Novel Concept of Attaching Endoscope Holder to Microscope for Two Handed Endoscopic Tympanoplasty

[Application of the follower arm endoscope holder in type i tympanoplasty]

Objective:To investigate the surgical outcomes and safety of the follower arm endoscope holder in assisting type Ⅰ tympanoplasty. Methods:The clinical data of 16 patients who underwent type Ⅰ tympanoplasty at the Department of Otorhinolaryngology, Peking Union Medical College Hospital, from November 2022 to September 2023 were retrospectively analyzed, among which 8 cases were operated by traditional otoscopy and 8 cases were operated by supported endoscopy.The surgical procedure was analyzed and the completion of supported endoscopic operation was observed, while the duration of the operation, the time consumed by the main steps, the frequency of wiping the lenses, the perioperative complications, and the improvement of the postoperative hearing were recorded and statistically analyzed. Results:Supporting endoscopic technology achieved real-time suction of bleeding, simultaneous traction and separation of tissues, precise removal of calcified spots on the inner side of the eardrum, trimming of the external auditory canal flap, stable separation of the handle of the malleus and the eardrum, and tensioned repositioning of the skin-cartilage flap. The average duration of surgery, time for external auditory canal flap preparation, and time for repositioning the skin-cartilage flap were reduced in the supporting endoscopic surgery group compared to the control group. The average lens wiping frequency was significantly lower in the supporting endoscopic surgery group compared to the control group. There was no statistically significant difference in postoperative hearing improvement between the two groups, and no infections or the need for secondary surgery due to eardrum re-perforation occurred postoperatively. Conclusion:Supported endoscopy technology realizes the need for endoscopic two-handed operation and convenient switching between one and two hands, accomplishes many operations that cannot be done by traditional endoscopic surgery, solves the problems of previous intraoperative one-handed operation and image instability, shortens the average operation time compared with traditional otoscopic surgery, and decreases the frequency of intraoperative wiping of the lens significantly compared with traditional otoscopic surgery, which is potentially worthwhile in terms of shortening the learning curve.

Feasibility and Applicability of Portable Goose Neck System as a Third Arm for Holding Endoscope in Two Handed Endoscopic ENT Surgeries

Endoscopes have revolutionised and have added a new dimension to the surgical domain. Many surgical techniques have reformed from the open surgical approach to a minimal access endoscopic one. In otolaryngology too, the indications and the use of endoscopes have been increasing in the last few decades. Even in otology, slowly and steadily Wulstein's microscopic techniques have been changing to endoscopic techniques. The only disadvantage of endoscopic ear surgery is that it is a single handed technique as the non dominant hand is utilised in holding the endoscope. We have developed portable endoscope holder based on the Goose neck system with rack and pinion mechanism. The goose neck system acts as a third arm to hold the endoscope. The novel portable endoscope holder bears the potential to provide benefits for various endoscopic ear nose and throat surgeries. We present our experience of feasibility and applicability of this endoscope holder.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-03604-9.

A Perfect Bent Flag Knife- Significance and Relevance During Two Handed Endoscopic Ear Surgery

The micro-ear instruments are designed to work with the operating oto-microscope where the principle of working depends on the magnification and the focal length of the objective lens. During the endoscopic ear surgery, the length of instrument interferes with the length of the endoscope making the working under the lens difficult. Hence certain modifications are required in the existing micro ear instruments so as to be used in endoscopic ear surgery to reach the nooks and corners of the middle ear. In this manuscript, we describe the angle rendered to the flag knife.

Portable Gas Spring with Rachet and Pinion System as a Third Arm for Holding Endoscope in Two Handed Endoscopic ENT Surgery

The role of endoscope has been changing from that being an adjuvant during microear surgery to the exclusive endoscopic middle ear surgery. However the only disadvantage of endoscopic ear surgery is its single handed technique as the non-dominant hand is used to hold the endoscope. We propose the concept and design of our portable endoscope holder for two handed endoscopic ear surgery. It is based on the gas spring action and rack and pinion system which act as a third arm to hold the endoscope. The novel portable endoscope holder bears the potential to provide benefits for various two handed endoscopic ear nose and throat surgeries. Level of evidence: Level V.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-022-03246-3.

Does the angle of the intsruments matter during two handed endoscopic ear surgery?

