Endoscopic Versus Microscopic Approach in Stapes Surgery: Are Operative Times and Learning Curve Important for Making the Choice?

Endoscopic Versus Microscopic Stapedotomy: A Randomized Clinical Trial

OBJECTIVE

To determine the outcomes and complications of endoscopic versus microscopic stapes surgery in patients with otosclerosis.

STUDY DESIGN

Randomized, single-blinded clinical trial.

METHODS

Patients with otosclerosis who underwent either trans-canal microscopic or endoscopic stapedotomy at a tertiary care hospital were compared. Thirty-two patients were randomly divided into two groups using blocked randomization. Group A consisted of 16 patients who underwent trans-canal microscopic stapedotomy, and group B consisted of 16 patients who underwent trans-canal endoscopic stapedotomy. Postoperative vertigo, ear pain, and complications such as tympanic membrane perforation or chorda tympani nerve injury were evaluated. Three months postoperatively, patients were assessed for dysgeusia and hearing improvement.

RESULTS

The mean pre-operative air-bone gap (ABG) in the microscopic and endoscopic groups was 32.81 ± 6.82 and 30.00 ± 7.96, respectively. The mean improvement in the ABG was 25.45 ± 11.21 dB in the microscopic group and 23.21 ± 10.68 dB in the endoscopic group. Although both techniques showed improvement in auditory outcomes (p-value <0.001), there were no statistical differences between the endoscopic and microscopic groups in the pre-operative, post-operative, and mean improvement of ABG (p-value >0.05). There were no significant differences between the two methods in chorda tympanic nerve injury, vertigo scores, and the mean operating time (p-value >0.05), but the mean pain score was higher in the microscopic group (2.56 ± 1.55 in the microscopic group versus 1.31 ± 0.70 in the endoscopic group) (p-value = 0.003).

CONCLUSIONS

Endoscopic stapes surgery can be a preferable alternative to conventional microscopic stapedotomy, as it yields similar hearing outcomes and lower pain scores.

LEVEL OF EVIDENCE

2 Laryngoscope, 134:2395-2400, 2024.

Exoscope-Assisted Stapedotomy: Evaluation of Safety and Efficacy

OBJECTIVE

Evaluate the safety and efficacy of exoscope-assisted stapedotomy.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary care neurotology clinic.

PATIENTS

Adult patients with otosclerosis undergoing stapedotomy.

INTERVENTIONS

Primary stapedotomy.

MAIN OUTCOME MEASURES

Evaluation of audiologic outcomes, including pure-tone average, bone-conduction thresholds, word recognition score, and air-bone gap. Complications, need for scutum removal, and length of surgery were also evaluated.

RESULTS

A total of 47 patients were identified, and 24 patients underwent surgery with the microscope and 22 with the exoscope. There were significant improvements in pure-tone average, mean bone-conduction thresholds, and air-bone gap for both groups. There was no difference in preoperative or postoperative audiologic status for either group. There was no difference in rates of dysgeusia, chorda tympani nerve damage, dizziness, or facial paresis in either group.

CONCLUSIONS

This study indicates similar audiologic outcomes, complication profiles, and visualization when comparing exoscopic and microscopic stapedotomy. Demonstrated here, exoscopic stapedotomy can be safely performed in a transcanal manner.

Training in Endoscopic Ear Surgery: A Scoping Review

OBJECTIVE

Despite the increasing popularity of Endoscopic Ear Surgery (EES), there is a lack of evidence to guide trainees as they introduce EES into practice. This review aims to evaluate training in EES including the optimal introductory procedures, methods of training, the learning curve, and the determination of competency in EES. In addition, this review seeks to identify any areas falling within these themes requiring further clarification.

DATA SOURCES

A database search of Pubmed, Embase and the Cochrane Library was conducted in June 2022. Original articles, systematic reviews, and meta-analyses reporting on training in EES, introduction into practice, learning curves, and competency assessment were included.

REVIEW METHODS

A scoping review was carried out in accordance with the Joanna Briggs Institute guidelines and reported according to PRISMA guidelines for scoping reviews. A qualitative assessment of results grouped thematically was performed.

RESULTS

Twenty-eight studies met the inclusion criteria, with 24 rating as "fair" or "good" on quality assessment. Surgical simulation was the most frequently described method of training as utilized in 11 studies. The most suggested introductory procedure was tympanoplasty which was advocated for in five studies. Heterogeneity existed in the outcomes and methodologies used to measure EES learning curves, with an overreliance on surgical times. No robust definition of competency in EES procedures exists at present.

CONCLUSIONS

Surgical simulation appears to be a beneficial training methodology for EES. However, there is a marked lack of objective data to describe the optimal introductory procedures or assessment of competency in EES. Laryngoscope, 133:3269-3278, 2023.

Management of cholesterol granuloma due to eosinophilic otitis media using large ventilation tube

A 46-year-old man who had been diagnosed with eosinophilic otitis media (EOM) and eosinophilic chronic rhinosinusitis was referred to our department. He suffered from bilateral earache, clogged ear sensation, and otorrhea associated with EOM. He had been treated with a myringotomy and a ventilation tube (VT) insertion. However, his symptoms did not improve, and the VT repeatedly fell out. We performed canal wall down mastoidectomy via a retro-auricular incision to remove the presumed cholesterol granuloma (CG) and a long-term VT insertion. The VT fell out repeatedly. Therefore, a large VT that Komune devised was inserted. Four months after reinsertion, there was no evidence of recurrent otorrhea or fallout of a large VT. A large VT insertion could be useful in the severe case of EOM with CG.

Brazilian Society of Otology task force - Otosclerosis: evaluation and treatment

OBJECTIVES

To review and provide evidence-based recommendations for the diagnosis and treatment of otosclerosis.

METHODS

Task force members were educated on knowledge synthesis methods, including electronic database search, review and selection of relevant citations, and critical appraisal of selected studies. Articles written in English or Portuguese on otosclerosis were eligible for inclusion. The American College of Physicians' guideline grading system and the American Thyroid Association's guideline criteria were used for critical appraisal of evidence and recommendations for therapeutic interventions.

RESULTS

The topics were divided into 2 parts: 1) Diagnosis - audiologic and radiologic; 2) Treatment - hearing AIDS, pharmacological therapy, stapes surgery, and implantable devices - bone-anchored devices, active middle ear implants, and Cochlear Implants (CI).

CONCLUSIONS

The pathophysiology of otosclerosis has not yet been fully elucidated, but environmental factors and unidentified genes are likely to play a significant role in it. Women with otosclerosis are not at increased risk of worsening clinical condition due to the use of contraceptives or during pregnancy. Drug treatment has shown little benefit. If the patient does not want to undergo stapedotomy, the use of hearing aids is well indicated. Implantable systems should be indicated only in rare cases, and the CI should be indicated in cases of profound deafness.

