The Role of Trublue Laser in Cholesteatoma Surgery

OBJECTIVE

The retrospective cohort study aimed to determine the safety and efficacy of TruBlue laser application in cholesteatoma surgeries.

METHODS

All cholesteatoma surgeries conducted from January 2018 to January 2022 in two tertiary referral hospitals in Hong Kong, with and without use of TruBlue laser, were included. Pure tone audiogram was done pre- and post-operatively to assess hearing. Disease extent was graded with ChOLE score and ChOLE staging. Residual disease was determined clinically, radiologically, or surgically with second look operation.

RESULTS

One hundred twenty cholesteatoma cases were identified. There are 39.2% (n = 47) of the cholesteatoma surgeries that utilized TruBlue laser, while 60.8% (n = 73) did not. Overall follow-up duration was 21 ± 12.4 months, ranging from 2 to 47 months. Both groups were similar in demographics, pre-operative hearing and ChOLE staging. The length of stay was comparable in both groups (2 ± 2 days in nonlaser, 1 ± 1 day in laser, p = 0.31). There was no facial nerve injury related to surgery in both groups, and overall complication rates were similar (4.1% in nonlaser, 4.3% in laser, p = 0.97). The postoperative hearing was comparable with good hearing preservation in both groups. Residual cholesteatoma occurred in 17.8% (n = 13) in nonlaser group, and 21.3% (n = 10) in laser group, which was not statistically significant (p = 0.64). Seventy percent of the cholesteatoma residual in laser group occurred at area that TruBlue LASER cannot be applied.

CONCLUSION

TruBlue LASER was safe in cholesteatoma surgeries, though no added benefits were shown in reducing cholesteatoma residual rate. A larger controlled study is warranted to discern the true effect of TruBlue LASER.

LEVEL OF EVIDENCE

Level 3.

External ear canal exostectomy: influence of surgeon's experience on 3-years recurrence and occurrence of complications

BACKGROUND

External ear canal exostoses are usually bilateral and broad-based, secondary to external ear canal chronic cold exposure, especially water.

OBJECTIVES

The objectives were to analyze the influence of the surgeon's experience on the 3-year recurrence and on the complication. We also studied the influence of prolonged exposure to cold water on the incidence of recurrence.

MATERIAL AND METHODS

This monocentric retrospective study included 98 ears operated for canalplasty between 2009 and 2016 by nine different operators including one senior, a junior, and seven beginner surgeons. Senior, Junior, and Beginner groups were compared.

RESULTS

3-year recurrence rate was higher in the Beginner and Junior groups than in the Senior group (69% and 38% vs 18%, P = .001). Although there was a difference between the Beginner (69%) and Junior (38%) groups, it was not significant (P = .407). Among the recurrences, 48% had continued exposure to cold water while only 7% of the ears without recidivism were still exposed (P < .001, OR = 1.25 [4.4; 36.1]). The complication rates were similar between groups, concerning pain (8% vs 30% vs 12%), per procedure perforation (17% vs 10% vs 16%), scarring disorders (25% vs 20% vs 13%), and osteitis (8% vs 0% vs 1%). Hearing was unaffected.

CONCLUSIONS

This is the first study evaluating the risk of recurrence of external ear canal exostoses after canalplasty based on the surgeon's experience. This risk of recurrence seems to decrease with the surgeon's experience. There was no difference in complication rates.

Recent advances in Otology: Current landscape and future direction

Hearing is an essential sensation, and its deterioration leads to a significant decrease in the quality of life. Thus, great efforts have been made by otologists to preserve and recover hearing. Our knowledge regarding the field of otology has progressed with advances in technology, and otologists have sought to develop novel approaches in the field of otologic surgery to achieve higher hearing recovery or preservation rates. This requires knowledge regarding the anatomy of the temporal bone and the physiology of hearing. Basic research in the field of otology has progressed with advances in molecular biology and genetics. This review summarizes the current views and recent advances in the field of otology and otologic surgery, especially from the viewpoint of young Japanese clinician-scientists, and presents the perspectives and future directions for several topics in the field of otology. This review will aid next-generation researchers in understanding the recent advances and future challenges in the field of otology.

