Does endoscopic stapedotomy increase hearing restoration rates comparing to microscopic? A systematic review and meta-analysis

The utility and safety of diode laser in endoscopic stapes surgery

Objective

The advantages of laser stapedotomy are less trauma and more precise and minimally invasive techniques; however, the potential risk of overheating from the laser combined with the endoscope tip must be considered. This study aimed to assess the efficacy and safety of diode lasers for endoscopic stapes surgery.

Methods

A retrospective review of 56 patients with otosclerosis who underwent primary endoscopic stapedotomy with a diode laser from 2017 to 2020 was conducted. Demographic data, intraoperative findings, preoperative and postoperative audiological assessments, and postoperative complications were analyzed.

Results

There was no statistically significant difference between the preoperative and postoperative bone conduction thresholds. The mean postoperative air-bone gap (ABG) improved significantly compared to the preoperative ABG (4.07 vs. 35.43 dB, p < .001). The postoperative ABG closure within 10 dB at 6 and 12 months was achieved in 87.50% and 91.07% of patients, respectively. The postoperative pain scores at 4 and 24 h were 2.55 and 0.39, respectively. Immediate postoperative vertigo was reported in 12.50% of patients, with 100% complete recovery 2 months after surgery. The chorda tympani nerve was preserved in all the cases. Postoperative taste disturbances at 2 and 12 months were observed in 17.86% and 1.79% of patients, respectively.

Conclusion

The diode laser in endoscopic stapedotomy is a safe and effective technique that provides satisfactory hearing outcomes. Temporary taste disturbances during the early postoperative period are a concern. The handheld diode laser delivery system is suitable for an endoscopic approach and is an alternative armamentarium for the treatment of otosclerosis. Level of evidence: IV.

Outcomes and learning curve of endoscopic tympanoplasty: A retrospective analysis of 376 patients

Objective

This study aimed to evaluate the procedural outcomes and learning curve of type I endoscopic tympanoplasty (ET) performed by a single surgeon.

Methods

This was a retrospective study of 376 patients who underwent type I ET performed by a single surgeon over 7 years. We evaluated the pre/post air-bone gap (ABG), time required for surgery, changes in pain after surgery, success, and failure rate of type I ET.

Results

Hearing results indicated an ABG of approximately 17.8 dB before surgery but decreased significantly to 9.8 dB at 6 months after surgery. The time required for the operation gradually decreased. In particular, the time required for the procedure was 67.6 min in the first year and decreased to 31.5 minutes in the fifth year, a drastic reduction. The graft failure rate up to 6 months after surgery was 13.0% and was the same for both primary and revision surgeries. Graft failure was significantly greater with increasing size of the preoperative tympanic perforation. The success rate varied depending on graft material, and the group with only acellular allogenic dermal matrix showed the lowest success rate. Postoperative pain significantly decreased from 2.01 immediately after surgery to 0.78 points the next day, and there were no severe complications during surgery.

Conclusions

ET produces superior cosmetic results with minimal pain and is associated with stable hearing improvement and high success rate. The operation time decreased with surgeon experience and continued to decrease until the fifth and final year of this analysis.

Level of Evidence

4.

Endoscopic vs. microscopic stapes surgery: An anatomical feasibility study

Objectives

To investigate the feasibility of the endoscopic approach vs. microscopic approach during stapes surgery, focusing on the visualization of the important anatomical structures of the middle ear, the volume of the resected scutum and chorda tympani (CT) injury.

Methods

Fresh frozen human cadaveric heads underwent two stapes surgeries using an operating microscope on one ear and an endoscope on the other ear. The surgeon documented the visualization of critical landmarks, as well as exposure and injury of the CT. The volume of resected scutum was evaluated using cone beam computed tomography scanning and three-dimensional imaging.

Results

We performed endoscopic stapes surgery in 10 ears and microscopic stapes surgery in 11 ears. A stapes prosthesis was placed in all ears. The volume of bony scutum resection was significantly lower in the endoscopic group (median = 2.20 mm³, IQR = 4.17) than in the microscopic group (median 13.25 mm³, IQR = 8.71). No scutum was removed in two endoscopic ears, while scutum was removed in all microscopic ears. The endoscopic and microscopic group had similar CT injury.

Conclusions

This study showed that the endoscopic stapes surgery procedure is feasible and might be less invasive than microscopic stapes surgery. Future clinical prospective and functional studies will be needed to support our findings.

