Is Routine Umbo Resection Necessary During Over–Underlay Tympanoplasty? A Histopathological and Clinical Study

Background The necessity of routine umbo resection during over–underlay tympanoplasty remains controversial. Objective To evaluate histopathological persistence of epithelial remnants according to perforation–umbo relationship and to estimate the risk of postoperative cholesteatoma. Methods Prospective cohort of 148 consecutive Type I over–underlay tympanoplasties with minimum 24‐month follow‐up. Patients were grouped by perforation relation to the umbo. All resected specimens were examined with haematoxylin–eosin (H&E); pan‐cytokeratin immunohistochemistry was not performed in this series. Categorical comparisons used Fisher's exact test; proportions are reported with 95% confidence intervals (CI). Post hoc upper 95% bound for cholesteatoma incidence was calculated using the Poisson approximation. Results Histopathology revealed epithelial remnants in 33.3% (12/36; 95% CI 18.6–51.0) of Group 1 and 21.9% (7/32; 95% CI 9.3–40.0) of Group 2; none were detected in Group 3. No cholesteatoma developed during mean follow‐up of 24 months; the upper 95% confidence bound for true cholesteatoma incidence was 2.02%. Conclusion Umbo‐involving perforations are associated with higher rates of microscopic epithelial remnants, but microscopic remnants did not translate into cholesteatoma within the observed follow‐up. Routine umbo resection is not mandatory when meticulous de‐epithelialisation is achievable; selective resection based on intraoperative assessment is recommended. Longer follow‐up and larger multicentre cohorts are required to exclude rare adverse events.