Endoscopic cartilage tympanoplasty in chronic otitis media

A comparison between endoscopic and microscopic approaches for stapes surgery: experience of a tertiary referral center

PURPOSE

Otosclerosis is a common ear disease causing ankylosis of the stapedio-vestibular joint and conductive hearing loss. Stapedoplasty is the most advisable surgical solution. The restoration of hearing depends on the condition of the patient and the surgery itself. The aim of our work was to compare the surgical and audiological results of stapedoplasty performed with endoscopic versus microscopic technique.

METHODS

This is a retrospective study of 254 patients treated with stapedoplasty with a microscopic approach (91/254) or with an endoscopic approach (163/254) between 2014 and 2021 at our tertiary referral center. Statistical significance of differences between the two methods was determined using the Mann-Whitney test for quantitative variables and the Wilcoxon matched-pairs signed-rank test for repeated measures. Categorical variables were assessed with Fisher's exact test.

RESULTS

Both techniques improved the hearing status of patients, with no statistically significant difference between them. There was also no statistically significant difference in reported complications between the two techniques. There is a statistical difference (p < 0.001) in operating time between the two techniques: the endoscopic technique had a mean operating time of 39 min versus 45 min for the microscopic technique.

CONCLUSIONS

The two techniques are comparable in terms of results and the choice depends on the surgeon's preferences and experience.

Audiometric Outcomes Comparing Endoscopic Versus Microscopic Ossiculoplasty

OBJECTIVE

To assess endoscopic and microscopic ossiculoplasty audiometric outcomes.

STUDY DESIGN

Retrospective review.

SETTING

Tertiary academic center.

PATIENTS

Adult patients who underwent ossiculoplasty with either partial ossicular replacement prosthesis (PORP) or total ossicular replacement prosthesis (TORP) from 2010 to 2019 with at least 1 year of audiometric follow-up were included.

INTERVENTIONS

Endoscopic or microscopic ossiculoplasty.

MAIN OUTCOME MEASURES

Postoperative air-bone gap (ABG) after at least 1 year.

RESULTS

A total of 198 patients, 53.5% female, and a median age of 47.5 years, met inclusion criteria. 64.1% of patients were reconstructed with a PORP, and 31.8% were reconstructed using an endoscopic approach. The median audiometric follow-up was 27 months. The median postoperative ABG was 16.9 dB overall, 15.6 dB for PORP reconstruction, and 19.4 dB for TORP reconstruction (PORP versus TORP, p = 0.002). For TORP reconstructions, the median ABG for both endoscopic and microscopic TORP was 19.4 dB (p = 0.92). For PORP reconstructions, the median ABG for endoscopic PORP was 12.3 dB compared with 16.3 dB for microscopic PORP (p = 0.02). Using multivariate linear regression to predict postoperative PORP ABG, and controlling for age, prior ossiculoplasty, middle ear mucosal disease (granulation, fibrosis, polyposis), middle ear atelectasis, myringitis, contralateral middle ear disease, and use of byte prostheses, endoscopic PORP reconstruction was associated with improvement in ABG over the microscopic approach by 4.4 dB (p = 0.04).

CONCLUSIONS

For PORP ossiculoplasty procedures, endoscopic ossiculoplasty is associated with improved postoperative ABG compared with microscopic ossiculoplasty.

Descriptive study of goat external and middle ear through computed tomography and endoscopic evaluation, compared with the human ear

OBJECTIVE

To describe the external and middle ear of goats, using computed tomography and endoscopic dissection, comparing them with the anatomy of the human ear, aiming to evaluate the viability of this animal model for training in otological endoscopic surgery.

METHODS

Images of the external and middle ear of goats were produced by computed tomography in the coronal and axial planes and analyzed. The radiological anatomy of the external and middle goat and human ear are described. Some measures of surgical interest were described, such as the length of the external auditory canal, external and internal cross-sectional area of the external auditory canal, middle ear depth, vertical angle of the external auditory canal, length of malleus and incus. After the tomographic study, we analyzed the importance of evaluations through the endoscopic dissection of the goat ear.