Endoscopic and Robotic Stapes Surgery: Review with Emphasis on Recent Surgical Refinements

Purpose of Review

Stapes surgery has been established as the gold standard for surgical treatment of conductive hearing loss in otosclerosis. Excellent outcomes with very low complication rate are reported for this surgery. Recent advances to improve surgical outcome have modified the surgical technique with endoscopes, and recent studies report development of robotical assistance. This article reviews the use of endoscopes and robotical assistance for stapes surgery.

Recent Findings

While different robotic models have been developed, 2 models for stapes surgery have been used in the clinical setting. These can be used concomitant to an endoscope or microscope. Endoscopes are used on a regular base regarding stapes surgery with similar outcomes as microscopes. Endoscopic stapes surgery shows similar audiological results to microscopic technique with an advantage of less postoperative dysgeusia and pain. Its utility in cases of revision surgery or malformation is emphasized.

Summary

Endoscopic stapes surgery is used on a regular basis with excellent outcomes similar to the microscopic approach, while reducing surgical morbidity. Robotic technology is increasingly being developed in the experimental setting, and first applications are reported in its clinical use.

The role of the endoscope in cochlear implantation. A systematic review

OBJECTIVE

To review the role of the endoscope in cochlear implantation (CI).

METHODS

MEDLINE, ScienceDirect, Google Scholar and the Cochrane Library databases as well as other sources were searched by two independent reviewers. Studies including patients undergoing either exclusively endoscopic or endoscopic ally assisted CI were eligible for inclusion. Endoscopic CI approaches and postoperative complications were the primary outcomes. Secondary endpoints included the degree of round window (RW) microscopic visualization according to St Thomas' Hospital classification as well as type of cochleostomy for electrode insertion in the scala tympani (ST).

RESULTS

Fourteen studies met the inclusion criteria comprising 191 endoscopic or endoscopically assisted CI cases. The endoscope was used for better visualization of the RW across all included studies, facilitated the insertion of the electrode in the ST and spared a mastoidectomy in a number of cases. No facial nerve palsy was reported in any of the studies. The most common complication was external auditory canal/ tympanic membrane tear followed by chorda tympani injury.

CONCLUSION

The microscopic CI approach is still the gold standard. The endoscope facilitates the recognition of the RW area and leads to successful and safe implantation particularly in difficult anatomical scenarios, ear malformations and advanced otosclerosis. Endoscopically assisted CI procedures offer the opportunity to avoid a posterior tympanotomy and reduce the risk of facial nerve injury. To date, the lack of long term data does not permit the widespread adoption of completely endoscopic CI procedures without a mastoidectomy.

Endoscopic Versus Microscopic Stapedotomy: A Single-Blinded Randomized Control Trial

OBJECTIVE

To demonstrate non-inferiority of endoscopic stapedotomy to microscopic stapedotomy for the treatment of otosclerosis.

STUDY DESIGN

Single-blinded randomized control trial.

SETTING

Tertiary, academic otology-neurotology practice.

PATIENTS

Adult subjects with a diagnosis of otosclerosis and a preoperative air-bone gap (ABG) more than or equal to 20 dB undergoing primary stapedotomy.

INTERVENTION

Endoscopic or microscopic stapedotomy.

MAIN OUTCOME MEASURES

Primary audiometric outcome was postoperative ABG. Secondary audiometric outcomes included speech reception threshold (SRT), word recognition score (WRS), bone- and air-conduction pure tone averages (PTA), change in ABG, and ABG closure rates to less than or equal to 10 dB and less than or equal to 20 dB.

RESULTS

Twenty-two patients were recruited. Eleven patients underwent endoscopic stapedotomy and 11 underwent microscopic stapedotomy. The endoscopic group was non-inferior to the microscopic group in terms of postoperative audiometric outcomes (endoscope versus microscope, p-value): ABG (8.1 dB versus 8.1 dB, <0.001), SRT (27.7 dB versus 25.9 dB, <0.001), WRS (92% at 65 dB versus 98% at 62 dB, <0.001), air-conduction PTA (33.5 dB versus 30.8 dB, <0.01), and change in ABG (23.0 dB versus 20.7 dB, <0.0001). ABG closure rates to less than or equal to 10 dB (72.7% versus 81.2%, p = 1.0) and less than or equal to 20 dB (90.9% versus 100%, p = 1.0) were not significantly different. There was no significant difference in operative time, necessity of scutum curettage, or postoperative dysgeusia. No patients required chorda tympani sacrifice. Preoperative tinnitus resolved in three patients in each group postoperatively.

