Transcanal Endoscopic Ear Surgery Research Articles

Transcanal endoscopic ear surgery in the treatment of ossicular disruption

Transcanal endoscopic ear surgery in the treatment of ossicular disruption

Endoscopic tympanoplasty type I using interlay technique

BackgroundTympanoplasty using the interlay technique has rarely been reported in transcanal endoscopic ear surgery, unlike the underlay technique. This is because many surgeons find it challenging to detach the epithelial layer of the tympanic membrane using only one hand. However, the epithelial layer can be easily detached from the inferior part of the tympanic membrane. Another key point is to actively improve anteroinferior visibility even if the overhang is slight because most perforations and postoperative reperforations are found in the anteroinferior quadrant of the tympanic membrane. We report the application of the interlay technique in endoscopic tympanoplasty type I for tympanic perforations.MethodsWe retrospectively reviewed the medical records of 51 patients who had undergone tympanoplasty using the interlay technique without ossiculoplasty between 2017 and 2020. We then compared the data with those of patients who underwent microscopic surgery (MS) using the underlay technique between 1998 and 2009 (n = 104). No other technique was used in each group during this period. Repair of tympanic membrane perforation and hearing outcomes were assessed for > 1 year postoperatively.ResultsThe perforation sites were limited to the anterior, posterior, and anterior–posterior quadrants in 23, 1, and 27 ears, respectively. Perforations were closed in 50 of the 51 ears (98.0%), and the postoperative hearing was good (average air-bone [A-B] gap was 6.8 ± 5.8 dB). The surgical success rate for the repair of tympanic membrane perforation was not significantly different from the MS group (93.3%, P = 0.15). The average postoperative average A-B gap in the group that underwent the interlay technique was significantly different from that in the MS group (10.1 ± 6.6 dB, P < 0.01).ConclusionThe interlay technique should be considered as one of the treatment methods in endoscopic surgery for tympanic perforations. Further study of the postoperative outcomes of this procedure should be conducted to establish the optimal surgical procedure for tympanic perforations.Trial registration: This study was retrospectively approved by the Institutional Review Board of the Jikei University, Tokyo, Japan (approval number: 32-205 10286).Video abstractEHU69PToR4KkpCPbQtPHKeVideo abstract

Endoscope Linear Motion System with Ultrasonic Motor and Gearless DC Motor for Transcanal Endoscopic Ear Surgery

Endoscope Linear Motion System with Ultrasonic Motor and Gearless DC Motor for Transcanal Endoscopic Ear Surgery

Results of one-day transcanal endoscopic ear surgery under local anesthesia

Results of one-day transcanal endoscopic ear surgery under local anesthesia

Transcanal Endoscopic Ear Surgery for Congenital Cholesteatoma: A Multi-institutional Series.

To assess outcomes of transcanal endoscopic ear surgery (TEES) for congenital cholesteatoma. Case series with chart review of children who underwent TEES for congenital cholesteatoma over a 10-year period. Three tertiary referral centers. Cholesteatoma extent was classified according to Potsic stage; cases with mastoid extension (Potsic IV) were excluded. Disease characteristics, surgical approach, and outcomes were compared among stages. Outcomes measures included residual or recurrent cholesteatoma and audiometric data. Sixty-five cases of congenital cholesteatoma were included. The mean age was 6.5 years (range, 1.2-16), and the mean follow-up was 3.9 years (range, 0.75-9.1). There were 19 cases (29%) of Potsic stage I disease, 10 (15%) stage II, and 36 (55%) stage III. Overall, 24 (37%) patients underwent a second-stage procedure, including 1 with Potsic stage II disease (10%) and 21 (58%) with Potsic stage III disease. Eight cases (12%) of residual cholesteatoma occurred. One patient (2%) developed retraction-type ("recurrent") cholesteatoma. Recidivism occurred only among Potsic stage III cases. Postoperative air conduction hearing thresholds were normal (<25 dB HL) in 93% of Potsic stage I, 88% of stage II, and 36% of stage III cases. TEES is feasible and effective for removal of congenital cholesteatoma not extending into the mastoid. Recidivism rates were lower with the TEES approach in this large series than in previously reported studies. Advanced-stage disease was the primary risk factor for recidivism and worse hearing result. As minimally invasive TEES is possible in the youngest cases, children benefit from early identification and intervention.