Endoscopic stapedotomy: classic versus reversal technique

OBJECTIVES

To compare hearing outcome and surgical complications between endoscopic classic and reversal stapedotomies.

PATIENTS AND METHODS

A prospective single blinded randomized clinical study carried out on 60 patients with otosclerosis who were randomized into two groups; each containing 30 patients. Patients in group 1 underwent endoscopic classic stapedotomy. Patients in group 2 underwent endoscopic reversal stapedotomy. Both groups were compared as regards hearing outcome and surgical complications.

RESULTS

The difference in the hearing outcome between the two groups was statistically non-significant. Post-operative closure of the air bone gap (ABG) within 10 dB was attained in 76.67% and 80% of patients in groups 1 and 2, respectively. The differences in the surgical complications between the two studied groups were statistically non-significant.

CONCLUSION

Endoscopic classic and reversal stapedotomies are comparable to each other as regards hearing outcome and surgical complications. The authors recommend further studies with relatively larger sample size.

Comparison of endoscopic and microscopic methods in stapedotomy: a retrospective analysis

PURPOSE

The goal of the present study was to compare the audiologic results, complications, and advantages/disadvantages of endoscopic and microscopic stapedotomy.

METHODS

Patients who experienced stapedotomy surgery in the Ear Nose Throat Clinic (ENT) of Selcuk University Faculty of Medicine between September 2011 and January 2018 were included in the study. The data of all patients were analyzed and divided into two groups. Those who underwent endoscopic stapedotomy were included in group I, and patients who underwent microscopic stapedotomy formed group II. Surgical findings, complications, and operation times were compared for the two groups. Air and bone conduction thresholds were evaluated at the frequencies of 500, 1000, 2000, and 4000 Hz pre- and postoperatively at 1, 3, and 6 months, and the mean (± SD) air-bone gap value was recorded.

RESULTS

While the mean pre- and postoperative air-bone gaps were 34.38 ± 7.47 dB (23-53 dB) and 9.69 ± 4.43 dB (0-19 dB), respectively, in group I, 34.32 ± 7.57 dB (23-6 dB) and 9.62 ± 4.25 dB (2-23 dB) were the respective means calculated in group II (p < 0.05). When the mean postoperative air-bone gap was compared, there was no statistically significant difference between the two groups (p = 0.774). The mean operative times for groups I and II were 57.22 ± 4.37 min and 63.70 ± 7.34 min, respectively (p < 0.001). The requirement for chorda tympani nerve manipulation and scutum curettage was significantly less in group I compared to group II (p = 0.003). Postoperative dysgeusia and postoperative pain were found to be higher in group II than group I, but they were not statistically significant (p > 0.05).

CONCLUSION

Endoscopic stapedotomy displayed similar audiological results, shorter operation times, and similar complication rates, as well as being a less invasive surgery, compared to the microscopic approach.

Hydroxyapatite Prostheses in Endoscopic Transcanal Stapes Surgery for Otosclerosis Cases

OBJECTIVES

Hydroxyapatite is a commonly used material for medical applications due to its excellent biocompatibility. We use hydroxyapatite prosthesis for the reconstruction of the ossicular chain in stapes surgery. In this study, we report a case series of endoscopic ear surgery using a basket-type hydroxyapatite prosthesis.

METHODS

We retrospectively examined 8 cases of endoscopic transcanal stapes surgery using hydroxyapatite prostheses. We evaluated the postoperative results and complications.

RESULTS

The average postoperative air-bone gaps were within 10 dB in all cases. Postoperative sensorineural hearing loss was not observed in any case. There was an intraoperative complication with the chorda tympani in 1 patient. We were able to preserve the chorda tympani of all patients, including this case. Postoperative transient dizziness and transient taste disorder were observed in 50% of cases. No other complications, including facial nerve palsy, tympanic membrane perforation, or postoperative infection, were observed.

CONCLUSIONS

The postoperative results and complications were comparable to those of surgery under a microscope. The hydroxyapatite prosthesis could be a possible alternative for the piston-type titanium or polytetrafluoroethylene prosthesis.

Endoscopic transcanal management of incus long process defects: rebridging with bone cement versus incus interposition

OBJECTIVES

to compare hearing outcomes between endoscopic transcanal rebridging with bone cement and endoscopic transcanal incus interposition in patients with incus long process defects secondary to chronic suppurative otitis media (inactive mucosal type).

METHODS

This retrospective study was performed on 83 ears of 83 consecutive patients with incus long process defects secondary to chronic suppurative otitis media (inactive mucosal type). According to the extent of incus long process erosion and subsequent ossiculoplasty technique, patients were divided into 2 groups. Patients in group 1 had erosion involving up to two thirds of the length of the incus long process and underwent endoscopic transcanal rebridging with bone cement. Patients in group 2 had erosion involving more than two thirds of the length of the incus long process and underwent endoscopic transcanal incus interposition.

RESULTS

Hearing gain (mean ± standard deviation) was 21.39 ± 2.15 dB in group 1 and 19.71 ± 6.12 dB in group 2. A significantly greater hearing gain was achieved in bone cement group than in incus interposition group (P value < 0.001). Successful hearing outcome (post-operative air bone gap closure within 20 dB) was achieved in 81.6% and 71.1% of patients of group 1 and group 2 respectively.

CONCLUSION

Endoscopic transcanal rebridging with bone cement offers greater hearing gain than endoscopic transcanal incus interposition. The two techniques remain reliable and cost-effective techniques in management of patients with incus long process defects. The main limitation of this study was the short follow-up period. Further studies with relatively long-term follow-up are strongly recommended.

Transcanal endoscopic management of isolated congenital middle ear malformations

BACKGROUND

A few studies have reported transcanal endoscopic management of isolated congenital middle ear malformations (CMEMs).

OBJECTIVE

The purpose of this study is to describe our surgical experience in endoscopic ear surgery for isolated CMEMs and evaluate the surgical effect of hearing reconstruction.

METHODS

From January 2017 to January 2022, a retrospective study was performed on 36 patients (37 ears) with isolated CMEMs who all underwent endoscopic surgery. Demographic data, high-resolution computed tomography (HRCT) findings, intraoperative findings, surgical management and audiometric data were recorded.

RESULTS

Anomalies were categorized according to the Teunissen and Cremers classification system: 8 ears were categorized as class I, 8 ears as class II, 19 ears as class III and 2 ears as class IV. The air conduction pure tone average (AC-PTA) of 37 cases was 61.5 ± 8.6 dB preoperatively and 29.6 ± 6.9 dB postoperatively (p < 0.001). The mean preoperative air-bone gap (ABG) significantly decreased from 43.1 ± 8.7 dB to 12.8 ± 5.5 dB postoperatively. 36 of 37 cases (97%) met the criteria for successful operation.

