Transcanal Endoscopic Ear Surgery Research Articles

Augmented Reality-Assisted Transcanal Endoscopic Ear Surgery for Middle Ear Cholesteatoma.

Background: The indications for transcanal endoscopic ear surgery (TEES) for middle ear cholesteatoma have expanded for cases involving mastoid extension. However, TEES is not indicated for all cases with mastoid extension. In addition, predicting the extent of external auditory canal (EAC) removal needed for cholesteatoma resection is not always easy. The purpose of this study was to use augmented reality (AR) to project the lesion onto an intraoperative endoscopic image to predict EAC removal requirements and select an appropriate surgical approach. Methods: In this study, patients showing mastoid extension were operated on using a navigation system with an AR function (Stryker). Results: The results showed that some cases with lesions slightly extending into the antrum required extensive resection of the EAC, while cases with lesions extending throughout the antrum required smaller resection of the EAC, indicating TEES. Conclusions: By predicting the extent of the needed EAC removal, it is possible to determine whether TEES (a retrograde approach) or canal wall-up mastoidectomy, which preserves as much of the EAC as possible, should be performed. We believe that our findings will contribute to the success of middle ear surgeries and the implementation of robotic surgery in the future.

Clinical course of five patients definitively diagnosed with idiopathic perilymphatic fistula treated with transcanal endoscopic ear surgery.

An idiopathic perilymphatic fistula (PLF) can be difficult to diagnose because patients present with sudden sensorineural hearing loss (SSHL) and/or vestibular symptoms without any preceding events. In such cases, we currently test for cochlin-tomoprotein (CTP) to confirm the diagnosis of idiopathic PLF because CTP is only detected in the perilymph. In this study, we report the clinical course of five patients definitively diagnosed with idiopathic PLF who underwent PLF repair surgery using transcanal endoscopic ear surgery (TEES). Five patients were initially treated with intratympanic dexamethasone for SSHL, at which time a CTP test was also performed (preoperative CTP test). Due to refractory hearing loss and/or fluctuating disequilibrium, PLF repair surgery using TEES was performed to seal the oval and round windows using connective tissue and fibrin glue. These patients were diagnosed with definite idiopathic PLF based on pre- or intra-operative CTP test results (negative, < 0.4 ng/mL; intermediate, 0.4-< 0.8 ng/mL; and positive, > 0.8 ng/mL). We evaluated pre- and intra-operative CTP values, intraoperative surgical findings via a magnified endoscopic view, and pre- and post-operative changes in averaged hearing level and vestibular symptoms. Pre- and intra-operative CTP values were positive and intermediate in three patients, positive and negative in one patient, and negative and positive in one patient. None of the patients had intraoperative findings consistent with a fistula between the inner and middle ears or leakage of perilymph. Only two patients showed a slight postoperative recovery in hearing. Four patients complained of disequilibrium preoperatively, of whom two had resolution of disequilibrium postoperatively. A positive CTP test confirms PLF in patients without obvious intraoperative findings. The CTP test is considered more sensitive than endoscopic fistula confirmation. We consider that CTP test results are important indicators to decide the surgical indication for idiopathic PLF repair surgery. In our experience with the five cases, two of them showed improvements in both hearing and vestibular symptoms.

Experiences of Percutaneous Endoscopic Approach for the Mastoid Lesions: A Novel Minimally Invasive Ear Surgery.

We developed a novel keyhole surgery, named "percutaneous endoscopic ear surgery" (PEES), with the aim of further reducing the invasiveness of otologic surgery. We reported the cases we encountered and retrospectively analyzed the invasiveness of PEES. We analyzed the ears of eight patients who underwent PEES for mastoid lesions that could not be manipulated with transcanal endoscopic ear surgery (TEES) at our hospital between July 2021 and November 2022. We performed PEES alone in three patients, including one case of type A (preauricular incision) and two cases of type B (retroauricular incision). The last five patients underwent combined endoscopic ear surgery, which is simultaneous PEES and TEES. In these cases, one patient underwent type A PEES, and four patients underwent type B PEES. PEES was performed in all patients without converting to conventional microscopic mastoidectomy. The mean length of skin incisions was 19.1 ± 4.5 mm, which was smaller than that in conventional mastoidectomy. In all cases, the average length of the major axis of the keyhole was <10 mm, indicating that sufficient minimally invasive surgery was achieved. The average depth from the keyhole to the deepest site was 21.6 ± 8.9 mm. There was no change in the mean hearing level before and after the surgery. PEES is a minimally invasive procedure for manipulating lesions in the mastoid. In addition, the combination of PEES and TEES is an ideal, minimally invasive procedure that can be used to treat all regions of the temporal bone.

