A Comparative Study of Endoscopic versus Microscopic Cartilage Type I Tympanoplasty

Endoscopic push through tragal cartilage tympanoplasty: A 10-year retrospective review of our technique and outcomes

BACKGROUND

Endoscopic ear surgery (EES) provides a magnified, high-definition view of the otological surgical field. EES allows otologists to avoid surgical incisions and associated postoperative complications. It is an ideal technique for the performance and teaching of tympanoplasty.

AIM

To examine the efficacy of total Endoscopic Push Through Tragal Cartilage Tympanoplasty (EPTTCT), at our institution over a 10-year period.

METHODS

A retrospective analysis of 168 cases of EPTTCT for closure of small to medium tympanic membrane perforations from 2013-2023 was conducted. Patient sex, age range (pediatric vs adult), etiology of injury, success rate, complications, and postoperative hearing status were collected.

RESULTS

Graft uptake results indicated success in 94% of patients, with less than a 2% complication rate. Postoperative pure tone audiometry demonstrated hearing status improvement in 69% of patients.

CONCLUSION

EPTTCT has been shown to be effective in tympanic membrane perforation closures with minimal complications. This study further demonstrates the efficacy and safety of these procedures in a single-center review.

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.

A comparative study of endoscopic myringoplasty versus microscopic myringoplasty at tertiary care center

BACKGROUND AND OBJECTIVES

Myringoplasty is a surgical procedure performed to repair tympanic membrane perforation which can be performed either using a microscope or an endoscope. The aim of this study is to compare the graft uptake, hearing outcome and operative time of endoscopic myringoplasty (EM) versus microscopic myringoplasty (MM) by underlay cartilage island graft technique.

SUBJECTS AND METHODS

In this prospective comparative study of sixty patients divided into two equal groups with small to medium sized tympanic membrane perforation were included. Tragal cartilage was used as graft material. Both the groups underwent myringoplasty by underlay cartilage island graft using endoscope (n = 30) and microscope (n = 30). The study was conducted between February 2022 to May 2023 after taking ethical approval from IRC of Nepalese Army Institute of Health Sciences. All patients were followed up on 7th postoperative day (POD), 1 and 3 months after surgery.

RESULTS

Graft uptake in was 90 % (27/30) in MM group and 93.33 % (28/30) in EM group. Mean operating time was more in MM group (66.46 ± 6.78min) than EM group (64.53 ± 6.6 min). The improvement in Air Bone Gap (ABG) was better in EM group (12.46 ± 6.58 dB) compared to MM group (10.9 ± 9.01 dB). The differences in graft uptake, operating time and improvement in ABG were not statistically significant.

CONCLUSION

The study concludes that it does not matter which approach is used, good results are predictable and choice of the tool used is up to the individual surgeon.

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.

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.

Postoperative Outcomes of Endoscopic versus Microscopic Myringoplasty in Patients with Chronic Otitis Media-A Systematic Review

Endoscopes are increasingly being used in middle ear surgery as an adjunct to or replacement for the operative microscope. The superior visualization of hidden areas and a minimally invasive transcanal approach to the pathology are some of the endoscope's advantages. The aim of this review is to compare the surgical outcomes of a totally endoscopic transcanal approach with a conventional microscopic approach for type 1 tympanoplasty in patients with chronic otitis media (COM) in order to establish if endoscopic myringoplasty (EM) could be a better alternative to microscopic myringoplasty (MM). A literature review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis recommendations. The selected articles were identified by searching PubMed Central, PubMed, MEDLINE and Embase databases for the relevant publications. Only studies where the same surgeon in the department performed both endoscopic and microscopic myringoplasty have been included in the review. The results suggest that with an endoscopic approach, minimally invasive myringoplasty can be achieved with a similar graft success rate and postoperative air-bone gap (ABG) improvement, a shorter operative time and less postoperative complications compared to a microscopic approach.