The micro-ear instruments are designed to work with the operating oto-microscope where the principle of working depends on the magnification and the focal length of the objective lens. The focal length of the microscope allows a greater working distance for manipulation of the instruments. During the endoscopic ear surgery, the length of instrument interferes with the length of the endoscope making the working under the lens difficult. Hence reaching to the corners of the middle ear becomes impossible with the straight micro-ear instruments during endoscopic ear surgery. Hence certain modifications are required in the existing micro ear instruments so as to be used in endoscopic ear surgery.

Endoscopic Cartilage Boomerang Ossiculoplasty- as Total Ossicular Replacement Using Endoscope Holder

We report the technique of two handed transcanal endoscopic ossiculoplasty using tragal cartilage in the form of boomerang as an option for total ossicular replacement in absence of stapes superstructure. In this technique, the vertical strut is fashioned as a boomerang and measures 10 mm in length and 2 mm in breadth. A partial thickness cut is made on the vertical strut at 4-4.5 mm along the length so that it can be bent into boomerang, one end of which is placed on the stapes footplate and the other part rests in the hypotympanum. This stable assembly is placed on the footplate of the stapes (when all ossicles are absent). Tympanic membrane reconstruction is performed with or without attic reconstruction, using sliced tragal cartilage of 0.5 mm thickness. Boomerang ossiculoplasty is good option in cases of absent stapes providing a stable assembly. The use of endoscope holder during ear surgery gives additional advantages of panoramic view of middle ear spaces due to use of endoscope along with benefits of two handed technique (similar to microscopic ear surgery).

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-021-02854-9.

Feasibility of Sheep Auricular Cartilage as a Teaching Tool for Training in Slicing Techniques for Cartilage Tympanoplasty

There are temporal bone dissection workshops organised all-over the world, however, there is no dedicated teaching program to train in slicing techniques for cartilage tympanoplasty. The aim of the study is to train the otologists in slicing techniques in cartilage tympanoplasty using sheep auricular cartilage as a teaching model and to evaluate the impact of the training on the participants. A total of 98 otologists have been trained in slicing techniques using cartilage slicer during 7 workshops organised at our centre from January 2016 to January 2020 for a total of 6 days for each trainee. Each trainee performed slicing techniques in cartilage tympanoplasty using 5 sheep pinna. Evaluation of the impact of the training was done in terms of assessment of improvement in performance. The feedback forms evaluated the training technique with sheep cartilage, its feasibility and usability as a model for teaching. The impact of the training on the overall performance of the trainee was assessed in terms of confidence, ability and speed in performing tasks related to slicing and cartilage tympanoplasty. The simulation in slicing techniques using sheep auricular cartilage has a teaching potential to improve the surgical outcomes of tympanoplasty as assessed by the performance of the participants. Level of evidence: 4.

Endoscopic Cartilage Umberlla Ossiculoplasty: As Total Ossicular Replacement Using Endoscope Holder

We describe our innovative technique of endoscopic cartilage tympanoplasty using cartilage fashioned as umbrella in stapes absent condition using endoscope holder. Tragal cartilage disc of 3 × 3 mm dimensions with a circular slot of 0.8 mm to accommodate the vertical strut measuring 3 mm × 7 mm in cases with absent incus and stapes. Tympanic membrane reconstruction was done, with or without attic reconstruction, using sliced tragal cartilage of less than 0.5 mm thickness.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-021-02518-8.

Novel Drill-burr Protection Sheath with Inbuilt Suction-irrigation for Endoscopic Ear Surgery

Abstract

We have developed a novel instrument which is a drill burr protection sheath with an inbuilt suction-irrigation system for endoscopic ear surgery. It allows simultaneous suction and irrigation. It is a metallic attachment onto the mastoid drill handpiece. It provides protection for the endoscope as well as the external auditory skin during transcanal drilling procedures. It is cost effective.

Level of evidence

5.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-021-02944-8.

