Endoscope affects decision making in cholesteatoma surgery

Outcomes of Totally Endoscopic Versus Microscopic Techniques in Middle Ear Cholesteatoma: A Systematic Review and Meta-Analysis

Endoscopes have revolutionized the field of otology for the past two decades due to its minimally invasive technique and improved visualization. The advantage of endoscope during surgery for middle ear cholesteatoma both for diagnosing and aiding in removal of residual disease from the hidden areas and the resulting lower recurrence rates have been proven in the past by many authors. But the feasibility of totally endoscopic ear surgery and its surgical and patient related outcomes are yet to be explored in detail. We conducted this systematic review and meta-analysis to compare the surgical and patient related outcomes between totally endoscopic and microscopic technique in cases of acquired middle ear cholesteatoma. This meta-analysis has been conducted as per Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. Search engines used to identify the eligible articles were Pubmed, Web of Science, Cochrane Library, Virtual Health Library databases. The studies that compared the outcomes of microscopic and endoscopic techniques in case of acquired middle ear cholesteatoma and with more than 10 patients were included. Outcomes like recurrence, residual disease, graft uptake rate, audiological outcome, conversion rate, pain score, surgery duration, complications and quality of life outcomes were compared.The quality of the included studies was assessed by Methodological Index for Non-randomized studies criteria in case of non-randomized studies and by means of Cochrane Risk of Bias Tool in case of randomized controlled studies. A random effects model was used to calculate pooled estimates. The ODDS ratio and 95% confidence interval were calculated. The heterogeneity among the studies was represented by the Q statistic and Higgins I2 statistic. The test for overall effect was calculated by Z test and a p value of < 0.05 was considered as statistically significant. 11 studies were included in this meta-analysis. Out of 11 included studies, 4 were prospectively designed and 7 were retrospective studies. The overall effect showed recurrence rate (Z:2.69, P:0.007) was lower among endoscopic technique. Post-operative pain was less among the endoscopic technique and there was no difference between the groups with respect to surgical duration. Although endoscopic technique showed lower residual rate and post-operative vertigo with better graft success rate among the individual studies, the overall analysis showed that the difference was not statistically significant. Endoscope has been an invaluable tool in the cholesteatoma surgery over the past 20 years due to its excellent optics and minimally invasive technique. Evaluation of the present data available in the literature reveals that both the techniques have similar outcomes except for a definite advantage of endoscopic technique in reducing the recurrence and post-operative discomfort.

Ears with Cholesteatoma: Outcomes of Canal Wall Up and Down Tympano-Mastoidectomies—A Comparative Prospective Study

This prospective study has been carried out to observe the outcomes of canal wall up (CWU) and canal wall down (CWD) Tympano-mastoidectomies in ears with cholesteatoma. Outcomes of the procedures have been done in terms of recurrence of cholesteatoma, complications, graft uptake rates and post-operative hearing gain. This study was carried out in the Department of Otorhinolaryngology of a reputed tertiary teaching hospital of North India from January 2016 to June 2020, with a mean follow-up of 32 months. The study included 100 patients of otitis media with cholesteatoma. In Canal Wall Up Tympano-mastoidectomy (CWUT) group, the number of males and females were 22 each. On the other hand, 36 males and 20 females underwent Canal Wall Down Tympano-mastoidectomy (CWDT). Each surgery was done as a single-staged and at the end of the surgical procedure angled oto-endoscopes were used for ensuring complete removal of the disease. Though there is no statistically significant difference in recurrence of cholesteatoma and complications rate in CWU and CWD Tympano-mastoidectomy techniques, but CWUT is superior to CWDT in terms of better graft uptake (p = 0.0156), and better average audiological gain (8.56 ± 0.93 dB) with p value = 0.0315. A diligent post-operative follow-up is must for assessing the outcomes of different types of mastoidectomies. This study shows no statistical difference in the disease recurrence and complication rates between Canal Wall Up and Down Tympano-mastoidectomies, though the anatomical changes and creation of the mastoid cavity in canal wall down procedure may affect the graft uptake and post-operative hearing gain. Use of Oto-endoscopes in cholesteatoma surgery helps in improving the outcomes of both techniques and thus recommended if the facility for the same is available.

Topographic Anatomy of the Medial Labyrinthine Wall: Implications for the Transcanal Endoscopic Approach to the Internal Auditory Canal

HYPOTHESIS

To characterize transcanal endoscopic landmarks of the medial labyrinthine wall and correlate these with anatomical features of the fundus of the internal auditory canal (IAC).

BACKGROUND

The transcanal transpromontorial approach (TTA) enables minimally invasive access to the IAC. The establishment of a landmark-based dissection technique for the approach is crucial to avoid injury to the facial nerve.

METHODS

Twenty temporal bones were dissected endoscopically through the TTA. Furthermore, high-resolution computed tomography (CT) scans from ten adult normal temporal bones were analyzed and three-dimensionally reconstructed.

RESULTS

A stepwise dissection technique for the TTA was demonstrated depending on a newly described landmark used in the identification of the facial nerve. The proposed landmark, which was named the intervestibulocochlear crest (IVCC), is an integrated part of the otic capsule. It can be differentiated after the excision of the lateral labyrinthine wall as a laterally based bony pyramid between the cochlea and the vestibule. Its medially directed apex blends with the central part of the falcifrom crest and points to the distal part of the meatal facial nerve. The IVCC is best detected on axial CT images at the level of the tympanic facial nerve. The union between the IVCC and the falciform crest appears radiologically as a short stem or mini-martini glass.

CONCLUSION

The proposed IVCC is a novel landmark with a consistent relationship to the IAC fundus and the facial nerve. It may be utilized in conjunction with the falciform crest to identify the facial nerve during minimally invasive transcanal surgeries.

History of Endoscopic Ear Surgery

The introduction of the microscope to ear surgery by Wullstein has been a transformative event in ear surgery. The ability to visualize disease and anatomy has resulted in more effective surgery and better functional outcomes. Many surgical disciplines have adapted the endoscope as the instrument of choice to access and correct internal pathology without disruption of overlying tissue. Multiple discussions and attempts at using the endoscope in ear surgery over the years have culminated in the development of transcanal endoscopic ear surgery. This article discusses the integration of the endoscope into the practice of otologic surgery.

