sensorineural hearing loss or an air–bone gap greater than 40 dB. • Patients with diabetes mellitus, hypertension, or tympanosclerosis of the tympanic membrane. • Patients with a history of ototoxic drug usage. Study Tools The following instruments and clinical assessment methods were used: 1. Clinical ENT examination: For assessing clinical symptoms, ear discharge, tympanic membrane perforation, and middle ear status. 2. Rigid otoendoscope: A Hopkins 0-degree rigid otoendoscope was used to evaluate tympanic membrane perforations and postoperative graft uptake. 3. Pure tone audiometer: Used to determine the degree of conductive hearing loss before and after surgery. 4. Air conduction headphones and bone vibrator: Used to assess hearing thresholds and characterize the type of hearing loss. 5. Audiometric assessment: Pure tone averages were determined using air conduction thresholds at 500, 1000, and 2000 Hz. 6. Surgical instruments: Standard otological surgical instruments were used for harvesting tragal cartilage and performing butterfly cartilage tympanoplasty. 7. Postoperative otoendoscopic and audiometric examinations: Used to assess anatomical graft success and functional hearing improvement at the sixth postoperative week. Data Collection Procedure • Patient recruitment: Fifty patients satisfying the inclusion and exclusion criteria were enrolled after obtaining informed consent. • Preoperative assessment: All patients underwent detailed ENT examination and otoendoscopic assessment using a Hopkins 0-degree rigid endoscope to identify the site and characteristics of tympanic membrane perforation. • Audiological evaluation: Preoperative pure tone audiometry was performed in a soundproof room. Air conduction hearing thresholds at 500, 1000, and 2000 Hz were used to calculate the pure tone average. Hearing impairment was classified according to the American Speech-Language-Hearing Association (ASHA) classification. • Surgical procedure: Following pre-anaesthetic assessment, all patients underwent butterfly cartilage tympanoplasty under general anaesthesia. Autologous tragal cartilage with perichondrium was harvested, and a circumferential groove was created along its margin to form a butterfly-shaped graft. After freshening the perforation margins, antibiotic-soaked absorbable gelatin sponge was placed in the middle ear, and the cartilage graft was positioned such that one flange remained medial and the other lateral to the perforation margin. • Postoperative management: The external auditory canal was packed with absorbable gelatin sponge and antibiotic ointment dressing. Patients received postoperative antibiotics, analgesics, and antihistamines and were discharged approximately two days after surgery with instructions to prevent water entry into the ear and avoid straining or heavy lifting. • Follow-up evaluation: Patients were reviewed weekly during the first two postoperative weeks and subsequently every fortnight. At six weeks, otoendoscopic examination was performed to evaluate graft uptake and identify residual perforation or graft failure. • Postoperative hearing assessment: Pure tone audiometry was repeated at the sixth postoperative week. Hearing improvement was determined by comparing preoperative and postoperative pure tone averages. • Outcome assessment: The primary outcomes were successful graft uptake at six weeks and the magnitude of postoperative hearing improvement expressed in decibels. Statistical Analysis The collected data were analyzed using descriptive and inferential statistical methods. Categorical variables, including age groups, gender, degree of hearing loss, and graft uptake, were expressed as frequencies and percentages. Continuous variables, including preoperative and postoperative pure tone averages, were summarized as mean and standard deviation. The paired Student's t-test was used to compare preoperative and sixth-week postoperative hearing thresholds in the same patients. A p-value of less than 0.05 was considered statistically significant. The magnitude of hearing improvement was calculated as the difference between preoperative and postoperative pure tone averages. The statistical analysis presented in the study demonstrated the significance of postoperative hearing improvement.