Paediatric Cartilage Tympanoplasty: A Two Handed Technique with Our Endoscope Holder

The aim of the study is to evaluate the functional and anatomical results of paediatric sliced cartilage type 1 tympanoplasty using our endoscope holder. It is Retrospective Non Randomized Clinical Study. A total of consecutive 81 children operated from January 2016 to December 2017 for endoscopic type I sliced cartilage tympanoplasty with endoscope holder were included in the study. The study included 44 males and 37 females. The patients ranged from 8 to 18 years. In early follow up period ranging from 24 to 48 months, the graft take up was seen in 76 follow up giving a success rate of 93.82 percent. The pre-operative air-bone gap was 32.34 ± 2.71 dB and the post-operative mean 4 tone air-bone gap at 1 and 2 years was 9.12 ± 2.37 dB and 9.42 ± 1.38 dB respectively. The study reports the good air bone closure and anatomical closure of perforation with sliced cartilage in paediatric tympanoplasty.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-021-02678-7.

Endoscopic Cartilage Butterfly Tympanoplasty: A Two-Handed Technique with Endoscope Holder

The aim of the study was to evaluate and report the short-term results of two-handed endoscopic cartilage butterfly tympanoplasty using endoscope holders. The efficacy of the operative technique was evaluated and assessed by comparing the air-bone-gap on pure tone audiometry preoperatively and on follow-up at 6 months and 1-year post operatively. Patients with uncomplicated otitis media and healthy middle ear status with no ossicular involvement underwent endoscopic transcanal cartilage butterfly tympanoplasty. Small and medium sized tympanic membrane perforations were included in the study. Pre- and postoperative air-bone gaps and presence for any residual perforation was noted. A total 69 patients consisting of 45 males and 24 females with a mean age of 24.45 years were included in the study group. Small perforations involving only one quadrant were 39 in number while the medium sized perforations involving two quadrants were 26 in number and the ones involving three quadrants were 4 in number. At the end of the follow-up period of 6 months and 1 year, successful closure occurred in 67 of 69 patients with a success rate of 97.1%. The mean preoperative Air-Bone gap was 34 ± 3.45 dB which showed a steady decline on follow-up at 6 months 13 ± 4.53 and 15.34 ± 3.39 dB at 1 year following surgery. Recurrent perforation was noted in two patients involving three quadrants of the tympanic membrane. Endoscopic two-handed butterfly cartilage tympanoplasty can be safely performed in small and medium sized perforations with no middle ear disease/ossicular involvement. The hearing outcomes and successful closure rate are similar to those of other surgical methods. Our study uses the endoscope which provides superior image quality and the use of an endoscope holder makes the technique a two handed one, thereby making the manoeuvring of the microear instruments easier. Moreover, it can be performed under local anaesthesia with low complication rates and quick recovery. Level of Evidence Level 4.

Learning Curve of Two Handed Endoscopic Ear Surgery on Sheep Temporal Bone: A Fellow’s Perspective

The study puts forth the learning curve of two handed endoscopic middle ear dissection on a sheep temporal bone. It also highlights the usage of sheep temporal bone as an effective simulation technique for two-handed cadaveric temporal bone dissection. 6 sheep temporal bone models were dissected in a period of 15 days. Harvesting of cartilage graft, endoscopic myringotomy and grommet insertion, cartilage butterfly tympanoplasty, ossiculoplasty, stapes surgery and facial nerve decompression, using the Endohold®, were conducted on each bone. There was a remarkable decrease in the time required for subsequent temporal bone dissections, with significant improvement in efficiency, accuracy and neatness of dissection. Practice and experience resulted in upliftment in the level of confidence of the fellow. Striking similarities were noticed between sheep and human temporal bones. Availability of both the hands with a clear endoscopic view made it easier and more convenient to perform various procedures. Two handed endoscopic technique provides an excellent approach for ear surgeries. Availability of both the hands for the delicate surgery along with the spectacular endoscopic view contributes to increase in efficiency and surgery outcome. Cadaveric dissection of sheep temporal bones provides a great learning experience for a trainee to practice these delicate and skilful two-handed endoscopic middle ear surgical exercises. Its easy availability and striking similarity of the anatomy makes it a boon for the beginners. It gives ample opportunity to the trainee to explore and learn the complex anatomy, try new skills and develop an expertise in this field. The efficiency and accuracy increases significantly with each dissection, smoothening out the steep learning curve, that is, for such fine and intricate surgical skills.