A volumetric three-dimensional evaluation of invasiveness of an endoscopic and microscopic approach for transmeatal visualisation of the middle ear

OBJECTIVE

This study aimed to compare the necessary scutum defect for transmeatal visualisation of middle-ear landmarks between an endoscopic and microscopic approach.

METHOD

Human cadaveric heads were used. In group 1, middle-ear landmarks were visualised by endoscope (group 1 endoscopic approach) and subsequently by microscope (group 1 microscopic approach following endoscopy). In group 2, landmarks were visualised solely microscopically (group 2 microscopic approach). The amount of resected bone was evaluated via computed tomography scans.

RESULTS

In the group 1 endoscopic approach, a median of 6.84 mm3 bone was resected. No statistically significant difference (Mann-Whitney U test, p = 0.163, U = 49.000) was found between the group 1 microscopic approach following endoscopy (median 17.84 mm3) and the group 2 microscopic approach (median 20.08 mm3), so these were combined. The difference between the group 1 endoscopic approach and the group 1 microscopic approach following endoscopy plus group 2 microscopic approach (median 18.16 mm3) was statistically significant (Mann-Whitney U test, p < 0.001, U = 18.000).

CONCLUSION

This study showed that endoscopic transmeatal visualisation of middle-ear landmarks preserves more of the bony scutum than a microscopic transmeatal approach.

Endoscopic versus microscopic surgery for treatment of middle ear cholesteatoma: A systematic review and meta-analysis

OBJECTIVE

Endoscopic ear surgery (EES) is minimally invasive and increasingly used to treat middle ear disease. In this meta-analysis, we compared the efficacies of EES and microscopic ear surgery (MES) in patients with middle ear cholesteatoma.

METHODS

The PubMed, Embase, Cochrane Library, and Web of Science databases were searched for studies that reported the comparative surgical outcomes of EES and MES in patients with middle ear cholesteatoma. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. All included studies involved ≥1 of the following outcomes: recurrence of or residual disease, graft intake success rate, audiological performance, and operation time. We calculated the pooled relative risk (RR) or weighted mean difference with 95% confidence intervals (CIs) by using STATA software.

RESULTS

Thirteen studies were included in the quantitative meta-analysis. The pooled recurrence and residual rates of cholesteatoma were significantly lower in the EES group than in the MES group [RR: 0.51, 95%CI: 0.31-0.84, heterogeneity (I²) = 4.7%; P = .394; RR: 0.68; 95%CI: 0.47-0.99; I² = 0.0%; P = .878; respectively]. There were no significant differences in other parameters, such as graft intake success rates, audiological performance, and operation times, between the 2 groups.

CONCLUSION

The pooled results showed that EES reduced the residual lesion rate and postoperative recurrence risk in patients with middle ear cholesteatoma. However, there was insufficient evidence to prove that EES was advantageous in graft intake success rate auditory performance, and operation time.

Pain After Ear Surgery: A Prospective Evaluation of Endoscopic and Microscopic Approaches

Objectives/Hypothesis

Assumed advantages of a minimally invasive endoscopic transmeatal approach in ear surgery are less postoperative pain, faster healing, and preservation of functional anatomy. We evaluated pain after ear surgery and compared endoscopic transmeatal, microscopic endaural, and retroauricular approaches.

Study Design

Prospective cohort study.

Methods

A prospective evaluation of pain during 3 weeks after ear surgery was performed. Three groups were defined: endoscopic transmeatal, microscopic endaural, and retroauricular. Data from 20 fully completed questionnaires (Brief Pain Inventory–Short Form) per group were analyzed with Bayesian and frequentist statistics.

Results

For all approaches, low pain scores were found, not exceeding 4 on a scale of 0 to 10. Analysis of the worst, least, and average pain scores documented per 24 hours showed no statistically significant difference nor equality between groups. With Bayesian statistics, a Bayes factor of 1.07, 0.25, and 0.51 was found, respectively. With frequentist statistics a p value of .092, .783, and 0.291 was found, respectively. Small, but statistically significant, differences were found for sleep, natural sleeping position, normal work, and pain medication taken. The location of pain correlates with the incision site.

Conclusions

The results of this study show that the surgical approach has no clinically relevant influence on postoperative pain after ear surgery. The statistically significant differences on natural sleeping position, sleep, normal work, and amount of pain medication taken are small and should be interpreted with caution. Therefore, these should not be decisive factors in the choice of surgical approach in ear surgery.

Level of Evidence

3 Laryngoscope, 131:1127–1131, 2021

COVID-19 and ear endoscopy in otologic practices

Purpose

Otolaryngologists have had to postpone the majority of surgical procedures in the current COVID-19 pandemic. Airborne transmission, beyond the projection of droplets from upper airways, expose healthcare workers to a risk of viral infection. Aerosol generating procedures (AGP) increase the risk of viral transmission to staff within the operating room.

Methods

Surgery of middle ear and mastoid is also considered an AGP, particularly mastoidectomy performed using a high-speed drill. The authors report their experience in endoscopic ear surgery as an alternative technique to reduce AGP in otologic procedures.

Results

Transcanal endoscopic ear surgery is a reliable technique used to manage many otologic conditions.

Conclusion

The endoscopic approach may reduce the risk of viral transmission to operating room staff by reducing the need for mastoidectomy.

Pinna stay suture in two handed endoscopic ear surgery: Our experience

Transcanal endoscopic ear surgery provides a minimally invasive approach to the middle ear. We operate exclusively by the two handed technique of endoscopic ear surgery with Endoscope holders. We have incorporated the technique of stay suture for retraction of external ear canal into our practice of transcanal two handed endoscopic ear surgery after observing this technique by Prof Muaaz Tarabichi at the First International Congress on Endoscopic ear surgery Dubai, April 2015 for the single handed endoscopic ear surgery.

AIM

To report our experience of the stay suture in transcanal two handed endoscopic ear surgery and highlight its advantages.

DESIGN

Prospective non randomized clinical study.

METHODS AND MATERIALS

A total of 354 two handed transcanal endoscopic ear surgeries (202 endoscopic cartilage tympanoplasties and 152 endoscopic attic cholesteatoma surgeries) with endoscope holders operated from May 2015 to September 2017 with the stay suture were included in the study.

RESULTS

The ear canal and the tympanic membrane visualisation, instrument manipulation were better with the stay suture technique of pinna retraction.