Endoscopic atticotomy for attic cholesteatomas using piezosurgery.

Attic cholesteatomas can be exenterated by transcanal endoscopic ear surgery (TEES). In the limited operative field of exclusive transcanal endoscopic atticotomy, surgeons use either a piezosurgery scalpel or a drilling system to remove the posterior lateral bony wall of the epitympanum. We aimed to investigate the feasibility of using piezosurgery or microdrill for endoscopic atticotomy during exenteration of attic cholesteatomas. This study is a retrospective chart review of patients diagnosed with attic cholesteatoma, who were treated by exclusive TEES. The superior and posterior external auditory canal bones were excised using a piezosurgery scalpel or microdrill. Preoperative and postoperative hearing thresholds were measured by pure-tone audiometry. The postoperative follow-up duration varied from 6 to 37 months. There were no significant differences in age, sex, laterality of the affected ear, and preoperative bone conduction thresholds between the piezosurgery scalpel and microdrill groups. The operative duration was longer in the piezosurgery group than in the microdrill group (135.6 ± 19.5 minutes vs 117.3 ± 29.1 minutes, p = 0.042). Seven of 30 (23.3%) patients in the microdrill group, but none in the piezosurgery group, had a friction injury from the drilling. Postoperative testing at higher frequencies of 2000, 3000, and 4000 Hz showed no deterioration in the bone conduction threshold in the piezosurgery group. Endoscopic atticotomy performed using a piezosurgery scalpel is potentially safer but slower than using a microdrill for exenteration of attic cholesteatomas.

Proof-of-Concept Computer Vision Model for Instrument and Anatomy Detection During Transcanal Endoscopic Ear Surgery.

High-definition video captured during transcanal endoscopic ear surgery (TEES) can serve as imaging data for computer vision algorithms. This report describes a proof-of-concept model for automated anatomy and instrument detection during TEES.

Treatment of external auditory canal stenosis and atresia after transcanal endoscopic ear surgery

PurposeTo discuss the treatment of external auditory canal stenosis or atresia occurring as a complication of transcanal endoscopic ear surgery. Materials and methodsWe retrospectively analyzed the medical records of 11 patients who developed external auditory canal stenosis or atresia after undergoing transcanal endoscopic ear surgery. The 10 patients with stenosis were treated with external auditory canal expansion via drainage tube insertion; 2 of these patients further received local injections of triamcinolone acetonide. One patient with atresia was treated with meatoplasty surgery followed by tube insertion and triamcinolone acetonide injection. ResultsThe stenosis/atresia improved in all patients, and the external auditory canal was unobstructed without restenosis. ConclusionsStenosis/atresia of the external auditory canal after transcanal endoscopic ear surgery should be treated with dilation therapy/meatoplasty in a timely manner to prevent progressive hyperplasia of the scar and regain a normal-sized ear canal.

반대측 신경초종이 동반된 내시경 귀수술로 제거한 고실 사구종

반대측 신경초종이 동반된 내시경 귀수술로 제거한 고실 사구종

Surgical results of 29 ears with congenital middle ear anomalies; Microscopic vs. endoscopic ear surgery