Our Experience with Two Handed Endoscopic Tympanoplasty

Endoscopic tympanoplasty is a minimally invasive procedure and may be an alternative to conventional microscopic tympanoplasty with less operative time, producing similar graft uptake. Endoscopic tympanoplasty has a major disadvantage of single handedness which is overcome by a novel concept of "Two-handed technique" using Khan's Justtach (endoholder). The aim was to study the outcomes of two handed endoscopic tympanoplasty in terms of graft uptake and hearing outcome. Two handed endoscopic tympanoplasty was performed in 20 patients with chronic suppurative otitis media between April 2018-April 2019, in the Department of Otorhinolaryngology, M.G.M. Medical college and MYH hospital, Indore. Tragal cartilage graft via palisading supported with perichondrium was used. Postoperative follow up was done at 3rd month's period, graft status and hearing evaluation was done using Pure tone audiometry. Graft uptake was intact in 19 (95%) out of 20 patients and infection and failure in 1 (5%) case, average preoperative A-B gap was 15-25 dB loss (minimal) in 1 (5%) patient, 3 (15%) patients had 25-40 dB loss (mild) and 16 (80%) patients had 40-55 dB loss (moderate) hearing loss. The post-operative improvement was evaluated in which 6 (30%) patient had 15-25 dB loss (minimal), 12 (60%) patients had 25-40 dB loss (mild), and 2 (10%) patients had 40-55 dB (moderate) conductive hearing loss. We used Wilcoxon Signed Ranks Test for audiological evaluation with a 'p value' of 0.000 making the hearing improvement significant. "Two handed endoscopic tympanoplasty" is an emerging technique which can overcome almost all the major issues related with single handed technique with high degree graft uptake and good hearing outcomes. Endoscope holder is a valuable adjunct to conventional endoscopic surgery.

Exclusive Two Handed Endoscopic Cartilage Type 3 Tympanoplasty with Endoscope Holders

In present world of contemporary techniques of microscopic ear surgery and single handed endoscopic ear surgery, we propose the technique of two handed endoscopic tympanoplasty using endoscope holders. The aim of the study  is to evaluate the functional and anatomical results of our technique of endoscopic type 3 cartilage tympanoplasty using endoscope holder. It is a Retrospective Non Randomized Clinical Study. A total of 67 endoscope holder assisted exclusively two handed endoscopic type 3 cartilage tympanoplasties performed from December 2014 to March 2017 with our technique were included in the study. Patients with pars tensa retractions and perforations with absent incus were included in the study. Those with cholesteatoma were excluded from the study. Full thickness tragal cartilage disc of 3 × 3 mm dimensions with a circular slot of 1 mm to fit onto the head of the stapes was used for reconstruction. Tympanic membrane reconstruction was done along with attic reconstruction, using sliced tragal cartilage of 0.5 mm thickness. Patients were assessed at 6, 12 and 24 months for graft status. In early follow up period ranging from 24 to 52 months, the graft take up was seen in 64 ears with three perforations giving a success rate of 95.52%. The pre-operative air-bone gap was 42.6 ± 3.26 dB and the post-operative air-bone gap at 6 months, 1 and 2 years was 18.36 ± 3.46 dB, 19.42 ± 4.32 dB and 19.53 ± 4.33 dB respectively. The study reports good air-bone closure to 20 dB postoperatively following type 3 endoscopic tympanoplasty using endoscope holder. Slotted cartilage graft is definitely an excellent option for ossiculoplasty in cases of absent incus providing a stable assembly. Level of evidence: Level 4.

Accurate and Specific Measuring Grid for Otorhinolaryngological Surgeries

Most of the ENT surgeries (tympanoplasty, rhinoplasty, ossiculoplasty, septoplasty) involve the reconstruction and the functional correction of the respective structures involved. Success of otorhinolaryngological surgeries depends on accurate measurements and precision in judgement. There is need to develop simple tools for measurements which are easy to procure, accurate and simple to handle. Every surgeon needs unique tools to accomplish such an outcome. In order to tackle this difficulty and to ease the learning process in ENT surgeries, we have developed an accurate specific measurement grid.

Two-handed endoscopic ear surgery: Feasibility for stapes surgery

OBJECTIVE

Endoscopic ear surgery is becoming an increasingly popular approach. Our aim in this study is to evaluate the feasibility of the two-handed endoscopic technique for stapes surgery, which has its own unique steps.