CONCLUSION

The study reports the successful application and use of the pinna stay suture. It is a good option during two handed technique in Endoscopic Ear Surgery for pinna retraction.

LEVEL OF EVIDENCE

Level 4.

Role of endoscopy in surgical management of cholesteatoma: A systematic review

Endoscopes are increasingly being used in cholesteatoma surgeries either as an adjunct to microscopes or sometimes exclusively. Their role at present is more as adjunct to microscope which still remains the work-horse for mastoidectomy. However, as endoscopy and endoscopic instruments are increasingly getting refined, role of endoscopy in management of cholesteatoma is continuously being appraised with progressively newer studies. This review aims to assess outcomes of several studies in which endoscopic techniques were used in cholesteatoma surgery and recognize common trends. An extensive review of literature on this theme was performed. Sixteen studies comprising of 1685 patients treated endoscopically either exclusively or in combination with microscope were included. Intra-operatively, in 267 (15.82%) cases, residual cholesteatoma was identified by endoscope in hidden areas after completion of surgery with microscope. On follow-up, recidivism was identified in 108 cases (6.4%) in second look procedures. Common sites of recurrence were hidden areas like sinus tympani. This review while acknowledging the value of microscope, highlights the merit of endoscope usage in cholesteatoma surgery and its role in reducing recurrence.

Use of the KTP laser in totally endoscopic cholesteatoma surgery

OBJECTIVE

This paper reviews our experience of potassium titanyl phosphate (KTP) laser in transcanal totally endoscopic cholesteatoma surgery.

METHODS

A prospective cohort study was conducted in a tertiary referral centre, involving a consecutive series of children with cholesteatoma who underwent totally endoscopic cholesteatoma surgery with a KTP laser.

RESULTS

The patients' mean age was 10.5 years (range, 1.8-18 years). A KTP laser was used in 70 of the 83 cases (84 per cent). The laser was not used in 13 'clean' cases, in which disease was removed more easily. Residual disease was detected in five cases (6 per cent), of which the KTP laser had been used in four (5 per cent). No complications were associated with KTP laser use.

CONCLUSION

The combination of KTP laser use with endoscopic visualisation is effective for minimising the risk of residual disease using a minimally invasive surgical approach. The thin, semi-flexible fibre carrier of the KTP laser is ideally suited to work alongside the endoscope within the narrow confines of the ear canal.

Clinical Characteristics of Pars Tensa Cholesteatoma: A Comparative Study of Area-Based Classification Systems Proposed by the Japanese Otological Society and the European Academy of Otology - Neuro-Otology

OBJECTIVES

To assess the clinical characteristics of extent patterns in pars tensa cholesteatoma.

MATERIALS AND METHODS

This was a retrospective chart review. Forty-four patients with pars tensa cholesteatoma who underwent primary surgery at a tertiary academic medical center were included. The main outcomes measured were sex, age, clinical background, and stage classification of pars tensa cholesteatoma (including the extent of cholesteatoma and involvement of the sinus tympani) according to two staging classifications: criteria advocated by the Japanese Otological Society (JOS) and those advocated by the European Academy of Otology and Neuro-Otology (EAONO)/JOS joint consensus statements.

RESULTS

The mean patient age ± standard deviation was 38.4±19.6 years. The patients comprised 19 men and 25 women. According to the JOS classification, 18 ears (40.9%) were classified as stage I, 22 (50.0%) as stage II, and 4 (9.1%) as stage III. According to the EAONO/JOS joint consensus statements, 14 ears (31.8%) were classified as stage I, 26 (59.1%) as stage II, and 4 (9.1%) as stage III. Fourteen ears (31.8%) demonstrated involvement of the sinus tympani. Four ears (9.1%) that were originally categorized as stage I cholesteatoma by the JOS criteria showed sinus tympani invasion and were subsequently categorized as stage II according to the EAONO/JOS criteria.

CONCLUSION

We determined the clinical characteristics of pars tensa cholesteatoma based on the novel and well-defined classification criteria. Further studies including long-term outcomes are necessary to demonstrate the clinical relevance of the discrepancy between the two criteria with respect to involvement of the sinus tympani.

Patterns of middle-ear cholesteatoma and implications for surgical approach

OBJECTIVES

Understanding the pattern of middle-ear cholesteatoma becomes pertinent with the rise of endoscopic surgery as surgeons decide on the optimal approach to visualise and extirpate disease. With modifications to the Telmesani attic-tympanum-mastoid staging system, this study aimed to evaluate the commonest patterns of middle-ear cholesteatoma and their implications for surgical approach.

METHODS

A retrospective study was conducted in a single tertiary institution in Singapore. All patients undergoing cholesteatoma surgery between January 2012 and June 2015 were included. Staging of cholesteatoma was based on clinical assessment corroborated by radiological findings.

RESULTS

Out of the 55 ears included, 98.2 per cent had cholesteatoma involving the attic. The disease extended into the mastoid antrum and beyond in 43 cases (78.2 per cent). The facial recess and/or sinus tympanum was affected in 26 cases (47.3 per cent).

CONCLUSION

The majority of cholesteatoma cases present with extensive attic disease and significant mastoid involvement. In these cases, endoscopes may be best suited to adjunctive rather than exclusive use in surgery.

Minimal Invasive Endoscopic Ear Surgery: A Two Handed Technique

To evaluate the surgical outcome of two handed technique of endoscopic ear surgery with endoscope holder. Retrospective Non Randomized Clinical Study. A total of 547 endoscope holder (Justtach) assisted ear surgeries (331 cartilage tympanoplasties and 216 cholesteatoma surgeries) were operated with Justtach from July 2013 to April 2016 with a follow up period ranging from 12 to 45 months to evaluate its feasibility and results with the technique. The design of the endoscope holder, Justtach is described along with its functioning and maneuvering techniques. In the endoscopic tympanoplasty group, at 1 year follow up, the graft uptake was seen in 323 ears with three residual perforation and 5 recurrent perforations giving a success rate of 97.58%. At the 2 years follow up, the graft uptake was in 322 ears with 6 recurrent perforations and 3 residual perforations with a success rate of 97.28%. Whereas in case of endoscopic cholesteatoma surgery, there was residual cholesteatoma in 5 and recurrent in 6 out of 216 cases. The study reports the successful application and use of endoscope holder in two handed technique of endoscopic ear surgery. Level of Evidence Level 4.

