Surgical anatomy of posterior tympanotomy: influence of the retrotympanum on round window exposure.

OBJECTIVES: To describe how the retrotympanic structures could influence the visibility of the round window niche and the round window membrane during cochlear implant surgery, and to investigate if a round window approach is possible even in cases with unfavourable anatomy. METHODS: Video recordings from 37 patients who underwent cochlear implantation were reviewed. The visibility of the round window niche and round window membrane at different timepoints was assessed according to a modified version of the Saint Thomas Hospital classification. The structures that concealed the round window niche and round window membrane were evaluated. RESULTS: After posterior tympanotomy, 54 per cent of cases had limited exposure (classes IIa, IIb and III) of the round window niche. After remodelling the retrotympanum, round window niche visibility significantly increased, with 100 per cent class I and IIa cases. Following remodelling of the round window niche, visibility of more than 50 per cent of the round window membrane surface was achieved in 100 per cent of cases. CONCLUSION: Remodelling the retrotympanum and the round window niche significantly increased exposure of the round window niche and round window membrane respectively, allowing round window insertion in all cases.

Effects of Total Intravenous Versus Inhalational Anesthesia on Bleeding During Endoscopic Ear Surgery: Preliminary Results From a Case-Control Study.

OBJECTIVE: To assess the impact of the type of maintenance anesthesia on the bleeding conditions of the surgical field and hemodynamic parameters during endoscopic ear surgery (EES), comparing totally intravenous inhalational anesthesia (TIVA) with inhalational anesthesia (IA). STUDY DESIGN: Retrospective case-control study. SETTING: Tertiary referral center. PATIENTS: Fifteen consecutive EES cases performed with TIVA between 2019 and 2020 at our Institution were matched to a control group of patients who underwent EES with IA in the same period. Patients with American Society of Anesthesiologists IV grade, acute otitis before surgery, congenital or acquired coagulopathies, use of anti-inflammatory drugs, or antiaggregant or anticoagulant therapy in the 5 days before the intervention were excluded. INTERVENTIONS: Both primary and revision tympanoplasty and stapes surgery were considered. MAIN OUTCOME MEASURES: Surgical videos were reviewed to quantify the entity of bleeding according to the Modena Bleeding Score. Hemodynamic parameters during surgery were retrospectively collected. A comparison between the two groups was performed. RESULTS: No statistically significant differences between the two groups in terms of bleeding were found at any of time point evaluated. The tympanomeatal flap elevation resulted in the bloodiest step in both groups. Hemodynamic parameters were similar in both groups ( p > 0.05). CONCLUSIONS: These preliminary data do not support a significant difference in bleeding conditions and hemodynamic parameters between EES patients receiving TIVA and those receiving IA. Further studies involving a higher number of patients will improve our understanding on how maintenance anesthesia with TIVA may be beneficial in terms of bleeding control as compared with IA for patients undergoing EES.

Prognostic role of EAONO/JOS, STAMCO, and ChOLE Staging for Exclusive Endoscopic and Endoscopic-Microscopic Tympanoplasty.

OBJECTIVE: The aim of the study is to evaluate cholesteatoma's surgical outcomes in patients treated with endoscopic ear surgery (EES) or a combined endoscopic-microscopic approach (cEMA) according to STAM, STAMCO, ChOLE, and EAONO/JOS system (EJS) classifications and staging. STUDY DESIGN: Retrospective study. SETTING: Monocentric study in a tertiary referral center. METHODS: One-hundred sixty-eight patients who underwent EES or cEMA for cholesteatoma between 2010 and 2018 were classified according to the abovementioned classification and staging. Data on cholesteatoma's recurrence and residual rates were collected. Inferential statistical analysis was performed to evaluate surgical outcomes and the prognostic value of classifications and staging. RESULTS: The recurrence rate was significantly lower in cholesteatomas classified in EJS stage 1 (2.6%) and STAM stage 1 (0%). A comparison of the different stages of the disease showed a significantly lower recurrence only for stage 1 versus the superior stages of both classifications. Involvement of mastoid bone was associated with a higher risk of recurrence (odds ratio [OR]: 4.12; p = .031). Attical involvement was associated with a higher risk of residual cholesteatoma (OR: 1.165; p = .046). CONCLUSION: EES or cEMA represents an effective treatment for middle ear cholesteatoma. The STAM classification and the EJS have shown a prognostic value, with STAM 1 and EAONO-JOS 1 stages associated with a better prognosis. Mastoid involvement represents a risk factor for recurrence. Attic localization is associated with residual disease. Localization at difficult access sites did not implicate a higher risk for recurrence or residual. ChOLE classification, Ossicular chain status, and complication status did not provide prognostic information regarding recurrence or residual cholesteatoma.