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.

The Impact of Piezoelectric Device in Cholesteatoma Endoscopic Surgery: Retrospective Evaluation of Safety and Functional Results

OBJECTIVE

Atticotomy represents an essential surgical step within the management of attical cholesteatoma during endoscopic ear surgery. The aim of the present study was to evaluate the safety and functional results of an endoscopic atticotomy performed with piezosurgery, in terms of audiological outcomes and tissue's healing.

METHODS

This is an observational retrospective study on patients with attical cholesteatoma who underwent endoscopic ear surgery with piezoelectric atticotomy and subsequent scutum reconstruction either with tragal cartilage or temporalis muscle fascia. Scutumplasty's status was evaluated via scheduled outpatient controls through an endoscopic check and classified as stable or unstable at least 10 months after surgery. A pre- and postoperative audiometric examination was performed in each patient.

RESULTS

Eighty-four patients were enrolled. In 50 out of 84 patients (59.52%), an exclusive endoscopic procedure was performed, whereas in 34 patients (40.48%) a combined microscopic/endoscopicapproach was adopted. In 72 cases (85.71%), scutum's reconstruction appeared to be normally positioned, whereas 12 patients developed a retraction pocket, which was self-cleaning in 8 of them and non-self-cleaning in the remaining 4. In 17 patients, a slight sensorineural hearing loss (between 5 and 15 dBHL) was observed, and in 2 patients, the loss was greater than 15 dBHL. Overall, no significative differences between pre- and postoperative pure-tone average bone thresholds resulted (p = 0.4983), though a mild significant hearing deterioration was detected by the specific analysis at 4000 Hz (p = 0.0291).

CONCLUSION

Piezosurgery represents an extremely useful tool in performing atticotomy during endoscopic tympanoplasties. Our data seem to support the safety of its usage in this specific step, as it did not lead to any significant sensorineural damage on overall pure-tone average. Moreover, satisfactory tissue healing in regard to scutum reconstruction was observed.

Registration of preoperative temporal bone CT-scan to otoendoscopic video for augmented-reality based on convolutional neural networks

PURPOSE

Patient-to-image registration is a preliminary step required in surgical navigation based on preoperative images. Human intervention and fiducial markers hamper this task as they are time-consuming and introduce potential errors. We aimed to develop a fully automatic 2D registration system for augmented reality in ear surgery.

METHODS

CT-scans and corresponding oto-endoscopic videos were collected from 41 patients (58 ears) undergoing ear examination (vestibular schwannoma before surgery, profound hearing loss requiring cochlear implant, suspicion of perilymphatic fistula, contralateral ears in cases of unilateral chronic otitis media). Two to four images were selected from each case. For the training phase, data from patients (75% of the dataset) and 11 cadaveric specimens were used. Tympanic membranes and malleus handles were contoured on both video images and CT-scans by expert surgeons. The algorithm used a U-Net network for detecting the contours of the tympanic membrane and the malleus on both preoperative CT-scans and endoscopic video frames. Then, contours were processed and registered through an iterative closest point algorithm. Validation was performed on 4 cases and testing on 6 cases. Registration error was measured by overlaying both images and measuring the average and Hausdorff distances.

RESULTS

The proposed registration method yielded a precision compatible with ear surgery with a 2D mean overlay error of 0.65 ± 0.60 mm for the incus and 0.48 ± 0.32 mm for the round window. The average Hausdorff distance for these 2 targets was 0.98 ± 0.60 mm and 0.78 ± 0.34 mm respectively. An outlier case with higher errors (2.3 mm and 1.5 mm average Hausdorff distance for incus and round window respectively) was observed in relation to a high discrepancy between the projection angle of the reconstructed CT-scan and the video image. The maximum duration for the overall process was 18 s.

CONCLUSIONS

A fully automatic 2D registration method based on a convolutional neural network and applied to ear surgery was developed. The method did not rely on any external fiducial markers nor human intervention for landmark recognition. The method was fast and its precision was compatible with ear surgery.

