This study was performed to compare the operation time, graft outcomes and complications between the endoscopic cartilage-perichondrium button technique and over-under technique for repairing large perforations. A total of 52 chronic large perforations were randomly allocated to receive treatment using the endoscopic cartilage-perichondrium button technique ( = 26) or over-under technique ( = 26). The graft outcomes, mean operation time and post-operative complications were compared between the two groups at 12 months. The study population consisted of 52 patients with unilateral chronic large perforations. All patients completed 12 months of follow up. The mean operation time was 32.3 ± 4.2 minutes in the button technique group and 51.6 ± 2.8 minutes in the over-underlay technique group ( < 0.01). The graft success rate at 12 months was 92.3 per cent (24 out of 26) in the button technique group and 96.2 per cent (25 out of 26) in the over-underlay group ( = 0.552). The endoscopic cartilage-perichondrium button technique had similar graft success rates and hearing outcomes for large chronic perforations to the over-under technique, but significantly shortened the mean operation time.