CONCLUSION

Isolated CMEMs are mainly manifested as aplasia of the stapes' superstructure and dysplasia of the long process of the incus. Transcanal endoscopic surgery seems a safe technique for the management of isolated CMEMs.

Endoscopic vs. microscopic stapes surgery: An anatomical feasibility study

Objectives

To investigate the feasibility of the endoscopic approach vs. microscopic approach during stapes surgery, focusing on the visualization of the important anatomical structures of the middle ear, the volume of the resected scutum and chorda tympani (CT) injury.

Methods

Fresh frozen human cadaveric heads underwent two stapes surgeries using an operating microscope on one ear and an endoscope on the other ear. The surgeon documented the visualization of critical landmarks, as well as exposure and injury of the CT. The volume of resected scutum was evaluated using cone beam computed tomography scanning and three-dimensional imaging.

Results

We performed endoscopic stapes surgery in 10 ears and microscopic stapes surgery in 11 ears. A stapes prosthesis was placed in all ears. The volume of bony scutum resection was significantly lower in the endoscopic group (median = 2.20 mm³, IQR = 4.17) than in the microscopic group (median 13.25 mm³, IQR = 8.71). No scutum was removed in two endoscopic ears, while scutum was removed in all microscopic ears. The endoscopic and microscopic group had similar CT injury.

Conclusions

This study showed that the endoscopic stapes surgery procedure is feasible and might be less invasive than microscopic stapes surgery. Future clinical prospective and functional studies will be needed to support our findings.

Endoscopic Versus Microscopic Stapedotomy: Our Experience

With technological improvements leading to enhanced image resolution, as well as recognized acceptance of endoscopes within the field of rhinology, there has been greater implementation of endoscopes in otologic and neurotologic procedures. Surgeons now use endoscopes for a wide range of otological procedure, one such procedure is endoscopic stapedotomy for otosclerosis. This study is done to compare merits and demerits of endoscopic stapedotomy with microscopic stapedotomy. This is a prospective observational study conducted in SMBT Medical College and Hospital, Nashik from January 2018 to January 2020. 40 patients who presented to ENT OPD with clinical features suggestive of otosclerosis and who fulfilled inclusion and exclusion criteria were included in the study. Detailed history, complete ENT examination and audiological investigations were done. Preanesthetic evaluation was done and patients were randomly allotted into two groups. Group A: consisted of twenty patients who underwent microscopic stapedotomy under local anesthesia Group B: consisted of twenty patients who underwent endoscopic stapedotomy under local anesthesia. Data was collected in pre-structured proforma and analyzed. There was no statistically significant difference between microscopic and endoscopic procedure in terms of duration of the surgery, hearing improvements or complications. However, surgeons noted that ease of visualization of middle ear structures and the better image quality favors endoscopic procedure over microscopic procedure. There is no increased risk of complications with endoscopic stapedotomy and hearing improvement is same as that of microscopic stapedotomy however the ease of visualization of middle ear structures and the better image quality favors endoscopic procedure over microscopic procedure. Hence, we conclude that endoscopic stapedotomy is a safe alternative to microscopic stapedotomy.

Perspectives and early experience on endoscopic stapedotomy from a group of "traditional school" otologists

Background: This paper evaluates endoscopic stapedotomy from the perspectives of a group of 3 surgeons, each of whose experience in endoscopic and microscopic stapedotomy is 3 years and more than 12 years, respectively.Methods: Thirty-four patients clinically diagnosed with stapedial otosclerosis were alternately assigned for unilateral, microscope- and endoscope-assisted stapedotomy following the selection criteria given. Results were evaluated with predetermined epidemiologic, preoperative, perioperative, and postoperative outcome parameters.Results: The microscope group had 12 ears with otosclerosis and the endoscope-assisted group 14. Ears found to have conditions other than otosclerosis at surgery, and patients lost to follow-up were excluded. Apart from the operative time, the difference in the results of none of the parameters was statistically significant in the two groups. The average operative times for microscope- and endoscope-assisted stapedotomy were 63 minutes and 86.5 minutes, respectively, the difference being statistically significant (P < .001).Conclusions: From the perspectives of otologists in differential positions in the learning curve for microscope- and endoscope-assisted stapedotomy, there were no statistically significant differences between the two procedures in the execution of the steps to achieve "adequate surgical exposure" and in postoperative outcomes, except for operative time.

Postoperative pain after transcanal endoscopic ear surgery: A systematic literature review

OBJECTIVE

Transcanal endoscopic ear surgery is hypothesized to result in less postoperative pain when compared to nonendoscopic techniques due to its minimally invasive nature. In this systematic literature review, we aim to summarize and evaluate the evidence surrounding postoperative pain control and analgesic utilization after transcanal endoscopic ear surgery.

DATABASES REVIEWED

PubMed, EMBASE, and Cochrane.

METHODS

A systematic literature search was performed using standardized methodology. Computerized and manual searches were performed to identify studies that evaluated postoperative pain outcomes following endoscopic ear surgery. Only studies that met predetermined criteria were selected and evaluated for quality and bias. Extracted data included demographics, pain scores, analgesic administered as well as the diagnosis and type of surgery undertaken. Exclusion criteria included letters/commentaries and reviews, lack of pain outcome data and studies not concerning endoscopic ear surgery.

RESULTS

The systematic literature review included 24 studies. Seven were RCTs, 10 were prospective and 7 were retrospective observational studies. A total of 1859 patients were evaluated for surgical approach and postoperative pain levels and analgesic use. Due to the lack of sufficient reporting of the data, a meta-analysis was not applicable. In the qualitative synthesis for the primary outcome, weighted pooled analysis showed that there was a slight reduction in postoperative pain after transcanal endoscopic ear surgery. Based on the Cochrane risk of bias tool, the quality for the finding is low.

CONCLUSION

There is a small reduction in postoperative pain after transcanal endoscopic ear surgery when compared to nonendoscopic approaches, however, the clinical significance of this reduction is unclear. The evidence was from studies of only low to moderate quality.

Endoscopic Versus Microscopic Stapedotomy: A Single-Blinded Randomized Control Trial

OBJECTIVE

To demonstrate non-inferiority of endoscopic stapedotomy to microscopic stapedotomy for the treatment of otosclerosis.

STUDY DESIGN

Single-blinded randomized control trial.

SETTING

Tertiary, academic otology-neurotology practice.

PATIENTS

Adult subjects with a diagnosis of otosclerosis and a preoperative air-bone gap (ABG) more than or equal to 20 dB undergoing primary stapedotomy.

INTERVENTION

Endoscopic or microscopic stapedotomy.

MAIN OUTCOME MEASURES

Primary audiometric outcome was postoperative ABG. Secondary audiometric outcomes included speech reception threshold (SRT), word recognition score (WRS), bone- and air-conduction pure tone averages (PTA), change in ABG, and ABG closure rates to less than or equal to 10 dB and less than or equal to 20 dB.

