Otoendoscopy in the era of narrow-band imaging: a pictorial review.

PURPOSE: Otoendoscopy represents the initial non-invasive diagnostic cornerstone for external and middle ear disorders. Recently, new techniques of enhanced imaging such as narrow-band imaging (NBI) have been introduced but their role as a potential aid in otological practice remains unproven. In this pictorial review, we want to present the potential application of this endoscopic method, highlight its limitations, and give some hints regarding its future implementation. METHODS: Representative cases of external and/or middle ear pathologies were selected to illustrate the role of NBI in this regard. RESULTS: NBI may represent a useful aid in the otological work-up, in the differential diagnosis of ear tumor-like masses, and, possibly, in the prognosis of tympanic perforations. For other ear disorders, instead, this technique does not seem to add anything to the standard clinical practice. CONCLUSIONS: NBI might prove useful in the assessment of selected external and middle ear disorders but its role must be prospectively validated.

Application and practice of a step-by-step method combined with case-based learning in Chinese otoendoscopy education.

BACKGROUND: Standardized training allows more physicians to master otoendoscopic surgery. However, the lecture-based learning (LBL) applied in otoendoscopy teaching may not be conducive to training students in clinical thinking and surgical ability. It is necessary to explore innovative methods for otoendoscopy teaching. This study aimed to determine the effect of a step-by-step (SBS) method combined with case-based learning (CBL) in otoendoscopy teaching. METHODS: Fifty-nine physicians who participated in otoendoscopy training were selected as the study subjects and randomly divided into two groups (A and B). Group A underwent training with the SBS & CBL method, while Group B underwent training with the LBL & CBL method. The effects of these two methods for otoendoscopy training were compared by evaluation of professional skills and questionnaires before and after the training. RESULTS: Proficiency in otoendoscopic anatomy and grades for both professional knowledge and otoendoscopic skills were significantly higher in Group A than in Group B(P < 0.05). In terms of learning interest, surgical ability, acting capacity during surgery, reducing surgical complications, and satisfaction with learning experience, all responses from Group A were better than those from Group B(P < 0.05). CONCLUSIONS: The SBS & CBL method may help to improve ability in otoendoscopic surgery and clinical thinking and appears suitable for endoscopy teaching.

A novel method to measure the external auditory canal: Normative data and practical implications.

PURPOSE: To accurately measure external auditory canal (EAC) dimensions by high resolution computed tomography (CT), and compare results with a traditional method of EAC measurement. METHODS: Using an advanced multidimensional open source digital imaging and communications in medicine (DICOM) analysis program (OsiriX, Pixmeo, Geneva, Switzerland) 91 adult EACs were analyzed on a previously obtained temporal bone CT scan. Tympanometric data were also recorded for each ear. The methods were compared using a linear mixed effect model. RESULTS: EAC volume was compared between tympanometrically calculated volumes and CT measured volumes. It was found that CT measured volumes are, on average, smaller (1.12cm3, SE=0.04) than tympanometry volumes (1.27cm3, SE=0.04cm3). There was a significant difference in CT measured volume between genders (p=0.0125), with males having larger measured volumes (1.23cm3, SD=0.28cm3) than females (1.06cm3, SD=0.20cm3). There was a significant difference in average circumference between ear laterality (p=0.0071), with the right ear having a slightly larger average circumference (2.49cm, SD=0.23cm) than the left ear (2.44cm, SD=0.50cm).There was also a significant difference in minimum circumference between age groups (p=0.0448), with patients younger than 60years having larger minimum circumferences (1.89cm, SD=0.21cm) than older patients (1.78cm, SD=0.25cm). CONCLUSIONS: This study demonstrates that CT analysis can provide more information about EAC dimensions than traditional techniques. Moreover, slight but statistically significant differences are associated with age, gender and laterality. Accurate estimation of EAC dimensions is important for the development of hearing aids and personal protective equipment and can also be helpful for surgical planning, specifically otoendoscopy. Future research will focus on simplifying computation, developing cross-cultural cohort comparisons, and application to otoendoscopic procedures.

Quantitative imaging analysis of transcanal endoscopic Infracochlear approach to the internal auditory canal.