CONCLUSIONS

This study is the first randomized control trial to demonstrate non-inferiority of endoscopic to microscopic stapedotomy.

Endoscopic Assisted Lateral Skull Base Surgery

Pathology of the lateral skull base poses a unique challenge for the surgeon. An intimate knowledge of the anatomy and the various approaches used for accessing pathology of the lateral skull base is critical. Three novel, minimally invasive, transcanal approaches for the management of lateral skull base pathology are described herein along with their respective indications, advantages, and disadvantages.

Exclusive Endoscopic Laser-Stapedotomy: Feasibility of an Ovine Training Model

OBJECTIVE

Stapedotomy is an effective treatment for conductive hearing loss associated with otosclerosis. However, the procedure, especially using the endoscopic technique requires extensive training and experience for optimal results. Due to limited training options in endoscopic stapes surgery, we aim to develop an ovine stapedotomy model and assess its feasibility for surgeons at different training levels.

METHODS

A fully endoscopic ovine laser-stapedotomy model was developed and described. During repetitive dissections, surgical time required for the different steps to assess the training curve and associated intraoperative complications were recorded in three surgeons of different training level. Additionally, subjective feedback was assessed.

RESULTS

Successful endoscopic laser-stapedotomy was performed in 25 cases in the ovine model. Assessment of surgical time revealed a stable curve for the experienced surgeon (mean 15:01 min) for the whole training with no intraoperative complications. The fellow showed a gradual reduction of surgical time from 27:21 (first five cases) to 24:10 minutes (last five cases) and the resident a reduction from 42:38 to 21:08 minutes respectively. The assessed learning curve for the trainees revealed a significant association between the operative time and observed intraoperative complications.

DISCUSSION

In this study, an ex-vivo model for exclusively endoscopic laser-stapedotomy was developed and tested for feasibility. We suggest the ovine model as a cost-effective, easily available, and realistic training model for future otologic surgeons. The surgeons were able to improve their performance with satisfactory results despite the small number of cases.

Three-dimensional exoscope-assisted laser stapedotomy: a preliminary experience

Purpose

Stapes surgery, despite the introduction of lasers and endoscopes, still represents a challenging procedure. Recently introduced 3-dimensional exoscopes have known advantages in otological surgery. This study aims to evaluate exoscopes role in stapes surgery, both from a surgical perspective and on the educational profile.

Methods

Seven consecutive otosclerosis patients underwent single-sided endaural laser stapedotomy with a 4K 3-dimensional exoscope. The surgical setting allowed all operating room personnel 3-dimensional vision. Pre- and postoperative pure tone audiometry and air-bone gaps, and information on the postoperative course and complications were systematically collected. An informal ergonomic evaluation was carried out by the operating room personnel and an informal didactic evaluation was provided by the trainees. A comparable group of microscope-assisted stapedotomy patients undergoing the same procedures and evaluations was chosen as a control group.

Results

Outcomes were solid in all patients, median air-bone gap decreased from 26.5 to 10 dB at the 3-month evaluation (p = 0.01, Wilcoxon’s test). No vertigo, tinnitus, or facial palsy was reported. The median operating time was 40 min. The compact design and configuration of the exoscope allowed more practical management of the operating theater. All personnel had the chance for a better understanding of the procedure and trainees felt more confident when asked to identify surgical landmarks and procedure steps. Audiological outcomes, operative times, and complication rates were not different between study and control groups.

Conclusion

Though further validation and systematic comparison with microscope- and endoscope-assisted stapedotomy are required, the exoscope proved a safe, practical, and educational tool.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00405-021-06672-1.

Systematic Review and Meta-analysis of Endoscopic vs Microscopic Stapes Surgery for Stapes Fixation

OBJECTIVE

To systematically review the current literature regarding the operative outcomes of stapes surgery for stapes fixation via the endoscopic and microscopic approaches.

DATA SOURCES

PubMed, Embase, and Web of Science.

REVIEW METHODS

An electronic search was conducted with the keywords "endoscop* or microscop*" and "stapes surgery or stapedectomy or stapedotomy or otosclerosis or stapes fixation." Studies were included if they compared endoscopy with microscopy for stapes surgery performed for stapes fixation and evaluated hearing outcomes and postoperative complications. Articles focusing on stapes surgery other than for stapes fixation were excluded.