Combined underwater endoscopic and microscopic surgery for external auditory canal cholesteatoma: A case report.

Transcanal endoscopic ear surgery is a minimally invasive procedure that allows a clear visualization of the middle ear. Recently, indications for endoscopic surgery have been expanding. We performed combined underwater endoscopic and microscopic surgery for external auditory canal cholesteatoma, the computer tomography of which indicates the possibility of cholesteatoma not only in the canal wall but also in the mastoid. The 30° endoscope and underwater technique makes the surgical view clear, and we could remove the cholesteatoma without canalplasty. To the best of our knowledge, no case of external auditory canal cholesteatoma treated with underwater endoscopic and microscopic surgery has been previously reported. This case indicates that the procedure could be a good indication for external auditory canal cholesteatoma.

Transcanal Endoscopic Ear Surgery for Advanced External Auditory Canal Cholesteatoma in Naim Stage III and IV

To report the clinical characteristics and treatment outcomes, as well as endoscopic-assisted ear surgery techniques used in patients with advanced external auditory canal cholesteatoma (EACC). Retrospective case series. University hospital. From October 2014 to September 2017, adult patients (age > 18) with advanced EACC (Naim's classification: stage III or IV) who underwent transcanal endoscopic ear surgery (TEES) were enrolled. The presenting features, extent of the lesion, and reconstruction techniques used were assessed. The healing time which was defined as the time required to develop a dry, re-epithelialized, and self-cleaning external auditory canal, was compared between stage III and IV. Twenty-three patients were included. EACC was categorized as stage III in 11 ears and stage IV in 12 ears. Cholesteatoma involved the mastoid (30%), middle ear (26%), chorda tympani (22%), temporomandibular joint, antrum, and facial nerve (17% for each). In 96% of patients, a dry and self-cleaning external auditory canal (EAC) was maintained after a mean follow-up of 15 months. The median healing time was 8 weeks in stage III, which was significantly shorter than the 12 weeks required for stage IV (p < 0.05). There was no significant difference in the median healing time between TEES and the canal wall up mastoidectomy for stage IV EACC (14 weeks) performed by the same surgeon over the same period (p > 0.05). TEES is a feasible and safe technique for the exposure and eradication of advanced EACC. Some critical endoscopic techniques for resecting disease and reconstructing the defect in the EAC and middle ear should be mastered before performing this operation.

“Transcanal view” computed tomography reformat: Applications for transcanal endoscopic ear surgery

PurposeTranscanal endoscopic ear surgery (TEES) is an increasingly used surgical approach for otologic surgeries, but no en face preoperative imaging format currently exists. We aim to assess the utility of a transcanal high resolution computed tomography (HRCT) reformat suitable for TEES preoperative planning. Materials and methodsPreoperative HRCTs of patients with middle ear pathologies (cholesteatoma, otosclerosis, and glomus tympanicum) who underwent TEES were obtained. Axial image series were rotated and reformatted −90 or +90 degrees for left and right ear surgeries, respectively, where additional rotation along the left-right axis was performed to align the transcanal series with the plane of the external auditory canal. Quantitative measurements of middle ear structures were recorded. Consecutive transcanal reformatted sections were then reviewed to identify critical middle ear anatomy and pathology with corresponding TEES cases. ResultsThe aforementioned methodology was used to create three transcanal view HRCTs. The mean left-right axis degree of rotation was 4.0 ± 2.2 degrees. In the cholesteatoma transcanal HRCT, areas of cholesteatoma involvement in middle ear compartments (e.g. epitympanum) and eroded ossicles were successfully identified in the corresponding case. In the otosclerosis transcanal HRCT, areas for potential otosclerotic involvement were visualized such as the round window as well as a low-hanging facial nerve. In the glomus tympanicum transcanal HRCT, the span of the glomus tympanicum was successfully visualized in addition to a high riding jugular bulb. ConclusionA transcanal HRCT reformat may aid preoperative planning for middle ear pathologies. This novel reformat may help highlight patient-specific anatomy.