RESULTS

The bony canal is extremely tortuous and shows a bony prominence with significant elevation near the lower edge of the tympanic membrane. The middle ear has a large tympanic bulla in the hypotympanum region. The malleus is shaped similarly to that of the human, but its handle is located anterior to its head. The mastoid is not pneumatized. Compared to the human mastoid, there was a statistically significant difference in the external and internal cross-sectional area, at the depth of the middle ear, in the vertical angle of the canal and in the length of the incus.

CONCLUSION

Goat morphometric anatomy showed that this model is suitable for surgical simulation in the initial training for endoscopic otological surgery. It is an important contribution to the development of skills to accelerate the subsequent endoscopic otological surgical training in humans, despite some differences found.

Comparison of efficacy of endoscopic versus microscopic transcanal inlay butterfly cartilage myringoplasty

BACKGROUND AND OBJECTIVES

Butterfly cartilage myringoplasty has been widely practiced over two decades due to its simplicity and feasibility. The present study is aimed to compare the efficacy of endoscopic versus microscopic transcanal inlay butterfly cartilage myringoplasty.

SUBJECTS AND METHODS

In this randomised control trial, fifty patients with small to medium sized perforation were included. The first group underwent butterfly cartilage myringoplasty using endoscope and the second group using microscope and, outcomes were compared.

RESULTS

Graft success rates in the endoscopic group was 96% ± 4% and in the microscopic group was 92% ± 8%. The improvement in the Air-Bone Gap was 11.00 ± 7.21 dB in the endoscopic group and 10.8 ± 7.59 dB in the microscopic group. The difference was not statistically significant.

CONCLUSIONS

The overall success rates and hearing outcomes were similar in the endoscopic and microscopic group with added advantages of less pain, shorter operative time and better field of vision in the endoscopic group.

The Pretragal Superficial Musculoaponeurotic System Fascia: A New Graft Material for Transcanal Tympanoplasty

OBJECTIVE

To compare outcomes of transcanal endoscopic tympanoplasty reconstructed using pretragal superficial musculoaponeurotic system (SMAS) fascia versus temporalis fascia.

STUDY DESIGN

Retrospective patient review and posttreatment questionnaire survey.

SETTING

Tertiary referral center.

PATIENTS

Sixty adult patients with chronic dry tympanic membrane perforation.

INTERVENTIONS

Patients underwent transcanal endoscopic type I tympanoplasty reconstructed using the SMAS fascia between September 2017 and May 2018; outcomes were compared with a matched cohort of patients where the temporalis fascia was used.

MAIN OUTCOME MEASURES

Tympanic membrane closure rate, audiogram threshold, duration of procedure, and donor site scar satisfaction survey.

RESULTS

Sixty patients were included in this study and were evenly divided into the SMAS and temporalis fascia groups. These cohorts were matched for age, sex, side of lesion, perforation size, and preoperative hearing level. The closure rate was 96.7% (29/30) and 93.3% (28/30) (p = 1.0), mean hearing gain was 8.3 ± 6.4 dB versus 8.2 ± 7.1 dB for air-conduction (p = 0.970) and 7.6 ± 5.1 dB versus 8.2 ± 6.8 dB for air-bone gap (p = 0.716), and mean surgical duration was 137.3 ± 23.0 versus 132.2 ± 27.3 minutes (p = 0.432) for the SMAS and temporalis fascia groups, respectively; there were no statistically significant differences for all the parameters listed. The posttreatment questionnaire survey revealed significantly higher acceptance of the SMAS fascia method.

CONCLUSION

This preliminary outcome report of SMAS fascia grafting in transcanal endoscopic type I tympanoplasty showed equivalent surgical outcomes and better cosmetic satisfaction compared with the temporalis fascia. The SMAS fascia is a reasonable alternative to conventional techniques for transcanal tympanoplasty.

Endoscopic versus microscopic ossiculoplasty in chronic otitis media: a systematic review of the literature

OBJECTIVE

The aim of this study was to compare the endoscopic and microscopic ossiculoplasty in patients with chronic otitis media.

