This study is conducted during the period between January 2005 and December 2010 in the ENT department, Assiut University Hospital, Egypt.
The study included 93 ears in 91 patients (2 patients had bilateral operations). Each ear had either total (6) or near total (87) perforation of the tympanic membrane (TM).
All operations were done under general anesthesia using endo-tracheal inhalation route. In each case the TM is grafted using underlay TFG taken through post-oral incision supported externally by STSG taken from the medial surface of the lobule of the ear using no 15 scalpel. The lobule is stretched between 2 hands and the graft is taken. The round knife is used to abrade the mucosa of the lateral wall of the Eustachian tube and attic anterior to the malleus, floor of the middle ear (ME) and the undersurface of any remaining parts of the TM. Next, a small rim of the remaining TM is trimmed to freshen the edge for better healing. The ME is then packed with small pledges of gelatin sponge, then, the dried TFG is laid over the gelatin sponges and positioned to be under the skin of the posterior meatal wall and any remaining part of the TM. The STSG is then laid partly over the TFG and partly over the deep meatal skin. It could be used as one piece or cut into pieces. The assembly is supported externally by other pieces of gelatin sponge. The external ear is packed with antibiotic-containing Vaselinesed gauze. The wound is closed in layers and the patient is discharged from the hospital next morning.
Patients come for the first post-operative visit at 5-7 days where the stitches are removed and so the aural pack and the patient is given steroid-containing antibiotic ear drops twice a day.
The next visit is usually at 3-4 weeks where the external canal is dry-cleaned and the graft is checked and the patient is asked to continue the ear drops if needed.
The 3rd post-operative visit is usually at the 3rd month where the ear is examined again for the status of the graft and checked audiologically where the post-operative air-conduction threshold is compaired with the pre-operative one at frequencies 500, 1000, and 4000Hz.to calculate the hearing improvement. Pure-tone average PTA change is calculated again for the 54 patients who came for follow up at one year.

Results

The success rate for this technique to close the large defects of the TM was about 92% (86 out of 92 operations).
The average PTA improvement was 16.3 decibel (dB) at 3 month follow up, dropped to 15.5 dB at one year.
Failure to close the TM defect was noticed in 7 patients (< 8 %), 2 of them had total perforation and 5 had near-total ones. The cause of failure was local infection in 3 cases and unidentified in 4 cases. All failures were in the anterior half of the tympanic membrane.
Prolonged swelling of the graft was noticed in 2 cases (with formation of a tag-like part in one of them) .It persisted for more than 2 months both recovered during follow-up.
Local infection with some muco-purulent discharge occurred in 3 cases, one of them improved with treatment and the other one ended with breakdown of the graft.
Bleeding from the Jugular bulb or one of its tributaries occurred twice during abrading the mucosa of the floor of the ME. One of them stopped with oxidized cellulose and the other required extraluminal packing of the sigmoid sinus after cortical mastoidectomy. In both cases the operation could be continued successfully.
No complications were noticed from any of the donor sites.