Endoscopic Ear Surgery for External Auditory Canal Cholesteatoma

Combined underwater endoscopic and microscopic surgery for external auditory canal cholesteatoma: A case report

Transcanal endoscopic ear surgery is a minimally invasive procedure that allows a clear visualization of the middle ear. Recently, indications for endoscopic surgery have been expanding. We performed combined underwater endoscopic and microscopic surgery for external auditory canal cholesteatoma, the computer tomography of which indicates the possibility of cholesteatoma not only in the canal wall but also in the mastoid. The 30° endoscope and underwater technique makes the surgical view clear, and we could remove the cholesteatoma without canalplasty. To the best of our knowledge, no case of external auditory canal cholesteatoma treated with underwater endoscopic and microscopic surgery has been previously reported. This case indicates that the procedure could be a good indication for external auditory canal cholesteatoma.

External Auditory Canal Cholesteatoma after Radiation Therapy for Nasopharyngeal Cancer: Case Series and Systematic Review

The authors performed a systematic review, in accordance with the PRISMA guidelines, across multiple databases, including all original studies published until November 2022, focusing on External auditory canal cholesteatoma (EACC) after radiation therapy (RT) for nasopharyngeal cancer (NC). Inclusion criteria were original articles reporting on secondary EACC after RT for NC. Articles were critically appraised to assess level of evidence using the Oxford Center for Evidence-Based Medicine criteria. Overall, 138 papers were identified and after duplicate removal (34 papers) and excluding papers not in English, 93 papers were assessed for eligibility; finally, only five papers were included and summarized with the three cases coming from our institution. These mainly involved the anterior and the inferior part of the EAC. The mean time of diagnosis after RT was the largest series of 6.5 years (with a range from 0.5 to 15.4 years). Patients undergoing RT for NC have 18 times a higher risk of developing EACC compared to the normal population. EACC is probably one of the most underreported side effects, because patients may present variable clinical findings, which could lead to misdiagnosis. Early diagnosis of RT related EACC is advised to enable conservative treatment.

Transcanal Endoscopic Ear Surgery for Advanced External Auditory Canal Cholesteatoma in Naim Stage III and IV

OBJECTIVE

To report the clinical characteristics and treatment outcomes, as well as endoscopic-assisted ear surgery techniques used in patients with advanced external auditory canal cholesteatoma (EACC).

STUDY DESIGN

Retrospective case series.

SETTING

University hospital.

METHODS

From October 2014 to September 2017, adult patients (age > 18) with advanced EACC (Naim's classification: stage III or IV) who underwent transcanal endoscopic ear surgery (TEES) were enrolled. The presenting features, extent of the lesion, and reconstruction techniques used were assessed. The healing time which was defined as the time required to develop a dry, re-epithelialized, and self-cleaning external auditory canal, was compared between stage III and IV.

RESULTS

Twenty-three patients were included. EACC was categorized as stage III in 11 ears and stage IV in 12 ears. Cholesteatoma involved the mastoid (30%), middle ear (26%), chorda tympani (22%), temporomandibular joint, antrum, and facial nerve (17% for each). In 96% of patients, a dry and self-cleaning external auditory canal (EAC) was maintained after a mean follow-up of 15 months. The median healing time was 8 weeks in stage III, which was significantly shorter than the 12 weeks required for stage IV (p < 0.05). There was no significant difference in the median healing time between TEES and the canal wall up mastoidectomy for stage IV EACC (14 weeks) performed by the same surgeon over the same period (p > 0.05).

CONCLUSIONS

TEES is a feasible and safe technique for the exposure and eradication of advanced EACC. Some critical endoscopic techniques for resecting disease and reconstructing the defect in the EAC and middle ear should be mastered before performing this operation.

Limits in endoscopic ear surgery

BACKGROUND

In recent decades, endoscopic ear surgery (EES) has been rapidly evolving, expanding its boundaries from the middle ear to the lateral skull base. Nonetheless, the advantages of the endoscopic technique are associated with a number of intrinsic limitations.

METHODS AND OBJECTIVE

A narrative review was conducted to investigate the current limits of EES, analyzing the different otologic and skull base surgery procedures.

RESULTS

Limitations of EES can be divided into general and procedure-related. General limitations have been extensively described in the literature and are related to the bidimensional image provided by the endoscope, as well as the one-handed surgical technique and its implications in the management of bleeding. Procedure-related limits are continuously evolving and are also discussed in the present review.

CONCLUSION

Although endoscope use is intrinsically associated with general limitations, these have been systematically overcome by the refinement of the surgical technique as a consequence of the increasing surgical experience gained over the last 20 years. The main limits of EES are currently associated with specific procedure- and disease-related situations. This review describes the general limitations and their management, as well as the current limits in the endoscopic management of various otologic diseases, from the external ear to the lateral skull base.