METHODS

MEDLINE, ScienceDirect, and the Cochrane Library databases as well as other sources were searched by two independent reviewers. Controlled studies comparing endoscopic and microscopic ossiculoplasty in patients with chronic otitis media were included. Mean air-bone gap closure was the primary outcome. Secondary outcomes were operation time and complications.

RESULTS

Three studies met the inclusion criteria. No statistically significant differences in audiometric outcomes between endoscopic and microscopic groups in all three included studies were reported. Although endoscopic technique was related to a fewer number of postoperative complications and a shorter operation time, these outcomes did not reach statistical significance.

CONCLUSION

Endoscopic ossiculoplasty is associated with similar postoperative hearing results compared to the traditional microscopic approach. A trend towards a shorter operative time and reduced morbidity for the endoscopic approach has been observed, but well-designed randomized controlled trials are warranted to confirm this finding.

The evaluation of prognostic factors in endoscopic cartilage tympanoplasty

PURPOSE

The aim of the present study was to evaluate the prognostic factors that may affect the success in endoscopic cartilage tympanoplasty and determine the outcomes of endoscopic cartilage tympanoplasty.

METHODS

This study included 312 patients who underwent transcanal endoscopic type I cartilage tympanoplasty. The effects of sex, the affected side, the size of the perforation, the location of the perforation, the absence of myringosclerosis, external ear canal protrusion, the condition of the contralateral ear, and surgical experience on the rate of graft success and hearing improvement were investigated.

RESULTS

The affected side, sex, location of the perforation, myringosclerosis, the condition of contralateral ear, and surgical experience did not significantly affect the surgical success (p > 0.05). However, the size of perforation and ear canal wall protrusion were significantly related to both functional and anatomical success (p < 0.05).

CONCLUSION

Endoscopic transcanal type I cartilage tympanoplasty can be performed with a high anatomical and functional success rate. However, surgeons should be more careful and design a case-specific operation strategy in patients with external ear canal anterior wall protrusion and large perforations.

Comparison of endoscopic butterfly-inlay versus endoscopic push-through myringoplasty in repairing anterior perforations of the tympanic membrane

OBJECTIVE

The aim of the present study was to evaluate the surgical and functional results of endoscopic butterfly-inlay cartilage myringoplasty and endoscopic push-through myringoplasty in the treatment of anterior perforation of the tympanic membrane.

METHOD

This open-label randomised clinical study was conducted on 71 patients with small- and medium-sized anterior perforations of the tympanic membrane. Graft success rate, hearing results, operative time and complications were analysed.

RESULTS

Graft success rates for endoscopic butterfly-inlay cartilage myringoplasty and endoscopic push-through myringoplasty were 94.1 and 91.8 per cent, respectively (p > 0.05). Post-operative air-bone gap values significantly improved in both the endoscopic butterfly-inlay cartilage myringoplasty and endoscopic push-through myringoplasty groups. The average operative time was significantly shorter in the endoscopic butterfly-inlay cartilage myringoplasty group (31.5 minutes) compared to the endoscopic push-through myringoplasty group (41.7 minutes; p < 0.05).

CONCLUSION

When compared with the endoscopic push-through myringoplasty, the endoscopic butterfly-inlay cartilage myringoplasty technique, which is technically easier to perform, does not require packing and has a shorter operating time. It is a reasonable approach for repair of anterior perforations of the tympanic membrane.

A Comparative Study of Endoscopic versus Microscopic Cartilage Type I Tympanoplasty

Introduction  The use of endoscope is rapidly increasing in otological and neuro-otological surgery in the last 2 decades. Middle ear surgeries, including tympanoplasty, have increasingly utilized endoscopes as an adjunct to or as a replacement for the operative microscope. Superior visualization and transcanal access to diseases normally managed with a transmastoid approach are touted as advantages with the endoscope.