An overview of endoscopic ear surgery in 2018

OBJECTIVE

To provide an overview of Endoscopic Ear Surgery, its development, principles, and penetration in otology practice in 2018.

DATA SOURCE

PubMed review of literature and cross-sectional email survey of otologists.

METHODS

We reviewed all PubMed published articles on use of endoscopy in practice of otology over the last 50 years. Articles were categorized based on date of publication and pattern of utilizing the endoscope. We also conducted two identical email surveys in 2010 and 2018 of otologists on the use of endoscope and tabulated and compared results.

RESULTS

The number of publications on use of endoscope has increased from 6 in 1990 to an accumulated total of 451 in 2018. There has been a clear shift in the area of interest away from diagnostic endoscopy, to endoscope-assisted surgery, and lately, to transcanal endoscopic ear surgery (TEES). Survey results further documented the increased awareness of the value of the endoscope and its increased use in clinical practice.

CONCLUSION

TEES has gained traction as a subject of research interest and in clinical practice and has lately dominated the discussion on the use of endoscope in otology.

LEVEL OF EVIDENCE

NA.

[Prospects of endoscopic otosurgery in children]

Active progress in otosurgery opens up new opportunities for minimally invasive surgeries and significantly improves the results of treatment, but a number of problems remain unsolved, including in children. Despite the general positive trend of using the endoscope in otosurgery, in pediatric practice the data are insufficient and extremely contradictory. Literary sources show that, with certain advantages, the existing techniques of endoscopic tympanoplasty are far from perfect and inferior in effectiveness to classical microscopic techniques, which also necessitates further research in this field.

Facial sinus endoscopic evaluation, radiologic assessment, and classification

OBJECTIVES

To describe facial sinus anatomy from an endoscopic perspective and present a radiologic classification.

METHODS

Facial sinus was studied by endoscopy and high-resolution computed tomography (HRCT) scan in 39 temporal bones that underwent exclusive transcanal endoscopic approach. A radiomorphologic classification based on the relationship between the facial sinus and the mastoid portion of the facial nerve is created as follows. In type A facial sinus, the pneumatization of the facial sinus did not extend medially or posteriorly to the mastoid portion of the facial nerve. In type B facial sinus, the pneumatization extended posteriorly to the mastoid portion of the facial nerve. In type C facial sinus, the pneumatization extended posteriorly and medially to the mastoid portion of the facial nerve.

RESULTS

In all the specimens that underwent HRCT (n = 31), facial sinus could be identified, and its depth classified, in relation to the facial nerve. In this group, 58% type A, 29% type B, and 13% type C facial sinuses were identified. In all the specimens (n = 39), the facial sinus could be assessed by means of an exclusive endoscopic transcanal approach, and anatomical variants of the chordiculus, previously known as chordal ridge, could be described: ridge (39%), bridge (18%), incomplete (15%), and absent (28%).

CONCLUSION

Endoscopic exploration of the retrotympanum guarantees a very good exposure of the facial sinus, allowing detailed anatomic descriptions of its conformation and relationships with other structures. Improvement in our knowledge of its anatomy might decrease the possibility of residual disease during cholesteatoma surgery. Angled endoscopes (e.g. 45 °, 70 °) can guarantee a better view of the facial sinus.

LEVEL OF EVIDENCE

NA. Laryngoscope, 128:2397-2402, 2018.

The anatomic applicability of transcanal endoscopic ear surgery in children

OBJECTIVE

The feasibility of TEES in dealing with pediatric middle ear disease is still under investigation. The goal of this study was to compare anatomical dimensions of the EAC between children and adults, and to analyze the anatomic applicability of TEES in children.

METHODS

Forty pediatric (18 years old and younger) and 20 adult patients who received TB-HRCT to evaluate middle ear conditions were enrolled from December 2010 to December 2015. Dimensions including the diameters of the EAC orifice, isthmus and tympanic membrane annulus, the length of EAC, the height of the middle ear, and the angle between tympanic membrane and EAC axis were determined according to the TB-HRCT data.

RESULTS

The diameters of the EAC orifice and isthmus and length of EAC in the pediatric patients were slightly smaller than those in the adult patients. The anatomical dimensions of middle ear were similar in both groups. Simple regression analysis indicated that the diameters of the EAC orifice and isthmus and the length of the EAC were positively correlated with the age of the pediatric patients. In the pediatric patients, 67 ears (83.75%) had an EAC isthmus diameter larger than 4 mm and are sufficient with a 3-mm endoscope manipulation.

CONCLUSION

TEES is applicable for most pediatric patients using an endoscope with a diameter of 3 mm or smaller. With an appropriate endoscope and instruments, TEES is a safe and effective alternative to treat pediatric middle ear disease.

[The modern state and prospects of development of endoscopic otosurgery]

In this review presents data on efficiency endoscopic operations at some ear diseases. Now endoscopic operations are widely applied at primary and residual (or recuring) middle ear cholesteatomas, tympanic membrane perforation, otosclerosis and cochlear implantation. Proceeding from resolving power of endoscopic technology, endoscopic operation can be applied as an independent method, or as an endoscopic assisted, to be combined with otomicrosurgery operation. Efficiency of endoscopic operation in many respects is defined by a possibility of panoramic visualization of anatomical structures of middle and inner ear, and also carrying out high-quality elimination of focus lesion from areas, being remote when performing otomicrosurgery operation.

Endoscopic and minimally-invasive ear surgery: A path to better outcomes

The development of endoscopic ear surgery techniques promises to change the way we approach ear surgery. In this review paper, we explore the current evidence, seek to determine the advantages of endoscopic ear surgery, and see if these advantages are both measureable and meaningful. The wide field of view of the endoscope allows the surgeon to better visualize the various recesses of the middle ear cleft. Endoscopes make it possible to address the target pathology transcanal, while minimizing dissection or normal tissue done purely for exposure, leading to the evolution of minimally-invasive ear surgery and reducing morbidity. When used in chronic ear surgery, endoscopy appears to have the potential to significantly reduce cholesteatoma recidivism rates. Using endoscopes as an adjunct can increase the surgeon's confidence in total cholesteatoma removal. By doing so, endoscopes reduce the need to reopen the mastoid during second-look surgery, help preserve the canal wall, or even change post-cholesteatoma follow-up protocols by channeling more patients away from a planned second-look.