Hearing Results in Patients With No Ossicular Chain Reconstruction and Factors Influencing the Outcome.

INTRODUCTION: Ossiculoplasty is aimed at improving or maintaining the conductive portion of hearing in patients subjected to otologic surgery. However, satisfying hearing is frequently observed after tympanoplasty even in the absence of ossicular chain reconstruction. Aims of this article would be to evaluate hearing outcomes, in terms of pure tone average air-bone gap (PTA-ABG), in patients subjected to tympanoplasty for middle ear disease whose ossicular chain has not been reconstructed, and then to investigate factors influencing those outcomes. MATERIALS AND METHODS: Retrospective chart review of patients who underwent ear surgery from year 2003 to 2021 at the Otolaryngology-Head and Neck surgery department of the University Hospital of Modena was performed. Audiometric test results from patients who did not receive any ossicular chain reconstruction were collected and analyzed. SETTING: Tertiary University referral center. RESULTS: The mean patients' follow-up was 34.1 months. Overall, mean PTA-ABG in the study population was 23.5 dB. Integrity of stapes superstructure, malleus handle and malleus head, together with the use of tragal cartilage graft over autologous temporalis fascia to reconstruct the tympanic membrane were found to be significantly associated with better hearing outcomes, as demonstrated by lower PTA-ABG values. Stapes superstructure was found to be associated with more favorable outcomes in multivariate analysis, net of confounding factors. CONCLUSION: Good hearing performance can be obtained in patients subjected to middle ear surgery, even if the ossicular chain is not reconstructed. Presence of ossicular chain remnants and the use of a rigid material for tympanic membrane reconstruction are the factors that seem to most favorably influence hearing outcomes after surgery for middle ear disease.

The Tensor Tympani Tendon: A Hypothetical Site of Origin of Congenital Cholesteatoma.

Multiple theories have been discussed about the etiopathogenesis of congenital middle ear cholesteatoma (CMEC) and its specific site of origin. The intraoperative identification of the precise location of the keratinous mass is important to guarantee its complete removal, in order to reduce the risk of recurrence. This study proposes the tensor tympani tendon (TTT) as a possible site of origin of CMEC. All CMECs treated between 2013 and 2019 were reviewed. Only Potsic stage I lesions were included. Preoperative radiologic images were compared to intraoperative findings. Three removed TTT were sent for histologic evaluation. Seven patients were included (M:F = 3:4). Preoperative CT images were classified as type A in 2 cases (28.6%) and type B in 5 cases (71.4%). At intraoperative evaluation all CMEC sacs were found pedunculated on the TTT. The histologic examinations confirmed the connection between the cholesteatomatous sac and the TTT. According to the correlation of imaging, intraoperative findings and histology, we proposed that the TTT could be the primary site from which CMEC originates.

Transcanal Endoscopic Ear Surgery for Congenital Cholesteatoma: A Multi-institutional Series.

OBJECTIVE: To assess outcomes of transcanal endoscopic ear surgery (TEES) for congenital cholesteatoma. STUDY DESIGN: Case series with chart review of children who underwent TEES for congenital cholesteatoma over a 10-year period. SETTING: Three tertiary referral centers. METHODS: Cholesteatoma extent was classified according to Potsic stage; cases with mastoid extension (Potsic IV) were excluded. Disease characteristics, surgical approach, and outcomes were compared among stages. Outcomes measures included residual or recurrent cholesteatoma and audiometric data. RESULTS: Sixty-five cases of congenital cholesteatoma were included. The mean age was 6.5 years (range, 1.2-16), and the mean follow-up was 3.9 years (range, 0.75-9.1). There were 19 cases (29%) of Potsic stage I disease, 10 (15%) stage II, and 36 (55%) stage III. Overall, 24 (37%) patients underwent a second-stage procedure, including 1 with Potsic stage II disease (10%) and 21 (58%) with Potsic stage III disease. Eight cases (12%) of residual cholesteatoma occurred. One patient (2%) developed retraction-type ("recurrent") cholesteatoma. Recidivism occurred only among Potsic stage III cases. Postoperative air conduction hearing thresholds were normal (<25 dB HL) in 93% of Potsic stage I, 88% of stage II, and 36% of stage III cases. CONCLUSION: TEES is feasible and effective for removal of congenital cholesteatoma not extending into the mastoid. Recidivism rates were lower with the TEES approach in this large series than in previously reported studies. Advanced-stage disease was the primary risk factor for recidivism and worse hearing result. As minimally invasive TEES is possible in the youngest cases, children benefit from early identification and intervention.