RESULTS

Twenty-two patients were recruited. Eleven patients underwent endoscopic stapedotomy and 11 underwent microscopic stapedotomy. The endoscopic group was non-inferior to the microscopic group in terms of postoperative audiometric outcomes (endoscope versus microscope, p-value): ABG (8.1 dB versus 8.1 dB, <0.001), SRT (27.7 dB versus 25.9 dB, <0.001), WRS (92% at 65 dB versus 98% at 62 dB, <0.001), air-conduction PTA (33.5 dB versus 30.8 dB, <0.01), and change in ABG (23.0 dB versus 20.7 dB, <0.0001). ABG closure rates to less than or equal to 10 dB (72.7% versus 81.2%, p = 1.0) and less than or equal to 20 dB (90.9% versus 100%, p = 1.0) were not significantly different. There was no significant difference in operative time, necessity of scutum curettage, or postoperative dysgeusia. No patients required chorda tympani sacrifice. Preoperative tinnitus resolved in three patients in each group postoperatively.

CONCLUSIONS

This study is the first randomized control trial to demonstrate non-inferiority of endoscopic to microscopic stapedotomy.

Endoscopic Stapedotomy: A Systematic Review

OBJECTIVES

Stapes surgery has evolved from its origins in 1956. Microscopic assisted stapedotomy remains the most common technique but the introduction of endoscopic ear surgery has led to some units using this new approach. The endoscope delivers a wide angled, contextual view of the stapes, and associated pathology. This systematic review provides a critical analysis of the current published endoscopic data, allowing comparison to the established microscopic technique.

DATA SOURCES

Six databases (PubMed, Medline, Cochrane database, AMED, EMBASE, and CINAHL) were searched for studies within the last 10 years.

STUDY SELECTION AND DATA EXTRACTION

English language articles including 5 or more cases were included. Primary outcomes included audiological results and reported complications. Data was extracted according to PRISMA guidelines.

RESULTS

Thirteen papers were identified comprising 361 endoscopic stapes surgeries. Postoperative temporary facial nerve weakness was reported in 3 patients (0.8%) which all resolved within 4 weeks. Chorda tympani injury occurred in 21 cases (5.8%) and vertigo in 61 (16.9%). The audiometric outcomes of endoscopic stapes surgery were available for 259 patients and showed air bone gap closure rates of 71.4% (0-10 dB), 25.9% (11-20 dB), 2.3% (21-30 dB), and 0.4% (>30 dB).

CONCLUSIONS

Endoscopic stapes surgery has similar audiometric outcomes compared to the traditional microscopic approach with air bone gap closure values of <20 dB in 97.3% of cases. However, the complication rates of chorda tympani damage, postoperative dysguesia, and tympanic membrane perforation for endoscopic stapes surgery are high. Caution should therefore be taken before undertaking stapes surgery with the endoscopic technique. Further studies are required to prove superiority over well established existing microsurgical methods.

Postoperative Pain After Endoscopic vs Microscopic Otologic Surgery: A Systematic Review and Meta-analysis

OBJECTIVE

Equivalent outcomes, such as procedural safety and audiometry, have been reported between endoscopic ear surgery (EES) and microscopic ear surgery (MES). This study aims to determine if EES leads to decreased postoperative pain when compared with MES.

DATA SOURCES

PubMed, OVID MEDLINE, Scopus, Web of Science, and Cochrane Central from 2000 to 2020.

REVIEW METHODS

A systematic review in accordance with the PRISMA guidelines and standardized bias assessment was performed. Studies containing original data on postoperative pain following EES and MES were included.

RESULTS

Fourteen studies fulfilled eligibility: 7 retrospective studies, 6 randomized controlled trials, and 1 case series. Studies included surgery for cholesteatoma (n = 3), tympanoplasty/myringoplasty (n = 6), and stapedotomy (n = 5), pooling data from 974 patients. Postoperative pain was quantitatively described through a variety of numeric pain scores. Meta-analysis was performed on 11 studies. Among the 7 studies utilizing the numeric rating scale or visual analog scale, postoperative pain in the EES cohort was significantly lower than that of the MES cohort (standardized mean difference = -1.45 [95% CI, -2.05 to -0.85], P < .001). Similarly, pain scores were lower in the EES cohort among the 4 studies utilizing the Three Grades Pain Scale (odds ratio = 0.2 [95% CI, 0.09-0.45], P < .001). Additional qualitative strengths identified in EES included significant improvements in visualization, operative time, postoperative complications, and decreased need for canalplasty. Quality assessment indicated low to moderate risk of bias for all studies.

CONCLUSION

Meta-analysis confirms that EES results in significantly less postoperative pain when compared with MES. This surgical approach should be considered in the armamentarium of otologic surgeons, allowing for improved outcomes.

Exclusive Endoscopic Laser-Stapedotomy: Feasibility of an Ovine Training Model

OBJECTIVE

Stapedotomy is an effective treatment for conductive hearing loss associated with otosclerosis. However, the procedure, especially using the endoscopic technique requires extensive training and experience for optimal results. Due to limited training options in endoscopic stapes surgery, we aim to develop an ovine stapedotomy model and assess its feasibility for surgeons at different training levels.

METHODS

A fully endoscopic ovine laser-stapedotomy model was developed and described. During repetitive dissections, surgical time required for the different steps to assess the training curve and associated intraoperative complications were recorded in three surgeons of different training level. Additionally, subjective feedback was assessed.

RESULTS

Successful endoscopic laser-stapedotomy was performed in 25 cases in the ovine model. Assessment of surgical time revealed a stable curve for the experienced surgeon (mean 15:01 min) for the whole training with no intraoperative complications. The fellow showed a gradual reduction of surgical time from 27:21 (first five cases) to 24:10 minutes (last five cases) and the resident a reduction from 42:38 to 21:08 minutes respectively. The assessed learning curve for the trainees revealed a significant association between the operative time and observed intraoperative complications.

DISCUSSION

In this study, an ex-vivo model for exclusively endoscopic laser-stapedotomy was developed and tested for feasibility. We suggest the ovine model as a cost-effective, easily available, and realistic training model for future otologic surgeons. The surgeons were able to improve their performance with satisfactory results despite the small number of cases.

Conventional approaches versus laser CO2 surgery in stapes surgery: a multicentre retrospective study

PURPOSE

To analyze and compare surgical and audiological outcomes of conventional approaches versus laser CO2 surgery in stapes surgery.

METHODS

333 patients who underwent stapes surgery were enrolled in the study; the patient population was divided into three groups: group 1: 170 patients treated with conventional stapedotomy with manual microdrill (average age 49.13 years); group 2: 119 patients treated with conventional stapedotomy with electrical microdrill (average age 51.06 years); group 3: 44 patients (average age 50.4 years) who underwent CO2 laser stapedotomy. Intra-operative, postoperative outcomes and audiological results were investigated.