METHODS

Patients who underwent two-handed endoscopic stapes surgery between September 2017 and February 2018 were included in this study. Preoperative and postoperative pure tone averages and air bone gaps, intraoperative complications were recorded. All procedures were performed under hypotensive general anesthesia by the same surgeon using 0° rigid endoscopes of 2.7-mm diameter, 14-cm length with an endoscope holder.

RESULTS

Seven endoscopic two-handed stapes surgery were performed between September 2017 and February 2018. Of these, six patients were operated entirely endoscopically because one patient was found to has perilymph gusher and converted to microscopic surgery. There were no intraoperative tympanic membrane injuries, facial nerve paresis or sensorineural hearing losses. The average preoperative ABG of patients who underwent fully endoscopic surgery was 31.3 dB, and the postoperative ABG closed up to 9.6 dB.

CONCLUSIONS

Adoption of the two-handed technique during endoscopic stapes surgery ensures the surgeon benefits from the advantages of endoscopy while overcoming the disadvantages of the one-handed technique.

Robot-Assisted Middle Ear Endoscopic Surgery: Preliminary Results on 37 Patients

Background: Endoscopy during middle ear surgery is advantageous for better exploration of middle ear structures. However, using an endoscope has some weaknesses as surgical gestures are performed with one hand. This may trouble surgeons accustomed to using two-handed surgery, and may affect accuracy. A robot-based holder may combine the benefits from endoscopic exposure with a two-handed technique. The purpose of this study was to assess the safety and value of an endoscope held by a teleoperated system.

Patients and Methods: A case series of 37 consecutive patients operated using endoscopic exposure with robot-based assistance was analyzed retrospectively. The RobOtol^® system (Collin, France) was teleoperated as an endoscope holder in combination with a microscope. The following data were collected: patient characteristics, etiology, procedure type, complications, mean air and bone conduction thresholds, and speech performance at 3 months postoperatively. Patients had type I (myringoplasty), II (partial ossiculoplasty), and III (total ossiculoplasty) tympanoplasties in 15, 14, and 4 cases, respectively. Three patients had partial petrosectomies for cholesteatomas extending to the petrous apex. Finally, one case underwent resection of a tympanic paraganglioma. Ambulatory procedures were performed in 25 of the 37 patients (68%).

Results: Complete healing with no perforation of the tympanic membrane was noted postoperatively in all patients. No complications relating to robotic manipulation occurred during surgery or postoperatively. The mean air conduction gain was 3.8 ± 12.6 dB for type I (n = 15), 7.9 ± 11.4 dB for type II (n = 14), and −0.9 ± 10.8 for type III tympanoplasties (n = 4), and the postoperative air-bone conduction gap was 13.8 ± 13.3 dB for type I, 19.7 ± 11.7 dB for type II and 31.6 ± 13.0 dB for type III tympanoplasty. They was no relapse of cholesteatoma or paraganglioma during the short follow-up period (<1 year).

Conclusion: This study indicates that robot-assisted endoscopy is a safe and trustworthy tool for several categories of middle ear procedures. It combines the benefits of endoscopic exposure with a two-handed technique in middle ear surgery. It can be used as a standalone tool for pathology limited to the middle ear cleft or in combination with a microscope in lesions extending to the mastoid or petrous apex.

Pinna stay suture in two handed endoscopic ear surgery: Our experience

Transcanal endoscopic ear surgery provides a minimally invasive approach to the middle ear. We operate exclusively by the two handed technique of endoscopic ear surgery with Endoscope holders. We have incorporated the technique of stay suture for retraction of external ear canal into our practice of transcanal two handed endoscopic ear surgery after observing this technique by Prof Muaaz Tarabichi at the First International Congress on Endoscopic ear surgery Dubai, April 2015 for the single handed endoscopic ear surgery.

AIM

To report our experience of the stay suture in transcanal two handed endoscopic ear surgery and highlight its advantages.

DESIGN

Prospective non randomized clinical study.

METHODS AND MATERIALS

A total of 354 two handed transcanal endoscopic ear surgeries (202 endoscopic cartilage tympanoplasties and 152 endoscopic attic cholesteatoma surgeries) with endoscope holders operated from May 2015 to September 2017 with the stay suture were included in the study.

