E n d o s c o p i c My r i n g o p l a s t y

and Type I Tympanoplasty

Zachary G. Schwam, MD*, Maura K. Cosetti, MD

KEYWORDS
Myringoplasty Tympanoplasty Endoscopic ear surgery TEES

KEY POINTS
Endoscopic tympano/myringoplasty has equivalent audiometric outcomes and rates of
graft success when compared with the microscopic approach.
A variety of grafts and techniques have been used to good effect. There are no high-
quality data supporting one graft or technique over others.
Endoscopic tympano/myringoplasty is a safe procedure, with less pain and a rapid return
to work expected.
The endoscopic approach may be favored in those with particular concerns regarding
cosmesis or operative times.

INTRODUCTION

Myringoplasty and tympanoplasty have a long history, with the first documented
attempt to close a tympanic membrane (TM) perforation occurring in 1640, with
Banzer placing a graft consisting of elkhorn wrapped in porcine bladder.1,2 With
the advent of surgical microscopes and a wide array of instrumentation, various oto-
logic procedures were developed and refined. In the 1950s, Wullstein3 published his
tympanoplasty classification system, which categorized the reconstruction of the
middle ear based on the status of the TM and ossicular chain into 5 types. Type I
consisted of a simple TM perforation with normal ossicles, and type V involved sta-
pes footplate fixation with lateral semicircular canal fenestration.3 Although there has
been some degree of variation in the literature with respect to nomenclature, many
investigators refer to a type I tympanoplasty as lifting a formal tympanomeatal flap
(TMF), whereas a myringoplasty does not include this step.4 This review focuses pri-
marily on type I tympanoplasty for dry perforations, as a detailed discussion on the
management of ossicular pathology and cholesteatoma are beyond the scope of this
article.

Icahn School of Medicine of Mount Sinai, Department of Otolaryngology-Head and Neck

Surgery, 1 Gustave L. Levy Place, Box 1189, New York, NY 10029, USA
* Corresponding author.
E-mail address: [email protected]

Otolaryngol Clin N Am - (2020) -–-

https://doi.org/10.1016/j.otc.2020.09.010 oto.theclinics.com
0030-6665/20/ª 2020 Elsevier Inc. All rights reserved.
2 Schwam & Cosetti

Although otoendoscopy has become increasingly popular since the 1990s, it was
first reported in 1967 and later in 1982, when Mer and colleagues5,6 and Nomura7
used endoscopes through TM perforations to evaluate the middle ear and ossicular
chain. At the time of this writing, transcanal endoscopic ear surgery (TEES) has
been used for a variety of procedures, including myringoplasty, tympano-
ossiculoplasty, tympanomastoidectomy, stapedotomy/stapedectomy, and lateral
skullbase surgery. In this review, we seek to inform the reader, whether an otolaryn-
gology resident or practicing otologist, of the current landscape with respect to endo-
scopic myringoplasty and type I tympanoplasty. Although the literature is rather
extensive on this topic, there is a dearth of randomized, prospective data regarding
techniques, nuances, patient criteria, and graft materials.8

DISCUSSION
Goals and Steps of Myringoplasty and Tympanoplasty
Regardless of approach, tympano/myringoplasty seeks to create an intact TM with
aerated middle ear, ensure continuity of the air-conduction mechanism from TM to in-
ner ear, preserve hearing with minimal air-bone gap (ABG), and to eliminate pathol-
ogy.8–10 In placing a graft to act as a scaffold for epithelial migration, steps include
optimizing hemostasis, harvesting an autologous graft (or in some cases using a xeno-
graft), preparing the TM and middle ear, eradicating pertinent pathology, reconstruct-
ing the ossicular chain, and opening ventilation routes as necessary, and placing the
graft.9 We have outlined the pertinent steps for performing type I tympanoplasty with a
chondroperichondrial underlay graft accompanied by operative images from one of
our own patients (Figs. 1–5).
Improved Visualization With Endoscopy and Its Downstream Effects
Using computed tomography (CT)-based models of temporal bones, Bennett and col-
leagues11 demonstrated that a 0 endoscope had superior visualization as compared
with a microscope for every subsite examined, and that the visual field was
augmented with higher degrees of angulation. Only the mesotympanum could be
adequately seen with a straight-line microscopic view, and bony overhangs or
tortuous canals may preclude visualizing the entire TM, particularly the anterior
aspect.12–16 With an endoscope, one can inspect the TM for epithelial ingrowth,13