Endoscopy-Assisted Ear Surgery for Treatment of Chronic Otitis Media With Cholesteatoma, Adhesion, or Retraction Pockets

The objective of this study was to analyze the results of endoscopy-assisted ear surgery for the treatment of chronic otitis media with cholesteatoma, adhesion, or retraction pockets.Fifty-one patients who underwent oto-endoscopy-assisted canal wall up tympanomastoid surgery and/or limited anterior atticotomy with tympanoplasty for chronic otitis media with cholesteatoma, adhesion, or retraction pocket from 2006 to 2013 have been included in this study. Eradication of the disease from the middle ear and mastoid air cells was achieved by combination of the oto-microscobic and oto-endoscopic approaches. Second look surgery was performed 18 months later from the initial surgery in selected patients. Age, gender, pre-/postoperative otoscopy findings/audiograms, type of the used prostheses, and follow-up time were obtained from the patient's file. Anatomic integrity rates of the tympanic membrane, the mean gains of air bone gap, on pure-tone audiogram at 4 frequencies and existence of the residual disease were reviewed parameters. Functional evaluation was made in patients with intact tympanic membrane.Of the 51 patients, the ratios of the chronic otitis media with cholesteatoma and isolated adhesive otitis or retraction pocket cases were 74.5% (38/51) and 25.5% (13/51), respectively. Ossicular chain reconstruction was made with PORP in 27 patients and TORP in 20 patients, whereas the ossicular chain was intact in 4 patients. Anatomic integrity rates of the tympanic membrane were 90.2% (46/51). The overall (n = 46) pre-/postoperative mean ABG obtained at 4 frequencies were 28.3 ± 12.26 and 9.18 ± 5.68 dB (P < 0.0001) respectively. Residual cholesteatoma rate was 10.5% (34/38) for chronic otitis media with cholesteatoma patients. However, there was no recurrence or new cholesteatoma formation in isolated retraction pockets or adhesive otitis patients.Oto-endoscopic eradication of the cholesteatoma or epithelial tissue from hidden area after the all visible cholesteatoma removal by oto-microscope improves the quality of surgery, significantly decreases the frequency of the canal wall-down procedure and posterior tympanotomy requirements with acceptable residual cholesteatoma rates.

Outcomes of Using Otoendoscopy During Surgery for Cholesteatoma

To determine the impact of using otoendoscopy at the time of primary surgery of cholesteatoma in identifying hidden "cholesteatoma remnant". Study was prospective study. Setting was University tertiary care hospital. One hundred fifty, patients diagnosed clinically and by CT as having cholesteatoma, have been operated. 64 patients operated by using canal up technique and 86 patients operated by using canal down technique. Once all visible cholesteatoma was removed with standard microscopic techniques, otoendoscopy was utilized in every patient to identify any hidden "cholesteatoma remnant". Despite apparent total microscopic eradication of cholesteatoma of the operated cases, otoendoscopy at time of primary surgery revealed an overall incidence of hidden cholesteatoma remnants of 18%. The incidence of hidden cholesteatoma remnants identified by otoendoscopy was 23% in the canal up group and 14% in the canal down group. Otoendoscopy should be used as an adjunct with standard microscopic technique to identify hidden cholesteatoma remnants during surgery of cholesteatoma.

[The endoscopic anatomy of the middle ear (a dissection study)]

The objective of the present work was to study the specific endoscopic anatomical features of the middle ear using the dissected temporal bones with the intact tympanic membrane. The 18 cm long endoscopes 4 mm in diameter with a visual angle from 0 to 45 degrees in the combination with some other microinstruments, such as ear pincers, needles, curettes, elevators, and suction tubes, were used during the examination. It was shown that endomeato-transtympanic endosopy provides a panoramic view of almost all structures of the middle ear. After the resection of the posterior bone edge of 'annulus tympanicus', the use of the 45o endoscope ensured the panoramic view not only of certain structures of the middle ear (e.g. the tympanic chord, the stapedius muscle tendon, the entire pyramidal process) but also of the structures of the retrotympanic and anterior epitympanic spaces.

Residual Cholesteatoma After Endoscope-guided Surgery in Children

OBJECTIVE

Endoscopes can facilitate surgery within tympanomastoid recesses that are not visible with the operating microscope. This study investigates whether use of endoscopes to guide dissection of cholesteatoma leads to lower rates of residual cholesteatoma than using the endoscope only for inspection after microscope-guided dissection.

STUDY DESIGN

Comparative cohort study.

SETTING

Tertiary pediatric center.

PATIENTS

Two hundred thirty-five patients with acquired or congenital cholesteatoma in children <18 years having intact canal wall surgery and follow-up >12 months.

INTERVENTIONS

Comparison of group (A) microscope surgery followed by endoscopic inspection, with group (B) endoscope-guided dissection.

MAIN OUTCOME MEASURES

Residual cholesteatoma rates, controlling for site of initial cholesteatoma, detection by second-stage surgery, and length of follow-up.

RESULTS

Analysis of all patients showed endoscopic dissection was associated with less residua in the middle ear (risk difference = 0.12; p = 0.026, Kaplan-Meier log rank analysis; number needed to treat = 9) but not at other sites. When restricting analysis to ears that were evaluated with second look surgery, no significant reduction in residual disease was found after endoscopic dissection at any site (e.g., retrotympanic residua: 12% Group A versus 7% Group B (NS, Fisher exact test). Endoscopic dissection allowed more permeatal surgery. No complications were attributable to endoscope use. Wound complications occurred in 4% of open cases.

CONCLUSION

Endoscopes enhance surgical access to tympanomastoid recesses. In conjunction with the availability of the operating microscope, angled instruments, and KTP laser, endoscope-guided dissection provides a small incremental benefit for prevention of residual cholesteatoma, and facilitates a minimally invasive approach.

The value of otoendoscopy in the management of middle ear cholesteatoma

BACKGROUND

The surgical management of cholesteatoma is a controversial issue, particularly regarding intact-canal-wall mastoidectomy (ICWM) versus canal-wall-down mastoidectomy (CWDM). The current experiment compared the quality of visualization in different middle ear structures using ICWM with otoendoscopy with findings of CWDM by microscopy.