RESULTS

The average surgical time of laser CO2 surgery was longer than for other surgical procedures. No statistical differences emerged in post-operative abnormal taste sensation. There was also no difference in postoperative dizziness. Air-bone gap (ABG) went down from 29.7 ± 10 dB (group 1) and 27.32 ± 9.20 (group 2) to 10 ± 6.9 dB (group 1) and 10.7 ± 6.03 dB (group 2). In group 3 the preoperative ABG was lowered from 28.3 ± 10.1 to 11.8 ± 10.9, with a statistical difference in auditory recovery (p = 0.0001); The group of patients treated with laser CO2 showed a percentage of patients with an ABG closure of between 0 and 10 dB higher than in the group treated with manual microdrills (77.2% vs. 60%, respectively; p = 0.03).

CONCLUSION

Overall surgical results of CO2 laser and conventional stapedotomy are comparable without any significant difference; however, the group treated with CO2 laser appears to have a percentage of patients with an ABG closure 0-10 dB higher than the group treated using the conventional technique.

Endoscopic versus microscopic surgery for treatment of middle ear cholesteatoma: A systematic review and meta-analysis

OBJECTIVE

Endoscopic ear surgery (EES) is minimally invasive and increasingly used to treat middle ear disease. In this meta-analysis, we compared the efficacies of EES and microscopic ear surgery (MES) in patients with middle ear cholesteatoma.

METHODS

The PubMed, Embase, Cochrane Library, and Web of Science databases were searched for studies that reported the comparative surgical outcomes of EES and MES in patients with middle ear cholesteatoma. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. All included studies involved ≥1 of the following outcomes: recurrence of or residual disease, graft intake success rate, audiological performance, and operation time. We calculated the pooled relative risk (RR) or weighted mean difference with 95% confidence intervals (CIs) by using STATA software.

RESULTS

Thirteen studies were included in the quantitative meta-analysis. The pooled recurrence and residual rates of cholesteatoma were significantly lower in the EES group than in the MES group [RR: 0.51, 95%CI: 0.31-0.84, heterogeneity (I²) = 4.7%; P = .394; RR: 0.68; 95%CI: 0.47-0.99; I² = 0.0%; P = .878; respectively]. There were no significant differences in other parameters, such as graft intake success rates, audiological performance, and operation times, between the 2 groups.

CONCLUSION

The pooled results showed that EES reduced the residual lesion rate and postoperative recurrence risk in patients with middle ear cholesteatoma. However, there was insufficient evidence to prove that EES was advantageous in graft intake success rate auditory performance, and operation time.

Systematic Review and Meta-analysis of Endoscopic vs Microscopic Stapes Surgery for Stapes Fixation

OBJECTIVE

To systematically review the current literature regarding the operative outcomes of stapes surgery for stapes fixation via the endoscopic and microscopic approaches.

DATA SOURCES

PubMed, Embase, and Web of Science.

REVIEW METHODS

An electronic search was conducted with the keywords "endoscop* or microscop*" and "stapes surgery or stapedectomy or stapedotomy or otosclerosis or stapes fixation." Studies were included if they compared endoscopy with microscopy for stapes surgery performed for stapes fixation and evaluated hearing outcomes and postoperative complications. Articles focusing on stapes surgery other than for stapes fixation were excluded.

RESULTS

The database search yielded 1317 studies; 12 remained after dual-investigator screening for quantitative analysis. The mean MINORS score was 18 of 24, indicating a low risk of bias. A meta-analysis demonstrated no statistically significant difference between the groups with regard to operative time, chorda tympani nerve manipulation or sacrifice, or postoperative vertigo. There was a 2.6-dB mean improvement in the change in air-bone gap in favor of endoscopic stapes surgery and a 15.2% increased incidence in postoperative dysgeusia in the microscopic group, but the studies are heterogeneous.

CONCLUSIONS

Endoscopic stapes surgery appears to be a reasonable alternative to microscopic stapes surgery, with similar operative times, complications, and hearing outcomes. Superior visibility with the endoscope was consistently reported in all the studies. Future studies should have standardized methods of reporting visibility, hearing outcomes, and postoperative complications to truly establish if endoscopic stapes surgery is equivalent or superior to microscopic stapes surgery.

Endoscopic Myringoplasty and Type I Tympanoplasty

Herein we provide a broad overview of the literature as it applies to endoscopic myringoplasty and type I tympanoplasty. Advantages and disadvantages of the endoscopic approach are reviewed for both the adult and pediatric populations and are compared with conventional microscopic techniques.

Endoscopic Stapes Surgery: Pearls and Pitfalls

The endoscopic approach to stapes surgery affords unique advantages but is not without its specific challenges. The following reviews the equipment and surgical steps required to perform endoscopic stapes surgery safely and effectively, highlighting tips and potential points of failure through a series of case examples.

A comparison of endoscopic and microscopic inlay butterfly cartilage tympanoplasties and their educational utility

Objectives

Inlay butterfly cartilage tympanoplasty (IBCT) is a simple grafting technique. Endoscopy facilitates visualization by eliminating blind spots. We analyzed the outcomes of IBCT using both endoscopic and microscopic approaches, and assessed how trainees perceived the educational opportunities afforded.

Materials and methods

Sixty patients who underwent IBCT were allocated to Group I (n = 30; microscopic IBCT) and Group II (n = 30; endoscopic IBCT) by the dates of their visits. Anatomical success was defined as an intact, repaired tympanic membrane; functional success was defined as a significant decrease in the air–bone gap. Postoperative discomfort was analyzed using a visual analog scale (VAS). Thirteen trainees completed structured questionnaires exploring anatomical identification and the surgical steps.

Results

The surgical success rates were 96.7% in Group I and 100% in Group II. We found no between-group differences in the mean decrease in the air–bone gap or the extent of postoperative discomfort. Significant postoperative hearing improvements were evident in both groups. The mean operative time was shorter when the microscopic approach was chosen (17.7±4.53 vs. 26.13±9.94 min). The two approaches significantly differed in terms of the identification of external and middle ear anatomical features by the trainees, and their understanding of the surgical steps.

Conclusion

Both endoscopic and microscopic IBCT were associated with good success rates. The endoscopic approach facilitates visualization, and a better understanding of the middle ear anatomy and the required surgical steps and thus is of greater educational utility.

Endoscopic stapes surgery outcomes and complication rates: a systematic review

OBJECTIVE

These days, the gold standard procedure for otosclerosis treatment is stapes surgery. The endoscopic approach of the procedure is gaining popularity as endoscopic ear surgery develops across the globe. The main objective of this study is to gather and compile well-documented and reliable data regarding surgical outcomes for the endoscopic approach to stapes surgery up to this date.

