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\begin{document}

\title{Hearing performance after myringoplasty with full-thickness cartilage: A
propensity score-matched cohort study}



\author[1]{Yi-bo Huang}%
\author[1]{Jiang-Hong Xu}%
\author[1]{Yu-Cheng Pan}%
\author[1]{Ji-Han  Lv}%
\author[2]{Ya-sheng Yuan}%
\author[3]{zhao han}%
\author[2]{Dong-dong Ren}%
\affil[1]{fu dan da xue fu shu yan er bi hou ke yi yuan}%
\affil[2]{Eye \& ENT Hospital, Fudan University}%
\affil[3]{Fudan University Eye Ear Nose and Throat Hospital}%


\vspace{-1em}



  
  \date{May 25, 2024}


\begingroup
\let\center\flushleft
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\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Objective: Hearing performance after myringoplasty with full-thickness
tragal cartilage (FTTC) has been questioned because a considerable
difference exists between the graft and natural tympanum. This study
aimed to analyze the air-bone gap (ABG) trends before and after
myringoplasty and its interaction with risk factors in the FTTC group;
further, it compared postoperative ABG in the FTTC group to that in the
temporalis fascia (TF) and partial-thickness tragal cartilage (PTTC)
groups. Design: A retrospective cohort study Setting: Tertiary care
University Hospital Methods: The general linear model repeated measures
was used to analyze ABG trends in the FTTC group and its influencing
factors. Non-parametric tests were used to compare ABGs in the FTTC
group and the other two groups. Propensity score matching was done to
balance baseline characteristics between the TF and FTTC group. Results:
The mean postoperative ABG in the FTTC group was 12.17\selectlanguage{ngerman}±6.58 dB, and
90.9\% of the patients had a mean ABG within 20 dB, which improved
significantly after surgery (F(1,108)=38.707, P\textless{}.001). The
tympanic perforation size and malleus handle exposure status, which
significantly affected the preoperative ABG, did not affect
postoperative hearing (P\textgreater{}.05). In the FTTC group, the mean
ABG was comparable to that in the other two groups (P\textgreater{}.05).
For all except 250 Hz, a similar audiological performance was observed
in the FTTC and PTTC groups; FTTC had a better performance at 250 Hz
(Z=-2.277, P=.023). Conclusions: Good hearing performance was achieved
after myringoplasty with FTTC, irrespective of the preoperative
perforation size and malleus handle exposure status.%
\end{abstract}\selectlanguage{ngerman}%



\sloppy


\textbf{Hearing performance after myringoplasty with full-thickness
cartilage: A propensity score-matched cohort study}

\textbf{Abstract}

\textbf{Objective:} Hearing performance after myringoplasty with
full-thickness tragal cartilage (FTTC) has been questioned because a
considerable difference exists between the graft and natural tympanum.
This study aimed to analyze the air-bone gap (ABG) trends before and
after myringoplasty and its interaction with risk factors in the FTTC
group; further, it compared postoperative ABG in the FTTC group to that
in the temporalis fascia (TF) and partial-thickness tragal cartilage
(PTTC) groups.

\textbf{Design:} A retrospective cohort study

\textbf{Setting:} Tertiary care University Hospital

\textbf{Methods:} The general linear model repeated measures was used to
analyze ABG trends in the FTTC group and its influencing factors.
Non-parametric tests were used to compare ABGs in the FTTC group and the
other two groups. Propensity score matching was done to balance baseline
characteristics between the TF and FTTC group.

\textbf{Results:} The mean postoperative ABG in the FTTC group was
12.17\selectlanguage{ngerman}±6.58 dB, and 90.9\% of the patients had a mean ABG within 20 dB,
which improved significantly after surgery
(F\textsubscript{(1,108)}=38.707, \emph{P} \textless{}.001). The
tympanic perforation size and malleus handle exposure status, which
significantly affected the preoperative ABG, did not affect
postoperative hearing (\emph{P} \textgreater{}.05). In the FTTC group,
the mean ABG was comparable to that in the other two groups (\emph{P}
\textgreater{}.05). For all except 250 Hz, a similar audiological
performance was observed in the FTTC and PTTC groups; FTTC had a better
performance at 250 Hz (Z=-2.277, \emph{P} =.023).

\textbf{Conclusions:} Good hearing performance was achieved after
myringoplasty with FTTC, irrespective of the preoperative perforation
size and malleus handle exposure status.