MATERIALS AND METHODS

The patients diagnosed with cholesteatoma underwent tympanomastoidectomy, and then the patients selected for CWDM were included in the study (25 patients: 11 females and 14 males). After removing the cholesteatoma from the involved areas, otoendoscopic examination was done with a 4 mm, 0° endoscope by a neurootologist. All five middle ear structures (lateral epitympanum, sinus tympani, posterior crus of the stapes, round window niche, and Eustachian tube orifice) suspected of occult cholesteatoma were evaluated in terms of having or lacking the pathology. Then, CWDM was performed and all of the mentioned sites were reevaluated for diagnosing occult cholesteatoma.

RESULTS

The symmetric measures were 73%, 92%, 63%, 81%, and 100% for lateral epitympanum, sinus tympani, posterior crus of the stapes, round window niche, and Eustachian tube orifice, respectively.

CONCLUSION

Otoendoscopy was confirmed to have a great potential to be adopted by surgeons as a less invasive procedure in the surgical management of middle ear cholesteatoma.

Safety of heat generated by endoscope light sources in simulated transcanal endoscopic ear surgery

OBJECTIVE

To determine whether heat generated by endoscope light sources during ear surgery is safe.

METHODS

Transcanal endoscopic ear surgery (TEES) was simulated using 2.7-mm or 4-mm endoscopes coupled to xenon or LED light sources and a 3D model of human temporal bone. The endoscope tip was fixed at the center of tympanic annulus. Light sources were tested at clinical (30% for xenon and 40% for LED) and 100% settings. Temperatures were measured using thermocouples attached to the endoscope tip and three points within the middle ear cavity: promontory, horizontal portion of the facial nerve and lateral semicircular canal.

RESULTS

Maximum temperatures measured within the middle ear cavity were below 31°C at clinical settings, while the temperatures rose to 44.1°C using a 4-mm endoscope with a xenon light source set at 100%. Temperatures measured at the tip were all safe at clinical settings, but rose dramatically to 110.1°C for the 4-mm endoscope with xenon at 100%.

CONCLUSION

Endoscopes can be safely used within the middle ear at clinical settings. However, operators should not exceed clinical settings, particularly with 4-mm endoscopes with a xenon light source, to ensure temperatures generated within the middle ear cavity are safe.

Endoscopic ear surgery in Canada: a cross-sectional study

Background

Endoscopic ear surgery is an emerging technique with recent literature highlighting advantages over the traditional microscopic approach. This study aims to characterize the current status of endoscopic ear surgery in Canada and better understand the beliefs and concerns of the otolaryngology – head & neck surgery community regarding this technique.

Methods

A cross-sectional survey study of Canadian otolaryngologists was performed. Members of the Canadian Society of Otolaryngology were contacted though an online survey carried out in 2015.

Results

The majority of participants in this study (70 %) used an endoscope in their practice, with a large proportion utilizing the endoscope for cholesteatoma or tympanoplasty surgery. To date, 38 Canadian otolaryngologists (70 % of respondents) have used an endoscope for at least 1 surgical case, but only 6 (11 %) have performed more than 50 endoscopic cases. Of the otolaryngologists who use endoscopes regularly, the majority still use the microscope as their primary instrument and use the endoscope only as an adjunct during surgery. However, the general attitude surrounding endoscopes is positive; 81 % believe that endoscopes have a role to play in the future of ear surgery and 53 % indicated they were likely to use endoscopes in their future practice. Participants who were earlier in their practice or who had more exposure to endoscopic techniques in their career were more likely to have a positive stance towards endoscopic ear surgery (p < 0.05, p < 0.01, respectively). The main concern regarding endoscopic ear surgery was the technical challenge of one-handed surgery, while the primary perceived advantage was the reduced rates of residual or recurrent disease.

Conclusions

Endoscopic ear surgery is a new technique that is gaining momentum in Canada and there is enthusiasm for its incorporation into future practice. Further investment in training courses and guidance for those looking to start or advance the use of endoscopes in their practice will be vital in the years to come.

Electronic supplementary material

The online version of this article (doi:10.1186/s40463-016-0117-7) contains supplementary material, which is available to authorized users.

Transcanal endoscopic ear surgery for pediatric population with a narrow external auditory canal

OBJECTIVES

To retrospectively determine the size of the external auditory canal (EAC) in a pediatric population and to describe our experience with transcanal endoscopic ear surgery (TEES) in this pediatric population which had been successfully treated for middle ear disease using TEES.

METHODS

We analyzed 31 patients ranging in age from 2 to 13 years old (median: 7.6 years) with middle ear disease who underwent TEES between November 2011 and August 2014. Sixteen of these patients had surgery for cholesteatomas; 11 for chronic otitis media; and 4 for malformation of the middle ear. A preoperative CT scan was performed to evaluate the middle ear disease. Transcanal endoscopic tympanoplasty was performed using a rigid endoscope with a 2.7mm outer diameter. Transcanal endoscopic atticoantrotomy was also performed, as necessary, on some patients to access pathologies in the antrum. The values of anterior-posterior diameters and superior-inferior diameters of the bony parts of EAC were measured retrospectively based on the preoperative CT scan data.

RESULTS

TEES was successfully performed in all 31 pediatric patients without resorting to a retroauricular incision. Twenty-seven patients were evaluated for postoperative hearing levels which were found to fall within an acceptable range and for postoperative air-bone gap (ABG) by pure tone audiometry with a resulting mean of 8.6dB. The smallest anterior-posterior diameters of the external ear canal ranged from 3.2 to 7.1mm (5.0±1.0mm) and the smallest superior-inferior diameters ranged from 3.4 to 10.3mm (5.9±1.3mm).

CONCLUSION

TEES can be used to safely and effectively treat middle ear disease even in the pediatric population in its narrow EAC.

Systematic review of outcomes following observational and operative endoscopic middle ear surgery

OBJECTIVES

Middle ear surgery increasingly employs endoscopes as an adjunct to or replacement for the operative microscope. We provide a systematic review of endoscope applications in middle ear surgery with an emphasis on outcomes, including the need for conversion to microscope, audiometric findings, length of follow-up, as well as disease-specific outcomes.

DATA SOURCES

PubMed, Embase, and Cochrane CENTRAL database.