A Transcanal Endoscopic Approach for Management of Pulsatile Tinnitus due to High-Riding Dehiscent Jugular Bulb.

Pulsatile tinnitus (PT) caused by a high-riding dehiscence jugular bulb (HDJB) is a rare but treatable otology disease. There are several managements include transcatheter endovascular coil embolization, transvenous stent-assisted coil embolization, or resurfacing the dehiscent bony wall of high jugular bulb under the use of microscope. Among those options, surgical resurfacing of HDJB might be an effective and safe choice with less destruction. However, previous studies approached middle ear cavity via microscope can only provide a lateral, indirect view, while resurfacing the vessel through a transcanal endoscopic ear surgery (TEES) approach may give surgeon a direct and easy way to manage HDJB. In this report, we presented a case of 40-year-old woman with HDJB and shared our clinical consideration and reasoning of the surgical management of PT via a transtympanic approach by TEES rather than a transmastoid approach.

내시경적 귀수술을 이용하여 제거한 외이도 연골성 분리종 1예

Cartilaginous choristoma of the exteranl auditory canal is very rare, and easily misdiagnosed as chondroma. Cartilaginous choristoma appears to be a simple mass of the external auditory canal, but unlike chondroma, it is a tumor consisting of normal chondrocytes without tumor characteristics. The treatment of cartilaginous choristoma can be surgical resection. We report a case of cartilaginous choristoma of external auditory canal removed via transcanal endoscopic ear surgery. (J Clinical Otolaryngol 2021;32:132-136)

Transcanal Endoscopic Ear Surgery with Piezoelectric Device for External Auditory Canal Lesions

External auditory canal exostosis (EACE) is prone to occur in patients frequently exposed to cold water, which causes earwax impaction, recurrent otitis externa, and conductive hearing loss. The main treatment for symptomatic EACE is surgical excision. External auditory canal cholesteatoma (EACC) is a bone-destructive cystic mass caused by accumulation of plugs of desquamated keratin debris in the external auditory canal (EAC), which is also mainly treated with surgical removal. The main difficulties in the surgical removal of obstructive EACEs or EACCs are related to the adjacency of EAC skin, tympanic membrane, temporomandibular joint, and the blockage of the medial EAC landmarks during the operation. The piezoelectric device (PZD), which has long been used to cut bony structures in dental surgery, has clinical advantages here with regards to accurate exclusive bone cutting ability and minimal heat production. We report a series of cases that managed EAC lesions using PZD.

A Novel Instrument for Endoscopic Ear Surgery With a Steerable Flexible Tip: A Pediatric Anatomical Validation Study.

This study compares the reaching ability of two classes of transcanal endoscopic ear surgery (TEES) instruments when operating on difficult to access anatomical targets; two novel instruments with steerable flexible tips (SFT-A and SFT-B) and suction capability are compared with standard commercially available tools. TEES surgeons identified the need for a new surgical instrument that can enable accessibility of all areas visualized by the endoscope. This motivated the development of the two instrument prototypes. Six temporal bone models were 3D printed based on CT data from five cholesteatoma patients. Four anatomical targets were marked on each model. Using these targets, the reaching ability while using four standard TEES instruments were compared with the SFT-A and SFT-B prototypes by five surgeon participants. Results were analysed to compare success rates of contacting each target using each tool by fitting four Firth's logistic regression models. This calculated the statistically significant differences (p < 0.05) in tool success rate. Using SFT-A to contact the sinus tympani (100%) was significantly more successful than the Panetti suction dissector for atticus (PAT) (77%) and to contact the sinodural angle (0%) was less successful than the PAT (10%) and SFT-B (93%). Using SFT-B to contact the lateral semicircular canal (90%) was significantly more successful than all current tools and to contact the sinodural angle (93%) was significantly more successful than all tools. Using SFT-B enables enhanced accessibility of anatomical structures during TEES which may lead to less extensive bone removal to facilitate minimally invasive TEES.