An Integrated (Microscopic/Endoscopic) Dissection Ear Surgery Course.

Traditionally, otologic surgical training consisted of microscopic cadaveric dissections. However, during the last decades the endoscope has significantly changed the surgical perspective in the otologic field. Thus, the modern ear and lateral skull base surgeon should master the entire spectrum of endoscopic and microscopic approaches, with the aim of tailoring the procedure and guaranteeing the best possible functional outcome. This work proposes a step-by-step guided and illustrated dissection course, including indications for the setup of the cadaver lab and the integration of the microscope and endoscope to enhance the use of both instruments. The alternation of the endoscope and microscope allows the novice to train the correct handling of the instruments in the surgical field under both optical views. This aspect is of utmost importance since it is not advisable to start off a technique without practicing the other one, as both are important and complementary in the modern otologic surgery setting.

Transcanal endoscopic management of lateral semicircular canal fistula: preliminary experience.

INTRODUCTION: Labyrinthine fistula is one of the most frequent complications of cholesteatoma (CHO), occurring in about 8% of cases in the literature. In about 90% of cases, it is located at the level of the lateral semicircular canal, and its clinical manifestation includes vertigo, nystagmus and positive Hennebert and Tullio signs. The management of lateral semicircular canal fistula (LSCF) secondary to CHO classically requires a retroauricular access by performing a canal wall-up (CWU) or canal wall-down (CWD) mastoidectomy. However, in case of a CHO confined to the tympanic cavity causing a LSCF on the ampullar arm, a transcanal exclusive endoscopic approach could be considered. AIMS: The aim of this study is to describe the feasibility of a transcanal exclusive endoscopic approach in the management of a CHO confined to the tympanic cavity causing a LSCF on the ampullar arm. METHODS: From January 2019 to December 2020, three patients with LSCF secondary to mesotympanic CHO underwent transcanal exclusive endoscopic ear surgery repair at the Department of Otolaryngology-Head and Neck Surgery, University Hospital of Modena, Italy. RESULTS: This technique was successfully employed to treat LSCF in all three cases and was planned as a two-stage surgery, performing ossiculoplasty after 12-18 months. Functional outcomes were also satisfactory: complete eradication of CHO, hearing preservation and complete resolution of symptoms. CONCLUSIONS: In case of a CHO confined to the tympanic cavity causing an LSCF on the ampullar arm, a transcanal exclusive endoscopic approach could be considered as a feasible and safe technique.

Endoscopic tympanoplasty type I for tympanic perforations: analysis of prognostic factors.

PURPOSE: To assess the anatomical and functional outcomes of endoscopic transcanal tympanoplasty type I for tympanic membrane perforations. METHODS: Eight hundred thirty-five patients who underwent tympanoplasty between January 2011 and January 2019 were selected. Patients with tympanic membrane perforation treated with a transcanal endoscopic tympanoplasty type 1 and a follow-up period longer than 6 months have been retrospectively reviewed. The presence of cholesteatoma or ossicular chain dysfunctions were considered exclusion criteria. Eighty-one patients were included in the present study population. The main outcome was the rate of overall graft success. Secondary outcomes included hearing results. Prognostic factors related to both the abovementioned outcomes were assessed. RESULTS: Overall, 66 patients (81.5%) had a successful graft at the last follow-up evaluation. Mean follow-up was 22.1 (range 6-104) months. The anterior quadrants were entailed by the perforation in 62 (76.5%) cases. The overall success rate with cartilage (or cartilage and perichondrium) was 91.2% (p < 0.01). The median preoperative and postoperative ABG were 18.7 (13.4-25.6) and 7.5 (2.5-12.5), respectively, revealing a significant median improvement of 11.2 (p < 0.001). The type of graft and the postoperative tympanic membrane status were significantly associated with the audiologic outcome with p = 0.01 and p = 0.02, respectively. CONCLUSIONS: Endoscopic tympanoplasty type I is a reliable technique with reasonable anatomic and audiologic results. Tympanic membrane grafting with cartilage (or cartilage and perichondrium) guarantees a higher rate of perforation closure and satisfactory hearing results. Anterior eardrum perforations can be successfully and safely managed with transcanal endoscopic approach avoiding postauricular approach and canalplasty.