ObjectiveAlthough congenital middle ear anomalies include various types of ossicular anomalies, all of these can be treated by ossiculoplasty or stapes surgery. Transcanal endoscopic ear surgery (TEES) is a minimally invasive surgical method for middle ear disease with an excellent surgical view that has been widely adopted worldwide. To determine the efficacy of TEES for middle ear anomalies, we describe the surgical results and compare the hearing outcomes between patients treated by TEES and microscopic ear surgery (MES). MethodsA total of 39 ears with congenital middle ear anomalies were treated surgically at the University Hospital of Kochi Medical School between January 2011 and December 2021. In total, 29 ears of 23 patients were included in the study. Demographics, type of anomaly, surgical methods, pre- and postoperative hearing thresholds, and surgical complications were investigated by retrospective chart review. ResultsOf the 29 ears, 11 were treated by MES and 18 were treated by TEES. There were no differences in sex, age, preoperative hearing thresholds, or rate of stapes surgery between the two groups. The mean air-bone gap improvement was 20.6 dB in the MES group and 28.8 dB in the TEES group; these values were not significantly different. The median operation time was not significantly different between the MES and TEES groups (125 and 130 min, respectively). The improvements of air conduction in class 1 and 2 (stapes surgery) and class 3 (ossiculoplasty) cases were also not different between the groups. ConclusionsTEES achieved comparable hearing outcomes to MES without postauricular or endaural incisions. Further, class 1 and 2 anomalies demonstrated hearing improvement similar to class 3 without major complications. Since the surgical field limited around the ossicular chain, coupled with the fact that the middle ear anomaly itself does not exhibit inflammation leading to unfavorable bleeding, TEES is a feasible surgical procedure for all types of congenital ossicular anomalies.

Comparison of the outcomes of endoscopic versus microscopic approach in cholesteatoma surgery: a randomized clinical study

BackgroundEndoscopic ear surgery is a new, less invasive otologic procedure. Since 1990s, it has been grown in prominence because of anatomical and physiological theories. It offers a view of hidden places, avoids mastoidectomies and endaural vertical and postauricular incisions, and has many other benefits over microscopic surgery. The purpose of this study was to distinguish the difference between the outcomes of microscopic and endoscopic cholesteatoma surgery.MethodsEighty individuals who were diagnosed with cholesteatoma participated in this randomized clinical research. Patients were randomly allocated into two equivalent treatment groups. One group submitted to tympanoplasty via microscopic ear surgery and the other group had exclusive trans-canal endoscopic ear surgery. All patients had preoperative otomicroscopic and radiologic assessment to ensure cholesteatoma diagnosis. Audiological evaluations were also obtained.ResultsThere was no discernible difference in the tested groups’ operational times, air-bone gaps, or air conduction. The endoscopic surgery group healed significantly more quickly than the microscopic surgery group (5.4 0.5 vs 7.7 0.5 weeks, p > 0.001). The frequency of residual lesions (5.0% vs 22.5%, p = 0.023) and recurrence (7.5% vs 27.5%, p = 0.019) was significantly lower in the endoscopic group of patients.ConclusionsWhen comparing healing times, rates of residual disease and rates of recurrence, endoscopic surgery clearly outperforms microscopic surgery. The endoscope encourages visualization and magnification of anatomy while being less invasive thanks to its improved picture quality, lighting, and capacity to “see around the corner.” Additionally, a significant portion of viable mastoid tissues and healthy mucosa were preserved.

The use of basic fibroblast growth factor to treat intractable Bell's palsy administered via transcanal endoscopic ear surgery

PurposeFacial nerve decompression surgery is an invasive procedure which has hitherto been the main option for patients with severe intractable Bell's palsy which is resistant to drug treatment. We have developed a new salvage treatment for such patients by using minimally invasive transcanal endoscopic ear surgery (TEES) to deliver the biological regenerative agent, basic fibroblast growth factor (bFGF), to the damaged facial nerve. Materials and methodsAn endoscopic salvage treatment group was studied prospectively and was made up of severe intractable Bell's palsy patients who did not respond to high dose steroid treatment and had an ENoG value of 5 % or less. This surgery group was retrospectively compared to a similar control group who had received high dose steroid only. ResultsComplete recovery to House-Brackmann (HB) Grade I was achieved by 44.8 % of the endoscopic salvage treatment group which was significantly higher than the 21.2 % of the control group at one-year follow up. Patients with an ENoG value of 1 % to 5 % exhibited a significantly higher complete recovery rate of 71.4 % in the endoscopic salvage treatment group than the 28.6 % of the control group. In addition, no complications were observed including hearing loss. ConclusionsbFGF delivered via TEES shows considerable promise as a new salvage treatment of severe intractable Bell's palsy that is resistant to high dose steroid treatment without the risks presented by facial nerve decompression surgery.

Total Transcanal Endoscopic Ear Surgery for Cholesteatoma.