\textbf{Keywords:} cartilage; hearing tests; linear models;
myringoplasty; propensity score; retrospective studies

\textbf{Key points:}

\begin{itemize}
\tightlist
\item
  To compare the hearing performance between the two myringoplasties,
  microscopic and endoscopic, and between full-thickness- and
  partial-thickness tragal cartilage graft (FTTC and PTTC, respectively)
  in endoscopic myringoplasty.
\item
  Hearing improvement was achieved irrespective of the preoperative
  tympanic perforation size and the malleus handle exposure status in
  the FTTC group.
\item
  The postoperative air-bone gap was comparable in the temporalis fascia
  and PTTC groups
\item
  The audiological improvement at 250 Hz was better in the FTTC group
  than in the PTTC group.
\item
  Good hearing performance was achieved after myringoplasty with FTTC,
  irrespective of the preoperative perforation size and malleus handle
  exposure status.
\end{itemize}

\textbf{Introduction}

Endoscopic myringoplasty has gained popularity in recent years, as its
use can help to achieve a clear surgical vision,\textsuperscript{1} less
postoperative pain, and a high success rate both in anatomy and
function.\textsuperscript{2} Full-thickness tragal cartilage (FTTC) is
the grafting material of choice for endoscopic
myringoplasty.\textsuperscript{3,4} FTTC is easy to harvest and suitable
for one-handed operations under the endoscope due to its hardness.
However, there is a considerable difference in the thickness, stiffness,
and elasticity between FTTC and the natural tympanic membrane. Many
otologists doubt its postoperative hearing performance. Performing
myringoplasty under the microscope with a temporalis fascia (TF) graft
is the classic surgical approach. However, in endoscopic myringoplasty,
partial-thickness tragal cartilage (PTTC) is used as a graft, which is
closer to the natural tympanic membrane. Here, we aimed to compare the
hearing performance between the two myringoplasties, microscopic and
endoscopic, and between FTTC and PTTC graft in endoscopic myringoplasty.
We also compared the postoperative audiological performance between
them.

\textbf{Materials and Methods}

\textbf{Subjects}

This retrospective cohort study was conducted at the Department of
Otolaryngology of a tertiary hospital in China between January 2017 and
February 2020. Adult patients (\textgreater{}18 years) with chronic
otitis media, persistent tympanic membrane perforation, an intact
ossicular chain on computed tomography scan, and ossicular chain
mobility during the intraoperative assessment were included. Hearing
performance in microscopic and endoscopic myringoplasties, each using a
different graft, was compared. For the FTTC group, cartilage with no
thinning and perichondrium on one side was used; the myringoplasty was
performed under the endoscope. For the TF group, traditional
myringoplasty was performed under the microscope using TF as a graft.
For the PTTC group, ultra-thin tragal cartilage was used and the
myringoplasty was performed under the endoscope. Postoperative tympanum
closure rate and hearing performance were evaluated 3 months after the
operation.

The study protocol was approved by the Ethics Committee of the Hospital.

\textbf{Definitions of variables}

The mean air-bone gap (ABG) was the average ABG value at 500 Hz, 1000
Hz, 2000 Hz, and 4000 Hz. The mean ABG was divided into four categories:
1) \selectlanguage{english}[?]10 dB, 2) 11--20 dB, 3) 21--30 dB, 4) \selectlanguage{english}[?]31 dB. Three factors
affecting the ABG were included in this study: time (before and after
surgery), tympanic perforation size (large {[}\selectlanguage{english}[?]50\%{]} and small
{[}\textless{}50\%{]}), and exposure of malleus handle (exposed and
unexposed).

\textbf{Statistical analysis}

Continuous variables were presented as mean +- standard deviation for
normally distributed variables and as median (interquartile range) for
variables that followed a non-parametric distribution. Categorical
variables were compared using the chi-square test. Quantitative
continuous variables were compared using the unpaired Student's\emph{t}
-test or the Mann-Whitney U test for normally and non-normally
distributed variables, respectively. The factors affecting ABG were
compared using the general linear model repeated measures test.