Audiologic Outcomes After Vestibulotomy in Patients With Congenital Absence of the Oval Window

OBJECTIVE

To examine the clinical features and surgical outcomes in patients with congenital absence of the oval window (CAOW), and to investigate the potential factors that affect audiologic results.

STUDY DESIGN

A retrospective chart review.

SETTING

A tertiary academic center.

PATIENTS AND INTERVENTION

A total of 17 ears among 16 patients were confirmed to have CAOW. Among them, 13 ears underwent vestibulotomy for hearing reconstruction. Clinical parameters associated with the hearing outcomes were analyzed.

MAIN OUTCOME MEASURES

A mean air-bone gap (ABG) after 6-month and long-term follow-up was compared with preoperative measurements.

RESULTS

Intraoperative findings showed that anomalies of the malleus or incus were observed in 11 ears (64.7%), stapes anomalies were present in all ears (100%), and facial nerve anomalies were present in 10 ears (58.8%). Because of unfavorable facial nerve anomalies, hearing reconstruction was aborted in four cases (23.5%). In the hearing reconstruction group, the mean ABG at 6 months postoperation was significantly reduced after compared with the preoperative value (44.0 ± 8.4 dB versus 58.8 ± 9.1 dB, p = 0.006). After dividing ears into a success subgroup (ABG ≤ 30 dB, seven ears) and non-success subgroup (ABG > 30 dB, six ears), the use of a drill during vestibulotomy was significantly related to a poor hearing outcome (100% versus 16.7%, p = 0.015). The long-term follow-up result (mean, 60 mo) revealed no deterioration compared with the 6-month postoperative result. Five ears (29.4%) underwent revision surgery, and three of them showed ABG improvements. No serious complications were reported.

CONCLUSION

Vestibulotomy is an effective and safe option for hearing restoration in patients with CAOW, particularly when the use of a drill is not required. The long-term audiologic outcome is also reliable.

Mid-term evaluation of the surgical management of patulous Eustachian tube dysfunction: a STROBE observational study

INTRODUCTION

Patulous Eustachian tube (PET) is a condition affecting approximately 0.3% to 6.6% of the population, with autophony being the predominant complain. The management of PET lacks a well-defined standard in the literature as no effective medical treatments have been documented but various surgical options are available. This study aims to report mid-term outcomes following surgical management of PET.

MATERIALS AND METHODS

All patients who underwent surgical intervention for PET between September 2017 and June 2022 were enrolled. Data encompassing general demographics, quality of life (GBI), and procedure-specific data were collected.

RESULTS

A total of 30 PET cases (in 19 patients) underwent surgical intervention including 9 injections of hyaluronic acid, 13 fat injections, 6 endoscopic shim insertions, 1 cartilage graft, and 1 injection of hydroxy apatite. After an average follow-up of 22 ± 14 months, 16 cases (53%) achieved complete symptom relief, while 8 cases (26.6%) reported partial relief. Additionally, 11(36%) cases required multiple surgeries. No specific surgical technique demonstrated superiority. Quality of life improved in 77% of cases based on 10 out of 13 GBI collected. Recurrence of PET symptoms occurred on average 10.6 ± 9.7 months after initial surgery, with an estimated global risk of 75% at 3 years. Transient serous otitis media was observed in only 4 cases (13.3%).

CONCLUSION

Surgical intervention for PET was found to be effective, achieving complete symptom relief in 53% of cases and significantly improving quality of life 2 years post-surgery. However, a substantial portion of cases necessitated one or more re-interventions. The durability of effectiveness appears to diminish over time.

Validity of endoscopic ossiculoplasty immediately after its introduction for ossicular chain disruption

BACKGROUND

Transcanal endoscopic ear surgery (TEES) reportedly requires a long learning curve and may be associated with more complications and longer operative times than microscopic ear surgery (MES). In this study, we aimed to examine the usefulness and validity of TEES for ossicular chain disruption in the early stages of its introduction in our institution.

