Tympanoplasty remains a cornerstone procedure in the management of chronic otitis media (COM), aiming to achieve tympanic membrane closure and restore hearing function. Reported graft uptake rates in adults’ range between 80% and 95%, with substantial improvement in air–bone gap following surgery¹¹-¹². Although the procedure is widely accepted as effective, variability in surgical outcomes persists, and multiple prognostic factors have been implicated, including perforation size, Eustachian tube function, middle ear mucosal status, and systemic comorbidities¹³–¹⁵.

Age has long been debated as a potential determinant of tympanoplasty success. Early reports suggested that advancing age may negatively influence graft uptake, possibly due to reduced vascularity, mucosal atrophy, and

impaired Eustachian tube function¹⁰. Emmett highlighted age as a possible contributing factor to reduced graft success, although the difference was not consistently significant¹. Similarly, Sheahan and Blayney evaluated tympanoplasty outcomes in adults and reported modest differences in hearing gain between younger and older patients³. In contrast, Demirci et al. demonstrated comparable graft uptake in elderly patients but noted diminished audiological improvement, likely attributable

to age-related cochlear changes².

More recent investigations have questioned whether chronological age independently predicts surgical outcome. Mangia et al. and Azar et al. emphasized that anatomical and disease-related factors, rather than age alone, are stronger predictors of graft success⁴,⁵. Aggarwal and Dev, using the Middle Ear Risk Index, observed outcome variations across age groups but underscored the influence of middle ear pathology over age itself⁶. Additional studies have demonstrated satisfactory hearing improvement across adult age groups, suggesting that tympanoplasty should not be withheld solely based on age⁷,⁸,¹¹.

Despite these findings, inconsistencies remain in the literature regarding the independent effect of age on both anatomical and functional outcomes. Given the growing elderly population and increasing expectations for hearing rehabilitation, a prospective evaluation of age-related outcomes is warranted. The present study was therefore undertaken to assess the impact of age on graft uptake and hearing improvement following tympanoplasty in adult patients.

This prospective observational study was conducted in the Department of Otorhinolaryngology of a tertiary care teaching hospital over a period of 18–24 months to evaluate the impact of age on anatomical and functional outcomes following tympanoplasty in adult patients with chronic otitis media. Adult patients aged 18 years and above diagnosed with inactive mucosal chronic otitis media and planned for tympanoplasty were consecutively enrolled after obtaining written informed consent. Patients were stratified into age-based groups for comparative analysis. For the purpose of statistical evaluation, patients were categorized into younger adults and older adults. Patients were included if they were aged 18 years or older, had a dry central tympanic membrane perforation, demonstrated conductive hearing loss on pure tone audiometry, were medically fit to undergo surgery, and were willing to participate in the study. Patients with cholesteatoma, ossicular chain discontinuity requiring reconstruction, active infection at the time of surgery, previous ear surgery, mixed or sensorineural hearing loss greater than 30 dB, or immunocompromised status were excluded from the study. The sample size was calculated using the formula for comparison of two proportions, based on previously reported graft success rates of approximately 90% in younger adults and 75% in older adults. Assuming a level of significance of 5% and a power of 80%, and accounting for a 10% attrition rate, a total sample size of 220 patients was determined to be adequate to detect a clinically meaningful difference in graft uptake between groups. All patients underwent detailed preoperative evaluation, including comprehensive history taking and otomicroscopic examination to assess the site and size of perforation and the condition of the middle ear mucosa. Comorbidities such as diabetes mellitus, hypertension, and smoking status were documented. Eustachian tube function was assessed clinically. Preoperative pure tone audiometry was performed to record air conduction, bone conduction, and air–bone gap thresholds. All surgical procedures were performed under operating microscopy using a standardized Type I tympanoplasty technique with temporalis fascia graft placed by the underlay method. The surgical approach, whether postauricular, endaural, or transcanal, was selected according to the clinical requirement of each case. Intraoperative findings including ossicular status and middle ear mucosal condition were recorded. A uniform surgical protocol was followed throughout the study period to minimize procedural variability. Postoperative follow-up was conducted at 1 month, 3 months, and 6 months. Graft status was assessed clinically and microscopically at each follow-up visit. Pure tone audiometry was repeated at 3 and 6 months to evaluate postoperative hearing outcomes. Graft uptake was defined as an intact tympanic membrane at 6 months. Functional outcome was assessed by measuring postoperative air–bone gap and calculating hearing gain in decibels. Postoperative complications including infection, reperforation, and sensorineural hearing loss were documented. All data were collected using a structured proforma and entered into excel sheet. Continuous variables were expressed as mean and standard deviation, while categorical variables were expressed as frequencies and percentages. Comparisons between age groups were performed using independent samples t-test for continuous variables and chi-square test for categorical variables. Binary logistic regression analysis was conducted to determine whether age independently predicted surgical success after adjusting for potential confounding factors including diabetes mellitus, hypertension, smoking status, perforation size, and Eustachian tube function. A two-tailed p-value of less than 0.05 was considered statistically significant.

A total of 220 adult patients undergoing tympanoplasty were included in the study, with 110 patients in the younger age group (18–50 years) and 110 patients in the older age group (>50 years). The mean age was 33.81 ± 9.06 years in the younger group and 63.65 ± 7.51 years in the older group, confirming appropriate age stratification between groups. The baseline demographic characteristics were comparable between the two groups with respect to gender distribution and smoking status. However, the prevalence of systemic comorbidities was significantly higher in the older age group. Diabetes mellitus was present in 32.7% of older patients compared to 7.3% in younger patients (p < 0.001). Similarly, hypertension was significantly more common in the older group (37.3% vs 3.6%, p < 0.001). No statistically significant differences were observed in Eustachian tube dysfunction, chronic sinusitis, or nature of discharge between groups (Table 1).