METHODS

A literature review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis recommendations. Articles were categorized based on study design, indication, and use of an endoscope either as an adjunct to or as a replacement for a microscope. Qualitative and descriptive analyses of studies and outcomes data were performed.

RESULTS

One-hundred three articles met inclusion and exclusion criteria. Of the identified articles, 38 provided outcomes data. The majority of these studies were moderate quality, retrospective, case-series reports. The indications for use of the endoscope were broad, with the most common being resection of cholesteatoma. In cholesteatoma surgery, endoscope approaches routinely identified residual cholesteatoma in primary and second-look cases. Other outcomes, including robust audiometric data, operating room times, wound healing, and quality of life surveys were not well described.

CONCLUSIONS

Endoscopes have consistently been used as an adjunct to the microscope to improve visualization of the tympanic cavity. Recent reports utilize the endoscope exclusively during surgical dissection; however, data comparing patient outcomes following the use of an endoscope to a microscope are lacking. Areas in need of additional research are highlighted.

LEVEL OF EVIDENCE

NA

Instrumentation and technologies in endoscopic ear surgery

This article covers state-of-the-art instruments and devices specially designated for endoscopic ear surgery. New technologies stimulate the creation of special endoscopic equipment and microinstruments specially designed to satisfy the exclusive requirements of endoscopic ear surgery, which contribute to the progress of the procedure. The article presents the advantages and disadvantages of working with ear endoscopes and details the advances in equipment used in ear endoscopies. New instruments specially modified for working with angled-vision endoscopes and considerations of the surgeon's use of them are discussed.

Transcanal endoscopic management of cholesteatoma

A detailed and comprehensive discussion of transcanal endoscopic management of cholesteatoma is presented. After a presentation of the anatomy of the area, the rationale, advantages and limitations, technique, and long-term results of each technique are presented. A case presentation follows each technique. Techniques presented are: endoscopic transcanal management of limited cholesteatoma, endoscopic open cavity management of cholesteatoma, and expanded transcanal access to middle ear and petrous apex.

Exclusive endoscopic ear surgery for acquired cholesteatoma: preliminary results

OBJECTIVE

To present preliminary results in transmeatal exclusive endoscopic ear surgery.

STUDY DESIGN

Retrospective.

INTERVENTION

Rigid endoscopes were used for all procedures. A wide posterior tympanomeatal flap was elevated transmeatally, and the scutum was removed with a bone curette or was drilled until visualization of cholesteatoma extension and the mastoid antrum. The malleus and incus were removed when they were involved in the cholesteatoma or restricted access to it. When present, the stapes was left intact. Endoscopic accessibility was defined by no extension of the cholesteatoma beyond the level of the lateral semicircular canal. Scutumplasty was by with tragal cartilage, and tympanic membrane defects were reconstructed with the palisade technique and perichondrium.

RESULTS

Thirty patients, aged 9 to 75 years, underwent the exclusive endoscopic transmeatal cholesteatoma eradication between July 2008 and May 2010. There were no incidents of iatrogenic injuries to the facial nerve or ossicles. Closure of the tympanic membrane and good hygienic status (water tolerance and absence of inflammation) were achieved in all operated ears. Two patients had significant postoperative worsening of their sensorineural hearing loss: the cholesteatoma of one of them involved all 3 ossicles and oval window and the other patient experienced postoperative labyrinthitis. There was no residual disease in 18 patients who were followed for more than 1 year, and the non-echo-planar base diffusion-weighted sequence magnetic resonance imaging was negative in 3 patients.

CONCLUSION

Our preliminary results indicate that the minimally invasive endoscopic ear surgery allowed complete eradication of cholesteatoma from the middle ear and its extensions, with minimal morbidity and good functional results.

Tympanoplasty: an up-to-date pictorial review

The indications for tympanoplasty are mainly chronic ear pathologies, such as cholesteatoma, atelectasis and chronic tympanosclerotic otitis. Usually, modification of the mastoid and temporal tissues in general mostly involves bone work, which means bone removal by burs or appropriate bone curettes. It is for this reason that, in both the pre- and postoperative periods, the computed tomography (CT) scan is the primary radiological tool for studying the middle-ear, and temporal bone structures and pathologies. The aim of this review is to illustrate the most up-to-date postoperative results for tympanoplasty, including the emerging endoscopic techniques. The present work focuses on the five types of tympanoplasty that are likely to be encountered by the radiologist: radical surgery; open tympanoplasty; closed tympanoplasty; closed endoscopic tympanoplasty; and open endoscopic tympanoplasty. Understanding and interpreting temporal bone images in relation to the different types of surgery are important, especially at the postoperative stage, because of the high risk of recurrence of middle-ear pathologies, and a good working knowledge of surgical changes is fundamental for distinguishing iatrogenic bone demolition from complications and new pathological foci.

Endoscopic anatomy of the middle ear

Good knowledge of anatomy is fundamental for every surgeon. Middle ear anatomy is really complex and sometimes is challenging for otologists, who need to explore every single compartment for a radical removal of pathology. With introduction of the endoscope in middle ear surgery, anatomy of middle ear spaces has become wider and clearer due to a better magnification and to the possibility to look "behind the corner". This article is a review of the state-of-art of endoscopic middle ear anatomy with description of every compartment, with particular attention to ventilation pathways and middle ear folds.

Endoscopic transcanal middle ear surgery

The advantages and limitations of the microscope have defined postauricular access as the surgical intervention of choice for the treatment of diseases of the middle ear. The wide-angle view provided by the endoscope enables transcanal access to the tympanic cavity, and its otherwise difficult-to-reach extensions: The attic, sinus tympani, facial recess, and hypotympanum. These areas are the primary sites of disease and surgical failure to cure. The endoscope also allows an all encompassing view of the three main elements in tympanoplasty surgery: The ear canal, tympanic membrane, and the tympanic ring. This report is a summary of the author's two 17 years of experience with the use of transcanal operative endoscopy as the primary approach to the management of middle ear disease.

Pyramidal eminence and subpyramidal space: an endoscopic anatomical study

OBJECTIVES/HYPOTHESIS

To describe retrotympanic endoscopic anatomy, especially the pyramidal eminence and contiguous spaces.

STUDY DESIGN

This was an anatomical study on a prospective case series.

METHODS

The anatomy of the retrotympanum was studied by endoscopy in nine patients affected by cholesteatoma who underwent tympanomastoid surgery and in six temporal bone dissections.