Propensity score matching (PSM) was performed to balance the baseline
characteristics between the TF group and the FTTC group. Age, gender,
size of perforation, exposure of malleus handle, and ABG values at
frequencies from 250 Hz to 4000 Hz before surgery were matched. Before
PSM, there were 40 patients in the microscopic group and 111 patients in
the endoscopic group. However, after the cohorts were propensity
score-matched to create a 1:1 matched set using a caliper width of 0.02;
a total of 38 patients were included in each group. After the two groups
were matched, the distribution of the ABG values for frequencies of 250
Hz, 500 Hz, 1000 Hz, 2000 Hz, and 4000 Hz did not obey normal
distribution; therefore, a non-parametric test, to compare
two-related-samples, was used for analysis.

\emph{P} -values \textless{} .05 was considered statistically
significant. IBM SPSS for Windows version 22.0 (IBM Corp., Armonk, NY,
USA) was used for analyses.

\textbf{Myringoplasty procedure}

After infiltration of the canal with local anesthesia, the edges of the
perforation were freshened.~A broad tympanomeatal flap was elevated from
11 to 6 o'clock (left ear) and the middle ear cavity was entered; care
was taken to preserve the chorda tympani nerve. The ossicular chain was
palpated and its mobility was confirmed. The tympanic mucosa, anterior
space of malleus, anterior and posterior tympanic isthmus, and
eustachian tube orifice were explored. FTTC was harvested with
perichondrium on one side, and a ''V'' shaped notch was made. The
epithelium on the malleus handle was removed, and the FTTC was inserted
between the malleus handle and the tympanum, with the perichondrium
facing outward. The ''V'' shape was embedded in the short process of the
malleus. The graft was supported with gelatin sponges soaked in normal
saline. A zero-degree endoscope (diameter, 3 mm; length, 140 mm) was
used under an endoscope monitoring system (Storz TC200, Germany).

In the TF group, a classic microscopic myringoplasty was performed
through postauricular and transcanal approaches utilizing the TF for
reconstruction. The graft was placed under the malleus handle.

In the PTTC group, endoscopic myringoplasty was performed utilizing
ultra-thin tragus cartilage with a perichondrium layer as the graft,
which was placed under the malleus handle.\textsuperscript{5}

\textbf{Results}

\textbf{Myringoplasty with FTTC graft: Factors affecting the mean ABG
and its trend}

The average thickness of the FTTC was 0.850 +- 0.117 mm (range,
0.642--1.083 mm). The mean operation time was 52.44 +- 14.04 minutes, and
the average postoperative dry ear time was 3.457 +- 1.78 weeks. The
tympanic membrane integrity was restored in 91\% of the cases. Figure 1
presents key images before, during, and after surgery. A mean ABG of
12.17 +- 6.58 dB was observed postoperatively (\selectlanguage{english}[?]10 dB, 45\%; 11--20 dB,
45.9\%; 21--30 dB, 7.2\%; \selectlanguage{english}[?]31 dB, 1.8\%; Figure 2A.)

Further, the impact of the factors affecting ABG was explored. The
factors assessed before and after surgical intervention were perforation
size and malleus handle exposure status. The mean ABG changed
significantly after surgical intervention (F\textsubscript{(1,108)} =
38.707, \emph{P} \textless{} .001). The tympanic perforation size and
malleus handle exposure status significantly affected the mean
preoperative ABG (F\textsubscript{(1,108)} = 5.969, \emph{P} = .016;
F\textsubscript{(1,108)} = 7.281, \emph{P} = .008, respectively).
Further, no interaction was found between surgical intervention and
perforation size (F\textsubscript{(1,108)} = 1.022, \emph{P} = .314) and
between surgical intervention and malleus handle exposure status
(F\textsubscript{(1,108)} = 0.053, \emph{P} = .818). To summarize these
findings, the perforation size and malleus handle exposure status did
not affect the ABG trend (change in the ABG values before and after
surgery). The distribution of mean ABG under different factors is
presented in Figure 2B.

\textbf{Comparison of audiological performance betweenTF and FTTC
groups}

\textbf{3.2.1 Comparison of the baseline characteristics before and
after PSM}

Baseline characteristics (age, gender, perforation size, malleus handle
exposure status, and ABG value for frequencies of 250 Hz to 4000 Hz
before surgery) in the TF and FTTC groups were compared; a significant
difference was observed in the ABG values at 2000 Hz. However, after
PSM, the variables in the two groups were balanced. The differences in
the baseline characteristics before and after surgery are shown in
Supplementary Table.

