Audiometric Outcomes Following Endoscopic Ossicular Chain Reconstruction

The New Semisynthetic TORP: A Prosthesis for Ossicular Reconstruction Both With the Absence and the Presence of the Stapes Superstructure

OBJECTIVES

To describe the new semisynthetic total ossicular replacement prosthesis (New-SSTORP) and to evaluate the New-SSTORP ossiculoplasty results both with the presence and absence of the stapes superstructure.

STUDY DESIGN

Prospective study.

SETTING

Tertiary referral center.

METHODS

From April 2023 to May 2023, 18 New-SSTORP ossiculoplasties were performed by the first author. In all patients, the New-SSTORP was interposed between the footplate and the eardrum. The study group was divided into two groups (group A and group B). Group A included 13 patients with the absence of stapes superstructure. Group B included five patients with the presence of stapes superstructure. A successful reconstruction was defined as a postoperative air-bone gap ABG ≤20 dB. For all patients of groups A and B, the last audiometric control considered was performed in January 2024. The mean follow-up was 8½ months. The χ2 test was used to compare results. p < 0.05 was considered significant.

MAIN OUTCOME MEASURES

Mean postoperative ABG ≤20 dB.

RESULTS

At the end of follow-up, the overall success rate (ABG ≤20 dB) of New-SSTORP ossiculoplasty was obtained in 88.8% (n = 16 of 18) of cases. In group A, the success rate of New-SSTORP ossiculoplasty occurred in 84.6% (n = 11 of 13) of cases, and in group B, the success rate of New-SSTORP ossiculoplasty occurred in 100% (n = 5 of 5) of cases. There was no audiological statistically significant difference between groups A and B (Fisher value is 1; p < 0.05). In all cases, the time for positioning of New-SSTORP was about 5 minutes.

CONCLUSION

The New-SSTORP has a minimal technical challenge for building and placement. The New-SSTORP ossiculoplasty results are very good both with the presence and absence of SS.

Endoscopic approach to geniculate ganglion: a multicentric experience

PURPOSE

A variety of lesions could arise from the GG area, or extend into this region from adjacent sites. The management of perigeniculate lesions includes observation, surgery, and radiation, according to the nature, the size of the lesion, and the accompanying symptoms. Preliminary experiences on the exclusive transcanal endoscopic approach to the GG area have shown safety and feasibility avoiding of any postauricular incision, or brain manipulation. The experience from two referral centers on patients treated for a GG lesion with a totally endoscopic approach is herein reported.

METHODS

Data about patients who underwent exclusive endoscopic approach to the GG area at the Otolaryngology Departments of the University Hospitals of Modena and Bologna between May 2017 and February 2022 were retrospectively collected.

RESULTS

The total number of patients included in our study was 11. 10 patients (91%) had progressive unilateral facial paralysis and 1 patient (11%) presented with chronic otorrhea. The mean largest diameter of the treated lesions was of 8 mm. The resection was extended to the fundus of the IAC in 2 patients (expanded approach). The remaining 9 patients (82%) underwent partial ossicular replacement prosthesis (PORP). No major complications occurred. Facial nerve outcomes were good in all patients and the mean ABG worsened from 12 dB pre-operatively to 22 dB post-operatively.

CONCLUSIONS

The exclusively endoscopic approach to GG lesions represents a viable alternative to traditional microscopic approaches and may be included in the armamentarium of ear surgeons.

Long-term outcomes following pediatric endoscopic titanium ossiculoplasty: A single-institution experience

INTRODUCTION

Endoscopic ossicular chain reconstruction (OCR) in adults has demonstrated equivalent outcomes to the traditional microscopic approach. Less data exist on endoscopic OCR outcomes in children, who have unique considerations including a smaller transcanal corridor and variable pathology. The purpose of this study was to investigate surgical and audiometric outcomes in children undergoing fully endoscopic and endoscopic-assisted OCR in both the short and long-term.

METHODS

Retrospective review of all children (<17 years) who underwent endoscopic OCR at one tertiary care center between 2017 and 2021. Children undergoing primary and revision endoscopic OCR with either partial (PORP) and total ossicular reconstruction prostheses (TORP) were included. Children undergoing surgery for juvenile otosclerosis or congenital stapes fixation, or any child receiving a stapes prosthesis were excluded. Primary outcome measures were post-operative change in 4 frequency (500 Hz, 1, 2, 4 KHz) air conduction pure tone average (AC PTA) and change in air-bone gap (ABG). Secondary measures included need for readmission and/or revision surgery, complication rate, and surgery duration.