Use of IMAGE1 S technology for detection of cholesteatoma in endoscopic ear surgery: a retrospective case series on 45 patients.

PURPOSE: To evaluate the role of selected modalities of Storz Professional Image Enhancement System (IMAGE1 S) in differentiating cholesteatoma during endoscopic ear surgery (EES); to assess the potential usefulness of IMAGE1 S in recognition of cholesteatoma residuals at the end of EES. METHODS: A retrospective study on 45 consecutive patients who underwent EES for cholesteatoma between March 2019 and November 2019 at a tertiary referral center was performed. For each case, Spectra A and Spectra B filters were applied intra-operatively. When examining the surgical field, a switch from white light (WL) to IMAGE1 S was performed to detect cholesteatoma and differentiate it from non-cholesteatomatous tissue. When the IMAGE1 S pattern was suspicious for the presence of cholesteatoma, images of the field under both enhancement modalities were taken and the targeted lesions were sent for histologic analysis. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of IMAGE1 S were calculated. A final recognition of the surgical field using the selected filters was performed to detect any possible cholesteatomatous residuals. RESULTS: Detection of cholesteatoma by IMAGE1 S selected filters revealed the following data: sensitivity 97%, specificity 95%, PPV 95%, NPV 97%. On three occasions, there was no correspondence between enhanced endoscopy and histology. In 5 out of 45 cases (11%), cholesteatoma residuals, which had not been identified at WL inspection at the end of the procedure, were detected by IMAGE1 S. CONCLUSION: Our results suggest a potential role for IMAGE1 S Spectra A and B filters in EES for cholesteatoma surgery. We propose the integration of IMAGE1 S as a final overview of the surgical cavity for recognition of cholesteatomatous residuals.

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.

Correlation of Radiologic Versus Endoscopic Visualization of the Middle Ear: Implications for Endoscopic Ear Surgery.

OBJECTIVES: To determine the limits of visualization during transcanal endoscopic ear surgery (EES) by correlating the relationship between radiologic and endoscopic anatomy using angled optics. METHODS: Radiology and endoscopic visualization of tensor fold, protympanum, facial sinus (FS), sinus tympani (ST), subtympanic sinus (STS), hypotympanum, and aditus ad antrum were analyzed using a transcanal approach in 30 human temporal bones specimens with different angled endoscopes (0 degree, 45 degrees, 70 degrees) to check for the full visualization of these regions. High-resolution computed tomography (CT) was performed prior to dissection to classify retrotympanic anatomy. According to previously published descriptions, FS, ST, and STS were classified into types A, B, and C depending on their morphology relative to the mastoid segment of the facial nerve. These radiologic findings were compared to endoscopic visualization of these same structures using a Chi-squared test. RESULTS: Visualization of the posterior wall of three different retrotympanic areas was significantly associated (FS p < 0.01; ST p < 0.01; STS p = 0.02) with the radiologic classification and endoscopic optical angle. Angled endoscopy improved visual access to the other subsites, especially the aditus ad antrum and the tensor fold (>70% with 45 degrees and 70 degrees). CONCLUSION: Complete visual access to the hidden recesses of the middle ear can be achieved using angled endoscopes (45 degrees and 70 degrees). We observed a statistically significant association of endoscopic visualization to radiologic description of the retrotympanum on CT and the optical angle used. The prediction of the endoscopic exposure of the retrotympanum from the preoperative CT is possible. Even with the use of 70 degrees lens, retrotympanum is not fully visualized on transcanal endoscopy if a type C retrotympanic recesses (posterior and medial to the facial nerve) is present. This represents a technical limit of exclusive transcanal EES.

Management of Jugular Bulb Injuries during Endoscopic Ear Surgery: Our Experience.

Objectives The main objective of this article is to describe endoscopic management of intraoperative massive bleeding from jugular bulb injury during exclusively transcanal endoscopic procedures for middle ear pathologies. Design Case series with chart review. Setting Tertiary referral center. Participants We retrospectively reviewed two patients who experienced jugular bulb injury during endoscopic transcanal approach for glomus tympanicum and chronic otitis media. The surgical videos and charts were carefully investigated and analyzed. Main Outcome Measures Feasibility and suitability of exclusive endoscopic management of jugular bulb bleeding and description of surgical maneuvers that should be performed to obtain safe and effective hemostasis. Results In both patients, jugular bulb bleeding was progressively controlled by means of exclusive endoscopic approach with no need to convert to microscopic approach. None of the cases required a second surgeon helping in keeping the endoscope during hemostatic maneuvers. Both patients had a normal postoperative period with no recurrence of hemorrhage. Conclusions Endoscopic management of jugular bulb bleeding is feasible by using the technique described with reasonable efficacy and with no additional risk or morbidity to the procedure. Knowledge of anatomy and its variants, preoperative evaluation of imaging, and the ability of the surgeon to adapt the surgical technique to the specific case are recommended to prevent vascular complications during endoscopic ear surgery.

