Comparison of endoscopic transcanal and microscopic approach in Type 1 tympanoplasty

Endoscopic Versus Microscopic Tympanoplasty: A Systematic Review and Metanalysis

OBJECTIVE

Endoscopic ear surgery is no longer a promising technique, but a well-established one. This study aims to compare endoscopic and microscopic tympanoplasty based on current literature evidence, in terms of their efficacy and safety characteristics.

DATA SOURCES

We conducted a systematic literature search of four medical databases (Pubmed, Cochrane Library, Scopus, ClinicalTrials.gov), focusing on randomized controlled or observational studies comparing microscopic to endoscopic tympanoplasty.

REVIEW METHODS

Data related to the efficacy and safety of each technique were extracted. Outcome data were summarized using pooled mean differences or pooled odds ratio along with their 95% confidence intervals. The risk of bias was estimated, by using the ROBINS-I and RoB-II assessment tools, while the overall quality of evidence was evaluated according to the GRADE working group.

RESULTS

Thirty-three studies, with 2646 patients in total, were included in the meta-analysis. Success rate was evaluated by estimating tympanic graft failure (pooled mean difference:-0.23; 95% CI: -0.61, 0.14, I2 = 33.42%), and air-bone gap improvement (pooled mean difference:-0.05; 95% CI:-0.23, 0.13, I2 = 52.69%), resulting in comparable outcomes for the two techniques. A statistically significant difference favoring the endoscopic technique was detected regarding postoperative wound infection (OR: -1.72; 95% CI: -3.39, -0.04, I2 = 0%), dysgeusia (OR: -1.47; 95% CI: -2.47, -0.47, I2 = 0%), otitis externa development (OR: -1.96; 95% CI: -3.23, -0.69, I2 = 0%), auricular numbness (OR: -2.56; 95% CI: -3.93, -1.19, I2 = 0%), as well as surgical duration (OR: -1.86; 95% CI: -2.70, -1.02, I2 = 43.95%), when compared to the postauricular microscopic approach.

CONCLUSION

Endoscopic tympanoplasty is an innovative alternative to the microscopic technique, resulting in commensurate outcomes regarding success rate. Furthermore, it offers superior results concerning postoperative complications, while it presents a significant reduction in the duration of surgery, mainly when it is compared to the postauricular microscopic approach.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:3466-3476, 2024.

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.

Endoscopic Versus Microscopic Type I Tympanoplasty: An Updated Systematic Review and Meta-analysis

OBJECTIVE

Our objective was to perform a systematic review and meta-analysis comparing the clinical outcomes after endoscopic and microscopic type I tympanoplasty.

STUDY DESIGN

Randomized controlled trials, two-arm prospective studies, and retrospective studies were included.

SETTING

Medline, Cochrane, EMBASE, and Google Scholar databases were searched until March 1, 2022 using the combinations of search terms: "endoscopic," "microscopic," and "tympanoplasty."

METHODS

Two independent reviewers utilized the abovementioned search strategy to identify eligible studies. If any uncertainty existed regarding eligibility, a third reviewer was consulted. Primary outcome measures were graft success rate, air-bone gap (ABG) improvement, and operative time. Secondary outcomes were the rate of need for canalplasty, the proportion of self-rated excellent cosmetic results, and pain visual analog scale (VAS).

RESULTS

Forty-three studies enrolled a total of 3712 patients who were undergoing type I tympanoplasty and were finally included. The pooled result showed endoscopic approach was significantly associated with shorter operative time (difference in means: -20.021, 95% confidence interval [CI]: -31.431 to -8.611), less need for canalplasty (odds ratio [OR]: 0.065, 95% CI: 0.026-0.164), more self-rated excellent cosmetic results (OR: 87.323, 95% CI: 26.750-285.063), and lower pain VAS (difference in means: -2.513, 95% CI: -4.737 to -0.228). No significant differences in graft success rate or ABG were observed between the two procedures.

CONCLUSION

Endoscopic type I tympanoplasty provides a similar graft success rate, improvement in ABG, and reperforation rate to microscopic tympanoplasty with a shorter operative time, better self-rated cosmetic results, and less pain. Unless contraindicated, the endoscopic approach should be the procedure of choice in type I tympanoplasty.

Endoscopic Tympanoplasty as an Alternative to Microscopic Tympanoplasty: A Comparative Study on Surgical Outcomes and patient satisfaction

Background

Chronic otitis media treatment has evolved, with microscopic surgeries as the gold standard and endoscopic surgeries as a newer addition.

Materials and Methods

This retrospective study includes 209 patients who underwent type 1 tympanoplasty, utilizing both endoscopic and microscopic techniques, between January 2019 and December 2022 at a tertiary care institute in India. The study aims to compare hearing outcomes, graft uptake, hospital stay, postoperative pain, and cosmesis between the two groups.