Transcanal Endoscopic Ear Surgery for Epitympanic Cholesteatoma With Obliteration Using Bioglass.

Transcanal Endoscopic Ear Surgery for Epitympanic Cholesteatoma With Obliteration Using Bioglass.

Comparing Transcanal Endoscopic Ear Surgery to Post-Auricular Microscope-Guided Surgery in Pediatric Ossiculoplasty: Hearing Outcomes and Post-Operative Pain.

This study compares post-operative hearing outcomes and morbidity after pediatric total ossicular replacement prosthesis (TORP) ossiculoplasty with transcanal totally endoscopic ear surgery (TEES) versus a post-auricular microscope-guided (PAM) approach. Forty-four children who underwent ossiculoplasty with titanium TORP after previous cholesteatoma surgery. Ossiculoplasty using TEES or PAM approach. Hearing outcome after ossiculoplasty was determined by post-operative air-bone gap (ABG) on audiogram nearest to 1 year after surgery. Post-operative morbidity was measured by total number of opiate doses the child received during hospital stay, along with the highest documented post-operative pain score. Comparisons were made with Mann-Whitney U test. Hearing data were available for 41 patients: 21 had undergone TEES (median preoperative ABG 39 dB) and 20 had PAM surgery (median preoperative ABG 39 dB). Post-operatively at 1 year, ABG closed significantly in each group (TEES 21 dB, p = 0.003; PAM 23 dB, p = 0.01), and there was no difference between groups (p = 0.6). 57% who underwent TEES and 50% who underwent PAM surgery experienced serviceable hearing post-operatively, defined as air conduction pure-tone average (PTA) ≤ 30 dB HL. Visual analogue pain scores from 0 (no pain) to 10 (worst pain imaginable) were available for 13 who underwent TEES and 18 who underwent PAM surgery. In children undergoing TEES, only two reported pain above 0, with the highest pain score being 4. Children undergoing PAM surgery had a median pain score of 3 (median difference = 3, p < 0.001). Children undergoing TEES required fewer weight appropriate doses of opiate analgesic (median = 0) than children who underwent PAM surgery (median = 1) (median difference = 1, p = 0.003). Children undergoing TEES had a significantly shorter surgical time (median 135 min) than those who underwent PAM surgery (median 168 min) (median difference = 33 min, p = <0.006). Hearing outcomes in TORP ossiculoplasty are similar in TEES and PAM surgery, and TEES may decrease post-operative pain.

COMPARISON OF THE EFFICACY OF ENDOSCOPIC TYMPANOPLASTY WITH MICROSCOPIC TYMPANOPLASTY

Introduction: Otological surgery has progressed rapidly over the past century. With the recent introduction of the 3-chip camera system and high denition video systems, endoscopes now provide ultra high resolution images of the middle ear that were never seen previously. We conducted this study to compare the efcacy of endoscopictympanoplasty over microscopic tympanoplasty in terms of preoperative ease of surgery including visualisation of ossicles and eustanchian tube and intraoperative bleeding, graft uptake, hearing improvement, post-operative pain score, post-auricular hypoesthesia, duration of hospital stay etc. Methods: The present study is prospective observational study, conducted in a Tertiary Health Care Centre. Results: Endoscopic tympanoplasty has many advantages over microscopic tympanoplasty and can be a better alternative or adjuct to microscopic tympanoplasty. Conclusion: Endoscopic ear surgery provides a better magnication, wide eld view, and the ability to look around corners. Further more transcanal endoscopic ear surgery (TESS) approaches transform external auditory canal into a minimally invasive surgical portal to access middle ear disease. The ease of surgery improves with time and has a gradual learning curve. The graft uptake rate is comparable with both approaches. The overall satisfaction score in terms of reduced pain and hypoesthesia with decreased hospital stay is higher in endoscopic approach.

