The team from Birmingham have provided a meta-analysis to answer the question of when to perform a type 1 tympanoplasty on chronic paediatric perforations (under 18 year olds). Forty-five studies were included which resulted in 2609 cases. Closure rate at one year was assessed. They found a mean closure rate of 83.4% which is slightly lower than the previous meta-analysis in 1999 on the same topic. This is accounted for by more stringent and longer follow up criteria in the current meta-analysis, the authors state. Age is not a significant factor affecting closure rate as we are traditionally taught, although the numbers for analysis are small. Large perforations (over 50% size) had a slightly lower rate of closure (80% vs 86%). An underlay, inlay or onlay graft did not affect outcome. They suggest that waiting till the contralateral ear OME has resolved before operating is best, and this seems very sensible although conclusive data on this seems to be lacking. There is an interesting discussion on the effect of concurrent adenoidectomy, eustachian tube function and contralateral OME in relation to the outcome of surgery, and future studies should focus on addressing these questions. I would recommend reading this article in full.