Table 1. Demographic and Preoperative Clinical Characteristics of Patients Undergoing Cartilage Tympanoplasty (N = 50) Parameter Category Number of patients (%) Age (years) 15–20 6 (12%) 20–25 8 (16%) 25–30 8 (16%) 30–35 7 (14%) 35–40 7 (14%) 40–45 2 (4%) 45–50 12 (24%) Gender Male 17 (34%) Female 33 (66%) Preoperative hearing loss Slight (16–25 dB) 1 (2%) Mild (26–40 dB) 27 (54%) Moderate (41–55 dB) 18 (36%) Moderately severe (56–70 dB) 2 (4%) Severe (71–90 dB) 2 (4%) Total patients 50 (100%) The study included 50 patients aged between 15 and 50 years, with a reported mean age of 34 years. The largest proportion belonged to the 45–50-year age group (24%), followed by the 20–25-year and 25–30-year groups (16% each). Female patients predominated, accounting for 66% of the study population, whereas males constituted 34%. Preoperative pure tone audiometry revealed that mild conductive hearing loss was most common (54%), followed by moderate hearing loss (36%). Only 8% of patients had moderately severe or severe hearing loss, indicating that most participants presented with mild to moderate auditory impairment. Postoperative graft uptake was assessed by otoendoscopic examination at the sixth postoperative week. Successful graft uptake was observed in 49 of the 50 patients, corresponding to an anatomical success rate of 98%. Only one patient (2%) exhibited partial graft uptake characterized by anterior gaping of the graft. The present study also reported methicillin-resistant Staphylococcus aureus in the aural swab culture of this patient. These findings demonstrate a high short-term anatomical success rate following butterfly cartilage tympanoplasty. However, longer follow-up would be necessary to determine the durability of graft integrity. Table 2. Comparison of Preoperative and Postoperative Pure Tone Audiometry Following Cartilage Tympanoplasty (N = 50) Audiological parameter Preoperative Postoperative (6 weeks) Number of patients 50 50 Mean PTA (dB) 42.65 30.61 Standard deviation (dB) 10.59 8.60 Mean hearing improvement (dB) — 12.04 Paired t-statistic — 15.963 Degrees of freedom — 49 Statistical test: Paired Student's t-test. PTA = Pure Tone Average. Mean hearing improvement = preoperative PTA − postoperative PTA. Comparison of preoperative and postoperative pure tone audiometry demonstrated a significant improvement in hearing thresholds following cartilage tympanoplasty. The mean preoperative PTA was 42.65 ± 10.59 dB, which decreased to 30.61 ± 8.60 dB at the sixth postoperative week. The overall mean hearing improvement was 12.04 dB. Paired Student's t-test demonstrated a statistically significant difference between preoperative and postoperative hearing thresholds (t = 15.963, df = 49, p < 0.0001). These findings indicate significant short-term functional hearing improvement after butterfly cartilage tympanoplasty. Table 3. Distribution of Patients According to Preoperative and Postoperative Degrees of Hearing Loss (N = 50) Degree of hearing loss Preoperative n (%) Postoperative n (%) Normal hearing (−10 to 15 dB) 0 (0%) 0 (0%) Slight (16–25 dB) 1 (2%) 19 (38%) Mild (26–40 dB) 27 (54%) 28 (56%) Moderate (41–55 dB) 18 (36%) 1 (2%) Moderately severe (56–70 dB) 2 (4%) 2 (4%) Severe (71–90 dB) 2 (4%) 0 (0%) Profound (>90 dB) 0 (0%) 0 (0%) Total 50 (100%) 50 (100%) Postoperative hearing thresholds were assessed at six weeks. Data represent the marginal distribution at each assessment, not individual patient transitions between hearing categories. Preoperative audiometric assessment revealed that 54% of patients had mild hearing loss, while 36% had moderate hearing loss. Following cartilage tympanoplasty, the proportion of patients with slight hearing loss increased markedly from 2% to 38%. The proportion with moderate hearing loss decreased from 36% to 2%, suggesting a substantial shift toward better hearing categories after surgery. No patient remained in the severe hearing loss category at the sixth postoperative week. These findings demonstrate favorable changes in the overall distribution of hearing impairment following cartilage tympanoplasty. Table 4. Mean Postoperative Hearing Improvement According to Preoperative Degree of Conductive Hearing Loss (N = 50) Preoperative degree of hearing loss Number of patients (%) Mean hearing improvement (dB) Slight (16–25 dB) 1 (2%) 3.40 Mild (26–40 dB) 27 (54%) 9.90 Moderate (41–55 dB) 18 (36%) 13.86 Moderately severe (56–70 dB) 2 (4%) 20.45 Severe (71–90 dB) 2 (4%) 16.60 Overall 50 (100%) 12.04 The magnitude of postoperative hearing improvement varied according to the preoperative degree of conductive hearing loss. Patients with moderately severe hearing loss demonstrated the greatest mean improvement of 20.45 dB, followed by those with severe hearing loss (16.60 dB). Patients with moderate hearing