MATERIALS AND METHODS

Publications in English were searched in the PUBMED/MEDLINE database and were systematically reviewed. A total of 16 articles were reviewed according to the inclusion criteria, obtaining a total of 573 patients managed surgically for otosclerosis, using an endoscopic approach. Data were systematically extracted and compared across variables.

RESULTS

Data were obtained as follows: mean age of 43 years; female proportion of 60%; 3 mm endoscope diameter of 51%, 4 mm of 39%; titanium piston-type prostheses of 52% and Teflon of 48%; length of the prosthesis (mode) was 4.5 mm; 0.6 mm diameter of the piston of 81% and 0.4 mm of 19%; mean surgical time was 55 min. Hearing results, mean preoperative air-bone gap (ABG) 31 dB; mean postoperative ABG 9 dB; ABG improvement of 22 dB; an ABG closure rate to 20 dB or less of 92% and an ABG closure rate to 10 dB or less of 77%. Complication rates: intraoperative tympanic membrane perforation of 5%; postoperative vertigo of 11%; postoperative dysgeusia of 10%; reported a postoperative neurosensorial hearing loss of 0.2%; reported gusher phenomenon of one case (0.2%).

CONCLUSION

Endoscopic stapes surgery is completely achievable using 0º angle and 4-mm-diameter sinus surgery endoscope. Instrument availability should not be an obstacle to the development of this type of surgery in any otolaryngology department. Audiological outcomes are comparable to microscopic approaches.

Tympanic Cholesterol Granuloma and Exclusive Endoscopic Approach

BACKGROUND Cholesterol granuloma is a histological entity containing cholesterol crystals surrounded by foreign-body giant cells and chronic inflammation. Tympanic cholesterol granuloma is a rare disease, while petrous bone cholesterol granuloma is more common. Surgery consists of elective management in most cases of CGs. There are several types of surgery described to treat cholesterol granuloma; however, a case treated by primary endoscopic ear surgery has not yet been described. The aim of this case report is to present the endoscopic characteristics of cholesterol granulomas and show how endoscopic ear surgery is possible in isolated and selected cases with this pathology. CASE REPORT We report the case of a 65-year-old patient affected by a cholesterol granuloma of the middle ear, with progressive hearing impairment and fullness of the left ear. The granuloma was diagnosed via medical imaging using magnetic resonance imaging, which identified the typical high signal intensity in T1- and T2-weighted images. In this case, cholesterol granuloma was limited to the epitympanic and mesotympanic regions. For small cholesterol granulomas confined to the middle ear, a canal wall-up or wall-down tympanoplasty plus ventilation tube insertion are usually performed. In this case, primary endoscopic surgery was performed under general anaesthesia to remove the presumed cholesterol granuloma. It was completely removed by this approach, without facial nerve injuries or postoperative complications. The patient had no disease recurrence at clinical and radiological investigation at 1-year follow-up. CONCLUSIONS An exclusive endoscopic approach to remove cholesterol granuloma is feasible. However, it should only be performed in selected cases.

Functional Results and Learning Curve of Endoscopic Stapes Surgery: A 10-Year Experience

OBJECTIVES/HYPOTHESIS

To assess hearing outcomes and complications of endoscopic stapes surgery by a single surgeon in a 10-year period, to compare these data with conventional microscopic procedures by the same operator, and to describe the learning curve of endoscopic stapedotomy.

STUDY DESIGN

Retrospective study.

METHODS

This is a retrospective study on patients who underwent endoscopic stapes surgery performed by the same senior surgeon, experienced both in microscopic and endoscopic techniques, between January 2009 and December 2018. Audiological data were compared, and intraoperative and postoperative complications were collected. The surgeon's last 30 cases of microscopic stapedotomy were enrolled as the control group. The results of the first 100 endoscopic stapes surgeries were analyzed separately to create a cumulative sum (CUSUM) control chart for learning curve assessment.

RESULTS

One hundred seventy-eight endoscopic and 30 microscopic stapes surgeries were included. In the endoscopic group, the mean postoperative air-bone gap was 8.2 dB. No significant differences between the endoscopic and microscopic preoperative and postoperative values were reported. A total of eight complications (4.5%) were observed in the endoscopic cohort, although in the control group, no complication occurred. The mean surgical time was 51.9 minutes in the endoscopic group versus 48.2 minutes in the microscopic group (P > .05). No association between stapedotomy success and the increasing number of procedures was found.

CONCLUSIONS

Our article demonstrates that functional results from endoscopic stapes surgery are similar to those from microscopic stapes surgery in terms of both safety and efficacy. After gaining endoscopic experience, the surgical duration of stapes surgery will be adequate starting from the first cases.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:885-891, 2021.

Does microscopic experience influence learning curve in endoscopic ear surgery? A multicentric study

OBJECTIVE

The aim of the present study was to illustrate the learning curve of endoscopic type-1 tympanoplasty comparing experts in microscopic otology versus neophyte surgeons.

METHODS

Eight ear surgeons, from tertiary referral centers, who had performed at least 30 endoscopic type 1 tympanoplasties were included in the study. Demographic data and medical records regarding the first 30 endoscopic type-1 tympanoplasties were retrospectively collected by each surgeon. A 14-questions survey focused on subjective aspects of the learning curve was administered. Surgeons were divided in two groups: one with previous experience in microscopic ear surgery (group 1) and one with no previous experience in ear surgery (group 2). The learning curve of endoscopic type 1 tympanoplasty was compared between the groups.

RESULTS

Mean surgical time was 89.2 min in group 1 vs. 79.5 min in group 2 (p < 0.01). When divided in 5 surgeries-steps, the only significant difference was appreciated in the first 5 surgeries with a longer mean time in group 1 vs. group 2 (+28.4 min; p < 0.05).

CONCLUSIONS

Surgeon's previous experience may influence the EES learning curve. Our results show that the first 5 surgical procedures are more challenging for surgeons experienced in microscopic surgery, subsequently the curve progression improves sharply and appears reversing the initial trend by the end of the 30 surgeries.

Would endoscopic surgery be the gold standard for stapes surgery in the future? A systematic review and meta-analysis

OBJECTIVE

This meta-analysis is aimed to review and analyze all available data of intraoperative and postoperative results of endoscopic and microscopic stapes surgery.

METHODS

According to the PRISMA statements checklist, this systematic review and meta-analysis were designed. Data were extracted from public databases, such as PubMed, Cochrane, Web of Science, and more. The quality of studies was evaluated using the MINORS scale. Odds ratios (ORs) and 95% CIs were estimated for binary outcome data, while the mean differences and 95% CIs were estimated for continuous data. I² and χ² tests were used to quantify statistical heterogeneity. If more than ten studies were included in each analysis, funnel plot would be performed to analysis publication bias.