METHODS

TEES was performed on 11 ears (10 with congenital ossicular chain discontinuity and 1 with traumatic ossicular chain dislocation), and MES was performed with a retroauricular incision on 18 ears (6 with congenital ossicular chain discontinuity and 12 with traumatic ossicular chain dislocation) in a tertiary referral center. Postoperative hearing results, operative times, and postoperative hospital length of stay were retrospectively reviewed. The Mann-Whitney U test and Fisher's exact test was performed to compare variables between the TEES and MES groups. Pre- and postoperative air- and bone-conduction thresholds and the air-bone gap of each group were compared using the Wilcoxon signed-rank test. The Mann-Whitney U test and Wilcoxon signed-rank was performed to compare the pre- and postoperative air-bone gaps between the diagnoses.

RESULTS

No significant differences in the postoperative air-conduction thresholds, bone-conduction thresholds, air-bone gaps, or incidence of air-bone gap ≤ 20 dB were observed between the TEES and MES groups. The air-conduction thresholds and air-bone gaps of the TEES group significantly improved postoperatively. The air-conduction thresholds and air-bone gaps of the MES group also significantly improved postoperatively. No significant difference was observed in the operative times between the groups (TEES group: median, 80 min; MES group: median, 85.5 min). The TEES group had a significantly shorter postoperative hospital stay (median, 2 days) than the MES group (median, 7.5 days).

CONCLUSIONS

TEES was considered appropriate for the treatment of ossicular chain disruption, even immediately after its introduction at our institution. For expert microscopic ear surgeons, ossicular chain disruption may be considered a suitable indication for the introduction of TEES.

Oval and round window reinforcement surgery leads to improvements in sound tolerance and quality of life for hyperacusis patients

PURPOSE

Hyperacusis is an audiological disorder in which patients become persistently sensitive and intolerant to everyday environmental sounds. For those patients that fail conservative options, a minimally invasive surgical procedure has been developed.

MATERIALS & METHODS

Retrospective case series of 73 adult patients with hyperacusis who underwent oval and round window reinforcement surgery between 1/2017-6/2023. Small pieces of temporalis fascia were used to reinforce the round and oval windows. Patients were separated into two groups based on their preoperative speech Loudness Discomfort Level (LDL). Patients with a preoperative speech LDL ≤ 70 dB were placed in the "low LDL group" whereas patients with a preoperative speech LDL >70 dB were placed in the "high LDL group." Preoperative and one-week postoperative audiogram and speech LDLs were compared. Quality of life was assessed using the Glasgow Benefit Inventory (GBI) survey.

RESULTS

73 patients met inclusion criteria - 21 patients in the low LDL group and 52 in the high LDL group. Patients in the high LDL group significantly improved their LDLs by an average of 3.5 dB (P < 0.0001). 42 patients (80.8 %) in the high LDL group had improvement and would recommend the surgery for hyperacusis. Patients in the low LDL group significantly improved their LDL by an average of 12.9 dB (P = 0.032). Ten patients (47.6 %) from the low LDL group experienced improvement and would recommend hyperacusis surgery.

CONCLUSION

Many patients with hyperacusis who undergo oval and round window reinforcement can receive significant improvement in sound tolerance and quality of life. Patients with a pre-op speech LDL > 70 dB have the greatest potential for improvement with surgery (80.8 %), probably because their hyperacusis was less severe. In the high LDL group(>70dB) the improvement in 1-10 scale went from 8.6 pre-op to 2.4 post op. In the low LDL group(<70dB) went from 9.2 pre-op to 6.8 post-op. These findings were consistent with the GBI results.

Comparison of capabilities and limitations of endoscopes in endoscopic ear surgeries using 3D printed models

PURPOSE

Endoscopic ear surgery has become a popular operative approach to treat middle ear diseases. Surgeons use either 0° or 30° endoscopes worldwide. The main aim of the work was to compare the properties of these two types of endoscopes.

MATERIAL AND METHODS

Since this type of evaluation is hard to perform in vivo during the actual surgery, we designed 3D printed temporal bone models with different levels of complexity. The evaluation of endoscopes was based on image analysis or visibility of anatomical structures.