\textbf{3.2.2 Comparison of hearing performance in the two groups}

The mean ABG values in the TF and FTTC group were 13.75 (8.75--16.25) dB
and 10 (6.25--15) dB, respectively; no significant difference was
observed in the mean ABG of the two groups (Z = -1.051, \emph{P} = .293,
Figure 3A.). Further, the ABGs at 250 Hz, 500 Hz, 1000 Hz, 2000 Hz, and
4000 Hz in the two groups were compared; for each frequency, no
significant difference was observed between the two groups
(\emph{P}\textgreater{} .05, Table 1).

\textbf{3.3 Comparison of audiological performance between the FTTC and
PTTC groups}

First, baseline characteristics between the two groups were compared,
and no statistically significant differences were observed (Table 2).
The mean ABG values in the PTTC and FTTC groups were 12.5 (8.75--16.25)
dB and 11.25 (6.25--15) dB, respectively, with no significant difference
between the two groups (Z = -0.958, \emph{P} = .338, Figure 3B.). At
frequencies 500 Hz, 1000 Hz, 2000 Hz, and 4000 Hz, there was no
significant difference in ABG values between the two groups
(\emph{P}\textgreater{} .05) (Table 3). The postoperative ABG in the
FTTC group at 250 Hz was 15 (10--20) dB, which was better than that in
the PTTC group (15 {[}15--20{]} dB, Z = -2.277, \emph{P} = .023).

\textbf{Discussion}

Hearing improvement was achieved irrespective of the preoperative
tympanic perforation size and malleus handle exposure status in the FTTC
group. The postoperative ABG was comparable in the TF and PTTC groups.
Moreover, the audiological improvement at 250 Hz was better in the FTTC
group than in the PTTC group.

Endoscopic myringoplasty has received special attention in recent years.
The grafts used in myringoplasty are diverse, such as temporalis muscle
fascia,\textsuperscript{6} tragus
perichondrium,\textsuperscript{7,8}tragus cartilage and perichondrium
complex,\textsuperscript{9} and porcine small intestine
submucosa.\textsuperscript{10} Minimal invasion and easy harvest, less
postoperative pain, quicker postoperative recovery in anatomy and
function, and strong ability to resist inflammation are the requirements
of an ideal graft; since it meets the requirements, tragus cartilage is
the material of choice. Moreover, it does not require an extra incision
behind the ear, thereby avoiding long-term numbness \textsuperscript{11}
after the operation.

Endoscopic myringoplasty is a flexible and variable procedure as it
facilitates multiple choices of grafts, varied graft placement, and
different surgical approaches; however, on the downside, diversity may
lead to discrepancies in postoperative hearing performance. There are
three main cartilaginous grafts: perichondrium, full-thickness cartilage
with perichondrium complex, and thinned cartilage with perichondrial
complex. The commonly employed surgical approaches include the ''put
through''\textsuperscript{12} method, which does not involve the
elevation of the tympanomeatal flap, and the method involving the
elevation of the tympanomeatal flap. The location of graft placement
also varies, such as incarceration on the tympanic membrane
(''butterfly'' method),\textsuperscript{13} placed between the tympanic
membrane and the malleus handle, or medial to the malleus handle. In
this study, a broad tympanomeatal flap was lifted, and the FTTC was
placed between the malleus handle and the tympanomeatal flap. In both
traditional microscopic tympanoplasty with the TF and the FTTC surgery,
a similar hearing performance was achieved after the surgery. In a
meta-analysis\textsuperscript{14} where different research groups
adopted different surgical and graft placement strategies, a
sub-analysis of prospective studies showed a lower mean postoperative
ABG in patients using TF graft. The heterogeneity may have affected the
stability of the results and led to the difference.

For all frequencies except 250 Hz, a similar audiological performance
was observed in the FTTC and PTTC groups; FTTC had a better performance
at 250 Hz. Similar comparisons were drawn in another
study,\textsuperscript{4} where no significant differences were observed
in hearing improvement between the PTTC and the FTTC groups at 250 Hz,
500--2000 Hz, and 8000 Hz. Overall, our findings were in agreement, but
PTTC had a better performance at 4000 Hz in the other study, whereas
FTTC had a better performance at 250 Hz in our study. In the same study,
the tensor tympani tendon was cut to make space in cases where the
handle was foreshortened or medially displaced. This manipulation may
have led to poor performance in the FTTC group at 250 Hz. The tensor
tympani tendon cut did not affect hearing at 0.5 Hz--4 kHz after
tympanoplasty,\textsuperscript{15} but tensor tympani tendon contraction
is related to low-frequency hearing loss.\textsuperscript{16} In
addition, barred cartilage, which might result in decreased tension of
drum, was placed under the malleus, which may be responsible for the
poor performance at 4000 Hz in the FTTC group in their study. In the
future, the effect of tensor tympani tendon cut on low-frequency hearing
can be explored.