This study aimed to evaluate the outcomes of total transcanal endoscopic cholesteatoma surgery. Twenty-seven cholesteatoma patients that had undergone transcanal endoscopic ear surgery (TEES) were included in the study. Age, sex, operation date of patients, operated side, need for ossiculoplasty, graft material, and surgical technique were recorded. All patients were evaluated through otoscopic, endoscopic, and audiological examinations and followed up for at least five months after surgery. All patients were staged using the European Academy of Otology and Neurotology/Japan Otological Society (EAONO/JOS) Staging System on Middle Ear Cholesteatoma. Mean age of the patients was 36.4 years (range, 4-67 years). According to the EAONO/JOS Staging System, 11 patients were stage 1, while 11 were stage 2, and five were stage 3. Two had lateral semicircular canal defect, one had facial canal dehiscence, and one had oval window defect. The average follow-up period was 19 months (range, 5-41 months), during which two patients experienced retraction pocket and hearing loss and one patient had perforation. One patient underwent revision surgery during follow-up and no recurrence or residual cholesteatoma was observed. The preoperative and postoperative air-bone gaps were 25.14±13.93 dB and 22.22±12.64 dB with no significant difference. TEES is a minimally invasive and safe procedure with low complication and recurrence rates. As with all surgical procedures, experience is essential, and as experience increases, the capability to perform endoscopic otologic surgery on more complex cases may become possible.

Inside-Out Transcanal Endoscopic Mastoidectomy: Literature Revision.

Introduction  Recently, there have been significant advancements in transcanal endoscopic ear surgery (TEES). The combination of rigid and thin otoendoscopes with high-definition cameras enabled a less invasive transcanal access to the middle ear and a clearer view of the surgical field. Several surgeons have recently published studies about cholesteatoma resection via transcanal endoscopic surgery, even in cases where the disease has extended to the mastoid, requiring transcanal endoscopic mastoidectomy. Objectives  To analyze the currently available literature on transcanal endoscopic inside-out mastoidectomy, and to determine its efficacy as a surgical technique by evaluating the disease's relapse/recurrence rate. Data Synthesis  Initially, the titles and abstracts of articles identified were analyzed. At this stage, 117 articles were analyzed, 97 of which were excluded for not meeting the inclusion criteria. The 20 remaining articles were further evaluated. The articles were classified on the basis of five levels of scientific evidence. Final Comments  The analysis of the studies showed that the transcanal endoscopic approach is effective in providing access to the attic or antrum, especially in cases of sclerotic mastoids. There was only one study with grade A recommendation, which showed the efficacy of endoscopic ear surgery in the treatment of cholesteatoma. Furthermore, there were three studies with grade B recommendation, showing less relapse/recurrence after TEES. More studies with grade A and B recommendations are needed to better evaluate the effectiveness of TEES, especially compared with that of traditional microscopic surgery.

Surgical Result of Resection of Benign Neoplasm on the External Auditory Canal Using Transcanal Endoscopic Ear Surgery

Various benign neoplasms such as osteoma, cholesteatoma, and cartilaginous choristoma can occur in the external auditory canal. The treatment method for these benign neoplasms is surgical excision. Previously, surgery had been performed using a microscope, but recently, a transcanal endoscopic ear surgery (TEES) method has been attempted. As a surgical method, it provides a better surgical view, enables rapid recovery and reduces pain through a minimally invasive approach. In this article, we introduce this endoscopic removal surgical method for benign neoplasms of the external auditory canal and the usefulness of the method.

Endoscopic Versus Microscopic Type 1 Tympanoplasty (Myringoplasty) in a Rural Tertiary Care Hospital in India: A Retrospective Comparative Study.