RESULTS

Twelve studies with 620 patients were included in this meta-analysis. Primary outcomes collected in this meta-analysis included average postoperative auditory gain (APAG), postoperative air-bone gap (ABG), the rate of chorda tympani handling and bone curettage, which all showed a statistically significant difference in favor of endoscopy. While only secondary outcomes about postoperative pain and dysgeusia demonstrated a significantly reduced incidence. Furthermore, there was not any statistically significant difference on postoperative dizziness and average operative time between endoscopy and microscopy.

CONCLUSION

Although there is a need for high-quality pooled data in the future, a consistently superior effect of the endoscopic group was still shown in terms of total effectiveness, when compared to the microscopic group. We have reasons to support the application of endoscopy in stapes surgery. The future of ESS, we believe, is blazing bright.

Investigating the learning curve in endoscopic compared to microscopic myringotomy and ventilation tube insertion

OBJECTIVE

Rate of learning is often cited as a deterrent in the use of endoscopic ear surgery. This study investigated the learning curves of novice surgeons performing simulated ear surgery using either an endoscope or a microscope.

METHODS

A prospective multi-site clinical research study was conducted. Seventy-two medical students were randomly allocated to the endoscope or microscope group, and performed 10 myringotomy and ventilation tube insertions. Trial times were used to produce learning curves. From these, slope (learning rate) and asymptote (optimal proficiency) were ascertained.

RESULTS

There was no significant difference between the learning curves (p = 0.41). The learning rate value was 68.62 for the microscope group and 78.71 for the endoscope group. The optimal proficiency (seconds) was 32.83 for the microscope group and 27.87 for the endoscope group.

CONCLUSION

The absence of a significant difference shows that the learning rates of each technique are statistically indistinguishable. This suggests that surgeons are not justified when citing 'steep learning curve' in arguments against the use of endoscopes in middle-ear surgery.

Primary endoscopic stapedotomy using 3 mm nasal endoscope: Audiologic and clinical outcomes

Objective

To report the use of a 3 mm rigid nasal endoscope in primary endoscopic stapedotomy and clinical and audiological outcomes.

Materials and methods

Thirty patients diagnosed with primary otosclerosis underwent endoscopic stapedotomy that was performed using a 3 mm nasal endoscope (Karl Storz). At 6 months follow-up, the patients were evaluated for intraoperative findings, postoperative hearing outcomes and complications.

Results

Canaloplasty was performed in 2 (6.66%) patients, and no curettage of the canal wall was required in 12 (40%) patients. Transposition of the chorda tympani nerve was conducted in 11 (36.66%) patients. The average duration of surgery was 36 min (range 31–65 min). The air-bone gap (ABG) was 35 dB (range 24–50 dB) preoperatively and 14.63 dB (range 9–20 dB) postoperatively (p = 0.00). At 6 months follow-up, <20 dB ABG was achieved in 93.33% of the patients. No major intraoperative/postoperative complications were detected.

Conclusion

A 3 mm rigid nasal endoscope can be effectively used in stapedotomy to obtain adequate audiological outcomes. It can be considered as a better alternative to the standard microscope or 4 mm endoscope in preserving the posterior canal wall and chorda tympani nerve while minimizing operative time without causing significant complications.

A comparison between endoscopic and microscopic approaches for stapes surgery: a systematic review

Objectives

To evaluate the surgical techniques, approaches, audiological outcomes and complications of endoscopic stapes surgery.

Methods

Systematic searches of the literature were performed in PubMed, Web of Science and Scopus databases, to identify studies of patients who underwent stapes surgery using endoscopic approaches and studies reporting objective post-operative hearing outcomes. The following information was extracted: surgery duration, complications, surgical technique and audiometric results.

Results

Fourteen studies were selected for appraisal, which included a total of 282 ears subjected to endoscopic stapes surgery. Endoscopic stapes surgery seems to provide adequate visualisation of the middle-ear structures, thereby allowing less invasive surgery and potentially equivalent audiological outcomes as compared with a traditional microscopic approach. Other advantages of endoscopic stapes surgery include decreased surgery time, a reduced need for drilling, and auditory results comparable to those of microscopic techniques.

Conclusion

Studies have shown that endoscopic stapes surgery has similar surgical and functional advantages as compared with microscopic surgery.

Tympanomeatal flap creation in endoscopic stapedotomy: cautery vs. cold instrumentation

PURPOSE

Bleeding is one of the most challenging issues for surgeons performing endoscopic stapedotomy. During creation and elevation of the tympanomeatal flap (TMF) prevention or control of bleeding greatly facilitates the safety and comfort in the next steps of the surgery. The aim of this study was to compare the effects of cautery versus cold instrumentation during creation of TMF at endoscopic stapedotomy surgery.

METHODS

We investigated 15 patients TMF created with cautery and 14 patients with cold instrument, and compared bleeding scores, operation time, postoperative hearing, pain and complications between groups.

RESULTS

The mean bleeding score was significantly lower in cautery incised patients compared to cold instrument patients (1.2 ± 0.9 vs. 2.3 ± 1, p = 0.005). Mean duration of surgery was also significantly shorter in cautery used patients (35.3 ± 6.8 vs. 48.8 ± 9.2 min, p < 0.001). There was no significant difference between postoperative pain, complications, wound healing, and auditory outcomes.

CONCLUSIONS

Cautery may be a better choice for the creation of TMF in endoscopic stapedotomy surgery due to reduced bleeding, shorter operation time and increased comfort without causing any complications.

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.

Total endoscopic stapes surgery: Systematic review and pooled analysis of audiological outcomes

OBJECTIVE

This study evaluates the current evidence base for total endoscopic stapes surgery, specifically to establish current efficacy and safety of the technique within clinical practice.

DATA SOURCES

A systematic review of the literature on endoscopic stapes surgery was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis checklist. A comprehensive search of PubMed, Embase, and the Cochrane Central Register of Controlled Trials database for relevant publications for all available dates with appropriate Medical Subject Headings search criteria in January 2018.

STUDY SELECTION

Out of the 160 articles identified in the search, 14 met the inclusion criteria for further analysis. Four of these were level III and 10 level IV evidence.

DATA EXTRACTION

A pooled patient population of 314 individuals was analyzed.

DATA SYNTHESIS

Documented postoperative air bone gap closure to within 20 dB was found in 95.3% of individuals (285 patients). Facial nerve palsy (temporary) occurred in three patients (0.6%), with all recovering. No total sensorineural hearing losses were recorded, but two moderate sensorineural hearing losses occurred (0.6%). Perilymph fistula was noted on four occasions (1.3%). Chorda tympani trauma was documented in 3.5% of cases, with taste disturbance documented in 13 patients (5%).

CONCLUSIONS

Our pooled analysis uses the current published evidence to establish the complication rate and audiological outcome for the endoscopic approach to stapes surgery. These outcomes are comparable to those documented in traditional use of the microscope for stapedectomy. Laryngoscope, 130:1282-1286, 2020.