Although reports on myringoplasty with FTTC graft have demonstrated good
hearing performance, only a few articles have provided a convincing
theoretical explanation. A study on biomechanical
analysis\textsuperscript{17} suggested the use of grafts with a
thickness of 0.1--0.2 mm for medium-to-large perforations and
\textless{}1.0 mm for small perforations, where the graft is a
substitute for both mechanical stability and audibility. However, in
this study, the thickness of the FTTC was 0.850 +- 0.117 mm, and good
hearing results were obtained at each frequency. The middle ear can only
provide about 20 dB of gain on average\textsuperscript{18} and most of
the gain comes from the area ratio of the tympanic membrane to the
stapes. The air-containing middle ear cavity can reduce the sound
pressure on the round window membrane.\textsuperscript{19} Figure 1F
shows that the graft fits well with the malleus handle; the new
cartilage drum could provide a sufficient drum area and an aired cavity,
so the graft would fit well and a good hearing performance with FTTC
graft could be achieved. Moreover, a better hearing performance at 250
Hz was achieved in the FTTC group than that in the PTTC group. The
possible reason for this could be that FTTC changes the stiffness of the
tympanic membrane, which may be beneficial in low-frequency conductions.
However, it does not mean that the FTTC graft can replace the PTTC
graft, which is convenient for postoperative examination and
manipulation.

Postoperative hearing performance in the FTTC group was independent of
the preoperative tympanic perforation size and the exposure status of
the malleus handle. According to our previous research, factors such as
the state of mucosa and location of tympanic perforation do not affect
the trends of ABG.\textsuperscript{5}Another study also reported similar
results.\textsuperscript{20} In a previous study, a linear correlation
was observed between the preoperative tympanum perforation size and
postoperative ABG (\emph{P} = .0017) at frequencies of 0.5 to 4 kHz,
indicating an increased postoperative ABG in larger perforations;
however, here, we specified only the \emph{P} -values and did not
provide the correlation coefficient or other parameters that reflect the
relationship between the perforation size and postoperative ABG.

There are some limitations of this study. First, this was a
retrospective analysis performed at a single center. Second, the sample
size of the TF group was small, and the baseline characteristics between
the TF and FTTC group were imbalanced. However, PSM was performed to
resolve the issue of imbalanced baselines and sample sizes. Third, the
follow-up duration of this study was short. The patients at this center
came from all over the country. Since improvement in hearing and dry ear
was observed in the early days after the surgery and a longer follow-up
meant increased loss to follow-up, we chose 3 months as the endpoint of
follow-up.

\textbf{Conclusions}

Good hearing performance at all frequencies was achieved in patients who
underwent myringoplasty with FTTC graft, and these results were
comparable to those of patients who underwent myringoplasty with TF and
PTTC graft. The hearing performance was stable and independent of the
preoperative tympanum perforation size and the exposure status of the
malleus handle.

\textbf{Conflict of Interest} The authors declare that there is no
conflict of interest.

\textbf{Data Availability Statement} The data that support the findings
of this study are available on request from the corresponding authors.
The data are not publicly available due to restrictions that they
contain information that could compromise research participants'
privacy.