RESULTS

The results show that a 30° endoscope offers a view of lateral walls from 4 mm distance, contrary to a 0° endoscope which cannot see lateral walls from this distance at all. On the other hand, visible area of the anterior wall is up to 40 % larger using 0° endoscope, compared to 30° endoscope. Angled endoscope distorts the picture and leads to the deterioration of the image. At commonly used distances above 5 mm from middle ear structures, resolution and image distortion is comparable between both endoscopes.

CONCLUSIONS

Our results do not offer a definitive opinion on which endoscope is better for ear surgery. Both types of endoscopes have advantages and disadvantages, and the choice depends on the surgeon's personal preference and on the type of planned procedure.

Quantitative measurement of airborne particles during endoscopic and microscopic ear surgery in the operating room

OBJECTIVE

This study aimed to quantitatively investigate airborne particle load in the operating room during endoscopic or microscopic epitympanectomy or mastoidectomy.

METHOD

In the transcanal endoscopic ear surgery group, drilling was performed underwater. A particle counter was used to measure the particle load before, during and after drilling during transcanal endoscopic ear surgery or microscopic ear surgery. The device counted the numbers of airborne particles of 0.3, 0.5 or 1.0 μm in diameter.

RESULTS

The particle load during drilling was significantly higher in the microscopic ear surgery group (n = 5) than in the transcanal endoscopic ear surgery group (n = 11) for all particle sizes (p < 0.01). In the transcanal endoscopic ear surgery group, no significant differences among the particle load observed before, during and after drilling were seen for any of the particle sizes.

CONCLUSION

Bone dissection carries a lower risk of airborne infection if it is performed using the endoscopic underwater drilling technique.

Initial Experience With Robotic-Assisted Otologic and Lateral Skull Base Surgery

Robotic-assisted surgery has gained popularity for otolaryngology procedures. It provides high-definition images and surgical precision to perform diverse procedures. It is an alternative to the operating microscope, endoscope, or exoscope when reaching hidden anatomical structures in the ear. In this proof-of-concept study, we aim to demonstrate the possibility of using a robotic-assisted device to perform ear surgery in conjunction with the microscope or the endoscope. In total, there were 9 ear and lateral skull base procedures performed with the use of robotic-assisted surgery. All surgeons underwent surveys to assess the performance and workload of the device compared to the microscope or endoscope. There were no postoperative complications. Robotic-assisted surgery was optimal for providing high image quality, ergonomics, and maintaining surgical performance. The size of the device and mental demand were higher compared to the microscope or endoscope. Robotic-assisted surgery can be an adjuvant to perform otologic and neurotologic surgery.

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

OBJECTIVE

Although 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).

METHODS

A 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.

RESULTS

Of 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.

CONCLUSIONS

TEES 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.

Intralabyrinthine schwannoma: Surgical management and cochlear lumen preservation

The present video reports the surgical removal of an intralabyrinthine schwannoma. The video contains patient's medical history, preoperative radiological evaluations and detailed description of surgical steps of the procedure, consisting in labyrinthectomy, cochleostomy and insertion of a dummy electrode in the preserved cochlear lumen within the context of a subtotal petrosectomy.

Educational Benefit of the Three-Dimensional Exoscope Versus Operating Microscope in Otologic Surgery

OBJECTIVE

To compare observation of otologic surgery using a traditional operating microscope (OM) and a three-dimensional exoscope.

STUDY DESIGN

Prospective, nonrandomized, noncontrolled study.

SETTING

Tertiary care center.

METHODS

Senior medical students and otolaryngology trainees observing otologic surgery performed with OM and exoscope were asked to complete a questionnaire comparing the two experiences. The key variables were image clarity, depth perception, observer's level of motion sickness during the surgery, the participant's understanding of middle ear anatomy, and their overall preference between OM and exoscope.