Application of artificial intelligence using a convolutional neural network for detecting cholesteatoma in endoscopic enhanced images

ObjectiveWe examined whether artificial intelligence (AI) used with the novel digital image enhancement system modalities (CLARA+CHROMA, SPECTRA A, and SPECTRA B) could distinguish the cholesteatoma matrix, cholesteatoma debris, and normal middle ear mucosa, and observe the middle ear cavity during middle ear cholesteatoma surgery. MethodsA convolutional neural network (CNN) was trained with a set of images chosen by an otologist. To evaluate the diagnostic accuracy of the constructed CNN, an independent test data set of middle ear images was collected from 14 consecutive patients with 26 cholesteatoma matrix lesions, who underwent transcanal endoscopic ear surgery at a single hospital from August 2018 to September 2019. The final test data set included 58 total images, with 1‒5 images from each modality for each case. ResultsThe CNN required only 10 s to analyze more than 58 test images. Using SPECTRA A and SPECTRA B, the CNN correctly diagnosed 15 and 15 of 26 cholesteatoma matrix lesions, with a sensitivity of 34.6% and 42.3%, and with a specificity of 81.3% and 87.5%, respectively. ConclusionOur preliminary study revealed that AI and novel imaging modalities are potentially useful tools for identifying and visualizing the cholesteatoma matrix during endoscopic ear surgery. The diagnostic ability of the CNN is not yet appropriate for implementation in daily clinical practice, based on our study findings. However, in the future, these techniques and AI tools could help to reduce the burden on surgeons and will facilitate telemedicine in remote and rural areas, as well as in developing countries where the number of surgeons is limited.

Current trends and applications in endoscopy for otology and neurotology.

There has been a rapid increase in endoscopic ear surgery for the management of middle ear and lateral skull base disease in children and adults over the last decade. In this review paper, we discuss the current trends and applications of the endoscope in the field of otology and neurotology. Advantages of the endoscope include excellent ergonomics, compatibility with pediatric anatomy, and improved access to the middle ear through the external auditory canal. Transcanal endoscopic ear surgery has demonstrated comparable outcomes in the management of cholesteatoma, tympanic membrane perforations, and otosclerosis as compared to microscopic approaches, while utilizing less invasive surgical corridors and reducing the need for postauricular incisions. When a postauricular approach is required, the endoscopic-assisted transmastoid approach can avoid a canal wall down mastoidectomy in cases of cholesteatoma. The endoscope also has utility in treatment of superior canal dehiscence and various skull base lesions including glomus tumors, meningiomas, and vestibular schwannomas. Outside of the operating room, the endoscope can be used during examination of the outer and middle ear and for debridement of complex mastoid cavities. For these reasons, the endoscope is currently poised to transform the field of otology and neurotology.

In Vivo Measurements of Middle Ear Temperature During Transcanal Endoscopic Ear Surgery

The light emitted from the endoscope during transcanal endoscopic ear surgery (TEES) heats the intratympanic space. This heat may potentially be dangerous to nearby important structures, as documented by in vitro and by animal and cadaveric studies. The aim of our work was to monitor middle ear temperatures during TEES in vivo. Cohort study. Tertiary referral hospital. Four patients (15-69 yrs old) underwent transcanal endoscopic tympanoplasties for chronic perforation or retraction. After elevating the tympanomeatal flap, a thermocouple was placed in the middle ear to measure the heat generated by a 30° Hopkins rod telescope (11 cm long, 2.7 mm wide) and fiberoptic light emitting diode light source. Middle ear temperature in the retrotympanum was monitored under these conditions: at 50 and 100% light intensity, after removing and wiping the endoscope tip, during suctioning and following middle ear irrigation. Maximum middle ear temperature ranged from 36.26-37.30°C. Pulling out and wiping the endoscope caused no change or minimal decrease of 0.16°C. Middle ear irrigation caused a temperature drop of 2.05°C to 5.11°C. Suctioning was associated with a drop from 0.24°C to 3.91°C that was dependent on the depth of the endoscopic tip. Middle ear temperatures during TEES using a Hopkins rod telescope and light-emitting diode light source reach values corresponding to physiological body temperature, and do not reach dangerous levels.