RESULTS

Seventeen patients met inclusion criteria. Average age was 11.3 years (range, 5-17 years); 14 were male. A variety of fixed length, titanium total and partial prostheses were used. The most common prosthesis length was 2 mm (range 2-5 mm), and there were no intra- or perioperative complications. Mean long-term follow-up was 2.6 years. Most common pathology was congenital cholesteatoma (11/17, 64%), followed by chronic otitis media with tympanic membrane perforation (5/17, 29.4%), and extruded prosthesis (1/17, 5.9%). Intraoperatively, the most common finding was incus erosion (10/17, 58.8%), followed by malleus erosion (6/17, 35.3%), stapes erosion (4/17, 23.5%), and stapes absence (4/17, 23.5%). Eight children (47%) were reconstructed with PORPs, and 9 children (52.9%) were reconstructed with TORPs. Average ABG improved from 36.8 dB preoperatively to 19.9 dB postoperatively in the short-term and remained stable at 19.5 dB in the long-term. Average short-term ABG improvement was 4.2 dB for PORPs and 18 dB for TORPs. In the long-term, average ABG improved by 2.3 dB in PORPs and 13.4 dB in TORPs. PORPs had higher rates of ABG closure and lower AC PTAs than TORPs in the long-term.

DISCUSSION

Endoscopic ossiculoplasty is a viable option in children presenting with ossicular erosion from various causes. Audiometric improvement following endoscopic partial and total ossicular reconstruction remains stable over time, with a preference towards partial in the long-term, and mirrors published outcomes for microscopic surgery.

Analysis of the effect of reconstructing the ossicular chain under otoendoscopy with and without a stapes superstructure

BACKGROUND

Numerous studies have been conducted on the effect of the stapes superstructure after ossicular chain reconstruction, but the findings are not uniform.

OBJECTIVE

To compare the hearing outcomes of ossicular chain reconstruction with partial ossicular replacement prosthesis (PORP) or total ossicular replacement prosthesis (TORP) under otoendoscopy.

MATERIALS AND METHODS

The records of 111 patients diagnosed with chronic suppurative otitis media were retrospectively analyzed. These patients were divided into PORP group (n = 57) and TORP group (n = 54). They were further subdivided into subgroups PORP-a (with a malleus handle) and PORP-b (without a malleus handle), subgroups TORP-a and TORP-b. Pre- and postoperative audiometric results were analyzed.

RESULTS

The mean postoperative air conduction hearing thresholds improvement, mean air-bone gap improvement, and the success rate of reconstruction were significantly higher in the PORP group than in the TORP group (p < .05). The mean postoperative air conduction hearing thresholds improvement and the success rate of reconstruction were significantly higher in the PORP-a group than in the TORP-a group (p < .05); and similar results were concluded in comparison of the PORP-b group and the TORP-b group.

CONCLUSIONS AND SIGNIFICANCE

The stapes superstructure has an important positive effect on the postoperative outcome of endoscopic ossicular chain reconstruction.

[Experiences with endoscopic ear surgery of a German tertiary hospital for otolaryngology]

BACKGROUND

The aim of this article is to report on the integration of endoscopic ear surgery (EES) into daily clinical practice.

MATERIAL AND METHODS

In a monocentric prospective study, the endoscopy unit was set up during even weeks over a period of 10 months and the procedure was primarily started endoscopically via a transmeatal approach. In odd weeks, the endoscopy was omitted. A total of 60 procedures in 59 patients were evaluated. Points of comparison were intraoperative vision, incision-suture time, postoperative hearing outcome, and postoperative otoscopic findings.

RESULTS

With the exception of the facial nerve (p = 0.15 Mann-Whitney U‑test), the EES showed significantly improved visualization of all areas in the middle ear. The incision-suture times were similar in both methods. If bimanual placement of an ossicular prosthesis was necessary, the incision-suture time increased disproportionately (MES: 57.18 ± 9.7 min, EES: 76.83 ± 24.99 min; p = 0.019, *). There were no statistically significant changes related to hearing outcomes when comparing EES with the microscopic technique. There were no postoperative complications in the EES surgery group.

CONCLUSION

Integration of EES proved to be successful and advantageous in a real patient collective at this location.

Exclusive endoscopic ossiculoplasty with autologous material: step-by-step procedure and functional results

PURPOSE

To describe the surgical procedure of exclusive endoscopic ossiculoplasty (EEO) with autologous grafts and evaluate audiological results, focusing on the advantages or drawbacks compared to the corresponding microscopic technique.

METHODS

A retrospective review of consecutive adult and pediatric patients affected by chronic otitis media (COM) with or without cholesteatoma who underwent EEO was conducted. Only autologous ossiculoplasty was included in the study. The procedure was performed by experienced surgeons of our institution between November 2014 and September 2019. Hearing outcomes were evaluated using postoperative air-bone gap (ABG) and success rates in different subgroups of patients and different types of ossiculoplasty (OPL) were analyzed. Our results were finally compared with the existing literature regarding both microscopic and endoscopic ossicular chain reconstruction.

