Endoscopic vs. microscopic ear surgery: a systematic review and meta-analysis of graft success, hearing outcomes, and perioperative benefits

Abstract Background Endoscopic ear surgery (EES) has emerged as a minimally invasive alternative to traditional microscopic ear surgery (MES) in otologic procedures. This study compares clinical outcomes between EES and MES. Methods A PRISMA-compliant systematic review and meta-analysis (PROSPERO: CRD420251147947) searched six databases (PubMed, Scopus, Cochrane Library, Web of Science, Medline, Google Scholar) from January 1, 2008, to September 30, 2025. Eligible studies directly compared EES and MES in tympanoplasty, myringoplasty, stapedotomy, or cholesteatoma surgery. Primary outcomes were graft success rate and hearing improvement (air-bone gap [ABG] reduction). Secondary outcomes included operative time, postoperative pain (VAS), complications, and cosmesis. Random-effects meta-analysis was performed using R software (v4.4.1). Risk of bias was assessed with Cochrane RoB 2 and ROBINS-I tools. Results From 9136 records, 110 studies involving 9475 patients were included. EES showed comparable graft success (OR 1.15, 95% CI 1.00–1.32; I 2 = 0%, 73 studies) and hearing improvement (mean ABG reduction: 14.9 dB vs. 14.5 dB, p > 0.05, 62 studies). EES significantly reduced operative time (MD −1.42 min, 95% CI −1.72 to −1.13; I 2 = 93%, 55 studies), postoperative pain, and complications, with superior cosmesis. GRADE certainty was high for graft success and moderate for operative time. Conclusion EES may be considered a viable, safe, and effective alternative to MES with potential perioperative advantages. Multicenter RCTs with standardized long-term outcomes are needed.