Results

Mean AB gap closure was 17.09 + 5.98 dB in the endoscopic group and 16.74 + 5.05 dB in the microscopic group (P = 0.687). The duration of surgery was 79.26 ± 17.37 min in the Endoscopic group and 91.92 ± 15.35 min in the Microscopic group. (P = < 0.00001). The Endoscopic group experienced less post-operative pain, shorter hospital stay (P = < 0.00001, P = 0.0008), and exhibited better cosmetic outcomes (P = 0.00001) compared to the microscopic group.

Conclusion

Endoscopic tympanoplasty is a better alternative to microscopic tympanoplasty, delivering comparable hearing outcomes, shorter surgical duration, improved pain scores, and better cosmesis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-04184-4.

Application of Machine Learning to Predict Hearing Outcomes of Tympanoplasty

OBJECTIVE

This retrospective study aimed to evaluate the performance of machine learning techniques in predicting air-bone gap after tympanoplasty compared with conventional scoring models and to identify the influential factors.

METHODS

We reviewed the charts of 105 patients (114 ears) with chronic otitis media who underwent tympanoplasty. Two numerical scoring systems (middle ear risk index [MERI] and ossiculoplasty outcome parameter staging [OOPS]) and three algorithms (random forest [RF], support vector machine [SVM], and k nearest neighbor [kNN]) were created. Experimental variables included age, preoperative air-bone gap, soft-tissue density lesion in the tympanic cavity in CT, otorrhea, surgical history, ossicular bone problems in CT, tympanic perforation location, perforation type (central or marginal), grafting material, smoking history, endoscopy use, and the operator whose experience was 20 years or longer, or shorter. Binary classification, postoperative air-bone gap ≤15 or >15 dB, and multiclass classification, classification into seven categories by 10 dB, were performed, and the percentages of correct prediction were calculated. The importance of features in the RF model was calculated to identify influential factors.

RESULTS

The percentages of correct prediction in binary classification were 62.3%, 72.8%, 81.5%, 81.5%, and 81.5% in MERI, OOPS, RF, SVM, and kNN, respectively, and those in multiclass classification were 29.8%, 21.9%, 63.1%, 44.7%, and 50% in the same order. The RF model suggested larger preoperative air-bone gap, and older age could make the postoperative air-bone gap larger.

CONCLUSION

The machine learning techniques, especially the RF model, are promising methods for precise postoperative air-bone gap prediction.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:2371-2378, 2023.

Endoscopic or Microscopic Tympanoplasty Advantages and Disadvantages: A Theory Domain Systematic Review

Introduction  Tympanoplasty is a reparative surgery that has multiple indications. The aid of a microscope or an endoscope is necessary to carry out the procedure. The classic method utilizes the microscope; however, in the recent decades, the endoscope has been popular. Although many articles try to compare these two techniques, there is still no robust evidence that confirms the superiority of either technique. In the present work, we seek to perform a systematic review contribute with this. Objectives  The present systematic review attempted to compare endoscopic and microscopic surgery techniques and to discover whether there would be superiority in the results of any of them, based on data currently available in the literature. Data Synthesis  The objectives of the present review were organized according to the PICO planning and strategy adapted for systematic reviews. The inclusion and exclusion criteria were established aiming to select only select primary data. The main medical databases were searched using an optimized search string with appropriate descriptors. The searched databases were MEDLINE, LILACS, SciELO, and EMBASE. A total of 99 studies were selected and 38 were fully assessed after the inclusion criteria were applied. All included articles were reviewed by all authors and their results were discussed and summarized. Conclusion  The endoscopic technique was shown to be a safer technique comparable in effectiveness to the use of microscopy. In addition, it provides possible advantages such as shortening the surgical time and better postoperative pain outcomes.

Comparison of Surgical Outcome of Endoscopic with Microscopic Type I Tympanoplasty in Chronic Otitis Media: A Randomized Controlled Trial

Aim of the study was to compare the surgical outcome of endoscopic with microscopic Type 1 tympanoplasty in dry, mucosal type of chronic otitis media with respect to graft uptake rate, hearing gain and duration of surgery. This randomized controlled trial of 3 years was carried out at Tertiary Care Hospital of Central India. Total 80 cases of mucosal type of chronic otitis media posted for Type I tympanoplasty were included in the study. They were randomly divided into two groups viz. Endoscopic tympanoplasty and microscopic tympanoplasty with 40 patients in each group. Chi-square test was used to compare the qualitative results and student's t-test was used to compare quantitative results with a level of significance of p ≤ 0.05. Intraoperatively, widening of external auditory canal and auxiliary incision were required in 45% and 47.5% patients of microscopic group respectively. Mean operative time for endoscopic tympanoplasty (62.5 ±14.94  mins) was less as compared to microscopic tympanoplasty (74.88 ± 15.83  mins). Graft uptake rate was 95% and 92.5% in endoscopic and microscopic tympanoplasty groups respectively with statistically insignificant difference (p = 0.32). The preoperative mean air bone gap in both the groups was improved significantly 6 months postoperatively. Air bone gap closure was of 13.21± 4.37 dB in endoscopic group and 12.54  ± 4.14 dB in microscopic group with statistically insignificant difference. Endoscope provides superior visualization of hidden areas of middle ear cavity and has shorter operative time than microscopic tympanoplasty with comparable surgical and functional outcomes. hence endoscopic tympanoplasty can be a good option to microscopic surgery.