loss showed an average improvement of 13.86 dB, while those with mild hearing loss improved by 9.90 dB. The patient with slight hearing loss demonstrated a comparatively smaller improvement of 3.40 dB. The overall mean improvement was approximately 12 dB, although subgroup comparisons should be interpreted cautiously because of the small numbers in several categories. Table 5. Correlation Between Preoperative and Postoperative Pure Tone Audiometry Thresholds in Patients Undergoing Cartilage Tympanoplasty (N = 50) Statistical parameter Result Number of paired observations 50 Preoperative mean PTA (dB) 42.65 Postoperative mean PTA (dB) 30.61 Pearson's correlation coefficient (r) 0.866 Coefficient of determination (r²) 0.749 Pearson's correlation analysis demonstrated a strong positive correlation between preoperative and postoperative pure tone audiometry thresholds (r = 0.866, p < 0.0001). The coefficient of determination was 0.749, indicating that approximately 74.9% of the variation in postoperative PTA was linearly associated with preoperative PTA in this sample. This suggests that patients presenting with higher preoperative hearing thresholds generally continued to exhibit relatively higher hearing thresholds following surgery. However, this positive correlation does not indicate an absence of improvement, as the paired comparison demonstrated a significant reduction in mean hearing thresholds. These findings indicate that baseline hearing status was strongly associated with postoperative hearing status.

The present prospective observational study evaluated the anatomical and audiological outcomes of butterfly cartilage tympanoplasty in 50 patients with inactive tubotympanic chronic suppurative otitis media (CSOM). The findings demonstrated a high postoperative graft uptake rate of 98% and significant improvement in hearing thresholds at the sixth postoperative week. The mean preoperative pure tone average (PTA) decreased from 42.65 ± 10.59 dB to 30.61 ± 8.60 dB, with an overall mean hearing improvement of 12.04 dB (p < 0.0001). These results suggest that butterfly cartilage tympanoplasty provides favorable short-term anatomical and functional outcomes in appropriately selected patients with mucosal-type chronic otitis media. The demographic distribution revealed that patients aged 45–50 years constituted the largest proportion (24%), followed by those aged 20–25 and 25–30 years (16% each). Females accounted for 66% of the study population, whereas males constituted 34%. The mean age was 34 years, indicating that the condition predominantly affected individuals in economically productive age groups. Preoperative audiometric evaluation demonstrated mild conductive hearing loss in 54% of patients and moderate hearing loss in 36%. This distribution suggests that most patients underwent surgery before developing severe auditory impairment. However, the observed demographic characteristics reflect the recruited clinical population and cannot establish age- or sex-specific disease prevalence. Successful graft uptake was observed in 49 patients (98%), while one patient (2%) experienced partial graft failure with anterior gaping. These findings are comparable to those reported by Venkatesan et al. [7], who conducted a prospective comparative study involving 60 patients undergoing type I tympanoplasty with temporalis fascia or tragal island cartilage. They reported graft uptake rates of 96.67% in the cartilage group and 90% in the temporalis fascia group. The mean hearing gain was 11.17 ± 4.06 dB with cartilage and 13.83 ± 8.11 dB with fascia, without a significant difference between groups. The present study similarly demonstrated favorable graft integration and hearing improvement, supporting the effectiveness of cartilage as a reconstructive material. Singh et al. [8], in a prospective randomized comparative study involving 160 patients, observed graft uptake rates of 95% with cartilage shield tympanoplasty and 72.5% with temporalis fascia grafting. Cartilage demonstrated particularly favorable anatomical outcomes in challenging cases, including revision surgery, subtotal perforations, and retracted tympanic membranes, without significantly compromising hearing improvement. The 98% graft uptake achieved in the present study is consistent with these findings. However, the current investigation included only patients with inactive tubotympanic disease and cannot establish the superiority of cartilage over other graft materials because no comparison group was included. The postoperative audiometric findings demonstrated a statistically significant improvement in mean PTA, with a reduction of approximately 12 dB. Mucha et al. [9], in a randomized comparative study of 80 pediatric patients undergoing tympanoplasty using temporalis fascia or tragal