RESULTS

The database search yielded 1317 studies; 12 remained after dual-investigator screening for quantitative analysis. The mean MINORS score was 18 of 24, indicating a low risk of bias. A meta-analysis demonstrated no statistically significant difference between the groups with regard to operative time, chorda tympani nerve manipulation or sacrifice, or postoperative vertigo. There was a 2.6-dB mean improvement in the change in air-bone gap in favor of endoscopic stapes surgery and a 15.2% increased incidence in postoperative dysgeusia in the microscopic group, but the studies are heterogeneous.

CONCLUSIONS

Endoscopic stapes surgery appears to be a reasonable alternative to microscopic stapes surgery, with similar operative times, complications, and hearing outcomes. Superior visibility with the endoscope was consistently reported in all the studies. Future studies should have standardized methods of reporting visibility, hearing outcomes, and postoperative complications to truly establish if endoscopic stapes surgery is equivalent or superior to microscopic stapes surgery.

Endoscopic Stapes Surgery: Pearls and Pitfalls

The endoscopic approach to stapes surgery affords unique advantages but is not without its specific challenges. The following reviews the equipment and surgical steps required to perform endoscopic stapes surgery safely and effectively, highlighting tips and potential points of failure through a series of case examples.

The Role for Microsurgery of the Ear

Microscopic ear surgery (MES) has been used since the 1950s whereas endoscopic ear surgery (EES) was introduced in the mid-1990s. The advantages of MES should not be forgotten as surgeons turn their attention to new technology. These include depth perception, wide angle view, and the ability to operate with 2 hands. EES affords the ability to look around corners but needs a pristine field and is limited to single-handed surgery in a narrow field. Trainees should be taught both, and technique used should reflect the experience and abilities of the surgeon and the nature of the disease in the particular patient.

Endoscopic stapes surgery outcomes and complication rates: a systematic review

OBJECTIVE

These days, the gold standard procedure for otosclerosis treatment is stapes surgery. The endoscopic approach of the procedure is gaining popularity as endoscopic ear surgery develops across the globe. The main objective of this study is to gather and compile well-documented and reliable data regarding surgical outcomes for the endoscopic approach to stapes surgery up to this date.

MATERIALS AND METHODS

Publications in English were searched in the PUBMED/MEDLINE database and were systematically reviewed. A total of 16 articles were reviewed according to the inclusion criteria, obtaining a total of 573 patients managed surgically for otosclerosis, using an endoscopic approach. Data were systematically extracted and compared across variables.

RESULTS

Data were obtained as follows: mean age of 43 years; female proportion of 60%; 3 mm endoscope diameter of 51%, 4 mm of 39%; titanium piston-type prostheses of 52% and Teflon of 48%; length of the prosthesis (mode) was 4.5 mm; 0.6 mm diameter of the piston of 81% and 0.4 mm of 19%; mean surgical time was 55 min. Hearing results, mean preoperative air-bone gap (ABG) 31 dB; mean postoperative ABG 9 dB; ABG improvement of 22 dB; an ABG closure rate to 20 dB or less of 92% and an ABG closure rate to 10 dB or less of 77%. Complication rates: intraoperative tympanic membrane perforation of 5%; postoperative vertigo of 11%; postoperative dysgeusia of 10%; reported a postoperative neurosensorial hearing loss of 0.2%; reported gusher phenomenon of one case (0.2%).

CONCLUSION

Endoscopic stapes surgery is completely achievable using 0º angle and 4-mm-diameter sinus surgery endoscope. Instrument availability should not be an obstacle to the development of this type of surgery in any otolaryngology department. Audiological outcomes are comparable to microscopic approaches.

Functional Results and Learning Curve of Endoscopic Stapes Surgery: A 10-Year Experience

OBJECTIVES/HYPOTHESIS

To assess hearing outcomes and complications of endoscopic stapes surgery by a single surgeon in a 10-year period, to compare these data with conventional microscopic procedures by the same operator, and to describe the learning curve of endoscopic stapedotomy.

STUDY DESIGN

Retrospective study.