The role of endoscopic stapes surgery in difficult oval window niche anatomy.

PURPOSE: The surgical treatment of otosclerosis can be challenging in case of anatomical abnormalities or variations of the oval window niche (OWN) area, as in very narrow OWN or in an overhanging facial nerve. The aim of the present study was to explore the role of endoscopic stapes surgery in cases with difficult OWN anatomy. METHODS: Patients undergoing endoscopic stapes surgery from 2008 to 2017, which fulfilled the CT scan criteria for a "difficult" anatomical condition, according to the measurements and cut-off values defined in the literature, were retrospectively selected. The intraoperative endoscopic view of the anatomical details and surgical difficulties were analysed through the review of the operative videos. Finally, a statistical analysis of the relationship between endoscopic visualization of anatomical details and radiological measurements was carried out. RESULTS: Eighteen out of 205 patients (8.7%) were included in the study. The 94.4% of patients obtained an optimal endoscopic exposure and visualization of all the anatomical details considered in the study, during each step of stapes surgery. The OWN measurements (width, depth and facial-promontory angle) did not affect significantly the endoscopic surgical exposure of the footplate or any of the other anatomical details. CONCLUSIONS: The anatomic features of the oval window area which reduce the visualization in microscopic surgery, did not affect the surgical exposure in endoscopic stapes surgery. Patients having a difficult anatomy of the OWN can be treated safely with the endoscopic approach. In the case of a predicted "difficult anatomy", the endoscopic approach can be considered a viable option.

Endoscopic revision stapes surgery: surgical findings and outcomes.

PURPOSE: Hearing results in revision stapes surgery are largely dependent on the cause of failure, and an appropriate intraoperative diagnosis is crucial for a good outcome. The endoscope allows a detailed exploration of the middle ear cavity and is particularly suitable for the intraoperative assessment of the cause of failure of previous stapes surgery. The present study analyzes the intraoperative findings and outcomes of patients undergoing revision stapes surgery through the endoscopic transcanal approach. METHODS: Surgical videos and charts of patients undergoing endoscopic revision stapes surgery from 2008 to 2017 were reviewed retrospectively. Intraoperative findings, difficulties encountered during the surgery and hearing outcomes were evaluated. The feasibility of each surgical step with the totally endoscopic approach or the need for bimanual manipulation was assessed as well. RESULTS: Thirty-four patients were included in the study. The endoscopic transcanal approach allowed a detailed exploration of the middle ear cavity and an accurate intraoperative diagnosis and management of the different causes of failure of the previous surgery. 89.8% of patients achieved an air-bone gap for the PTA ≤ 20 dBHL and 68.5% a closure of the air-bone gap. CONCLUSIONS: The present study showed that totally endoscopic revision stapes surgery is a feasible, safe and effective procedure. The transcanal endoscopic approach allowed an accurate intraoperative diagnosis without the need for an endaural or retroauricular approach, with the possibility to manage all the possible intraoperative scenarios. A larger series with a longer follow-up is needed to validate the results.

Discovering Middle Ear Anatomy by Transcanal Endoscopic Ear Surgery: A Dissection Manual.

The middle ear is located in the center of the temporal bone and bears a highly complex anatomy. The recently introduced exclusively endoscopic transcanal approach to the middle ear is a minimally invasive technique sparing the bone and mucosa of the mastoid bone, since the middle ear is accessed through the external auditory canal. This emerging method has several advantages over the traditional (microscopic) approaches to the middle ear such as the panoramic wide-angle views of the anatomy, the possibility to approach and magnify tiny structures, and the possibility of looking around the corner using angled endoscopes. The cadaveric dissection method presented here consists of an overview on the technical requirements and a precise description of a step-by-step protocol to discover the anatomy of the middle ear. Each step and anatomical structure is carefully described in order to provide a comprehensive guide to endoscopic ear anatomy. In our opinion, this is particularly important to any novice in endoscopic ear surgery as it provides thorough anatomical knowledge and may improve surgical skills.