cartilage, reported comparable functional outcomes between graft materials, although anatomical success was numerically higher with cartilage. Their findings support the suitability of cartilage reconstruction for maintaining satisfactory hearing outcomes. Nevertheless, differences in age distribution, surgical techniques, and postoperative evaluation periods should be considered when comparing these studies. Analysis of hearing-loss categories in the present study demonstrated a marked postoperative shift toward lower degrees of auditory impairment. The proportion of patients with slight hearing loss increased from 2% preoperatively to 38% postoperatively, whereas moderate hearing loss decreased from 36% to 2%. Furthermore, no patients remained in the severe hearing-loss category. Hearing improvement was greatest among patients with moderately severe preoperative hearing loss (20.45 dB), followed by severe (16.60 dB), moderate (13.86 dB), mild (9.90 dB), and slight hearing loss (3.40 dB). These findings suggest that clinically meaningful improvement can occur across different degrees of preoperative hearing impairment. However, subgroup estimates involving only one or two patients require cautious interpretation. Jhawar et al. [10] compared temporalis fascia, fascia lata, and sliced tragal cartilage in 75 patients undergoing type I tympanoplasty. They observed significant differences in air–bone gap improvement among graft groups (p = 0.047), with fascia lata demonstrating favorable anatomical and audiological outcomes. These findings indicate that surgical success is influenced by graft selection and clinical characteristics and that cartilage cannot be presumed superior in every patient. The present study contributes additional evidence of satisfactory postoperative hearing outcomes following butterfly cartilage tympanoplasty, although direct comparison of graft materials was not possible. Jacob et al. [11], in a comparative study involving 52 patients, reported residual perforation in one of 26 patients undergoing cartilage tympanoplasty and two of 26 patients receiving temporalis fascia grafts. Hearing gain exceeding 10 dB was observed in 12 cartilage recipients and 11 fascia recipients. These results are consistent with the favorable anatomical and functional outcomes observed in the present study and reinforce the clinical utility of cartilage grafting. Similarly, Shah et al. [12], in a prospective randomized study involving 60 patients, reported superior structural stability and graft uptake with cartilage, although temporalis fascia demonstrated marginally better short-term hearing outcomes. These findings emphasize the importance of balancing anatomical durability and hearing improvement when selecting graft materials. Pearson's correlation analysis in the present study demonstrated a strong positive association between preoperative and postoperative PTA values (r = 0.866, p < 0.0001), indicating that higher baseline hearing thresholds were generally associated with higher postoperative thresholds. However, this association should not be interpreted as evidence that baseline hearing loss determines the magnitude of hearing recovery. Although only one partial graft failure occurred, the associated anterior gaping and positive culture for methicillin-resistant Staphylococcus aureus highlight the importance of postoperative surveillance. The principal limitations include the relatively small sample size, single-center design, absence of a temporalis fascia comparison group, and short postoperative follow-up of six weeks. Furthermore, graft integrity and hearing outcomes were not evaluated longitudinally, and additional factors influencing surgical success could not be adequately assessed. Despite these limitations, the study provides clinically relevant evidence supporting favorable early outcomes following butterfly cartilage tympanoplasty in carefully selected patients with inactive tubotympanic CSOM.

The present study demonstrated that butterfly cartilage tympanoplasty using autologous tragal cartilage achieved a 98% graft uptake rate and a mean hearing improvement of 12.04 dB at the sixth postoperative week. The statistically significant reduction in postoperative pure tone audiometry thresholds (p < 0.0001), together with the favorable anatomical outcomes, supports the effectiveness of this technique for tympanic membrane reconstruction in patients with inactive tubotympanic CSOM. Butterfly cartilage tympanoplasty represents a useful surgical option for achieving early graft integration and functional hearing improvement. However, larger comparative studies with longer postoperative follow-up are necessary to establish its relative effectiveness and long-term anatomical durability.

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