Endoscope Affects Decision Making in Cholesteatoma Surgery

Endoscopic vs Microscopic Overlay Tympanoplasty for Correcting Large Tympanic Membrane Perforations: A Randomized Clinical Trial

Objective

Although overlay grafting for complicated tympanic perforations offers a high success rate, potential complications may outweigh its advantages. This study aimed to assess endoscopic overlay tympanoplasty (EOT), compared with microscopic overlay tympanoplasty (MOT), to optimize outcomes while minimizing complications associated with large tympanic perforations.

Study Design

Nonmasked, randomized.

Setting

Tertiary care university hospital.

Subjects and Methods

Altogether, 70 patients with large tympanic perforations were randomized to undergo overlay tympanoplasty between June 2014 and July 2016. Primary outcome was the visual analog scale (VAS) of pain. Secondary outcomes were anatomic closure, hearing results, middle ear findings, and postoperative complications.

Results

Overall, 34 EOT patients and 30 MOT patients completed the follow-up. VAS scores at 4, 24, and 48 hours in EOT and MOT groups were, respectively, 3 and 8, 1.7 and 6.0, and 0.6 and 4.1. Postoperative pain was less in the EOT group ( P < .001), and canalplasty was not required ( P = .003). Graft “take” rates for EOT and MOT were 97.1% and 93.3%, respectively ( P = .60). Postoperative air-bone gap was lower with EOT (5.0 vs 10.3 dB) ( P = .01). Various middle ear structures were more visible after EOT than after MOT ( P < .001). Ear protrusion ( P = .008) and postauricular numbness ( P < .001) occurred after 50 MOTs.

Conclusion

EOT for repairing large tympanic perforations provides more favorable anatomical and audiometric outcomes. It also offers superior visibility of middle ear structures without lifting the annulus, with fewer complications and less invasiveness than MOT.

Pediatric Endoscopic Cholesteatoma Surgery

Objectives

(1) To describe and review a single center’s pediatric endoscopic cholesteatoma experience, including surgical and audiologic outcomes. (2) To assess the most common locations of residual cholesteatoma following endoscopic removal.

Study Design

Case series with chart review.

Setting

Tertiary otologic referral center.

Subjects

Patients <19 years of age who underwent cholesteatoma removal with either endoscopic or microscopic visualization.

Methods

In a comparison of patients who underwent total endoscopic ear surgery (TEES), combined endoscopic-microscopic surgery, or microscopic surgery, analyzed outcomes included locations and incidence of recurrent and residual cholesteatoma, complications, and audiometric testing.

Results

Sixty-six patients (mean age, 10.9 years; range, 4-18 years; 43.4% female) with 76 ears met inclusion criteria. The average overall follow-up was 18.8 months (range, 6.7-48.3). Forty-seven (61.8%) ears underwent microscopic removal of cholesteatoma; 29 (38.1%) ears underwent combined endoscopic-microscopic removal; and 8 (10.5%) ears underwent TEES removal. Significantly more mastoidectomies were completed in microscopic cases as compared with endoscopic cases ( P = .049). Though second-look procedures occurred in 15 (51.7%) endoscopic cases and 10 (21.3%) microscopic cases ( P = .006), the rate of residual disease was 20.0% and 40.0% in endoscopic and microscopic cases, respectively ( P = .38). When controlling for preoperative hearing, only the air-bone gap for TEES demonstrated significant improvement ( P = .009). No complications were noted.

Conclusion

The present report describes our experience with pediatric endoscopic cholesteatoma surgery, demonstrating similar hearing outcomes, rates of recurrence and residual disease, and complication rates as compared with traditional microscopic techniques.

Tympanomastoidectomy with otoendoscopy

A cadaveric study was performed to test the hypothesis that intact-canal-wall mastoidectomy (ICWM) with otoendoscopy allows for equal or better visualization of the middle ear cavity structures when compared with canal-wall-down mastoidectomy (CWDM) with microscopy. Ten temporal bones were prepared with a reversible canal-wall-down tympanomastoidectomy technique. Five anatomic sites in each middle ear cavity (lateral epitympanum, posterior crus of the stapes, the sinus tympani, eustachian tube orifice, and round window niche) were marked with paint. Two otolaryngologists blinded to the purpose of the study viewed the temporal bones with the microscope. Following replacement of the posterior canal walls, the bones were then viewed with a 30° and a 70° otoendoscope. All visualized paint marks for each viewing were recorded and compared. We found that ICWM with 30° or 70° otoendoscopy provided significantly better visualization of the sinus tympani than did CWDM (p ≤ 0.001). There was no significant difference among the three methods in visualization of the lateral epitympanum, posterior crus of the stapes, and round window niche. With respect to the eustachian tube orifice, one of the observers reported significantly better visualization with CWDM (p = 0.036). With adjunctive otoendoscopy, it is not necessary to remove the posterior canal wall to adequately visualize or remove disease from various areas of the middle ear cleft. The use of otoendoscopy during cholesteatoma surgery may allow for more frequent preservation of the posterior canal wall and reduced rates of residual cholesteatoma, given the equal or better visualization of the middle ear cavity.