Objectives  The present study aimed to compare the outcomes of endoscopic and microscopic cartilage tympanoplasty (Type I)

Methods  This was a retrospective comparative study of 70 patients (25 males and 45 females) who underwent type I tympanoplasty between March 2015 and April 2016. The subjects were classified into 2 groups: endoscopic tympanoplasty (ET, n  = 35), and microscopic tympanoplasty (MT, n  = 35). Tragal cartilage was used as a graft and technique used was cartilage shield tympanoplasty in both groups. Demographic data, perforation size of the tympanic membrane at the preoperative state, operation time, hearing outcome, and graft success rate were evaluated.

Results  The epidemiological profiles, the preoperative hearing status, and the perforation size were similar in both groups. The mean operation time of the MT group (52.63 ± 8.68 minutes) was longer than that of the ET group (48.20 ± 10.37 minutes), but the difference was not statistically significant. The graft success rates 12 weeks postoperatively were 91.42% both in the ET and MT groups, that is, 32/35; and these values were not statistically significantly different. There was a statistically significant improvement in hearing within the groups, both pre- and postoperatively, but there was no difference between the groups.

Conclusion  Endoscopic tympanoplasty is a minimally invasive surgery with similar graft success rate, comparable hearing outcomes and shorter operative time period as compared to microscopic use.

Transcanal Endoscopic Tympanoplasty for Pediatric Patients Under 15 Years of Age With Chronic Otitis Media

Objectives.

To evaluate the results of transcanal endoscopic tympanoplasty for pediatric patients with chronic otitis media (COM) and compare them to that of the previously standard microscopic assisted tympanoplasty technique.

Methods.

The patients were divided into two groups based on the operative method. Group 1 underwent tympanoplasty with a totally endoscopic assisted technique (n=21, 24 ears), and group 2 underwent tympanoplasty with the conventional microscopic technique (n=14, 15 ears). We used a transcanal approach in group 1 and a postauricular approach in group 2. In group 1, there were 15 cases of simple COM and nine cases of adhesive otitis media. In group 2, only 15 cases of simple COM were present. We analyzed the outcomes in terms of the hearing gain according to the surgical method and COM type, operation time, hospital stay after surgery, and graft success rate.

Results.

Postoperative hearing gain results including air conduction (AC) thresholds and air-bone gap (ABG) were not significantly different between the two groups (P>0.05). In both the groups, significant improvement in the postoperative AC and ABG was observed compared to the preoperative hearing. The hospital stay after surgery was significantly shorter in group 1 than the group 2: 2.1±0.4 days and 4.8±0.9 days (P<0.001), respectively. The intact graft success rate was 91.6% in group 1 and 93% in group 2; the values were not significantly different (P>0.05). There was neither intra- nor postoperative complications.

Conclusion.

Transcanal endoscopic ear surgery technique is more conservative than microscopic approach and can be performed in pediatric patients under 15 years of age with COM. Moreover, it offers similar surgical results compared to traditional microscopic technique, and a shorter operative time and hospital stay after surgery are the advantages of this technique.

Total Endoscopic Transcanal Cartilage Myringoplasty: A Prospective Study

Introduction  Middle ear surgeries, including myringoplasty, have increasingly utilized endoscopes as an adjunct to or as a replacement for the operative microscope.

Objectives  The objective of the present study was to evaluate the graft uptake rate and to evaluate the hearing results.

Methods  This is a prospective study. We have analyzed 139 patients who underwent surgery for chronic otitis media (COM) of the mucosal type. All of the surgeries were performed exclusively under total endoscopic transcanal approach using tragal cartilage as graft, underlay technique. We have evaluated the postoperative graft uptake and performed a hearing evaluation at 6 weeks, at 12 weeks, and at 6 months.

Results  During the study period, 139 patients were included, out of which 13 were lost to follow-up; therefore, only 126 patients were assessed. All of the cases were performed under total endoscopic approach. As for the surgical outcome at the postoperative otoscopy, 3 cases had initial uptake at 3 months and failed later; therefore, complete closure of the perforation was observed in 97.6% ( n  = 123) of the patients 6 months after the intervention.