RESULTS

Twenty-two observers participated in the study. Subjective clarity of the image was significantly better with the exoscope compared with the OM (9.7 ± 0.6 versus 6.9 ± 1.7, p = 0.0004) as well as the depth perception (9.25 ± 0.87 versus 5 ± 2.69, p = 0.0007). Observers subjectively had an improved understanding of middle ear anatomy after observing an exoscopic surgery, but not a microscopic surgery. All but one observer preferred the exoscope.

CONCLUSION

The three-dimensional exoscope may be a valuable educational tool for teaching trainees otologic surgery. More objective studies are needed in the future to assess the degree of improvement.

[Features of otosurgery in children after blast injuries]

An explosion is a process that rapidly releases a huge amount of energy in the form of heat, kinetic energy, and high-pressure shock waves. Since the organ of hearing is most susceptible to pressure changes, damage to the sound-conducting or sound-receiving systems is inevitable in case of an explosive injury. This article examines the mechanism of formation of explosive injuries of the middle and inner ear in children and adolescents, the features of diagnosis and tactics of surgical reconstructive treatment of explosive ear injuries based on the data available in the scientific literature and their own experience.

Low-Lying Tegmen and Surgical Outcomes Following the Middle Cranial Fossa Repair of Superior Canal Dehiscence

OBJECTIVE

To compare treatment response from the middle cranial fossa repair of superior canal dehiscence (SCD) between cases with and cases without low-lying tegmen (LLT).

STUDY DESIGN

Cohort study.

SETTING

Single tertiary care institution.

METHODS

Two investigators independently reviewed preoperative high-resolution temporal bone computed tomography images and classified the ipsilateral tegmen as either "low-lying" or "control." Patients completed a symptom questionnaire and underwent audiometric testing pre- and post-operatively. Multivariable regression models assessed for symptomatic resolution and audiometric improvement following surgery with tegmen status as the primary predictor. Models controlled for patient age, sex, bilateral SCD disease, dehiscence location, prior ear surgery status, surgery duration, and follow-up duration.

RESULTS

Among a total of 410 cases included, we identified 121 (29.5%) LLT cases. Accounting for all control measures, patients with LLT were significantly less likely to experience overall symptom improvement (adjusted odds ratio: 0.32, 95% confidence interval [CI]: 0.18-0.57, p < .001) and reported a significantly lower proportion of preoperative symptoms that resolved following surgery (adjusted β: -25.6%, 95% CI: -37.0% to -14.3%, p < .001). However, audiometric outcomes following surgery did not differ significantly between patients with and patients without LLT.

CONCLUSION

This is the first investigation on the relationship between LLT and surgical outcomes following the middle fossa repair of SCD. Patients with LLT reported less favorable symptomatic response but exhibited a similar degree of audiometric improvement.

Training in Endoscopic Ear Surgery: A Scoping Review

OBJECTIVE

Despite the increasing popularity of Endoscopic Ear Surgery (EES), there is a lack of evidence to guide trainees as they introduce EES into practice. This review aims to evaluate training in EES including the optimal introductory procedures, methods of training, the learning curve, and the determination of competency in EES. In addition, this review seeks to identify any areas falling within these themes requiring further clarification.

DATA SOURCES

A database search of Pubmed, Embase and the Cochrane Library was conducted in June 2022. Original articles, systematic reviews, and meta-analyses reporting on training in EES, introduction into practice, learning curves, and competency assessment were included.

REVIEW METHODS

A scoping review was carried out in accordance with the Joanna Briggs Institute guidelines and reported according to PRISMA guidelines for scoping reviews. A qualitative assessment of results grouped thematically was performed.

RESULTS

Twenty-eight studies met the inclusion criteria, with 24 rating as "fair" or "good" on quality assessment. Surgical simulation was the most frequently described method of training as utilized in 11 studies. The most suggested introductory procedure was tympanoplasty which was advocated for in five studies. Heterogeneity existed in the outcomes and methodologies used to measure EES learning curves, with an overreliance on surgical times. No robust definition of competency in EES procedures exists at present.

