Learning objectives: Understand the detail of the procedure of SUM and its advantages, including simplicity of technique, a high rate of closure of the perforation and very low incidence of complications.

Introduction: Simple underlay myringoplasty (SUM) has been widely performed over the last 26 years in Japan as a less invasive procedure of myringoplasty than conventional methods. SUM has been gradually recognized in the world since the detail of the procedure had been introduced into instruction courses in AAO-HNS for the last 9 years.

Methods: A transcanal approach is applied. No skin incision is necessary except to harvest subcutaneous connective tissue for the graft from the retro-auricular region. After the topical anesthesia of the tympanic membrane, the perforation edge is removed for both the debridement and the vascularization to the graft. The pressed graft is inserted into the tympanic cavity through the perforation, and then the graft is elevated to touch the perforation edge. The graft is fixed to the tympanic membrane with a little fibrin glue. Packing is not necessary either in the tympanic cavity or in the external auditory canal. The surgery is performed under local anesthesia except in cases with children because thirty minutes is sufficient to accomplish the surgery for one ear by this method. For the persistent perforation after this method, re-closure is attempted in the outpatient clinic by the same procedure using frozen autologous tissue which has been harvested in the initial surgery.

Results: The rate of initial closure was 478/621 (77.0%). Overall success rate after the re-closure was 595/621 (95.8%). There was no significant difference of the success rate among any size of the perforation or any frequency of otorrhea. There was no serious complication such as sensorineural hearing loss.

Conclusions: SUM is indicated for the case of chronic otitis media with central perforation as a minimally invasive surgery without serious complications.