RESULTS

In total, 74 endoscopic ossicular chain repair procedures performed within the study period met the inclusion criteria. Of these, 21 were pediatric patients (28%) and 53 were adults (72%). Surgical reconstruction procedures included 43 partial ossicular reconstructions (POR) and 31 total ossicular reconstructions (TOR). The postoperative ABG improved significantly compared to preoperative measurements, and the mean ABG closure was 7.85 dB HL (p = 0.00064). No statistically significant differences in audiological outcomes between TOR/POR techniques and pediatric/adult groups were found in our study cohort, with p values of 0.10 and 0.88, respectively.

CONCLUSIONS

At present, EEO can be considered a valid surgical option for re-establishing a functioning ossicular chain with acceptable hearing restoration in children and adults. Further reports in wider case series are required to confirm these results.

A retrospective study of audiological outcomes after endoscopic tympanoplasty and tympanomastoidectomy in patients with cholesteatoma

OBJECTIVES

To investigated whether endoscopic tympanoplasty and tympanomastoidectomy could present satisfying audiological outcomes for cholesteatoma patients.

METHODS

This was a retrospective study of 83 patients with cholesteatoma who underwent endoscopic tympanoplasty and tympanomastoidectomy between 2019 and 2021. The preoperative and postoperative audiological evaluations were performed. The evaluation methods included air conduction (AC), bone conduction (BC), and air-bone gap (ABG) procedures.

RESULTS

Eighty-three patients were included in the study, all of whom underwent endoscopic tympanoplasty and tympanomastoidectomy. Forty-seven patients presented postoperative ABG≤20 dB (59.49%). The frequencies tested included low-frequency (LF), middle-frequency (MF), high-frequency (HF), and pure-tone average (PTA). All three audiological parameters significantly decreased after surgery (P < 0.05) at every frequency, except for BC-LF (P > 0.05). There were also significant differences between the preoperative and postoperative proportions of degree of hearing (P < 0.05). Additionally, shifts in AC, BC, and ABG were linearly related to preoperative AC, BC, and ABG. Lastly, postoperative ABG-PTA presented differently depending on preoperative stapes superstructure conditions (present: 15.81 ± 11.23 dB, absent: 22.94 ± 12.20 dB, P = 0.009).

CONCLUSIONS

Our study of endoscopic tympanoplasty and tympanomastoidectomy presented complete audiological outcomes for cholesteatoma patients. It had a positive surgery success rate and improved AC, BC, and ABG at every frequency except BC-LF. Additionally, AC-LF and AC-MF improved to a greater degree than AC-HF due to these procedures. Moreover, the linear regression analyses demonstrated that preoperative ABG-PTA was the most efficient audiological indicator for surgery. Likewise, the preoperative condition of the stapes superstructure was proved to be the most efficient anatomical indicator for hearing outcomes.

Comparison of endoscopic vs microscopic ossiculoplasty: a study of 157 consecutive cases

PURPOSE

The relatively new technique of trans-canal endoscopic ear surgery (TEES) when compared to microsurgery for ossiculoplasty has advantages of better visualization and no external incision but also has the disadvantage of being a one-handed procedure. Our study aimed to compare audiometric outcomes following ossiculoplasty performed via TESS with results of microsurgery.

MATERIALS AND METHODS

Data from a prospective audit of 157 consecutive patients who underwent ossiculoplasty by a single otologist from 2009 to 2018 was analyzed. TEES was introduced in the department in 2014; therefore, all patients before this period underwent microsurgery. Patients were classified by surgical approach, TEES, or microsurgery. Audiological outcomes were recorded at 3 and 12 months postoperatively and compared to pre-operative levels. Other variables included were the condition of stapes and reconstruction material used.

RESULTS

Of the 157 cases, 50 were TEES and 107 were microsurgery (81 microscope only and 27 combined with endoscope). There was statistically significant improvement (p < 0.001) in AC (43.4 dB pre-operatively, 36.2 dB postoperatively), BC (20.3 dB pre-operatively, 17.6 dB postoperatively), and ABG (21.8 dB pre-operatively, 16.7 dB postoperatively) in the total cohort. Both groups achieved an ABG better than 20 dB; 72% in TEES, 73% in the microscopic group, and there was no significant difference. There was no change in hearing at 12 months when compared to 3 months. No statistically significant difference was noted based on stapes condition, type of material used for ossiculoplasty, or tympanic membrane graft.