CONCLUSIONS

Surgical simulation appears to be a beneficial training methodology for EES. However, there is a marked lack of objective data to describe the optimal introductory procedures or assessment of competency in EES. Laryngoscope, 133:3269-3278, 2023.

[Experiences with endoscopic ear surgery of a German tertiary hospital for otolaryngology]

BACKGROUND

The aim of this article is to report on the integration of endoscopic ear surgery (EES) into daily clinical practice.

MATERIAL AND METHODS

In a monocentric prospective study, the endoscopy unit was set up during even weeks over a period of 10 months and the procedure was primarily started endoscopically via a transmeatal approach. In odd weeks, the endoscopy was omitted. A total of 60 procedures in 59 patients were evaluated. Points of comparison were intraoperative vision, incision-suture time, postoperative hearing outcome, and postoperative otoscopic findings.

RESULTS

With the exception of the facial nerve (p = 0.15 Mann-Whitney U‑test), the EES showed significantly improved visualization of all areas in the middle ear. The incision-suture times were similar in both methods. If bimanual placement of an ossicular prosthesis was necessary, the incision-suture time increased disproportionately (MES: 57.18 ± 9.7 min, EES: 76.83 ± 24.99 min; p = 0.019, *). There were no statistically significant changes related to hearing outcomes when comparing EES with the microscopic technique. There were no postoperative complications in the EES surgery group.

CONCLUSION

Integration of EES proved to be successful and advantageous in a real patient collective at this location.

[Clinical application of retrosigmoid approach for BONEBRIDGE implantation after auricle reconstruction using expanded postauricular flap]

Objective: To explore the safety and reliability of retrosigmoid approach BONEBRIDGE implantation in patients with auricle reconstruction using skin expansion flap. Methods: A retrospective analysis was conducted on 43 congenital aural atresia cases (43 ears) who underwent BONEBRIDGE implantation from September 2019 to January 2023 in Beijing Tongren Hospital. 30 males and 13 females were included in this work. The implantation age was 9-36 years old (median age=10 y/o). All cases underwent auricle reconstruction surgery using the posterior ear flap expansion method, with 36 cases using the single expanded postauricular flap method and 7 cases using two-flap method. BONEBRIDGE implant surgery was performed during the third stage of auricle reconstruction or after all stages. The hearing improvements were evaluated by comparing the changes in pure tone hearing threshold and speech recognition rate of patients before and after BONEBRIDGE implantation. Routine follow-up was conducted to observe the hearing results and complications. SPSS 14.0 software was applied for data statistical analysis. Results: All 43 patients healed well and had no surgical complications when discharge. The average bone conduction hearing threshold after surgery was (8.2±6.6) dBHL, and there was no statistically significant difference compared to the preoperative [(8.1±5.7) dBHL] (P=0.95). After surgery, the threshold of hearing assistance with power on was significantly lower than that without hearing assistance [(32.8±4.6) dBHL vs (60.5±5.5) dBHL], and the difference was statistically significant (P<0.001). The speech recognition rate of monosyllable words, disyllabic words and short sentences in quiet environment increased to 72%, 84%, and 98% respectively. The differences were statistically significant (P<0.001). The speech recognition rate of monosyllabic words, disyllabic words, and short sentences in noise environment was significantly increased by 70%, 80%, and 92% respectively (P<0.001). After a follow-up of 4 to 47 months (median=24 months), the hearing results were stable and the aesthetic outcomes were satisfying. One patient had delayed hematoma around coil of the implant. After aspiration and compressed dressing for one week, hematoma was not recurrent. Conclusion: For patients after auricle reconstruction using expanded postauricular flap, the preference of retrosigmoid approach is a good choice in terms of safety and reliability of operation, as well as aesthetic appearance.

Management of a Posterior Mesotympanic Cholesteatoma using the Transcanal Endoscopic Approach

With the constant evolution in the role of endoscopy in middle ear surgery, this article presents a technical note on the transcanal endoscopic approach to resection of a cholesteatoma limited to the posterior mesotympanum. We believe that this technique provides a suitable, minimal-invasive alternative to the classic microscopic transmastoid approach.