Fig. 1. Preoperatively, a medium-sized perforation can be seen in the anterosuperior and

posterosuperior quadrants of the patient’s left ear.
Endoscopic Tympanoplasty 3

Fig. 2. (A) Once an incision had been made with a #72 Beaver blade, the tympanomeatal
flap was raised with a suction-round knife. (B) Once the flap had been raised to the inter-
face of the bony and fibrous annulus, a suction-Rosen was used to enter the middle ear
space.

detect stapedial and light reflexes through a perforation,17 and evaluate various crev-
ices in the retro-, epi-, pro-, and hypotympanum for cholesteatoma.18,19 It is also more
difficult to tear the TMF endoscopically as the surgeon may see both surfaces thereof
while dissecting.17
Due to superior circumferential visualization with an endoscopic approach, rates of
canalplasty are exceedingly low and frequently nil,12–14,20–26 as compared with the
microscopic approach, which ranges from 4.0% to 33.3%.12,23–27 In a meta-
analysis by Manna and colleagues27 examining 21 studies encompassing 1323 ears
undergoing tympanoplasty, canalplasty rates were significantly lower in endoscopic
cases (0% vs 18%, P < .0001).
As the visual field is significantly wider when using endoscopes, not only is the rate
of canalplasty minimized, but so is that of a postauricular approach.20,21 In using the

Fig. 3. (A) The tympanic membrane was dissected off the malleus handle sharply with a
endoscopic microscissor. (B) Once the malleus was skeletonized, the middle ear was packed
with Gelfoam.
4 Schwam & Cosetti

Fig. 4. (A) A cartilagenous shield graft with cutout for the malleus handle was introduced
and (B) put in position. (C) A tragal perichondrial graft was placed lateral to it.

Fig. 5. Once the tympanic membrane was reconstructed, the external canal was carefully
packed with Gelfoam to stabilize the graft.
Endoscopic Tympanoplasty 5

endoscope, Tarabichi and colleagues17,28 were able to decrease their rate of postaur-
icular incisions for middle ear procedures from 42% to 0%. With a more minimally
invasive approach, there were expected improvements in cosmesis, pain, and time
to return to work. With a postauricular incision, not only is there a scar, hypoesthesia,
and palpable depression, but also changes to the auriculomastoid angle, which may
result in a protruding pinna. In several series, an endoscopic approach was found to
have a superior cosmetic profile to a postauricular incision.9,12,13,24,27,29 In the report
of Harugop and colleagues24 of 50 endoscopic and 50 microscopic myringoplasties,
100% of endoscopic patients were found to have an “excellent” cosmetic result,
whereas 20% and 50% of the microscopic group were found to have a poor or satis-
factory cosmetic outcome, respectively. Similarly, endoscopic patients were found to
have significantly less pain and have a shorter admission or time period to return to
work as compared with their counterparts undergoing microscopic ap-
proaches.13,21,23–26,30–32 In the series of Tseng and colleagues,21 endoscopic patients
took pain medications for a mean of 2.0 days, and resumed normal activity within
1.0 day. In the report of Harugop and colleagues,24 the endoscopic and microscopic
groups returned to normal activity in 2.4 and 5.4 days, respectively. The rigorous pain
study of Kakehata and colleagues32 involved keeping all patients undergoing middle
ear surgery as inpatients for a period of 1 week to eliminate recall bias and enhance
data collection. They found that mean pain scores were significantly lower in the endo-
scopic group at every time point, and that significantly less pain medication was
consumed as compared with the patients undergoing postauricular approaches.32

Shorter Operative Times With an Endoscopic Approach

As a consequence of better visualization, saving time in not making or closing a post-
auricular incision, and largely avoiding a canalplasty, most reports document shorter
operative times for equivalent procedures when using the
endoscope.21,25,27,30,31,33–35 Some series did not compare their times to that of a con-
ventional postauricular approach but did document times of approximately an hour or
less for a variety of techniques.14,20,21,36,37 Although this was most reports, it was not
uniform; both Gaur and colleagues29 and Harugop and colleagues24 documented
longer operative times with the endoscopic approach while performing
myringoplasties.