RESULTS

The ear canal and the tympanic membrane visualisation, instrument manipulation were better with the stay suture technique of pinna retraction.

CONCLUSION

The study reports the successful application and use of the pinna stay suture. It is a good option during two handed technique in Endoscopic Ear Surgery for pinna retraction.

LEVEL OF EVIDENCE

Level 4.

Endoscope holder-assisted endoscopic coblation tonsillectomy

BACKGROUND

Tonsillectomy is being performed either with a headlight, surgical loupe magnification or with microscopic aid. We report the technique of endoscope holder-assisted endoscopic tonsillectomy using coblation. Coblation tonsillectomy has the primary advantage of limited thermal damage compared with alternative forms of surgery.

METHODS

Our endoscope holder, primarily designed for endoscopic ear surgery, has been extrapolated for the use in two-handed technique of tonsillectomy. The method is described in detail.

CONCLUSION

Endoscope gives a panoramic view, better optics, magnified image of the bleeders and hence there is applicability of the endoscope holder for endoscopic tonsillectomy.

Modified Endoscope Holder for Two Handed Endoscopic Ear Surgery

We have been doing Endoscopic ear surgeries since 2013. Inorder to overcome the disadvantage of the single handed endoscopic ear surgery technique, we have developed the endoscope holders, Justtach^® and EndoHold^®. Due to its certain limitations, we modified the pre-existing, endoscope holder-Justtach, to add more features as well as to increase the comfort and ease of the technique. The aim of this paper is to describe the design of our modified endoscope holder and to report our preliminary experience of two handed endoscopic ear surgery with it. Descriptive study. A total number of 68 two handed endoscopic tympanoplasties have been operated with the modified endoscope holder from January 2017 to May 2018 with a minimum follow up period of 10 months. Our study reports the successful application of the modified endoscope holder for two handed endoscopic ear surgery, highlighting its advantages. Our modified endoscope holder, is a good option for two handed endoscopic tympanoplasties and mastoidectomies. Level of Evidence Level 4.

Robot-based assistance in middle ear surgery and cochlear implantation: first clinical report

PURPOSE

Middle ear surgery may benefit from robot-based assistance to hold micro-instruments or an endoscope. However, the surgical gesture performed by one hand may perturb surgeons accustomed to two-handed surgery. A robot-based holder may combine the benefits from endoscopic exposure and a two-handed technique. Furthermore, tremor suppression and accurate tool control might help the surgeon during critical surgical steps. The goal of this work was to study the safety of an otological robot-based assistant under clinical conditions in a limited series of patients.

METHODS

The RobOtol system has been used as an endoscope or a micro instrument holder for this series. Eleven cases were operated on with the robot as an endoscope holder for chronic otitis. Twenty-one cases were operated on with the robot as a micro-instrument holder for otosclerosis (9 cases), transtympanic tube placement (2 cases), or cochlear implantation (10 cases).

RESULTS

No complications related to the robot manipulation occurred during surgery nor in postoperative. In the chronic otitis group, all perforations were sealed and 3-month postoperative pure-tone average air-bone gap (PTA ABG) was 15 ± 2.6 dB. In the otosclerosis group, 1-month post-op PTA ABG was 10 ± 1 dB. For cochlear implantation cases, a scala tympani insertion, a vestibular scala translocation occurred and a full scala vestibuli insertion was observed in 7, 2 and 1 case, respectively.

CONCLUSION

The RobOtol system has reached the clinical stage. It could be used safely and with accurate control as an endoscope holder or a micro instrument holder in 32 cases.

Can endoscopic ear surgery replace microscopic surgery in the treatment of acquired cholesteatoma? A contemporary review

Acquired cholesteatoma leads to significant morbidities while current surgical options remain a challenge. The principles of surgery include complete removal of disease, prevention of recurrence, and restoration of hearing function when possible. Traditionally, this has been performed using microscopes; however, a novel technique using endoscopes offers a new perspective on our understanding of anatomy, pathogenesis and surgical approaches. In recent years, various studies have demonstrated good outcomes with transcanal endoscopic ear surgery (EES) in cholesteatoma surgery. Nevertheless, the use of EES is not universal and remains controversial due to the efficacy of microscopes, specific limitations of endoscopes and the need to learn new skills. This review focuses on recent advances in EES for the treatment of acquired cholesteatoma, benefits, current challenges, and a discussion on the indications and contraindications of EES.