Trans-canal tragal cartilage myringoplasty; a comparative analysis of endoscopic and microscopic approaches

BACKGROUND

The advent of Endoscopic Ear Surgery (EES) has allowed otologists an improved view of the surgical field compared with conventional Microscopic Ear Surgery (MES). EES presents different challenges for surgeons and a learning curve is necessary.

AIMS

The purpose of this study was to compare the efficacy of EES and MES for trans-canal tragal cartilage myringoplasty, an entry level EES.

METHODS

We retrospectively analysed patients who underwent push through trans-canal tragal cartilage myringoplasty in our institution over 5 years (2016-2020). Exclusion criteria were: patients with prior ear surgery, non-tragal cartilage tympanic membrane graft, additional procedure at time of surgery and patients with insufficient follow up. EES and MES groups were compared using outcomes such as graft success rate, changes in pure tone audiometry (PTA), operative time and complications.

RESULTS

Seventy-four patients met inclusion criteria (MES = 38, EES = 36). Mean age of included patients was 29.3 years with no significant demographic differences between groups. Graft success rate at 12 months was higher among the EES group versus MES (94.4% v 86.8%, p = 0.43). Mean operative time was reduced in the EES group (47.3 min v 53.8 min, p = 0.04). Hearing outcomes did not differ significantly between groups. No major operative complications occurred in either group.

CONCLUSIONS

Outcomes were marginally better in the cohort who underwent EES. This supports that EES offers an otologic choice to complement established practice for trans-canal myringoplasty and may be used to facilitate introduction to EES for trainees and otologists wishing to learn this technique.

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.

Comparison of the clinical outcome of endoscopic push-through myringoplasty and microscopic overlay myringoplasty: matching co-variated designs

Background

The conventional microscopic overlayer myringoplasty is preferred because it allows a both hands technique, not reducing middle ear space, increasing the blood supply in the repaired area, and providing graft support; however, this technique may be troublesome for the novice surgeon during tympanomeatal flap elevation. Recently, the endoscopic push-through myringoplasty technique has developed. It provides better visualization of the hidden areas and does not require raising tympanomeatal flap. Therefore, the comparison of clinical outcomes between endoscopic push-through myringoplasty and conventional microscopic overlay myringoplasty technique was investigated.

Methods

A retrospective case–control hospital-based study was conducted using archival data from the patients who underwent myringoplasty between January 2015 and May 2021 at Srinagarind Hospital and Khon Kaen Hospital, Thailand. The medical records of patients who underwent endoscopic push-through technique or microscopic overlayer technique were chosen by simple randomization and matched 1:1 based on the air conduction threshold, air-bone gap, size of perforation, and experience of the surgeon. The two techniques were compared for clinical outcome success, including tympanic membrane closure, improved air conduction threshold, air-bone gap closure, and operation time duration.

Results

Medical records of 70 patients were retrieved and classified into 35 patients who underwent endoscopic push-through and 35 patients who underwent microscopic overlayer myringoplasty. The size of tympanic membrane perforation and preoperative audiometry were not significantly different between both groups (p > 0.05). The postoperative outcome in endoscopic technique revealed that the air-bone gap and the success rate of tympanic membrane closure were comparable with microscopic techniques (p = 0.420 and p = 0.156, respectively). The operation time was significantly shorter in the endoscopic technique (p < 0.05). Complications were found in one patient with otitis externa in the endoscopic technique group and one patient with graft lateralization in the microscopic technique group.

Conclusions

Endoscopic push-through myringoplasty is an alternative minimally invasive technique that may allow the potential outcomes comparable with the microscopic overlayer myringoplasty and with a significantly shorter operation time.

Comparing Transcanal Endoscopic Ear Surgery to Post-Auricular Microscope-Guided Surgery in Pediatric Ossiculoplasty: Hearing Outcomes and Post-Operative Pain

OBJECTIVE

This study compares post-operative hearing outcomes and morbidity after pediatric total ossicular replacement prosthesis (TORP) ossiculoplasty with transcanal totally endoscopic ear surgery (TEES) versus a post-auricular microscope-guided (PAM) approach.