Background Chronic suppurative otitis media (CSOM) is described as middle ear cleft inflammation that results in long-term alterations to the tympanic membrane and/or the middle ear structures.In cases of CSOM, type 1 tympanoplasty, also known as myringoplasty, is a successful procedure for repairing the tympanic membrane and can even help restore hearing loss. This study aims to compare functional and clinical outcomes of type 1 tympanoplasty performed using transcanal endoscopic ear surgery (TEES) versus those performed via microscopic ear surgery (MES) for perforation in the tympanic membrane in the safe type of CSOM. Methodology Between January 2018 and January 2022, a retrospective analysis of 100 patients (47 men and 53 women) operated for the safe type of CSOM with a perforated tympanic membrane was conducted in our department. Based on the surgical methods, cases were randomly divided into two groups. There were 50 people in group 1 who underwent endoscopic tympanoplasty and 50 in group 2 who underwent microscopic tympanoplasty. The following factors were assessed: patient demographics; tympanic membrane perforation size at the time of surgery; operating room time; hearing outcomes, that is, closure of air-bone gap (ABG); graft uptake success rate; postoperative hospital stay; and medical resource usage.Patients were followed up for 12 weeks. Results Both groups shared similar epidemiological profiles, preoperative hearing status, and perforation sizes. In both groups, the rate ofgraft uptake was comparable. The average ABG closure was also quite comparable. In the case of endoscopic surgeries, the mean operative time was shorter; which was statistically significant, and complications were significantly lower in group 1. Conclusions Compared to its microscopic counterpart, endoscopic tympanoplasty has a similar graft uptake success rate and a comparable hearing outcome; however, it requires less operative time and hospital stay, has early recovery, and makes lesser use of medical resources, and it is cosmetically better.

Transcanal endoscopic type 3 tympanoplasty with mastoid preservation for advanced active chronic mucosal otitis media

Background Chronic mucosal otitis media is a very common ear disease for which patients attend otolaryngology clinics. Most of these patients present with actively discharging ears. Aims/Objectives This study aims to observe the middle ear space pathology and obtain surgical outcomes as a treatment for patients with advanced chronic mucosal otitis media with a transcanal endoscopic ear surgery approach. Materials and methods: A prospective study was designed, and patients suffering from chronic mucosal otitis media in the active suppurative phase with an air-bone gap larger than 20 dB were included. Results 70 operated ears were included. Underlying macroscopic pathology within the middle ear space was observed: Middle ear granulomas at 58.6%; Tympanosclerosis 41.4%. Blockage of the tympanic isthmus was evaluated, obtaining a blockage rate of 81.4%. At 12 months of evaluation after surgery, a postoperative ABG < 20 dB was achieved in 85.7% of the operated ears. An overall closed tympanic membrane was obtained in 88.6% of the patients. Conclusion This prospective cohort study shows the short-term efficacy of transcanal endoscopic type 3 tympanoplasty with mastoid preservation for managing advanced chronic mucosal otitis media. Clinical trials are required to give more evidence to the present matter.

Outcomes of transcanal endoscopic middle ear surgery for congenital cholesteatoma

Background Transcanal endoscopic surgery offers advantages for congenital cholesteatoma (CC) which is expanding cystic mass located on an intact tympanic membrane. Objectives To determine the efficacy of transcanal endoscopic ear surgery for the treatment of CC. Material and methods Eleven patients with CC confined to the middle ear underwent transcanal endoscopic ear surgery by surgeons who were skilled in otoscopic surgery. According to the Potsic classification, four, three, and four patients had lesions in stages 1, 2, and 3, respectively. The mean follow-up duration was 24.5 months. We retrospectively analyzed the recurrence rate, complications, and average hearing thresholds of the patients with CC. Results All CCs were successfully resected via the transcanal endoscopic approach, without any immediate or serious complications. The only complication was external auditory canal stenosis due to postoperative scarring, which occurred in a patient with a stage-3 cholesteatoma that recurred and required reoperation and second-stage ossicular chain reconstruction. Two more patients underwent one-stage ossicular chain reconstruction. All three patients received a total artificial ossicular replacement prosthesis, and two of them also received cartilage grafts. Conclusions and significance Transcanal endoscopic ear surgery is an effective method to treat CC belonging to Potsic stages 3 or below.

Stapes Bar-Normal Stapedial Superstructure with a Mobile Footplate Fixed to the Promontory.

This report describes a case of stapedial superstructure fixation with a mobile footplate, which is a rare occurrence among the ossicular malformations that cause conductive hearing impairment. A 44-year-old man with symptoms of left-sided hearing impairment since childhood presented to our department. The eardrum was normal, and pure tone audiometry showed conductive hearing impairment with a three-frequency (500, 1000, and 2000 Hz) mean of 53.3 dB and a normal tympanogram result. An abnormal shadow was observed on the internal side of the left stapes during the three-dimensional reconstruction of computed tomography. We suspected a stapes malformation and performed an exploratory tympanotomy with transcanal endoscopic ear surgery. We found a bony bar between the superstructure of the stapes and the promontory. The mobility of the stapes was significantly improved by removing the bony bar. Findings of postoperative audiometry were normal after surgery. The treatment of such cases of stapedial fixation is simple, and the prognosis of hearing gain after surgery is quite good. Thus, regarding the treatment of patients with conductive hearing impairment, clinicians and surgeons should be aware of the possibility of single stapedial superstructure fixation.