Endoscopic transcanal versus conventional microscopic tympanoplasty in treatment of anterior tympanic membrane perforations

PURPOSE

To compare the surgical outcomes of endoscopic transcanal tympanoplasty (ETT) and conventional microscopic tympanoplasty (CMT) in repairing anterior tympanic membrane perforations (ATMPs).

METHODS

We retrospectively analyzed the graft success rate, hearing outcomes, operative time, hospitalization period and complications in patients who underwent ETT and CMT between October 2015 and July 2018. In addition, the authors investigated whether anterior canal wall protrusion (ACWP) affects the graft success rate and operative time.

RESULTS

The graft success rates for ETT and CMT were 93.7% (30 out of 32 patients) and 91.4% (32 out of 35 patients), respectively (p = 0.640). There was no significant relationship between ACWP and graft success rates in either the endoscopic (p = 0.685) and microscopic (p = 0.894) group. The mean operative time was significantly shorter in the ETT group (37.2 ± 3.1 min) than in the CMT group (52.9 ± 9.2 min) (p < 0.001). Regarding operative time, there was no statistically significant difference between patients with and without ACWP (38.3 versus 36.3 min, respectively (p = 0.124)) in the ETT group. However, the mean operative time of patients with ACWP in the CMT group was significantly longer than patients without ACWP [62.3 versus 48.8 min, respectively (p < 0.001)].

CONCLUSIONS

ETT offering fewer complication rates and shorter duration of surgery may serve as a reasonable alternative to CMT in repairing ATMPs, with comparable graft success rates.

Endoscopic approach in second stage ossicular chain reconstruction

PURPOSE

Today limited studies regarding surgical and hearing outcomes in patients undergoing the totally endoscopic ossicular chain reconstruction has been published. The aim of this study is to show the different materials and endoscopic technique used in our experience to perform a second stage endoscopic ossiculoplasty.

MATERIALS AND METHODS

Patients underwent to second stage endoscopic ossiculoplasty has been enrolled in the study. According to the ossicular defect the endoscopic surgical procedures of ossicular chain reconstruction used in our clinical practice were: ossicular chain reconstruction using PORP (13 cases); ossicular chain reconstruction using TORP (11 cases); incus interposition ossiculoplasty (6 cases); cartilage ossiculoplasty (10 cases). Intraoperative and postoperative complications were analyzed. Final hearing recovery at 6 months follow-up was used to evaluate audiological outcomes.

RESULTS

None of the patients developed intraoperative complications. Postoperative TM complications emerged in 5% of cases: one patient (2.5%) presented TM perforation and prosthesis extrusion (TORP) after 3 months follow up. A significative difference between preoperative and postoperative values of AC-PTA, ABG and WRS (p < 0.05 in each case) emerged.

CONCLUSIONS

Different materials and methods can be used for performing an endoscopic ossicular chain reconstruction in order to obtain optimal clinical-audiological outcomes. Endoscopic surgery can be considered a valid alternative technique to traditional microscopic surgery for ossiculoplasty surgery.

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 Stapedotomy: Overcoming Limitations of Operating Microscope

The study is aimed to assess the scope of endoscopic stapedotomy in overcoming technical challenges faced during conventional stapedotomy using operating microscope. Sixty-four patients with clinical and audiological diagnosis of otosclerosis were randomly assigned into one of the 2 groups-one underwent conventional stapedotomy using operating microscope, while the other group underwent endoscopic stapedotomy, the operating surgeon being the same for both groups, for all cases. The 2 groups were observed in terms of extent of the postero-superior canal bone curettage/drilling, chorda tympani repositioning, visualization of footplate area, surgical time from first incision to ear packing, post-operative morbidity in terms of post-operative pain, vertigo, hearing outcome, and changes in taste sensation. It was observed that irrespective of the width of the external auditory canal, endoscopic approach offered better access to the footplate area requiring lesser bone removal and chorda tympani repositioning. The operating time, post-operative pain, and changes in taste sensation were significantly less in the endoscopic group. However, no difference was noted in terms of the post-operative hearing outcome and incidence of vertigo. Endoscopic stapedotomy has clear advantages in terms of the technicality and accessibility to the working area as well as faster recovery.

A modified method of local infiltration for endoscopic stapes surgery: how I do it

PURPOSE

To present a modified method of local infiltration (MMLI) for endoscopic stapes surgery to reduce surgical time, bleeding and complications.

MATERIALS AND METHODS

This study involved 70 patients who underwent stapes surgery for otosclerosis by endoscopic and microscopic approaches. The MMLI was applied as follows: local infiltration was performed with one hand while the other hand inserted the endoscope into the ear canal to observe vasoconstriction signs on the monitor; the single site of infiltration was located at the center of the anterior conchal cartilage. Operative time, intraoperative blood loss, preservation of anatomical structures, postoperative hearing and complications were evaluated.

RESULTS

The MMLI allowed for quick bleeding control and a clear and dry operative field. Operative time, intraoperative blood loss and preservation of anatomical structures were significantly reduced in the endoscopic group (P < 0.00) versus the microscopic group. The scutum was removed less frequent in the endoscopic group 7.1% versus 53.6% of the microscopic group (P < 0.00). The chorda tympani was preserved in all cases but it was more manipulated in the microscopic group 39.3% versus 9.5% of the endoscopic group (P < 0.00). No complications were observed and the hearing outcomes were significantly better than the preoperative thresholds.

CONCLUSIONS

This is the first report on the use of a MMLI for endoscopic stapes surgery. Using this method, the surgeon performs the infiltration at one site and concurrently observes the vasoconstriction signs without the use of a microscope, frontal lamp or speculum. This method provides benefits in terms of operative time and complications.

Fully endoscopic laser stapedotomy: is it comparable with microscopic surgery?

BACKGROUND

Microscopic stapedotomy is very successful and has long history, but it still has some constraints. Thus, otoendoscopy is increasingly popular nowadays.

AIMS/OBJECTIVES

The retrospective review study was to investigate the role of endoscopic laser stapedotomy in treating patients with otosclerosis.

MATERIALS AND METHODS

Seventeen patients who received endoscopic laser stapedotomy from April 2014 to July 2017 were enrolled and compared to 13 patients who had microscopic stapedotomy from February 2009 to March 2012. The anatomical structures, operative time, and postoperative hearing outcomes were assessed in two groups. Relation between external acoustic canal and operative time was also analyzed.

RESULTS

Using an endoscope, the operative field was clear, with easily identified anatomy, without need to sacrifice bony structures. The operative time was significantly longer in the endoscopic group in 2014 and decreased in the following years. There was no significant difference of hearing improvements between the two groups. There was a weak correlation between the width of the external auditory canal and the operative time.

CONCLUSIONS AND SIGNIFICANCE

Fully endoscopic stapes surgery is a feasible and safe surgical technique and results in satisfactory hearing outcomes. However, surgeons take longer to master the technique and to achieve shorter endoscopic operative times.