Objectives/Hypothesis: The purpose of this study was to analyze the anatomical and audiologic results in more than 1,000 cartilage tympanoplasties that utilized a logical application of several techniques for the management of the difficult ear (cholesteatoma, recurrent perforation, atelectasis). Our hypothesis was that pathology and status of the ossicular chain should dictate the technique used to achieve optimal outcome. Study Design: Retrospective clinical study of patients undergoing cartilage tympanoplasty between July 1994 and July 2001. A computerized otologic database and patient charts were used to obtain the necessary data. Methods: A modification of the perichondrium/cartilage island flap was utilized for tympanic membrane reconstruction in cases of the atelectatic ear, for high-risk perforation in the presence of an intact ossicular chain, and in association with ossiculoplasty when the malleus was absent. A modification of the palisade technique was utilized for TM reconstruction in cases of cholesteatoma and in association with ossiculoplasty when the malleus was present. Hearing results were reported using a four-frequency (500, 1,000, 2,000, 3,000 Hz) pure-tone average air-bone gap (PTA-ABG). The Student t test was used for statistical comparison. Postoperative complications were recorded. Results: During the study period, cartilage was used for TM reconstruction in more than 1,000 patients, of which 712 had sufficient data available for inclusion. Of these, 636 were available for outcomes analysis. In 220 cholesteatoma cases, the average pre- and postoperative PTA-ABGs were 26.5 ± 12.6 dB and 14.6 ± 8.8 dB, respectively (P < .05). Recurrence was seen in 8 cases (3.6%), conductive HL requiring revision in 4 (1.8%), perforation in 3 (1.4%), and postand intraoperative tube insertion in 11 (5.0%) and 18 ears (8.2%), respectively. In 215 cases of high-risk perforation, the average pre- and postoperative PTA-ABGs were 21.7 ± 13.5 dB and 11.9 ± 9.3 dB, respectively (P < .05). Complications included recurrent perforation in 9 ears (4.2%), conductive HL requiring revision in 4 (1.9%), postoperative and intraoperative tube insertion in 4 (1.9%) and 6 ears (2.8%), respectively. In 98 cases of atelectasis, the average pre- and postoperative PTA-ABGs were 20.2 ± 10.9 dB and 14.2 ± 10.2 dB, respectively (P < .05). Complications included 1 perforation (1.0%), conductive loss requiring revision in 2 cases (2.0%), and post- and intraoperative tube insertion in 7 (7.1%) and 12 ears (12%), respectively. In 103 cases to improve hearing (audiologic), the average pre- and postoperative PTA-ABGs were 33.6 ± 9.6 dB and 14.6 ± 10.1 dB, respectively (P < .05). Complications included 1 perforation (1.0%), conductive loss requiring revision in 11 (11%), and post- and intraoperative tube insertion in 6 (5.8%) and 2 (1.9%), respectively. Conclusions: Cartilage tympanoplasty achieves good anatomical and audiologic results when pathology and status of the ossicular chain dictate the technique utilized. Significant hearing improvement was realized in each pathological group. In the atelectatic ear, cartilage allowed us to reconstruct the TM with good anatomic results compared to traditional reconstructions, which have shown high rates of retraction and failure. In cholesteatoma, cartilage tympanoplasty using the palisade technique resulted in precise reconstruction of the TM and helped reduce recurrence. In cases of high-risk perforation, reconstruction with cartilage yielded anatomical and functional results that compared favorably to primary tympanoplasty using traditional techniques. We believe the indications for cartilage tympanoplasty (atelectatic ear, cholesteatoma, high-risk perforation) were validated by these results.