Discussion
To our knowledge, our study is the biggest series comparing ossiculoplasty by microscopic route to that of TEES performed by a single surgeon and has demonstrated that it produces comparable hearing outcomes in AC, BC and ABG less than 20dB
There was no significant difference in the improvement in AC, BC, and ABG of the 93 patients undergoing TM-stapes reconstruction via the microscopic approach compared to 35 patients in the TEES group. Our study also showed that there was also no significant difference with various tympanic membrane grafts and ossiculoplasty materials including just using cartilage as opposed to the use of titanium PORP and incus transposition. These results were comparable to those obtained by Potsangbam et 4  al in their cases with cartilage ossiculoplasty with intact stapes superstructure.
Only 19 patients were noted to have stapes dehiscence at the time of operation. Despite this, all patients achieved improvement in AC, BC, and ABG. There was no statistical difference in hearing improvement between those 19 patients with dehiscence compared to those 138 without, approached either microscopically or via TEES.
There are some studies in the literature 5-9 , including an RCT of 118 cases comparing TEES and microsurgery using PORP and TORP showing similar results between microsurgery and TEES. But unlike our series, they were not by a single surgeon and haven’t included cartilage and incus grafts.
Our study has certain limitations. The patients who were operated on before 2014 all had a microscopic approach before the surgeon started TEES. In addition, there was no randomization of patients to groups, therefore the potential for selection bias exists. But the advantages to our study are prospective data collection and all surgeries being conducted by a single surgeon, thus eliminating some of the bias.