Four patients presented with preoperative anacusis; therefore, only 122 patients were included for hearing evaluation. The preoperative air conduction threshold (ACT) and airbone gap (ABG) were 43.34 ± 11.53 and 24.73 ± 7.89, respectively.

Postoperatively, the ACT and ABG closure were 28.73 ± 15.75 and 11.91 ± 8.41, respectively. This difference was statistically significant ( p  < 0.001).

Conclusion  The endoscopic approach for myringoplasty offers excellent visualization; avoids postaural approach, enables a faster recovery, requires less hospital stay, with excellent graft closure rate and improved functional outcomes.

Results of endoscopic transcanal tympanoplasty performed by a young surgeon in a secondary hospital

Introduction

Tympanoplasty is performed to close the tympanic membrane perforation and recover the hearing level of patients with non-suppurative chronic otitis media. Endoscopic tympanoplasty has recently been increasingly preferred by ear nose and throat surgeons to treat tympanic membrane perforations.

Objective

The aim of this study is to discuss the outcomes of patients undergoing endoscopic tympanoplasty performed by a young surgeon in a secondary hospital in the context of the literature.

Methods

Fifty patients undergoing endoscopic Type 1 tympanoplasty between February 1, 2017 and February 1, 2018, were included. The patients’ age, gender, perforation side and size, preoperative and postoperative pure tone audiometry, graft failure, postoperative pain and complication status were evaluated.

Results

The graft success rate was 94% at 6 months postoperatively. Audiometry thresholds were obtained at frequencies of 0.5, 1, 2 and 4 kHz. Preoperative pure tone audiometric thresholds were 41.6, 36.3, 34.1, and 39.1 dB, and postoperative, 6 months after surgery, 19.5, 17.8, 17.5, and 20.8 dB. Pure tone audiometry air-bone gaps at the same frequencies changed from 30.5, 24.6, 22.2, and 28.6 dB preoperatively, to 11.0, 9.3, 8.6, and 13.9 dB 6 month after the surgery. There was a statistically significant improvement between the preoperative and postoperative pure tone audiometry, and air bone gaps at all measured frequencies (p < 0.05).

Conclusion

Endoscopic transcanal cartilage tympanoplasty has become more commonly performed by otolaryngologists due to the shortening of operation and hospitalization times as well as similar audiological results to those obtained with microscopic tympanoplasty. The surgical and audiological results of a young ear nose throat specialist can reach a similar level of success to those of experienced surgeons, due to a fast learning curve.

Endoscopic tympanoplasty: learning curve for a surgeon already trained in microscopic tympanoplasty

The aim of this study was to evaluate the learning curve of endoscopic tympanoplasty for a surgeon already trained in microscopic tympanoplasty. We analyzed the clinical records of 81 patients who underwent transcanal endoscopic type 1 tympanoplasty and 30 control patients who underwent microscopic tympanoplasty between 2013 and 2015 in a tertiary hospital. All operations were performed by a single surgeon already trained in microscopic tympanoplasty. Patients were divided into four groups according to the date of surgery chronologically (group 1 early stage, group 2 intermediate stage, group 3 advanced stage and group 4 control). We evaluated the four groups according to surgery duration, audiometric results, and graft intake success. The operation duration shortened in accordance with the surgeon's experience and there were two subsequent steps during the learning curve: first, after 30 procedures; and second, after 60 procedures. The mean operation duration was 88.60 ± 21.10 min in group 1, and 62.00 ± 12.48 min in group 2. After 60 procedures, the mean operation duration was 43.81 ± 8.34 min in group 3. In the control group, the microscopic tympanoplasty duration was 69.93 ± 12.56 min. When we compared audiologic results (air conduction, bone conduction, and air-bone gap) and graft intake success rates, there were no significant differences between groups. Endoscopic tympanoplasty is a minimally invasive and effective technique. Mastering endoscopic tympanoplasty takes approximately 60 operations for a surgeon already trained in microscopic tympanoplasty. Graft intake success rates and hearing results are stable during the learning curve.