Minimal Invasive Endoscopic Ear Surgery: A Two Handed Technique

To evaluate the surgical outcome of two handed technique of endoscopic ear surgery with endoscope holder. Retrospective Non Randomized Clinical Study. A total of 547 endoscope holder (Justtach) assisted ear surgeries (331 cartilage tympanoplasties and 216 cholesteatoma surgeries) were operated with Justtach from July 2013 to April 2016 with a follow up period ranging from 12 to 45 months to evaluate its feasibility and results with the technique. The design of the endoscope holder, Justtach is described along with its functioning and maneuvering techniques. In the endoscopic tympanoplasty group, at 1 year follow up, the graft uptake was seen in 323 ears with three residual perforation and 5 recurrent perforations giving a success rate of 97.58%. At the 2 years follow up, the graft uptake was in 322 ears with 6 recurrent perforations and 3 residual perforations with a success rate of 97.28%. Whereas in case of endoscopic cholesteatoma surgery, there was residual cholesteatoma in 5 and recurrent in 6 out of 216 cases. The study reports the successful application and use of endoscope holder in two handed technique of endoscopic ear surgery. Level of Evidence Level 4.

The Goat Model for Exclusive Two Handed Endoscopic Middle Ear Surgery Training: A Novel Technique

With the popularity of exclusive transcanal endoscopic ear surgery, the need for a suitable and affordable surgical training model has grown. To develop an ex vivo animal model for exclusive endoscopic ear surgery. In an experimental study, we studied goat middle ear anatomy in 8 specimens to assess the similarity with the human middle ear as a model for two handed endoscopic ear surgery with endoscope holders. After confirming its suitability, we have developed a surgical training program for grommet insertion, canaloplasty, myringoplasty, butterfly tympanoplasty, ossiculoplasty, atticotomy. The goat model is suitable for two handed endoscopic ear surgery using endoscope holder. We describe a novel, exclusively two handed endoscopic approach in an ex vivo animal model for middle ear surgery. The proposed surgical program will guide the trainee endoscopic ear surgeon for a step by step through the main otologic procedures to enhance his or her surgical skills.

Comparison of surgical and audiological outcomes of endoscopic and microscopic approach in stapes surgery

Objective:

The main objectives of the present study were to compare the surgical and audiological outcomes of endoscopic and microscopic approach in stapes surgery.

Methods:

Sixty-one patients who underwent the stapes surgery with the endoscopic and microscopic approach between January 2012-November 2018 were included in the study. Patients were divided into two groups as a Group-I (endoscopic) and Group-II (microscopic). The audiometric measurements, duration of surgery, intraoperative findings and complications were recorded and evaluated retrospectively.

Results:

Mean operative time for the Group-I and II was 45.1±8.4 minutes and 48.7±5.6 minutes, respectively (p>0.05). The preoperative and postoperative average air-bone gap in the Group-I was 27.8±7.2 dB and 8.7±3.4 dB and these values in Group-II were 30.2±5.1 dB and 7.4±4.8 dB, respectively (p<0.001). The requirement of chorda tympani nerve manipulation and scutum curettage were significantly less in Group-I as compared Group-II (p<0.05). Dysgeusia and postoperative pain were observed significantly higher ratios in Group-II relative to Group-I (p<0.05). There was no significant difference between endoscopic and microscopic approach in stapes surgery in terms of difficulty of prosthesis insertion (p>0.05).

Conclusion:

Endoscopic stapes surgery provides comparable audiological outcomes, shorter operative times, fewer complications rates, and more minimally invasive surgery, relative to the microscopic approach.