CONCLUSION

TEES is safe and as effective as microsurgery in ossiculoplasty with possibly much less pain and morbidity.

LEVEL OF EVIDENCE: 3

Comparison of Long-Term Microscopic and Endoscopic Audiologic Results After Total Ossicular Replacement Prosthesis Surgery

OBJECTIVE

To compare short-term and long-term outcomes after transcanal endoscope-assisted with microscope-assisted ossiculoplasty using the Fisch titanium total prosthesis (FTTP).

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary referral center.

PATIENTS

Pediatric (<18 yr of age) and adult patients undergoing ossiculoplasty with the FTTP between January 2016 and December 2019.

INTERVENTION

Transcanal endoscope-assisted (n = 30) or microscope-assisted (n = 76) ossiculoplasty with the FTTP. In the microscopic group, 48 were performed through the ear canal and 28 by retroauricular approach.

MAIN OUTCOME MEASURE

Short-term (3 mo) and long-term (average 20.2 mo) PTA 0.5-2kHz air and bone conduction thresholds were evaluated.

RESULTS

In total, 106 patients were included. Nine of 30 (30.0%) of endoscopic and 15 of 76 (19.7%) of microscopic patients were pediatric. Endoscopic preoperative air conduction PTA 0.5-2kHz was 52.1 ± 15.8 dB and 52.2 ± 17.9 dB for the microscopic group ( p > 0.05). Three months postoperative endoscopic air conduction PTA 0.5-2kHz was 37.6 ± 17.4 dB (14.5 dB improvement) and 44.6 ± 19.9 dB (7.6 dB improvement) in the microscopic group ( p > 0.05). Three months postoperative endoscopic PTA 0.5-2kHz ABG was 26.8 ± 16.6 dB and 28.4 ± 14.7 dB in the microscopic group ( p > 0.05). Latest follow-up endoscopic air conduction PTA 0.5-2kHz audiogram (mean follow-up, 20.6 ± 10.4 mo) was 36.1 ± 18.2 dB (16.0 dB improvement) and 40.1 ± 16.8 dB (12.1 dB improvement) in the microscopic group (mean follow-up, 19.9 ± 10.3 mo)( p > 0.05). For endoscopic air conduction PTA 0.5-2kHz , between the 3 months and latest follow-up audiogram, 25.0% showed improvement, 50.0% remained stable, and 25.0% deteriorated. In the microscopic group, 26.7% improved, 46.6% remained stable, and 26.7% deteriorated ( p > 0.05).

CONCLUSION

Our study shows that hearing results with the Fisch titanium total prosthesis are in line with literature. Endoscope-assisted total ossiculoplasty proves to be a suitable technique with comparable results to the microscopic approach.

Comparison of endoscopic underlay and over-under tympanoplasty techniques for type I tympanoplasty

Objective

To compare the indications and efficacy of endoscopic over-under tympanoplasty versus endoscopic underlay tympanoplasty.

Methods

Retrospective cohort study of patients undergoing type I endoscopic tympanoplasty via either an underlay or over-under technique by a single surgeon from 2017 to 2021. Patients were excluded if they had a concurrent mastoidectomy, ossiculoplasty, or advanced cholesteatoma defined by involvement of multiple subsites. Patient demographics, perforation size and location, middle ear status, preoperative and postoperative audiograms, and perforation closure were reviewed. Middle ear status was represented using the Ossiculoplasty Outcome Parameter Score (OOPS). The primary outcome was perforation closure at most recent follow-up and secondary outcomes were change in postoperative pure-tone average (PTA) and air-bone gap (ABG).

Results

Of 48 patients, 27 underwent endoscopic underlay tympanoplasty and 21 underwent endoscopic over-under tympanoplasty. Tragal cartilage-perichondrium graft was used in 90% of procedures. Distribution of OOPS scores was not significantly different between groups. Over- under technique addressed significantly larger perforations (mean size of 54% vs. 31%, p < .001) and a higher rate of anterior extension (95% vs. 22%, p < .001) than underlay technique. Perforation closure rate was not different between groups (95% vs. 96%). Patients experienced significant improvement in PTA and ABG in both groups.

Conclusion

The endoscopic over-under tympanoplasty is comparable to endoscopic underlay tympanoplasty in terms of graft take and audiologic improvement. The over-under technique is effective for repairing larger perforations or those with anterior extension.

Level of evidence

IV.