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\textbf{Tables}

\textbf{Supplementary Table} \textbf{The baseline before and after PSM
in temporalis fascia and thick tragal cartilage groups}\selectlanguage{english}
\begin{longtable}[]{@{}llllllll@{}}
\toprule
Variables & Variables & Before PSM & Before PSM & \emph{P} & After PSM &
After PSM & \emph{P}\tabularnewline
& & TF & FTTC & & TF & FTTC &\tabularnewline
Age & Age & 42(34.25\textasciitilde{}55) & 48(34\textasciitilde{}58) &
.231 & 43.289\selectlanguage{ngerman}±14.268 & 42.684\selectlanguage{ngerman}±11.727 & .844\tabularnewline
Gender & Male(\%) & 10(25) & 40(36) & .204 & 10(26.3) & 9(23.7) &
1\tabularnewline
& Female(\%) & 30(75) & 71(64) & & 28(73.7) & 29(76.3)
&\tabularnewline
Perforation size & [?]50\% (\%) & 28(70) & 89(80.2) & .186 & 27(71.1)
& 24(63.2) & .581\tabularnewline
& \textless{}50\% (\%) & 12(30) & 22(19.8) & & 11(28.9) & 14(36.8)
&\tabularnewline
Malleus & exposed & 14(35) & 46(41.4) & .475 & 13(34.2) & 9(23.7) &
.344\tabularnewline
& unexposed & 26(65) & 65(58.6) & & 25(65.8) & 29(76.3) &\tabularnewline
BS\_ABG250 & BS\_ABG250 & 30.00(20\textasciitilde{}35) &
30.00(25\textasciitilde{}35) & .554 & 28.816\selectlanguage{ngerman}±10.229 & 26.974\selectlanguage{ngerman}±9.763 &
.561\tabularnewline
BS\_ABG500 & BS\_ABG500 & 25.00(16.25\textasciitilde{}30) &
25.00(20\textasciitilde{}30) & .986 & 24.079\selectlanguage{ngerman}±8.994 & 21.974\selectlanguage{ngerman}±9.411 &
.465\tabularnewline
BS\_ABG1000 & BS\_ABG1000 & 20.00(15\textasciitilde{}25) &
20.00(10\textasciitilde{}25) & .609 & 18.553\selectlanguage{ngerman}±7.157 & 19.211\selectlanguage{ngerman}±9.968 &
.299\tabularnewline
BS\_ABG2000 & BS\_ABG2000 & 15.00(10\textasciitilde{}20) &
10.00(10\textasciitilde{}20) & .032 & 16.316\selectlanguage{ngerman}±7.230 & 15.658\selectlanguage{ngerman}±9.456 &
.291\tabularnewline
BS\_ABG4000 & BS\_ABG4000 & 20.00(15\textasciitilde{}25) &
15.00(10\textasciitilde{}25) & .293 & 19.605\selectlanguage{ngerman}±8.086 & 20.158\selectlanguage{ngerman}±13.310 &
.908\tabularnewline
\bottomrule
\end{longtable}

\textbf{TF: the temporalis fascia}

\textbf{FTTC: full-thickness tragal cartilage}

\textbf{Table 1.} \textbf{Comparison of ABG after surgery between the
temporalis fascia and full-thickness tragal cartilage groups for each
frequency}\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\textbf{Frequency} & \textbf{Group} & \textbf{ABG after surgery} &
\textbf{Z value} & \textbf{P}\tabularnewline
250Hz & TF & 15(10\textasciitilde{}20) & -.270 & .787\tabularnewline
& FTTC & 15(10\textasciitilde{}20) & &\tabularnewline
500Hz & TF & 15(10\textasciitilde{}20) & -1.074 & .283\tabularnewline
& FTTC & 10(10\textasciitilde{}16.25) & &\tabularnewline
1000Hz & TF & 10(10\textasciitilde{}16.25) & -1.499 &
.134\tabularnewline
& FTTC & 10(5\textasciitilde{}15) & &\tabularnewline
2000Hz & TF & 10(5\textasciitilde{}15) & -.999 & .318\tabularnewline
& FTTC & 5(5\textasciitilde{}10) & &\tabularnewline
4000Hz & TF & 10(5\textasciitilde{}20) & -.031 & .975\tabularnewline
& FTTC & 10(5\textasciitilde{}21.25) & &\tabularnewline
\bottomrule
\end{longtable}