Endoscopic Management of Tympanic Membrane Retraction Pockets: A Two Handed Technique with Endoscope Holder

The tympanic membrane retraction pocket is a pathological invagination of tympanic membrane into the middle ear space. The most common sites for formation of retraction pocket are pars flaccida and postero-superior parts. Decision about the procedure and the timing of the treatment of retraction pockets is debatable and depends on the functional and anatomic condition of the ear. To evaluate the results of the technique of two handed endoscopic management of retraction pockets with sliced tragal cartilage. Prospective Non Randomized Clinical Study. The study included 41 ears operated with the technique of two handed endoscopic cartilage tympanoplasty for retraction pockets with endoscope holders from November 2013 to May 2016 with a follow up period ranging from 22 to 53 months. Cases of cholesteatoma and tympanic membrane perforation were excluded from the study. Pre and postoperative symptoms and air-bone gaps were recorded. The average preoperative air-bone gap in the study group was 24.53 ± 4.326 dB. 28 ears were of pars tensa retractions (stage II-4, stage III-15, and stage IV-9) and 13 were pars flaccida retractions (stage III-8 and stage IV-5). 24 ears had ossicular erosion. The follow up revealed that, the results of two handed endoscopic sliced cartilage tympanoplasty for retraction pockets were stable and there was no recurrence of the retraction and the post-operative air-bone-gap closure was achieved to 13.62 ± 4.78, 14.13 ± 5.91 dB, 14.32 ± 3.46 and 14.57 ± 3.88 dB at 6 months, 1 year, 2 years, 3 years respectively. Though, indications for surgery are based mostly on anatomic status and observation of behaviour of retraction pocket over time, we recommend early management of retraction pockets by the technique of endoscopic sliced tragal cartilage tympanoplasty with tragal cartilage of 0.5 mm thickness using endoscope holder. Level of Evidence: Level 4.

Comparison of endoscopic and microscopic ear surgery in pediatric patients: A meta-analysis

OBJECTIVES

Recently, the endoscope has been increasingly introduced for middle-ear surgery. To evaluate the postoperative outcomes of endoscopic ear surgery (EES) in pediatric patients, we did a qualitative analysis with a systematic review and quantitative analysis with meta-analysis of available literature.

METHODS

Studies reporting the comparative surgical outcomes of EES in pediatric patients were systematically reviewed by searching the MEDLINE, PubMed, and Embase databases from database inception through 2017. The selected articles included clinical studies conducted with at least 30 subjects and at least one postoperative parameter, including residual or recurrent cholesteatoma and graft success in tympanoplasty. Two investigators independently reviewed all studies and extracted the data using a standardized form. A meta-analysis was performed using a random-effects model and qualitative review was performed on the smaller studies.

RESULTS

Ten studies were identified as appropriate for quantitative meta-analysis and 19 studies for qualitative analysis. In the meta-analysis, residual or recurrence rate of cholesteatoma was significantly lower in the EES group than in the microscopic ear surgery (MES) group (odds ratio [OR]: 0.56, 95% confidence interval [CI]: 0.38-0.84, P = .005). The graft success rate of tympanoplasty was not statistically different between EES and MES groups (OR: 0.72, 95% CI: 0.41-1.26, P = .249). In the qualitative analysis, most of the studies reported similar audiological outcomes after tympanoplasty and success rate of cholesteatoma removal between the two groups.

CONCLUSIONS

It appears that EES reduces the risk of residual cholesteatoma in children and that the success of perforation closure is equivalent to MES. Laryngoscope, 129:1444-1452, 2019.

New Cartilage Slicer for Slicing Techniques in Tympanoplasty: Design and Applications

ABSTRACT

Cartilage-perichondrium composite graft is used in middle ear surgery for tympanic membrane, ossicular and for soft wall reconstruction. The thickness of the cartilage is thought to interfere with the sound conduction. In our otology practice for tympanic membrane reconstruction, we prefer the sliced cartilage graft to achieve acoustic benefit. At times in the process of slicing, the cartilage gets wasted if not sliced with a precision slicing instrument. We have designed and developed a multi-purpose cartilage slicer for precise reduction of the thickness of the cartilage. To describe the design of our cartilage slicer and to report our preliminary experience with the cartilage slicer. Descriptive study. The technique of slicing with our new cartilage slicer and its usage has been described in detail. A total number of 689 cartilages in tympanoplasty and mastoidectomy have been sliced with it from 2013 to 2017. Our study reports the technique of slicing the tragal cartilage for tympanoplasty, highlighting its advantages and precision of the cartilages slices obtained. Our cartilage slicer is a good option for cartilage slicing in tympanoplasty.

LEVEL OF EVIDENCE

Level 4.