Endoscopic Ear Surgery: Our Experience

Endoscopes are presently used as an adjunct to microscopic surgery for better visualization of hidden areas of middle ear or they are used as a primary modality replacing the microscopes. We performed primary endoscopic ear surgery at a tertiary care center to evaluate the scope of endoscopic ear surgeries and to evaluate the anatomical, functional and quality of life outcomes. We evaluated 103 cases of which included patients with chronic otitis media mucosal disease (64), chronic otitis media squamous disease (29), otosclerosis (6), and benign ear tumors (4). In our study, the structural and functional outcomes of endoscopic ear surgeries were comparable to microscopic techniques however it conferred superior patient related outcomes of cosmesis, post-operative pain and early return to daily routine. Thus endoscopic ear surgery is a minimally invasive alternative option to microscopic techniques in the field of otology.

Audiometric Outcomes Comparing Endoscopic Versus Microscopic Ossiculoplasty

OBJECTIVE

To assess endoscopic and microscopic ossiculoplasty audiometric outcomes.

STUDY DESIGN

Retrospective review.

SETTING

Tertiary academic center.

PATIENTS

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

INTERVENTIONS

Endoscopic or microscopic ossiculoplasty.

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

Endoscopic transcanal facial nerve decompression in Bell's palsy: A pilot study

PURPOSE

To explore the surgical effects of endoscopic facial nerve decompression in Bell's palsy.

MATERIALS AND METHODS

This retrospective study included 15 patients with Bell's palsy. All had grade VI (House-Brackmann grading system) complete unilateral facial paralysis before surgery and a >95% reduction in amplitude on electroneurography testing compared to the unaffected side. Their MRI results indicated perineural edema in the geniculate ganglion area. Endoscopic decompression surgery was performed soon after they presented at our hospital. The time between onset of facial paralysis and surgery ranged from 25 to 93 days. All patients had no relevant surgical history or ear diseases.

RESULTS

At 1-year follow-up, 13 of the 15 (87%) patients had recovered to normal or near-normal facial function (House-Brackmann grade I-II), and all patients had reached House-Brackmann grade III or lower facial function. No obvious air-bone gap or sensorineural hearing loss occurred after surgery, and there were no severe complications or synkinesis.

CONCLUSIONS

Endoscopic transcanal facial nerve decompression provides a less traumatic and improved exposure of the geniculate ganglion, and may also help prevent permanent severe facial sequela. Results of intraoperative facial nerve stimulation may be related to the length of time required for recovery. The optimal time of surgery after onset of paralysis needs to be investigated further, to identify a post-drug surgical therapy which may be more acceptable for patients. Patients' response to conservative treatments should be assessed as soon as possible so as not to delay surgery.

Endoscopic Assisted Lateral Skull Base Surgery

Pathology of the lateral skull base poses a unique challenge for the surgeon. An intimate knowledge of the anatomy and the various approaches used for accessing pathology of the lateral skull base is critical. Three novel, minimally invasive, transcanal approaches for the management of lateral skull base pathology are described herein along with their respective indications, advantages, and disadvantages.

A Novel Instrument for Endoscopic Ear Surgery With a Steerable Flexible Tip: A Pediatric Anatomical Validation Study

HYPOTHESIS

This study compares the reaching ability of two classes of transcanal endoscopic ear surgery (TEES) instruments when operating on difficult to access anatomical targets; two novel instruments with steerable flexible tips (SFT-A and SFT-B) and suction capability are compared with standard commercially available tools.

BACKGROUND

TEES surgeons identified the need for a new surgical instrument that can enable accessibility of all areas visualized by the endoscope. This motivated the development of the two instrument prototypes.

METHODS

Six temporal bone models were 3D printed based on CT data from five cholesteatoma patients. Four anatomical targets were marked on each model. Using these targets, the reaching ability while using four standard TEES instruments were compared with the SFT-A and SFT-B prototypes by five surgeon participants. Results were analysed to compare success rates of contacting each target using each tool by fitting four Firth's logistic regression models. This calculated the statistically significant differences (p < 0.05) in tool success rate.

RESULTS

Using SFT-A to contact the sinus tympani (100%) was significantly more successful than the Panetti suction dissector for atticus (PAT) (77%) and to contact the sinodural angle (0%) was less successful than the PAT (10%) and SFT-B (93%). Using SFT-B to contact the lateral semicircular canal (90%) was significantly more successful than all current tools and to contact the sinodural angle (93%) was significantly more successful than all tools.

CONCLUSION

Using SFT-B enables enhanced accessibility of anatomical structures during TEES which may lead to less extensive bone removal to facilitate minimally invasive TEES.

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.

[Endoscopically guided reconstruction of the ossicular chain-an introduction]

The term "endoscopic ossiculoplasty" refers to surgical methods with the intention to reconstruct the ossicular chain using endoscopic vision. Apart from malformations and injuries, inflammatory processes cause the majority of indications for ossicular reconstruction. This article offers a commented overview of current literature and preliminary personal experience.