Transcanal Endoscopic Versus Microscopic Tympanoplasty: Is There a Difference in Perforation Closure Rates?

Objective

To compare closure rates of endoscopic and microscopic tympanoplasty (MT) as influenced by perforation size, perforation location, and graft position.

Study Design

Retrospective chart review.

Setting

Tertiary university medical center.

Patients

Adult patients who underwent tympanoplasty by a fellowship-trained neurotologist from January 2010 to December 2019, had at least 2 months of follow-up, and had a tympanic perforation with no cholesteatoma before surgery.

Interventions

Transcanal endoscopic tympanoplasty (ET) or MT.

Main Outcome Measures

The primary outcome is postoperative closure of the tympanic membrane perforation as assessed using otomicroscopy at the last follow-up appointment.

Results

Two-hundred and eleven patients-98 in the transcanal ET group and 113 in the MT group-were identified. Tympanic membrane closure rates were not significantly different between the ET and MT groups (79.6% and 84.1% respectively; P = 0.473), and further multivariable analysis revealed that closure rates for ET relative to MT had an insignificant odds ratio (0.56; P = 0.144). Similar analyses also found no significant difference between the 2 methods in subsets of perforation size (small, large, subtotal/total), perforation location (anterior, posterior, inferior), and graft position (underlay, overlay).

Conclusions

ET resulted in similar rates of postoperative closure rates compared with the microscopic technique.

Endoscopic type 1 tympanoplasty: comparison of the effects of three different thicknesses grafts

BACKGROUND

The effects of graft thickness on tympanoplasty is uncertain.

OBJECTIVE

To compare the results of endoscopic tympanoplasty using different thicknesses of autologous tissues.

METHODS

This retrospective analysis included 186 patients who received type I tympanoplasty, divided into three main groups based of grafting material: perichondrium (A), cartilage-perichondrium (B), or cartilage-perichondrium plus additional perichondrium (C). Group A was subdivided based on whether the placement was inside (A1) or outside (A2) of the malleus. The hearing improvement, graft success rate, and surgery duration were analysed.

RESULTS

Statistical analysis showed significant hearing improvement in the three main groups (p < .001); recovery in group A occurred the earliest. Six months postoperatively, group A1 showed significantly greater hearing recovery compared with groups B and C (p < .05). There were no statistical differences the other groups (p > .05) or in the graft success rate among the three main groups (p = .235). The surgery duration of group A was significantly longer than that of groups B and C (p < .001).

CONCLUSION AND SIGNIFICANCE

Our results suggest that graft thickness affects hearing recovery; however, graft thickness does not affect the rate of grafting success. Endoscopic transplantation of the perichondrium is more difficult and requires more time.

Endoscopic versus microscopic ossiculoplasty: Does the functional outcome vary according to the type of osciculoplasty?

OBJECTIVE

To compare functional outcome of microscopic and endoscopic approach regarding type of ossiculoplasty.

METHODS

In this retrospective study, cases who had undergone type-II and type-III tympanoplasty between February 2007 to September 2019 were divided into two groups according to the type of approach as microscopic and endoscopic. In cases with type-II reconstruction; Partial Ossicular chain Replacement Prosthesis (PORP), incus interposition and bone cement were used in order of frequency. Whereas in cases with type-III reconstruction, only Total Ossicular chain Replacement Prosthesis (TORP) was used. The average Air Bone Gap (ABG) was determined pre- and post-operatively for the calculation of Air Conductance Gain (ACG). The ACG, pre- and post-operative ABG values of each group were compared with regard to the type of ossiculoplasty.

RESULTS

A total of 79 cases consisting of 32 females and 47 males who had undergone type-II and type-III tympanoplasty were enrolled. No statistically significant difference between microscopic and endoscopic approach was found in terms of ACG (p = 0.42), pre-(p = 0.23) and postoperative ABG (p = 0.99). We did not find any significant difference in terms of ACG, pre- and postoperative ABG between two approaches for type-II and type-III reconstructions (p > 0.05).

CONCLUSIONS

According to the current study, endoscopic approach in type-II and type-III reconstruction is at least reliable as microscopic approach regarding functional outcome. Since both techniques have similar functional results, other factors (anatomic characteristics, habitude of the surgeon and duration of the surgery) should be considered when choosing the technique.

LEVEL OF EVIDENCE

In the current paper we present a retrospective comparative study of two different approaches of a particular type of otologic surgery. Level of evidence corresponds to level III.