PATIENTS

Forty-four children who underwent ossiculoplasty with titanium TORP after previous cholesteatoma surgery.

INTERVENTION

Ossiculoplasty using TEES or PAM approach.

MAIN OUTCOME MEASURES

Hearing outcome after ossiculoplasty was determined by post-operative air-bone gap (ABG) on audiogram nearest to 1 year after surgery. Post-operative morbidity was measured by total number of opiate doses the child received during hospital stay, along with the highest documented post-operative pain score. Comparisons were made with Mann-Whitney U test.

RESULTS

Hearing data were available for 41 patients: 21 had undergone TEES (median preoperative ABG 39 dB) and 20 had PAM surgery (median preoperative ABG 39 dB). Post-operatively at 1 year, ABG closed significantly in each group (TEES 21 dB, p = 0.003; PAM 23 dB, p = 0.01), and there was no difference between groups (p = 0.6). 57% who underwent TEES and 50% who underwent PAM surgery experienced serviceable hearing post-operatively, defined as air conduction pure-tone average (PTA) ≤ 30 dB HL. Visual analogue pain scores from 0 (no pain) to 10 (worst pain imaginable) were available for 13 who underwent TEES and 18 who underwent PAM surgery. In children undergoing TEES, only two reported pain above 0, with the highest pain score being 4. Children undergoing PAM surgery had a median pain score of 3 (median difference = 3, p < 0.001). Children undergoing TEES required fewer weight appropriate doses of opiate analgesic (median = 0) than children who underwent PAM surgery (median = 1) (median difference = 1, p = 0.003). Children undergoing TEES had a significantly shorter surgical time (median 135 min) than those who underwent PAM surgery (median 168 min) (median difference = 33 min, p = <0.006).

CONCLUSION

Hearing outcomes in TORP ossiculoplasty are similar in TEES and PAM surgery, and TEES may decrease post-operative pain.

Transcanal Endoscopic Retrograde Mastoidectomy for Cholesteatoma: A Prospective Study

OBJECTIVES

To evaluate the feasibility, morphological, and functional outcomes of endoscopic retrograde transcanal mastoidectomy.

STUDY DESIGN

Prospective study.

SETTINGS

Tertiary Referral Hospital.

MATERIALS AND METHODS

We analyzed 31 patients with a diagnosis of chronic otitis media with cholesteatoma that extended to the mastoid cavity who underwent endoscopic transcanal retrograde canal wall down mastoidectomy under general anesthesia. The tympanic membrane and posterior canal wall reconstruction were done using the tragal cartilage palisade technique reinforced with perichondrium. Morphological and functional results were reported in the follow-up of a minimum of 1 year. The graft uptake was also compared with the presence of granulations and discharge status.

RESULTS

Graft uptake and disease-free conditions were achieved in 21 of 24 patients, that is, 87.5%, and 3 patients required revision surgery. The graft uptake rate was not affected by the presence of granulation tissues and discharge. The hearing was improved after the surgery, which was statistically significant.

CONCLUSION

Endoscopic retrograde mastoidectomy is a new technique to deal with cholesteatoma with excellent results. It is more functional, ideal for sclerotic mastoid, allows faster wound healing, has excellent outcomes, and is a minimally invasive procedure that avoids postauricular incision and tissue dissection. Because the set up for the surgery costs less, it holds a promising future for the developing countries.

Endoscopic versus microscopic type-I cartilage tympanoplasty for anterior perforation - a comparative study

BACKGROUND

Chronic otitis media with anterior perforation is a challenging condition to treat with a microscope especially if the canal is narrow or has overhang. The endoscope provides the advantage of wide-angle view and transcanal access avoiding postauricular approach and canaloplasty.

OBJECTIVE

To compare the anatomical, functional outcomes, and surgical duration between endoscopic and microscopic type-I tympanoplasty performed for anterior perforation.