Hearing Outcomes With a Novel Total Ossicular Replacement Prosthesis

INTRODUCTION

A total ossicular replacement prosthesis (TORP) is used to reconstruct the ossicular chain in the absence of the stapes suprastructure. The Wildcat prosthesis is a novel TORP that eliminates the need for a separate footplate shoe prosthesis and aims to improve ease-of-use and stability. This study evaluates hearing outcomes using the Wildcat prosthesis.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary neurotology referral center.

METHODS

Retrospective chart review of 64 patients undergoing ossicular chain reconstruction using the Wildcat TORP. Hearing outcomes after surgery were assessed with air conduction pure-tone average, bone conduction pure-tone average, air-bone gap (ABG), speech recognition threshold , and word recognition score as primary outcome measures. The stability of hearing outcomes was evaluated on subsequent long-term follow-up.

RESULTS

At mean short-term follow-up of 4.4 ± 2.7 months, ABG improved from 31.0 ± 13.0 dB preoperatively to 22.5 ± 10.0 dB (p < 0.001) with 51.6% achieving ABG less than 20 dB. No significant difference in any primary outcome measures was found when analyzing outcomes by initial versus revision surgery, use of cartilage graft, or type of mastoidectomy. The only exception was a smaller reduction in ABG of 4.2 dB for patients with canal wall down mastoidectomy compared with a 13.7 dB ABG closure in patients with canal wall up mastoidectomy (p = 0.039).

CONCLUSION

Total ossicular chain reconstruction using the Wildcat demonstrates versatility in challenging cases to provide hearing outcomes that are comparable to published data using TORPs.

Ossicular chain reconstruction: endoscopic or microscopic?

OBJECTIVE

To compare the results of endoscopic and microscopic ossicular chain reconstruction surgery.

METHODS

Patients undergoing ossicular chain reconstruction surgery via an endoscopic (n = 31) or microscopic (n = 34) technique were analysed for age, gender, Middle Ear Risk Index, ossicular chain defect, incision type, ossicular chain reconstruction surgery material, mean air conduction threshold, air-bone gap, air-bone gap gain, word recognition score, mean operation duration and mean post-operative follow up.

RESULTS

Post-operative air conduction, air-bone gap and word recognition score improved significantly in both groups (within-subject p < 0.001 for air conduction and air-bone gap, and 0.026 for word recognition score); differences between groups were not significant (between-subject p = 0.192 for air conduction, 0.102 for air-bone gap, and 0.709 for word recognition score). Other parameters were similar between groups, except for incision type. However, endoscopic ossicular chain reconstruction surgery was associated with a significantly shorter operation duration (p < 0.001).

CONCLUSION

Endoscopic ossicular chain reconstruction surgery can achieve comparable surgical and audiological outcomes to those of microscopic ossicular chain reconstruction surgery in a shorter time.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Endoscopic ossiculoplasty: Is there any edge over the microscopic technique?

OBJECTIVES/HYPOTHESIS

To compare endoscopic ossiculoplasty with conventional microscopic technique in terms of postoperative hearing outcomes and complications.

STUDY DESIGN

Randomized controlled trial.

METHODS

One hundred eighteen patients diagnosed with ossicular chain discontinuity were randomly assigned into two groups, one undergoing endoscopic ossiculoplasty and the other undergoing ossiculoplasty by the microscopic technique, with the operating surgeon being same for both groups. The two groups were compared in terms of operative time, postoperative air-bone gap, mean air-bone gap closure, and incidence of complications. Teflon prostheses (partial ossicular chain replacement prosthesis [PORP] and total ossicular chain replacement prosthesis [TORP]) were used for reconstruction in all cases.

RESULTS

Endoscopic ossiculoplasty with PORP rendered a statistically significant mean postoperative air-bone gap and air-bone gap closure at 1 month when compared to that of microscopic PORP ossiculoplasty. However, there was no significant difference between the two techniques in terms of mean postoperative air-bone gap and air-bone gap closure at 3 and 6 months. In the TORP ossiculoplasty cases, there was no significant difference in mean postoperative air-bone gap and air-bone gap closure at 1, 3, and 6 months. In terms of operative time and incidence of complications, no statistical significance was found between the two groups.

CONCLUSIONS

Endoscopic ossiculoplasty appears to provide superior visualization and better early audiological outcome (in PORP ossiculoplasty cases) when compared to microscopic technique. However, long-term audiological outcomes and incidence of complications remain comparable.