\textbf{TF: temporalis fascia}

\textbf{FTTC: full-thickness tragal cartilage}



\textbf{Table 2.} \textbf{The balanced baseline of the partial-thickness
tragal cartilage and full-thickness tragal cartilage groups}\selectlanguage{english}
\begin{longtable}[]{@{}llllll@{}}
\toprule
\textbf{Variables} & \textbf{Variables} & \textbf{PTTC} & \textbf{FTTC}
& \selectlanguage{greek}\textbf{Z or χ\textsuperscript{2}}\selectlanguage{english} & \textbf{P}\tabularnewline
Mean ABG before surgery & Mean ABG before surgery &
17.5(12.5\textasciitilde{}22.5) & 18.75(13.75\textasciitilde{}25) &
-.996 & .319\tabularnewline
Age & Age & 45(35.25\textasciitilde{}54) & 48(34\textasciitilde{}58) &
&\tabularnewline
Gender & Male(\%) & 45(35.7) & 40(36) & .003 & .959\tabularnewline
& Female(\%) & 81(64.3) & 71(64) & &\tabularnewline
Perforation size & [?]50\% (\%) & 90(71.4) & 89(80.2) & 2.445 &
.118\tabularnewline
& \textless{}50\% (\%) & 36(28.6) & 22(19.8) & &\tabularnewline
Malleus & Exposed & 43(34.1) & 46(41.4) & 1.346 & .246\tabularnewline
& Unexposed & 83(65.9) & 65(58.6) & &\tabularnewline
BS\_ABG250 & BS\_ABG250 & 27.5(20\textasciitilde{}35) &
30(25\textasciitilde{}35) & -1.276 & .202\tabularnewline
BS\_ABG500 & BS\_ABG500 & 22.5(15\textasciitilde{}30) &
25(20\textasciitilde{}30) & -1.531 & .126\tabularnewline
BS\_ABG1000 & BS\_ABG1000 & 15(10\textasciitilde{}25) &
20(10\textasciitilde{}25) & -.231 & .817\tabularnewline
BS\_ABG2000 & BS\_ABG2000 & 10(8.75\textasciitilde{}15) &
10(10\textasciitilde{}20) & -.888 & .375\tabularnewline
BS\_ABG4000 & BS\_ABG4000 & 15(10\textasciitilde{}25) &
15(10\textasciitilde{}25) & -.599 & .549\tabularnewline
\bottomrule
\end{longtable}

\textbf{PTTC: partial-thickness tragal cartilage}

\textbf{FTTC: full-thickness tragal cartilage}

\textbf{Table 3.} \textbf{ABG after surgery between partial-thickness
tragal cartilage and full-thickness tragal cartilage group}\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
Frequency & Group & ABG after surgery & Z value &
\emph{P}\tabularnewline
250Hz & PTTC & 15(15\textasciitilde{}20) & -2.277 &
.023\tabularnewline
& FTTC & 15(10\textasciitilde{}20) & &\tabularnewline
500Hz & PTTC & 15(10\textasciitilde{}15) & -.133 & .894\tabularnewline
& FTTC & 15(10\textasciitilde{}20) & &\tabularnewline
1000Hz & PTTC & 10(10\textasciitilde{}15) & -.952 &
.341\tabularnewline
& FTTC & 10(5\textasciitilde{}15) & &\tabularnewline
2000Hz & PTTC & 10(5\textasciitilde{}10) & -1.030 &
.303\tabularnewline
& FTTC & 5(5\textasciitilde{}10) & &\tabularnewline
4000Hz & PTTC & 15(8.75\textasciitilde{}20) & -.619 &
.536\tabularnewline
& FTTC & 10(5\textasciitilde{}20) & &\tabularnewline
\bottomrule
\end{longtable}

\textbf{PTTC : partial-thickness tragal cartilage}

\textbf{FTTC : full-thickness tragal cartilage}



\textbf{Figure Legends}

Figure 1A. Tympanum perforation before surgery. B. The malleus handle
with removed epithelium. C. Full-thickness tragal cartilage with a ''V''
shape (*). D. the graft placed appropriately between the malleus handle
and the tympanomeatal flap (star). E. Postoperative tympanum 3-months
after surgery. F. The relationship between the postoperative tympanum
and the malleus handle on reconstructed computed tomography scan.

Figure 2. Mean air-bone gap (ABG) before and after myringoplasty with
full-thick tragal cartilage graft. A. ABG distribution before and after
surgery. B, C. The impact of tympanum perforation size and malleus
handle exposure status on the mean ABG before and after surgery.

Figure 3. Comparison of the mean postoperative air-bone gap (ABG) A.
Comparison of mean ABG between temporalis fascia and full-thickness
tragal cartilage groups B. Comparison of mean ABG between
partial-thickness tragal cartilage and full-thickness tragal cartilage
groups.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-1/Figure-1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-2/Figure-2}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-3/Figure-3}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