Endoscopic Learning Curve

Although rigid endoscopy has been a mainstay of rhinologic procedures, it has only
recently come into favor in the otologic community. As one might expect with any
newer procedure, there is an associated learning curve. Dogan and Bayraktar38 esti-
mated that the learning curve for an experienced tympanoplasty surgeon would be 60
procedures to achieve the same outcomes and operative times. Tseng and col-
leagues4 demonstrated a shortening operative time between their 10th (75 minutes)
and 150th patients (55 minutes) and an accompanying increase in graft success
rate from 75% to 95%. The graft success rate plateaued at patient number 50 and
fluctuated between 85% to 100%. There was a positive correlation between perfora-
tion size and the time required to repair it as well as an inverse correlation between
perforation size and closure of the postoperative ABG.4 In the report of Zhu and col-
leagues39 of endoscopic ossiculoplasty for pediatric congenital stapes malformations,
operative times decreased from 110.4 minutes for their first 5 cases to 70.67 minutes
for their last 3. In their examination of the learning curve for endoscopic stapes sur-
gery, Iannella and Magliulo40 showed a similar improvement in operative times, with
the last 10 endoscopic and microscopic cases in his series having similar operative
6 Schwam & Cosetti

times. In looking at microscopic approaches, Liu and colleagues41 tracked residents

longitudinally as they became attendings, and found that it took 5 years to reach a
plateau in speed, with no differences in surgical success and complication rates be-
tween years 3 and 7.
Tips for making the learning curve less steep include incremental addition of tech-
niques, trimming ear hair, starting on left ears if the surgeon is right-handed (with the
opposite being the case if the pathology is inferior), using flexible suction tubing, adept
hemostasis, and having a variety of suction instruments available.42,43 In addition,
starting with easier cases or smaller perforations and attending a training course
may be useful.4

Cost
The literature with respect to cost of endoscopic versus microscopic tympano-
plasty is scant. In Kuo and Wu’s30 comparison of endoscopic and microscopic
tympanoplasty, they found that the average cost of an endoscopic case was
645 euros as compared with 1170 euros for the microscopic approach. Patel
and colleagues44 examined totally endoscopic versus canal-wall-up tympanomas-
toidectomies and found an overall savings of 2978.89AUD when taking into ac-
count operative time, anesthesia setup, and other resources used. Both Migirov
and colleagues18 and Harugop and colleagues24 maintain that the cost of their 2
approaches was comparable, but did not provide concrete figures. Any facility in
which endoscopic sinus surgery is performed is expected to have a high-
definition multichip camera and endoscopic tower; startup costs may include
3 mm endoscopes 14 to 18 cm in length and specialty endoscopic instruments.
Although most of the cases can be completed using standard otologic instru-
ments, certain specialty instruments such as a suction-enabled round knife or
Rosen pick are very helpful.

Education
Although there are no formal data in the literature, anecdotally endoscopic ear surgery
is appreciated by trainees for its common field of view and demonstration of anatomic
relationships.12,13 For an attentive assistant, anticipation of next steps and observing
how instruments are used and in what order may provide invaluable training.

Disadvantages of Endoscopic Ear Surgery

The disadvantages of endoscopic ear surgery include 1-handed surgery, frequent lens
fogging, difficulty with hemostasis, loss of binocular vision, and the potential for unin-
tentional heat injury.
Although otologists may initially decry the loss of one hand to holding the endo-
scope, some investigators believe that tympano/myringoplasty is simple enough
that it should not be a large impediment.13 Use of a suction-round-knife or suction-
Rosen may also obviate the need for a second hand while raising the TMF or entering
the middle ear space. Most published articles report not having to convert to a micro-
scopic approach, but it is occasionally done when removing sclerotic plaques or
releasing adhesions.16,18 Although we do not recommend use of an endoscope holder
due to the possibility of patient movement causing unintentional damage,43 there are
reports of its successful use during myringoplasty; it may be more amenable to this
procedure as opposed to cholesteatoma surgery as there is less of a need for a dy-
namic field of view.45
Maintaining visualization with frequent fogging and controlling bleeding may be
difficult for the beginner otoendoscopist. Frequently wiping the scope on defogging
Endoscopic Tympanoplasty 7