Teaching Middle Ear Anatomy and Basic Ear Surgery Skills: A Qualitative Study Comparing Endoscopic and Microscopic Techniques

OBJECTIVE

Endoscopic ear surgery is gaining popularity as a minimally invasive surgical technique for middle ear diseases. Its ongoing implementation into clinical routine has consequences regarding teaching of middle ear anatomy and surgery. To improve undergraduate and postgraduate training, we investigated the perception of and preference for endoscopy as compared with microscopy at different educational levels.

STUDY DESIGN

Qualitative study based on a thematic analysis approach.

SETTING

Tertiary academic medical center.

METHODS

After a standardized curriculum was run on endoscopic and microscopic anatomy and surgical skills education, 5 focus groups were held. The interviews were conducted, video recorded, transcribed, and analyzed. Analysis of the data gave rise to 11 themes showing the participants' perceptions and preferences.

RESULTS

Five medical students, 11 otorhinolaryngology residents, and 3 staff members participated in this qualitative study. For anatomy teaching, there was a clear preference for the endoscopic technique. The main advantages were the enhanced overview and perception of the anatomic details provided through endoscopy. For skills acquisition, the perceived advantages of the techniques were the same view of the surgical field for endoscopy and the 2-handed surgical technique for microscopy. However, there was no clear preference between the techniques for skills acquisition.

CONCLUSION

The endoscopic technique was generally judged more beneficial for teaching anatomy, especially due to the greater visualization of the complex middle ear anatomy. Given that both techniques will remain important to future surgeons, the relative unique benefits of each must be considered when designing and optimizing curricula for otologic education.

Pain After Ear Surgery: A Prospective Evaluation of Endoscopic and Microscopic Approaches

Objectives/Hypothesis

Assumed advantages of a minimally invasive endoscopic transmeatal approach in ear surgery are less postoperative pain, faster healing, and preservation of functional anatomy. We evaluated pain after ear surgery and compared endoscopic transmeatal, microscopic endaural, and retroauricular approaches.

Study Design

Prospective cohort study.

Methods

A prospective evaluation of pain during 3 weeks after ear surgery was performed. Three groups were defined: endoscopic transmeatal, microscopic endaural, and retroauricular. Data from 20 fully completed questionnaires (Brief Pain Inventory–Short Form) per group were analyzed with Bayesian and frequentist statistics.

Results

For all approaches, low pain scores were found, not exceeding 4 on a scale of 0 to 10. Analysis of the worst, least, and average pain scores documented per 24 hours showed no statistically significant difference nor equality between groups. With Bayesian statistics, a Bayes factor of 1.07, 0.25, and 0.51 was found, respectively. With frequentist statistics a p value of .092, .783, and 0.291 was found, respectively. Small, but statistically significant, differences were found for sleep, natural sleeping position, normal work, and pain medication taken. The location of pain correlates with the incision site.

Conclusions

The results of this study show that the surgical approach has no clinically relevant influence on postoperative pain after ear surgery. The statistically significant differences on natural sleeping position, sleep, normal work, and amount of pain medication taken are small and should be interpreted with caution. Therefore, these should not be decisive factors in the choice of surgical approach in ear surgery.

Level of Evidence

3 Laryngoscope, 131:1127–1131, 2021

Pleomorphic Adenoma of External Auditory Canal: Case Report of First Endoscopic Resection and Literature Review

Ceruminous pleomorphic adenoma is a very rare, mostly benign tumor originating from the ceruminal glands in the external auditory canal. Histologically, it is a mixed tumor with epithelial and stromal parts of different proportions, and is recognized today by the World Health Organization (WHO) as a ceruminous adenoma. Similar to the pleomorphic adenoma of salivary glands, recurrence or malignant degeneration with cellular atypia and metastasis can occur on rare occasions. Here, we describe an 87-year old female patient with a growing spherical mass in the right external auditory canal. After exclusive endoscopic tumor resection, a ceruminous pleomorphic adenoma was histologically diagnosed. Due to the absence of nuclear pleomorphism, no increased mitotic rate, no perineural invasion and no fusion transcripts of the MYB or MYBL1 gene loci, an adenoid cystic carcinoma could be excluded. The postoperative course was without any evidence of complications. A literature review identified 44 articles with 49 patients that were considered. Hearing loss and ear sensations were the most commonly reported symptoms. Most cases underwent an excision via an endaural or retroauricular approach. Recurrences were described in four patients, three of which had a malignant transformation.