Outcomes of Inverted Tympanomeatal Flap Elevation for Large Anterior Tympanic Membrane Perforations in Narrow External Auditory Canals

ABSTRACT Background and Objective Anterior tympanic membrane perforations—particularly in patients with a narrow external auditory canal—remain technically challenging due to limited visualization and inadequate anterior support. The inverted tympanomeatal flap technique has been proposed to address these issues, but evidence is limited. This study aimed to evaluate its anatomical and functional outcomes in large anterior perforations treated with endoscopic transcanal tympanoplasty. Methods This retrospective single‐surgeon study included 70 patients with large anterior perforations and ≥ 20% anterior quadrant non‐visualization. All underwent standardized audiometry and at least 6 months of follow‐up. Outcomes were graft success, complications, and hearing improvement. Analyses included audiometric comparisons, logistic regression, and ROC curves to identify predictors of graft failure. Results The graft success rate was 95.7% (67/70). Mean ABG improved from 23.44 ± 10.95 dB preoperatively to 13.52 ± 8.86 dB postoperatively ( p < 0.001), with a mean hearing gain of 9.91 ± 8.61 dB (Cohen's d = 1.00). Larger perforation size ( p = 0.046) and severe external auditory canal narrowing ( p = 0.041) independently predicted graft failure. ROC analysis identified > 72% perforation size (AUC = 0.78) and > 40% canal narrowing (AUC = 0.71) as risk thresholds. No cases of chorda tympani injury, canal trauma, or iatrogenic cholesteatoma occurred. Conclusion In conclusion, inverted tympanomeatal flap elevation showed favorable graft success and hearing improvement in challenging anterior perforations with narrow canals. However, due to the retrospective single‐surgeon design and absence of a control group, these results should be interpreted cautiously. Larger prospective studies are needed to validate its effectiveness. Level of Evidence 4.