solution (and thereafter warm saline as the defogging solution may be ototoxic) may
ensure image clarity but also control heat emission from the tip of the scope. To
maintain hemostasis, tips include reverse Trendelenburg of approximately 15 , using
suction dissectors, avoiding hypertension (and even maintaining slight hypotension),
using total intravenous anesthesia, and frequent use of topical
epinephrine.9,12,15,19,43
The potential for heat injury and desiccation of the chorda tympani and middle ear
structures has always been a concern, as maximum temperatures can quickly reach
44.1 to 46.0 C using a 4 mm endoscope and a xenon light source at maximum inten-
sity.46 By using a smaller diameter scope with light intensity of less than 40%, frequent
repositioning and irrigation, and keeping the tip of the endoscope as lateral as is
feasible, unintentional damage can be avoided without compromising visualization
or outcomes.9,39,43,46
Although the loss of binocular vision may be initially disorienting, many investiga-
tors find that the loss of depth perception is compensated for by experience and a
higher fidelity view.16–18,28 Due to the fish-eye design of all endoscopes, the
center of the field is slightly less magnified than the periphery; therefore, to make
a TMF of adequate length, the lateral cut should be made a bit further out than
anticipated.47

Equivalent Audiometric Outcomes and Tympanic Membrane Closure Rates

In the literature reviewed, audiometric outcomes were equivalent or in some cases su-
perior with an endoscopic approach. Other articles reported high success rates in their
endoscopic-only series.4,12,14,20,25,27,30,34,35,48,49 When analyzed in aggregate by
Manna and colleagues27 in their meta-analysis, the audiometric outcomes were also
comparable between the 2 techniques. As with the microscopic approach, results
will depend on primary versus revision surgery, concomitant pathology, reconstructive
technique, and status of the middle ear.
In the large microscopic series of Nardone and colleagues50 of 1040 myringoplasty
patients, his overall 10-year graft success rate was 78% with a significant recurrence
rate for chronic otitis media. In the Common Otology Database of the United Kingdom,
myringoplasty data are collected for 33 otolaryngologists, and their overall primary
microscopic closure rate was 90.6%, compared with 84.2% for revisions.51 Many of
the endoscopic series document shorter-term graft success rates greater than
80%, typically in the mid-80s to low-90s, which compare favorably to their respective
microscopic numbers.4,10,12,13,15,20,21,23–27,29,31,49,51 Select series show superior rates
for their microscopic myringoplasties; Dundar and colleagues33 had a 1-year failure
rate of 12.5% for endoscopic type I tympanoplasty as compared with 5.71% for iden-
tical microscopic procedures with the caveat that the endoscopic group had on
average larger perforations. In their report of 60 myringoplasties, Maran and col-
leagues35 noted higher success rates for microscopic approaches for larger central
perforations and a negligibly higher rate for medium-sized perforations. This is in
contrast to the article of Tseng and colleagues,20 which noted no difference in larger
or even marginal perforations.

The Pediatric Population

Pediatric tympano/myringoplasty has classically been thought of as less successful
than adult surgery due to more middle ear infections, prominent adenoid tissue, and
eustachian tube dysfunction.9 However, the endoscopic literature has shown excel-
lent results in this group. Although the bony ear canal is narrower in young children
and grows with time,19 the shorter, straighter conformation of the canal is
8 Schwam & Cosetti

considered advantageous in an endoscopic approach, allowing increased angula-

tion and range.14 Various investigators suggest a canal size of at least 4.5 mm to
make an endoscopic approach feasible.19,52 Typically, a 3-mm endoscope should
provide adequate visualization and working room for other instruments. A protected
drill shaft and curved burr allow for nontraumatic canalplasty should the need
arise.26 Awad and Hamid37 stratified his pediatric cohort into those older and
younger than 10 years and noted similarly high rates of graft uptake between the
groups. Although some groups note successful use of a tragal chondroperichondrial
underlay graft,33 James26 found less success with a tragal perichondrial underlay or
push-through graft than in using a lateral graft with either autologous tissue or a
xenograft. In addition, it is important to note that in small children, the tragus may
be of insufficient size to harvest an adequate graft.26