METHODS

This is a retrospective study on patients who underwent endoscopic stapes surgery performed by the same senior surgeon, experienced both in microscopic and endoscopic techniques, between January 2009 and December 2018. Audiological data were compared, and intraoperative and postoperative complications were collected. The surgeon's last 30 cases of microscopic stapedotomy were enrolled as the control group. The results of the first 100 endoscopic stapes surgeries were analyzed separately to create a cumulative sum (CUSUM) control chart for learning curve assessment.

RESULTS

One hundred seventy-eight endoscopic and 30 microscopic stapes surgeries were included. In the endoscopic group, the mean postoperative air-bone gap was 8.2 dB. No significant differences between the endoscopic and microscopic preoperative and postoperative values were reported. A total of eight complications (4.5%) were observed in the endoscopic cohort, although in the control group, no complication occurred. The mean surgical time was 51.9 minutes in the endoscopic group versus 48.2 minutes in the microscopic group (P > .05). No association between stapedotomy success and the increasing number of procedures was found.

CONCLUSIONS

Our article demonstrates that functional results from endoscopic stapes surgery are similar to those from microscopic stapes surgery in terms of both safety and efficacy. After gaining endoscopic experience, the surgical duration of stapes surgery will be adequate starting from the first cases.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:885-891, 2021.

Would endoscopic surgery be the gold standard for stapes surgery in the future? A systematic review and meta-analysis

OBJECTIVE

This meta-analysis is aimed to review and analyze all available data of intraoperative and postoperative results of endoscopic and microscopic stapes surgery.

METHODS

According to the PRISMA statements checklist, this systematic review and meta-analysis were designed. Data were extracted from public databases, such as PubMed, Cochrane, Web of Science, and more. The quality of studies was evaluated using the MINORS scale. Odds ratios (ORs) and 95% CIs were estimated for binary outcome data, while the mean differences and 95% CIs were estimated for continuous data. I² and χ² tests were used to quantify statistical heterogeneity. If more than ten studies were included in each analysis, funnel plot would be performed to analysis publication bias.

RESULTS

Twelve studies with 620 patients were included in this meta-analysis. Primary outcomes collected in this meta-analysis included average postoperative auditory gain (APAG), postoperative air-bone gap (ABG), the rate of chorda tympani handling and bone curettage, which all showed a statistically significant difference in favor of endoscopy. While only secondary outcomes about postoperative pain and dysgeusia demonstrated a significantly reduced incidence. Furthermore, there was not any statistically significant difference on postoperative dizziness and average operative time between endoscopy and microscopy.

CONCLUSION

Although there is a need for high-quality pooled data in the future, a consistently superior effect of the endoscopic group was still shown in terms of total effectiveness, when compared to the microscopic group. We have reasons to support the application of endoscopy in stapes surgery. The future of ESS, we believe, is blazing bright.

Acquisition of basic ear surgery skills: a randomized comparison between endoscopic and microscopic techniques

BACKGROUND

Endoscopic ear surgery is gaining increasing popularity and has an important impact on teaching middle ear anatomy and basic surgical skills among residents and fellows. Due to the wide-angled views offered, the approach significantly differs from the established microscopic technique. This randomized study compares the acquisition of basic ear-surgery skills using the endoscopic and microscopic technique under standardized conditions. We aim to investigate the required surgical times, attempts and accidental damages to surrounding structures (errors) in surgeons with different training levels.

METHODS

Final-year medical students (n = 9), residents (n = 14) and consultants (n = 10) from the Department of Otorhinolaryngology, Head and Neck Surgery at the University Hospital of Bern, Switzerland were enrolled in the present study. After randomization every participant had to complete a standard set of grasping and dissecting surgical tasks in a temporal bone model. After the first session the participants were crossed over to the other technique.

RESULTS

Time required for completion of the surgical tasks was similar for both techniques, but highly dependent on the training status. A significant increase in the number of damages to the ossicular chain was observed with the microscopic as compared to the endoscopic technique (p < 0.001). Moreover, students beginning with the endoscopic technique showed an overall significantly lower amount of time to complete the tasks (p = 0.04). From the subjective feedback a preference towards the endoscopic technique mainly in medical students was observed.

CONCLUSIONS

The endoscopic approach is useful and beneficial for teaching basic surgical skills, mainly by providing a reduction of damage to surrounding tissues with similar operating times for both techniques. Moreover, medical students performed significantly faster, when first taught in the endoscopic technique. Especially for young surgeons without previous training in ear surgery, the endoscope should be considered to improve surgical skills in the middle ear.