先天性耳小骨奇形の手術

Transcanal endoscopic ear surgery (TEES) is a minimally invasive surgical treatment technique for middle ear diseases and is recently becoming popular around the world. TEES enables accurate surgical manipulation under a wide magnified, and clear surgical view. We describe the results of surgical treatment for congenital middle ear anomalies by comparing the hearing outcomes between patients treated by TEES and those treated by microscopic ear surgery (MES). Congenital middle ear anomalies were safely treated by TEES, with comparable hearing outcome to those after MES. The surgical field is limited in the tympanic cavity, inflammation is usually absent, and there is little bleeding during the operation; therefore, TEES is a feasible surgical approach for the treatment of congenital middle ear anomalies. However, as middle ear anomalies are diverse, preoperative diagnosis is sometimes difficult, and the surgeon must be adequately prepared in advance for various types of procedures.

A comparative study of endoscopic versus microscopic tympanoplasty in chronic otitis media

Background: To compare the results between tympanoplasty performed with transcanal endoscopic ear surgery and microscopic ear surgery for the treatment of chronic otitis media. Materials and Methods: A double-blind randomized prospective study was performed on inactive chronic otitis media patients that underwent tympanoplasty and later follow-up for at least 6 months in terms of graft uptake and hearing gain. Seventy patients were selected and randomized in Group A-endoscopic tympanoplasty and Group B-microscopic tympanoplasty. Results: In our study, we found that the graft take up rate was 94.3% (33/35) in Group A and 91.4% (32/35) in Group B. The improvements in the air-conduction levels and the air-bone gaps were not significantly different between the two groups (P > 0.05). The average hearing gains in the endoscopic group postsurgery were 10.51 ± 4.71 dB and in the microscopic group were 12.23 ± 4.72 dB (P = 0.132). The average operating time was 37.77 ± 5.33 min in the endoscopic group which was better than the microscopic group which was 45.77 ± 5.29 min, (P < 0.001). Conclusion: Endoscopic tympanoplasty technique is a feasible alternative to the conventional microscopic technique owing to the findings in terms of duration of surgery and graft uptake. In addition, the endoscopic approach provides better postoperative cosmesis, patient satisfaction, and early mobilization.

Factors affecting the incidence of chorda tympani nerve transection in middle ear surgery.

To reveal the factors affecting the incidence of chorda tympani nerve (CTN) transection during middle ear surgery. Retrospective case review. Tertiary referral center. We analyzed 232 ears (117 ears with cholesteatoma, 101 ears with chronic otitis media, and 14 ears with otosclerosis) that underwent tympanoplasty or stapes surgery during 2017-2020. Eighty-four ears underwent transcanal endoscopic ear surgery (TEES), 103 ears underwent microscopic ear surgery (MES), and 45 ears underwent surgery using both endoscopy and microscopy (Dual). To confirm CTN transection, intraoperative endoscopic/microscopic video images were evaluated. We used the same video images to determine the anatomical variation of the CTN course in the middle ear. In 18 ears (7.8%: 6/84 TEES ears [7.1%], 6/103 MES ears [5.8%], and 6/45 Dual ears [13.3%]), the CTN was cut during middle ear surgery. There was no significant difference in CTN transection among groups. In cholesteatoma patients, stapes involvement resulted in a significantly higher CTN transection incidence. CTN anatomical variants such as the "Attached Short type" and "Ultrashort type" showed a significantly higher CTN transection incidence. Although endoscopic surgery did not reduce the incidence of CTN transection during middle ear surgery, pathological involvement of the stapes and CTN anatomical variants, such as the "Attached Short type" and "Ultrashort type," may increase this incidence. Preoperative evaluation of stapes involvement and anatomical location of the CTN course could help identify patients at greater risk for iatrogenic CTN transection. 4.