Graft Materials
The full gamut of grafting material, from autologous to xenograft, has been reported in
the endoscopic literature. Due to the various approaches and pathology across re-
ports, recommendations cannot be made with respect to the most effective grafting
material for a given location or perforation type. Although temporalis fascia is often
the graft material of choice in a postauricular approach, many endoscopic investiga-
tors tend to harvest tragal chondroperichondrial grafts, as the cartilage provides rigid
support against negative middle ear pressures, its location within the surgical field, the
expediency with which it can be harvested, and minimal effect on cosmesis as long as
the lateral cap is left intact.9,21,31,50 Tragal cartilage also has acceptable acoustic
transfer, does not stimulate an inflammatory response, and has prolonged viability
should wound healing prove slow. The tragus has 2 layers of perichondrium, with
the undersurface being thinner and perhaps more suited to primary TM reconstruc-
tion, with the anterior layer preferred for composite grafting in scutum reconstruction.9
In addition, if one is planning concurrent ossiculoplasty, the graft can be placed on top
of a titanium prosthesis to prevent extrusion and improve the frequency response of
the TM.53,54
Fat, which is typically taken from the lobule of the pinna, may be used as an inlay
graft for smaller perforations, and may be done in the office or in the operating
room. Adipose tissue promotes neovascularization and tissue repair via the secretion
of angiogenic growth factors.9,55 Its use was first reported by Ringenberg in 1962,56
with recent reports documenting success rates between 76% and 92%.1,9
In recent years, xenografts, particularly Biodesign (Cook Group, Bloomington, IN),
a multilayered product derived from porcine intestinal submucosa, has been used to
good effect in the tympano/myringoplasty literature. De Zinis and colleagues45 used it
with a 100% success rate in 10 children, noting savings in operative time and surgical
morbidity. Similarly, James26 used it in his endoscopic cases when there was insuffi-
cient autologous tissue, allowing him to repair larger perforations. Yawn and col-
leagues57 evaluated its utility in 37 adults and children with a mix of endoscopic
and microscopic approaches, harvesting a concomitant cartilage graft in most cases.
The overall success rate of the graft material was 86.5%, with a significant improve-
ment noted in those undergoing concurrent cartilage graft.57

Specific Techniques
A range of grafting techniques have been used successfully in the endoscopic liter-
ature, with the selected technique at the discretion of the surgeon; there is a
paucity of data with respect to randomized trials comparing techniques or
Endoscopic Tympanoplasty 9

approaches. The following seeks to highlight some of the possibilities in one’s

armamentarium.
The butterfly chondroperichondrial inlay graft has been used extensively by various
investigators with very high success rates and fast operative times.9,20,36,58 It can be
used to reconstruct a wide variety of perforations, with particular utility in anterior per-
forations.17,58 Because of the reduced vascular supply, relatively poor visualization
(particularly when using the microscope), and lack of support, anterior perforations
are characteristically more difficult to repair.9,20 Butterfly grafts are best for small to
medium-sized perforations and rely on the strength of the surrounding remnant TM;
subtotal or marginal perforations, or cases in which a remnant has significant tympa-
nosclerosis, are not ideal situations in which to use this technique.36,59 Eren and col-
leagues58 reported using an otologic compass to measure the size of the tympanic
membrane perforation (TMP) and to size their graft accordingly. In Güls‚en and
Erden’s59 randomized control trial of small and medium anterior TMPs, they compared
an endoscopic butterfly inlay graft to an endoscopic push-through graft and noted
comparable success rates greater than 90%. However, the butterfly graft took
approximately 10 minutes less and required no middle ear packing.59
The push-through method has also been used successfully in other series, and
avoids raising a TMF.9,20 Although raising the TMF allows one to fully explore the
middle ear and remove disease, it may not be necessary in simple perforations
with low likelihood of concurrent pathology as determined by physical examina-
tion, audiometry, and preoperative imaging.4,9,20 In his series of 91 endoscopic
myringoplasties, Tseng and colleagues21 raised a TMF only when the perforation
was greater than 50% and noted no difference in audiometric or graft-take out-
comes. However, in James’26 pediatric series, he found push-through myringo-
plasty the least successful of his techniques, with a success rate of only 68%.
In not raising a TMF, the vascular strip is untouched; preserving the malleolar
and radial arterial blood supply may theoretically contribute to faster wound
healing.14
Whether to choose an underlay or lateral graft largely depends on surgeon and
regional preferences; both are effective and have similar outcomes when used prop-
erly.50 Lateral grafts may be favored particularly in the case of a subtotal or anterior
perforation. Although lateral grafts have been placed successfully in several endo-
scopic series,17,22,23,26 the endoscopic view may lead one to underestimate the
depth of the anterior sulcus and subsequently lead to blunting.17 It is also consider-
ably more tedious and may take significantly longer. Some investigators make use
of an interlay technique, in which the graft is placed between the squamous and
fibrous layers of the TM and the fibrous annulus is not raised.9,26 In the exclusively
microscopic series of 1040 tympanoplasties by Nardone and colleagues,50 lateral
grafts were more successful in revision surgery, and were typically used in anterior
or subtotal perforations. Wick and colleagues60 performed 34 lateral endoscopic
chondroperichondrial grafts in both children and adults with total or near-total per-
forations or myringitis; their initial success rate was 88.2% and 79% achieved a
postoperative ABG less than 20 dB.50