MATERIALS AND METHODS

A comparative study was conducted. The two groups, the microscopic (MT) and the endoscopic (ET) were created with 50 cases each and underwent type-I tympanoplasty. Results were evaluated at a minimum follow-up of 12 months.

RESULTS

The graft uptake rate in MT and ET was 81.8% and 91.3% respectively and was not statistically significant. The mean operative time for MT and ET was 68.68 ± 18.79 min and 61.24 ± 11.18 min respectively which was significant (p-.003). Endoscopic tympanoplasty significantly saved time. The difference in hearing outcomes was highly significant within the groups but not between the groups.

CONCLUSION AND SIGNIFICANCE

The endoscopic tympanoplasty offered superior visualization avoiding postauricular incision and canaloplasty, with morphological and functional outcomes comparable to microscopic tympanoplasty. It offers significantly faster completion of procedure and provides minimally invasive surgery.

Comparison of clinical outcome between endoscopic and postauricular incision microscopic type-1 tympanoplasty

BACKGROUND

Microscopic type-1 tympanoplasty (T1T) is a classical method for the treatment of chronic otitis media. However, it has its limitations. The development of otoendoscopy provided a new method for T1T.

OBJECTIVE

To investigate the difference between endoscopic T1T and microscopic T1T.

MATERIAL AND METHODS

Seventy-four patients who underwent T1T were evaluated retrospectively. About 52 cases underwent endoscopic T1T, and 22 cases accepted microscopic T1T. Parameters including operative duration, incision size, graft site, duration of postoperative hospitalization, visual analog scale (VAS) score, complications, hearing improvement, and expenses were compared.

RESULTS

Operative duration of endoscopic T1T (47.0 ± 8.2 min) was shorter than microscopic T1T (58.0 ± 9.3 min) (p < .05). The VAS score under endoscopic T1T (1.5 ± 0.2) was lower than microscopic T1T (5.6 ± 0.4) (p < .05). There was no complication during endoscopic T1T, but damage to the chorda tympani nerve (one case) was noted for microscopic T1T. There was no difference in hearing improvement between endoscopic (15.0 ± 1.5 dB) and microscopic T1T (16.0 ± 1.1 dB). Duration of postoperative hospitalization and expenses were lower for endoscopic T1T.

CONCLUSIONS AND SIGNIFICANCE

Endoscopic T1T is a minimally invasive surgery with similar graft success rate, comparable hearing improvement, fast recovery, low cost, and high patient satisfaction compared to microscopic T1T.

Comparison of frequency-specific hearing outcomes after endoscopic and microscopic tympanoplasty

BACKGROUND

Hearing results of endoscopic and microscopic tympanoplasty have been compared using the average pure tone threshold which could conceal subtle differences at a specific frequency.

OBJECTIVES

To compare frequency-specific hearing outcomes of endoscopic and microscopic tympanoplasty.

MATERIAL AND METHODS

The study included 42 patients who underwent endoscopic or microscopic type I tympanoplasty. The medical charts of these patients were reviewed retrospectively. We evaluated the pure tone audiometry at 250, 500, 1000, 2000 and 4000 Hz, including bone conduction (BC), air conduction (AC) and air-bone gap (ABG) before and after the surgery. The main outcome measures were frequency-specific pre- and post-operative hearing thresholds and the corresponding changes. We also assessed the graft success rate and surgical complications.

RESULTS

BC revealed a significant aggravation at 4000 Hz in microscopic tympanoplasty group, but no significant differences between the two groups at any frequencies. Both groups showed improvements in AC and ABG at all frequencies, without significant differences between the two groups at any single frequency. The maximum improvement of AC and ABG was found at 250 Hz. The graft success rate and operative complications were also similar.

CONCLUSIONS AND SIGNIFICANCE

The frequency-specific hearing outcomes of endoscopic and microscopic tympanoplasty are similar.