Preoperative audiological assessment demonstrated comparable air conduction thresholds between the groups. However, bone conduction thresholds were significantly higher in the older group, indicating reduced cochlear reserve (p < 0.001). Consequently, the preoperative air–bone gap was significantly wider in younger patients compared to older patients (p < 0.001). These findings reflect the underlying sensorineural component associated with advancing age (Table 2).

Postoperative audiological evaluation showed significant improvement in both groups. While postoperative air conduction thresholds were comparable between groups, the younger cohort demonstrated significantly greater hearing gain (13.23 ± 1.65 dB vs 10.97 ± 1.65 dB, p < 0.001). Postoperative air–bone gap closure was also significantly greater in younger patients. These findings suggest that although both age groups benefit functionally from tympanoplasty, younger adults achieve relatively superior audiological improvement (Table 2).

At six months follow-up, graft uptake was successful in 90.0% of younger patients and 87.3% of older patients. The difference was not statistically significant (p = 0.524), indicating comparable anatomical success between age groups. The overall graft failure rate was low in both groups (Table 3).

Postoperative complications were infrequent and comparable between the two groups. Infection, reperforation, and sensorineural hearing loss occurred at similar rates without statistically significant differences (p = 0.491). The majority of patients in both groups experienced an uncomplicated postoperative course (Table 4).

Binary logistic regression analysis was performed to evaluate whether age independently predicted surgical success after adjusting for diabetes, hypertension, smoking, size of perforation, and Eustachian tube function. The overall model was not statistically significant (Omnibus p = 0.199), and age group did not emerge as an independent predictor of surgical outcome (Adjusted OR 0.837; 95% CI 0.363–1.932; p = 0.677). Among the variables analyzed, large perforation size was the only independent predictor associated with reduced surgical success (Adjusted OR 2.457; 95% CI 1.022–5.908; p = 0.045). These findings suggest that anatomical factors rather than chronological age influence graft outcomes (Table 5).

Table 1: Baseline Demographic and Clinical Characteristics.

              *Chi-square test

               #Independent t test

Table 2: Preoperative and Postoperative Audiological Parameters.

           Independent samples t-test

Table 3: Graft Uptake at 6 Months.

                     Chi-square test

Table 4: Postoperative Complications.

                  Chi-square test

Table 5: Multivariate Logistic Regression for Surgical Success.

Dependent Variable: Final Outcome (Successful)

Model Fit:

• Omnibus test p = 0.199
• Hosmer–Lemeshow p = 0.575
• Nagelkerke R² = 0.073

*Significant predictor

The present study evaluated the influence of age on tympanoplasty outcomes in a prospective cohort of adult patients. The findings demonstrate that graft uptake rates at six months were comparable between younger and older adults, with no statistically significant difference observed. These results are consistent with the observations of Demirci et al., who reported satisfactory graft success in elderly patients², and align with the conclusions of Mangia et al. and Azar et al., who emphasized that disease-related factors rather than chronological age primarily determine anatomical success⁴,⁵. Although anatomical outcomes were similar, functional outcomes showed a modest difference between groups. Younger patients demonstrated significantly greater hearing gain compared to older adults. This observation parallels the findings of Sheahan and Blayney³, who noted differences in audiological improvement despite comparable graft uptake. The reduced hearing gain in older adults may be attributed to age-related sensorineural changes, as previously suggested by Nakano et al.¹⁰. Preoperative bone conduction thresholds were significantly higher in the older cohort in the present study, supporting the role of diminished cochlear reserve in limiting postoperative audiological improvement. The overall graft success rate in this study falls within the range reported in classical and contemporary literature¹¹,¹²,¹⁵. Indorewala et al. highlighted that middle ear environment and perforation characteristics significantly influence graft uptake¹³. In the current analysis, logistic regression demonstrated that age was not an independent predictor of surgical success, whereas large perforation size was significantly associated with reduced success rates. This finding corroborates earlier reports identifying perforation size as a critical determinant of outcome¹⁴,¹⁵. Importantly, postoperative complication rates were low and comparable between age groups, suggesting that tympanoplasty is a safe procedure in older adults. These findings are in agreement with studies indicating that age alone should not be considered a contraindication for surgical intervention⁷,¹¹. Taken together, the results of this study support the growing body of evidence that chronological age does not independently compromise graft uptake following tympanoplasty. While functional gains may be modestly reduced in elderly patients due to pre-existing cochlear changes, anatomical success remains comparable. These findings reinforce the concept that surgical candidacy should be determined by middle ear status and overall health rather than age alone.

The findings of this prospective study indicate that chronological age does not independently influence graft uptake following tympanoplasty in adults. Anatomical success rates were comparable between younger and older patients, suggesting that age alone should not be considered a contraindication for surgical intervention. Although older adults demonstrated relatively lower hearing gain, this difference appears attributable to age-related cochlear reserve rather than surgical failure. Large perforation size emerged as a more significant determinant of outcome than age. Overall, tympanoplasty remains a safe and effective procedure across adult age groups when appropriate patient selection and standardized surgical techniques are employed.

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