Poor Prognostic Factors

Poor predictors of success include otorrhea,20,50 large or subtotal
perforations,13,14,50,61 significant myringosclerosis,13 marginal or anterior
perforations,14,37,48,50,58 and concurrent ossicular pathology.61 In Awad and
Hamid’s37 pediatric series, patient age, eustachian tube dysfunction, and previous
adenotonsillectomy were interestingly not found to be predictive of success rates.
10 Schwam & Cosetti

However, attention should be paid to the status of the contralateral ear when risk-
stratifying patients for risk of recurrence.50

Complications
The most common complication of tympanoplasty is residual perforation or graft fail-
ure, the rates of which vary with operative technique as well as the size and location
of the perforation. To prevent iatrogenic cholesteatoma, it is necessary to evaluate
the medial side of the TM for inappropriate epithelial migration.62 Even in taking
the proper precautions, superficial cholesteatomas or epithelial pearls in the TM
are possible.1,15,23 Although this is theoretically lower in endoscopic cases due to
enhanced visualization, James26 had similar rates between the 2 approaches. Over-
all, the complication rate in an endoscopic approach is low and comparable to the
microscopic approach, without the risk of soft tissue complications from a postaur-
icular approach. External canal stenosis is, however, possible and documented in
one report. For a tympano/myringoplasty, rates of hearing deterioration or facial
nerve injury were found to be rare or did not occur.10,46 If there is graft take and
an intact ossicular chain, lack of improvement in hearing may be from the altered
structure of the neotympanic membrane.50 Both Marchioni and colleagues46 and
Glikson and colleagues63 documented their complication rates in resecting middle
ear cholesteatomas and in endoscopic ear surgery, respectively. Glikson and col-
leagues63 had minor and major complication rates of 16.6% and 6.0%, respectively,
with a 3.3% rate of stapes footplate fracture, 5.0% sensorineural hearing loss
(SNHL), 3.3% labyrinthitis, and 3.3% superficial surgical site infection of the tragal
graft site. Marchioni and colleagues46 had the following complications: 1.9% chorda
tympani injury, 0.2% transient facial palsy, 1.2% SNHL, 0.1% ossicular disruption,
and one footplate fracture. Caution must be used when evaluating the middle ear
and retrotympanum with an angled scope for potential cholesteatoma; ossicular
subluxation may occur and requires immediate repair.15 A myringoplasty/type I tym-
panoplasty is expected to have a lower complication profile than more complex
procedures.

SUMMARY

Endoscopic tympano/myringoplasty is both feasible and safe, with comparable suc-

cess rates to a microscopic approach. In many cases using an endoscopic approach
may obviate the need for a postauricular incision and its attendant morbidity, even in
the case of an anterior perforation or a stenotic/tortuous canal. A variety of grafts and
techniques have been used successfully, with the decision of which to use based on
surgeon preference and specific pathology.

CLINICS CARE POINTS

Endoscopic tympano/myringoplasty has equivalent audiometric outcomes and
rates of graft success when compared with the microscopic approach in both
adults and children.
A variety of grafts and techniques have been used to good effect. There are no
high-quality data supporting one graft or technique over others.
Endoscopic tympano/myringoplasty is a safe procedure, with less pain and a
rapid return to normal activity expected.
The endoscopic approach may be favored in those with particular concerns
regarding cosmesis or operative times.
Endoscopic Tympanoplasty 11

DISCLOSURE

Z.G. Schwam: none. M.K. Cosetti has received travel grants from Med-El, Cochlear,
Stryker, educational research grants from Advanced Bionics, and has done clinical
research with Advanced Bionics, Cochlear, and Otonomy.

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