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

Hypoxia-inducible factor-1α contributes to the proliferation of cholesteatoma keratinocytes through regulating endothelin converting enzyme 1 expression

Objective

Cholesteatoma is a hyperproliferative, pseudoneoplastic lesion of the middle ear characterized by aggressive growth and bone destruction. Hypoxia-inducible factor-1α (HIF-1α, also known as HIF1A) is a key transcription factor that enters the nucleus and upregulates many genes involved in cancer progression in the oxygen-free environment. This study is designed to explore the role and mechanism of HIF1A in the progression of cholesteatoma.

Methods

HIF1A and endothelin converting enzyme 1 (ECE1) levels were determined using real-time quantitative polymerase chain reaction. The protein levels of HIF1A, Cyclin D1, proliferating cell nuclear antigen, and ECE1 were measured using western blot. Cell viability, proliferation, and cell cycle progression were analyzed using cell counting kit-8, Colony formation, 5-ethynyl-2'-deoxyuridine, and flow cytometry assays. Binding between HIF-1α and ECE1 promoter was predicted by Jaspar and verified using Chromatin immunoprecipitation and dual-luciferase reporter assays.

Results

HIF1A and ECE1 were highly expressed in cholesteatoma patients and keratinocytes. Moreover, HIF1A knockdown might suppress the cell viability, proliferation, and cycle progression of cholesteatoma keratinocytes. Furthermore, HIF1A upregulated the transcription of ECE1 through binding to its promoter region.

Conclusion

HIF1A might expedite cholesteatoma keratinocyte proliferation partly by increasing ECE1 expression, providing a possible therapeutic target for the cholesteatoma treatment.

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.

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.

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.

The Role of Cartilage-perichondrium Tympanoplasty in the Treatment of Tympanic Membrane Retractions: Systematic Review of the Literature

Introduction  Tympanic retraction is a condition characterized by the displacement of the tympanic membrane toward the structures of the middle ear. Clinically, tympanic retractions can lead to hearing loss, ear discharge and/or ear pain. In most of the cases, however, tympanic retractions are asymptomatic and are found accidentally during an ear, nose, and throat (ENT) examination. This condition has created numerous debates regarding the optimal choice of treatment, especially in the asymptomatic forms. The main controversy is regarding the relationship between retraction and the development of cholesteatoma, which would justify a surgical intervention performed for preventive purposes.

Objectives  To study the effectiveness of cartilage tympanoplasty in the management of tympanic membrane retractions by analyzing the results of the studies conducted on the use of cartilage as a reconstruction material.

Data Synthesis  A literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses group (PRISMA). Study selection, data extraction, and quality assessment were conducted independently by two reviewers. Our initial literature search yielded 2,258 references. Applying the PRISMA flow chart, 1,415 duplicates were excluded, and the remaining 843 abstracts were examined. Afterwards, 794 articles were excluded based on the research protocol criteria. Only 8 papers were included in the review by applying the inclusion and exclusion criteria.

Conclusions  Despite the limitations of the studies taken into consideration, we can conclude that cartilage tympanoplasty may successfully rehabilitate the atelectatic ear especially in the more advanced stages of retraction, unlike the conservative strategies.

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.

Management of tympanic membrane retractions: a systematic review

Importance

Tympanic membrane retraction (TMR) is a relatively common otological finding. However, no consensus on its management exists. We are looking especially for a treatment strategy in the military population who are unable to attend frequent follow-up visits, and who experience relatively more barotrauma at great heights and depths and easily suffer from otitis externa from less hygienic circumstances.

Objective

To assess and summarize the available evidence for the effectiveness of surgical interventions and watchful waiting policy in patients with a tympanic membrane retraction.

Evidence review

The protocol for this systematic review was published at Prospero (207859). PubMed, Embase, and the Cochrane Database of Systematic Reviews were systematically searched from inception up to September 2020 for published and unpublished studies. We included randomized trials and observational studies that investigated surgical interventions (tympanoplasty, ventilation tube insertion) and wait-and-see policy. The primary outcomes of this study were clinical remission of the tympanic membrane retraction, tympanic membrane perforations and cholesteatoma development.

Findings

In total, 27 studies were included, consisting of 1566 patients with TMRs. We included data from 2 randomized controlled trials (76 patients) and 25 observational studies (1490 patients). Seven studies (329 patients) investigated excision of the TMR with and without ventilation tube placement, 3 studies (207 patients) investigated the wait-and-see policy and 17 studies (1030 patients) investigated tympanoplasty for the treatment of TMRs.

Conclusions and relevance

This study provides all the studies that have been published on the surgical management and wait-and-policy for tympanic membrane retractions. No high level of evidence comparative studies has been performed. The evidence for the management of tympanic membrane retractions is heterogenous and depends on many factors such as the patient population, location and severity of the TMR and presence of other ear pathologies (e.g., perforation, risk of cholesteatoma and serous otitis media).

Supplementary Information

The online version contains supplementary material available at 10.1007/s00405-021-06719-3.

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.