Transcanal Transpromontorial Acoustic Neuroma Surgery: Results and Facial Nerve Outcomes.

BACKGROUND: Recently, the transcanal approach for the removal of acoustic neuromas has been introduced. Facial nerve (FN) preservation is one of the main challenges of this kind of surgery. OBJECTIVE: To describe our experience in the surgical treatment of acoustic neuromas, focusing on the functional results of FN preservation after a transcanal approach. METHODS: A retrospective chart review was carried out on clinical data and videos from operations on 49 patients who underwent surgery with a totally transcanal exclusive endoscopic approach for Koos stage I-II lesions, or an enlarged transcanal transpromontorial approach for Koos stage II-III tumors, between March 2012 and February 2017. Patients and tumor characteristics, clinical manifestations, radiologic features, audiological results, FN outcomes (according to the House-Brackmann [HB] grading system) and complications were evaluated. Tumors were classified according to the Koos grading system. RESULTS: The age of the patients (34 females and 15 males) ranged from 27 to 77 years (mean age: 54.9 yr). Preoperative diagnosis was "vestibular schwannoma" in all patients. At the last follow-up (range 1-60 mo, mean 13.9 mo), 42 of 49 showed grade I HB FN function, 5 of 49 grade II HB, and 2 of 49 grade III HB. Overall, in 95.9%, FN function was preserved (grade I-II HB) with stable results at follow-up; in 4.1% of cases, FN function was reduced, but not worse than grade III. CONCLUSION: The transcanal approach represents a feasible, minimally invasive, and conservative technique for the management of acoustic neuromas of the internal auditory canal.

Management of Bleeding in Exclusive Endoscopic Ear Surgery: Pilot Clinical Experience.

Objective Transcanal exclusive endoscopic ear surgery requires the management of the endoscope and the surgical instruments in the external auditory canal. Bleeding in this narrow space is one of the most challenging issues, especially for novice endoscopic ear surgeons. We aim to assess the severity and occurrence of bleeding and describe strategies to control the bleeding during endoscopic ear surgery. We hypothesize that bleeding is reasonably controllable in endoscopic ear surgery. Study Design Case series with chart review. Setting Tertiary referral center. Subjects and Methods We retrospectively assessed 104 consecutive cases of exclusive endoscopic ear surgery at the University Hospital of Modena, Italy. The surgical videos and the patient charts were carefully investigated and analyzed. Results Hemostatic agents included injection of diluted epinephrine (1:200,000, 2% mepivacaine), cottonoids soaked with epinephrine (1:1000), mono- or bipolar cautery, washing with hydrogen peroxide, and self-suctioning instruments. The localization of bleeding in the external auditory canal was most frequently the posterior superior part, and inside of the middle ear, it was the pathology itself. Statistical analysis revealed significant differences comparing the mean arterial pressure and the type of intervention among bleeding scores. Conclusion The management of bleeding in endoscopic ear surgery is feasible through widely available hemostatic agents in reasonable frequency. This study gives an instructive overview on how to manage the bleeding in the exclusive endoscopic technique. Even the highest bleeding scores could be managed in an exclusively endoscopic technique.

The variants of the retro- and hypotympanum: an endoscopic anatomical study.

The retro- and hypotympanum are hidden areas of the middle ear, only poorly recognized. Nevertheless, this region is of relevant clinical significance, since it is regularly affected by disease such as cholesteatoma. The aim of this study is to explore and describe the anatomical variants of the hypo- and retrotympanum by the means of transcanal endoscopy. We hypothesize a significant variability of this hidden region of the middle ear. Moreover, we believe that the minimal invasive, endoscopic access is suitable since angled scopes may be used to explore the region. To this end a total of 125 middle ears (83 cadaveric dissections, 42 surgical cases) were explored by the means of 3 mm straight and angled scopes. The variants were documented photographically and tabularized. The bony crests ponticulus, subiculum and finiculus were most frequently represented as ridges. The ponticulus showed the highest variability with 38% ridge, 35% bridge and 27% incomplete presentation. The subiculum was bridge-shaped only in 8% of the cases, the finiculus in 17%. The sinus tympani had a normal configuration in 66%. A subcochlear canaliculus was detectable in 50%. The retro- and hypotympanum were classified, respectively, to the present bony crests and sinus in a novel classification type I-IV. In conclusion, we found abundant variability of the bony structures in the retro- and hypotympanum. The endoscopic access is suitable and offers thorough understanding and panoramic views of these hidden areas.