Endoscopic ear surgery in middle ear cholesteatoma

ObjectiveEndoscope has been used as diagnostic tool for recidivism and as an adjunct to microscopic technique in the management of cholesteatoma. At present transcanal endoscopic ear surgery (TEES) is being used as a minimally invasive alternative for microscopic approach. We aim to evaluate the feasibility, structural, functional and quality of life outcomes of endoscopic technique in middle ear cholesteatoma. MethodThis prospective study was conducted at a tertiary care hospital from January 2017 to January 2018 including 32 adult patients who were treated by TEES for middle ear cholesteatoma. Feasibility of endoscopic technique was assessed by the conversion rates, visualization of middle ear structures and complications. Structural outcomes were evaluated in terms of graft uptake at the third month follow-up and presence of residual or recurrent disease. Functional outcomes were evaluated in terms of post-operative air-bone gap closure at third month follow-up. Patient outcomes in terms of post-operative pain, cosmetic score, day of return to daily activities and patient comfort scores were evaluated. The quality of life outcomes were evaluated using chronic ear survey (CES) and short form questionnaire −12 version 2 (SF-12V2) which are disease specific and general quality of life assessment tools respectively. ResultOut of 32 patients, endoscopic intact canal wall mastoidectomy was done for 28 and endoscopic canal wall down mastoidectomy in 4 patients. One (3.1%) patient had to be converted to microscopic technique. Median follow-up period was 32.8 months (9–46 months). There were no post-operative complications in any of our patients. The mean middle ear structural visibility index score was 8.4 ± 1.4 with the use of zero-degree endoscope. Graft uptake rate at third month follow-up was 100%. Two (6.3%) patients had recurrent disease at 6 months follow-up and were treated by revision endoscopic surgery. The air conduction (51.3 ± 20.2 dB vs. 34.5 ± 20.4 dB, p < 0.001), and air-bone gap (33.5 ± 11.1 dB vs. 16.9 ± 11.8 dB, p < 0.001) has been significantly improved. The mean pain score at 0 hours, 6 hours and 24 hours after surgery were 2.5/10, 1.6/10 and 0.75/10 respectively. At the discharge, the mean patient comfort score was 9.3 ± 0.6 out of 10. Mean cosmetic score was 9.3 ± 0.5 at the third month follow-up. There was significant post-operative improvement in the sub-scale and total scores of CES and SF-12V2. ConclusionEndoscopic approach to middle ear cholesteatoma is feasible and confers excellent structural, functional as well as patient related quality of life outcomes.

Characterization of patient head motion in otologic surgery: Implications for TEES

PurposeMiddle ear disease is increasingly being managed via transcanal endoscopic ear surgery (TEES). A limitation of TEES is that it restricts the surgeon to single-handed dissection. One solution to this would be an endoscope holder to facilitate two-handed dissection. Current endoscope holders are stationary, and can cause potential damage from endoscope contact with the ossicles or ear canal if unintended head motion occurs from inadequate anesthetic. A dynamic device that could detect and react to patient motion would mitigate these concerns, but currently there is little formal characterization of the frequency, velocity and acceleration of unintended patient head motion during otologic procedures performed under general anesthesia. The present study aims to characterize intraoperative patient head motion kinematics during cases utilizing TEES. Materials and methodsThis is a prospective study of adults undergoing otologic procedures performed with general anesthesia and without paralysis. Head motion was characterized using a nine-axis inertial measurement unit (IMU), (LPMS-B2, Life Performance Research) mounted to each patient's forehead for the procedure duration. ResultsData was collected across 10 cases; 50% of patients were female and mean age was 50 ± 14 years. There was observed patient head motion in 40% of cases with maximum linear acceleration of 0.75 m/s2 and angular velocity of 12.50 degrees/s. ConclusionsPatient movement during otologic procedures was commonly observed, demonstrating the need for a dynamic holder to allow two-handed TEES. Results from this study are the first objective characterization of patient head motion kinematics during otologic procedures performed under general anesthesia.