LEVEL OF EVIDENCE

1 Laryngoscope, 130:797-802, 2020.

Transcanal endoscopic ear surgery for traumatic ossicular injury

Background: Transcanal endoscopic ear surgery (TEES) for traumatic ossicular injuries (TOI) is not well studied.Objectives: To analyze the treatment outcomes of TEES for TOI.Material and methods: Retrospective case review of fifteen patients (15 ears) with TOI was performed. The patients underwent an either ossiculoplasty or stapes surgery according to status of the ossicular chain using ear endoscopes. Postoperative audiometric results and complications were analyzed.Results: All subjects demonstrated improvement in their air conduction threshold and air-bone gap (ABG). The mean preoperative air conduction threshold and ABG were 55.3 dB (SD: 12.8) and 33.0 dB (SD: 9.5), respectively. Postoperatively, the air conduction threshold and ABG significantly improved to 28.1 dB (SD: 16.0) and 8.1 dB (SD: 4.5), respectively. Separation of the incudomalleolar joint accompanied by defect of the tegmen, which was not discernible on preoperative imaging, could be identified without additional incision or mastoidectomy. No patients experienced complications or a sensorineural hearing loss. Conversion to open approach was not necessary for any of the 15 procedures performed.Conclusion and significance: TEES for TOI yielded favorable audiometric results without any complication. TEES can provide an alternative method to manage TOI with the advantage of avoidance of skin incisions and mastoidectomy.

Short and Long-Term Outcomes of Titanium Clip Ossiculoplasty

OBJECTIVE

To report short (∼4 mo) and long-term (>12 mo) audiometric outcomes following ossiculoplasty using a titanium clip partial ossicular reconstruction prosthesis.

METHODS

Case series at a single tertiary referral center reviewing 130 pediatric and adult patients with conductive hearing loss (CHL) secondary to chronic otitis media (n = 121, 93%) or traumatic ossicular disruption (n = 9, 7%) who underwent partial ossiculoplasty from January 2005 to December 2015 with the CliP prosthesis.

RESULTS

At both short and long-term follow-up, postoperative air-bone gap (ABG) was significantly improved (18 dB HL, IQ range 13-26, p < 0.0001 and 18 dB HL, IQ range 13-29, p = 0.0002, respectively) when compared with preoperative values (29 dB HL, IQ range 19-37). No significant change in ABG was noted when comparing short and long-term intervals (18 versus 18 dB HL, p = 0.44). Fifty seven percent of cases (51/89) achieved a long-term ABG less than or equal to 20 dB at the time of their last follow-up. The extrusion and displacement rates were 1.5% (2/130), and 0.8% (1/130), respectively. There were no cases of iatrogenic sensorineural hearing loss.

CONCLUSIONS

Partial ossiculoplasty with the titanium CliP produces good hearing outcomes with a favorable safety profile. At long-term follow-up (minimum of 12 mo), median ABG was 18 dB and remained stable when compared with short-term follow-up. The majority of patients had successful long-term results, with 57% of patients achieving an ABG is less than or equal to 20 dB. Low rates of extrusion (1.5%) and prosthesis displacement off the stapes (0.8%) support the long-term stability of the CliP prosthesis in the middle ear.

Pediatric ossiculoplasty: optimizing outcomes

PURPOSE OF REVIEW

Despite years of research, pediatric ossiculoplasty remains a challenging surgery with numerous variables factoring into successful outcomes. The aim of this review is to summarize recent publications on surgical technique, timing, and reconstruction materials.

RECENT FINDINGS

The cause behind ossicular discontinuity does not seem to play a role in hearing results after ossiculoplasty; however, revision surgery is associated with worsening outcomes. The status of the ossicles remains an active area of interest, but the data remain mixed in terms of them playing a role in predicting outcomes in adults and pediatric patients. There remains debate regarding the utility of staging the reconstruction and is often undertaken on a case-by-case basis. Other recent publications highlight positive outcomes associated with canal wall-up procedures, titanium prostheses, and partial ossicular reconstruction prostheses. Endoscopic middle ear surgery in ossiculoplasty has been shown to be successful in monitoring and removal of disease and helpful in reconstruction.

SUMMARY

Pediatric ossiculoplasty remains a challenging yet rewarding procedure. The bulk of publications are retrospective making much of the literature difficult to interpret. There remains a need for prospective and well controlled studies in both adult and pediatric populations.

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.

The Antrum-Malleus-Tegmen Score: A Pilot Study Assessing Preoperative Radiographic Predictors for Transcanal Endoscopic Cholesteatoma Dissection

OBJECTIVE

Identify features on computed tomography (CT) that predict mastoidectomy conversion (MC) during transcanal endoscopic ear surgery (TEES).

STUDY DESIGN

Retrospective case-control.

SETTING

University otology practice.

PATIENTS

Consecutive patients with cholesteatoma.

INTERVENTION

TEES cholesteatoma dissection versus those requiring MC.