RESULTS

Pneumatization of the sinus tympani and posterior tympanic sinus or both, noted in 12 ears out of 15, may give rise to a recess beneath the pyramidal eminence, which we have called the subpyramidal space. This space can manifest with a variable degree of depth, shape, or extent depending on the shape and dimensions of the pyramidal eminence.

CONCLUSIONS

Endoscopic exploration of the middle ear may guarantee a very good exposure of retrotympanic structures, allowing detailed anatomical descriptions of hidden areas. Improvement in our knowledge of the anatomy may decrease the possibility of residual disease during cholesteatoma surgery.

[A new visualization device for ENT surgery : the panoramic visualization system (HD-PVS)]

BACKGROUND

This work examines the application possibilities of the panoramic visualization system (HD-PVS) in ENT surgery. The HD-PVS is a new optical system that is neither an endoscope nor a microscope. It has a focal length of 200 mm and a wide field of view.

PATIENT AND METHODS

The analysis of the visualization quality took place under laboratory conditions at 4 close-to-surgery scenarios with a total of 40 result values. Furthermore, the system was used for 45 operative procedures on patients (tympanoplasty, parotidectomy, neck dissection, septumplasty, transfacial approaches). The results were analyzed following the ICCAS workflow-scheme and with standardized questionnaires.

RESULTS

The analysis of the visualization quality of the PVS exhibited the best total evaluation in 2 out of 4 scenarios, in 1 scenario HD-PVS attained the maximum score possible, as did the microscope and the endoscope was better than HD-PVS in 1 scenario. The microscope was never evaluated as being better than HD-PVS. Apart from its use in middle ear surgery, the HD-PVS can be considered operational in 4 out of 5 clinical applications with only slight modifications.

CONSEQUENCES

The advantages of HD-PVS over gold standards such as the surgical microscope are lower initial costs for the optical system with frequently already existing HD-video system, smaller space requirements, equal or sometimes better visualization quality, possibility of videoendoscopic representation of surgery and better ergonomic conditions.

Otoendoscopy in cholesteatoma surgery of the middle ear: what benefits can be expected?

OBJECTIVE

This study was conducted with the aim of determining the contribution of otoendoscopy in the surgical management of cholesteatoma of the middle ear.

BACKGROUND

The anterior epitympanum and the retrotympanum are anatomic sites that are difficult to access under otomicroscopy. Otoendoscopy offers a large field of vision using direct vision and lateral vision endoscopes, particularly in the supratubal recess and sinus tympani, for which visualization is excellent with reduced surgical approaches.The objectives of the study were to evaluate otoendoscopy as a means of identifying residues of lesions after excision of the disease under otomicroscopy in the same stage of surgery and its impact on the frequency of residual cholesteatomas at the time of surgical revision.

STUDY DESIGN

Retrospective case review.

SETTING

Private hospital center.

PATIENTS

Patients operated on a tympanoplasty under otomicroscopy with or without an otoendoscopic exploration for a cholesteatoma or an uncontrollable tympanic retraction pocket.

INTERVENTIONS

Between 1994 and 2005, 350 patients underwent tympanoplasty for a cholesteatoma or an uncontrollable tympanic retraction pocket.The surgical procedures were divided into closed tympanoplasty via the transmeatal approach, closed tympanoplasty with antroatticomastoidectomy and open tympanoplasty. Tympanoplasty was initially performed systematically under otomicroscopy.After excision of the disease, the cavities of the middle ear were examined by otovideoendoscopy, with the aim of identifying any peroperative residue of the lesion, to determine its location, especially in the epitympanum and retrotympanum, and the quality of its excision under otovideoendoscopy.During surgical revision, the frequency and location of any residual cholesteatoma were systematically recorded to determine the prognostic value of the quality of excision under otovideoendoscopy.

MAIN OUTCOME MEASURES

The repartition of the canal wall down, canal wall up, and transmeatic tympanoplasties was compared between the population operated with or without the otoendoscopy as a complementary exploration of the otomicroscopy in the same surgical time. The frequency and the location of a residual disease identified by the otoendoscopy and the frequency of a residual disease in a second surgical stage were evaluated.

RESULTS

Eighty patients (34%) who presented with an initial location of the disease at the epitympanum underwent complementary exploration by otovideoendoscopy. In this population, the frequency of open tympanoplasty was significantly lower.In 35 cases (44%), otoendoscopy revealed a residual lesion after an apparently total excision by otomicroscopy during closed tympanoplasty.The use of otoendoscopy did not produce a significant reduction in the number of residual cholesteatomas at the second stage of surgery compared to the population that underwent surgery under otomicroscopy alone. Nevertheless, the 35 residual lesions identified under otoendoscopy, as a complement to the microscope, during the first stage of surgery would have led systematically to a residual cholesteatoma at the second stage of surgery.Complementary exploration by otoendoscopy was performed on 85 patients (34%) who presented with a lesion of the retrotympanum. In this population, the frequency of open tympanoplasty was significantly reduced, while the techniques by the transmeatal approach were used in the majority of cases.In 65 cases (76%), a residual lesion was identified by otoendoscopy during the first stage of surgery in the sinus tympani or on the footplate of the stapes, between the crura of the stapes. Otoendoscopy did not produce a reduction in the frequency of residual cholesteatomas during surgical revision. Nevertheless, as for the epitympanum, the 65 residual lesions discovered under otoendoscopy would have led systematically to a residual cholesteatoma at the second stage of surgery if otoendoscopy had not been performed during the first stage.

CONCLUSION

This study confirms the real value of otoendoscopy in the surgical management of cholesteatomas of the middle ear. It belongs entirely to the minimally invasive surgical procedures, while significantly reducing the frequency of open tympanoplasty and recourse to posterior tympanotomy and offering excellent access to numerous lesions by the transmeatal approach. Analysis using otoendoscopy reduces the incidence of residual cholesteatomas by identifying lesion extensions that are overlooked under otomicroscopy. Nevertheless, some residual cholesteatomas persist at the second stage of surgery. The quality of excision under otoendoscopy constitutes an important parameter in the decision regarding revision surgery. By targeting the at-risk regions where a residual lesion was discovered, it allows the control scanner to be read with greater accuracy, thus facilitating the decision on whether to perform surgical exploration.