MAIN OUTCOME MEASURES

Antrum opacification, depth of scutum involvement, and erosion of the mastoid trabeculae, ossicular chain, and tegmen were evaluated. Univariable and multivariable regression analysis was performed. The Antrum-Malleus-Tegmen (AMT) score was created using receiver operating characteristic curves to assess feasibility of performing TEES for cholesteatoma dissection.

RESULTS

There were 39 TEES and 19 MC cases. Groups had similar age (median 28.5 yr), gender, laterality, and revision surgery status. Median surgical time for MC cases was longer than TEES (231 min vs. 171 min, p < 0.001). Radiographic predictors of MC by multivariable regression included antrum opacification (p = 0.036), malleus erosion (p = 0.044), and tegmen erosion (p = 0.023). The AMT score predicted the feasibility of TEES without MC with a sensitivity of 90% and specificity of 75% when ≥2 of the following conditions were met on preoperative CT: intact tegmen, intact malleus, and absence of antrum opacification.

CONCLUSIONS

An aerated antrum, intact malleus, and intact tegmen suggest that TEES cholesteatoma dissection without the need for mastoidectomy is highly likely. A score of ≥2 on the AMT score predicts this with a positive predictive value of 88% and negative predictive value of 78%.

Endoscopic type 3 tympanoplasty: Functional outcomes in chronic otitis media

BACKGROUND

Type 3 tympanoplasty is the surgery of choice for middle ear reconstruction in cases where an integral stapes suprastructure and mobile footplate are present.

OBJECTIVE

The objective of this study was to obtain functional results after endoscopic type 3 tympanoplasty in chronic otitis media.

MATERIALS AND METHODS

Prospective study including 24 patients who underwent endoscopic type 3 tympanoplasty, using PORP for ossicular chain reconstruction (OCR) and cartilage graft for tympanic membrane reconstruction. Audiograms were made preoperatively, and 6 months after surgery.

RESULTS

Dry, closed, self-cleaning ears were obtained in 91.7% of the cases. Mean preoperative air-bone gap (ABG) was 30.4dB, mean postoperative ABG was 16.7dB, dB gain of 13.6dB. ABG closure rate to 20dB or less of 79.2%, and to 10dB or less of 29.2%.

CONCLUSION AND SIGNIFICANCE

Endoscopic tympanoplasty and OCR is a valid option for surgeons who are comfortable with the use of endoscopes for middle ear surgery as it allows improved visualization of the prosthesis and graft placement during middle ear reconstruction.

Endoscopic Type 1 Tympanoplasty in Chronic Otitis Media: Comparative Study with a Postauricular Microscopic Approach

OBJECTIVE

To compare surgical outcomes after tympanoplasty without ossiculoplasty for chronic otitis media between transcanal endoscopic ear surgery (TEES) and postauricular microscopic ear surgery (PAMES).

STUDY DESIGN

Case-control study.

SETTING

Tertiary care university hospital.

SUBJECTS AND METHODS

Consecutive patients (N = 122) who had undergone tympanoplasty without ossiculoplasty for chronic otitis media were enrolled in this retrospective study and divided into 2 groups: TEES (n = 47) and PAMES (n = 75). Middle ear condition was graded with the middle ear risk index. Hearing, repair of tympanic membrane perforation, and surgical time were assessed.

RESULTS

The surgical success rate for hearing (air-bone gap ≤20 dB) was 95.7% in the TEES group and 84.0% in the PAMES group. Lower middle ear risk resulted in similar mean (95% CI) closure of air-bone gaps (TEES: 9.6, 6.5-12.6; PAMES: 8.0, 6.4-9.7; P = .333), whereas higher middle ear risk demonstrated significantly larger closure of air-bone gaps for the TEES group (10.1, 3.3-16.9) than the PAMES group (-0.2, -4.5 to 4.2; P = .009). The surgical success rate for repair of tympanic membrane perforation and surgical time were equivalent between TEES and PAMES.

CONCLUSION

Under favorable conditions of the middle ear, TEES and PAMES resulted in similar hearing improvement by tympanoplasty without ossiculoplasty. However, under adverse conditions of the middle ear, TEES was a more beneficial approach for hearing improvement than PAMES.

Anatomy and Surgical Approach of the Ear and Temporal Bone

The temporal bone is one of the more complex structures at the skull base that houses the hearing and vestibular organs, numerous nerves, and vessels. A host of inflammatory and neoplastic processes can occur within the temporal bone that often necessitate permanent and frozen section pathologic examination. A number of simple to complex surgical procedures are used to manage temporal bone pathology. This chapter will provide a brief overview of normal temporal bone anatomy, common surgical approaches, normal histology, and indications for pathologic examination.