PURPOSE: A transcanal endoscopic infracochlear surgical approach to the internal auditory canal (IAC) in a human temporal bone model has previously been described. However, the proportion of patients with favorable anatomy for this novel surgical technique remains unknown. Herein, we perform a quantitative analysis of the transcanal endoscopic infracochlear corridor to the IAC based on computed tomography. MATERIALS AND METHODS: High resolution computed tomography scans of adult temporal bones were measured to determine the accessibility of the IAC when using an endoscopic transcanal, cochlear-sparing surgical corridor. RESULTS: This approach to the IAC was feasible in 92% (35 of 38) specimens based on a minimum distance of 3mm between the basilar turn of the cochlear and the great vessels (jugular bulb and carotid artery). CONCLUSIONS: Infracochlear access to the IAC is feasible in the majority of adult temporal bones and has implications for future hearing preservation drug delivery approaches to the IAC.

The value of otoendoscopy in the management of middle ear cholesteatoma.

BACKGROUND: The surgical management of cholesteatoma is a controversial issue, particularly regarding intact-canal-wall mastoidectomy (ICWM) versus canal-wall-down mastoidectomy (CWDM). The current experiment compared the quality of visualization in different middle ear structures using ICWM with otoendoscopy with findings of CWDM by microscopy. MATERIALS AND METHODS: The patients diagnosed with cholesteatoma underwent tympanomastoidectomy, and then the patients selected for CWDM were included in the study (25 patients: 11 females and 14 males). After removing the cholesteatoma from the involved areas, otoendoscopic examination was done with a 4 mm, 0° endoscope by a neurootologist. All five middle ear structures (lateral epitympanum, sinus tympani, posterior crus of the stapes, round window niche, and Eustachian tube orifice) suspected of occult cholesteatoma were evaluated in terms of having or lacking the pathology. Then, CWDM was performed and all of the mentioned sites were reevaluated for diagnosing occult cholesteatoma. RESULTS: The symmetric measures were 73%, 92%, 63%, 81%, and 100% for lateral epitympanum, sinus tympani, posterior crus of the stapes, round window niche, and Eustachian tube orifice, respectively. CONCLUSION: Otoendoscopy was confirmed to have a great potential to be adopted by surgeons as a less invasive procedure in the surgical management of middle ear cholesteatoma.

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.

Smartphone-enabled otoscopy: method evaluation in clinical practice.

OBJECTIVE: To assess the diagnostic agreement between smartphone-enabled otoscopy and rigid otoendoscopy in tympanic membrane and middle ear diseases. METHODS: A cross-sectional study was carried out to analyze otoscopies in patients seen at a general otorhinolaryngology (ORL) outpatient clinic, from June to December 2019. Eighty-three images of patients obtained from otoscopies performed through a smartphone device and a rigid endoscope were included, recorded, and stored for further analysis. The images were first analyzed by an experienced otologist, who assigned his diagnostic impression (defined as the gold standard) on each of the images. After this analysis, the images were displayed to a group of secondary raters (an experienced otorhinolaryngologist, a second-year resident in ORL, and a general practitioner). A questionnaire was applied related to each image. RESULTS: There was high agreement between the smartphone device and the otoendoscopy images for all professionals, with a Kappa coefficient of 0.97 (p < 0.001). The smartphone device showed a diagnostic sensitivity of 81.1% and a specificity of 71.1%. As for the otoendoscopy, it showed a sensitivity of 84.7% and a specificity of 72.4%. The image classification as "2 = Good" was the most frequent one, with 34.9% for otoendoscopy and 31.6% for the smartphone device. CONCLUSION: There was a high diagnostic agreement between smartphone device-guided otoscopy and the rigid otoendoscopy, demonstrating the feasibility of using this device in clinical practice.

An Innovative, Quick and Cost-Effective Technique of Dispensing Endoscopy Reports.

Endoscopy is a commonly performed out patient procedure in the field of Otorhinolaryngology. One of the important parts of an endoscopy is the task of reporting and printing the report to make it available for the patient as well as the treating physician. Most endoscopy reporting software available commercially are expensive and needs appropriate hardware, expertise and manpower for running the same. The following article describes an innovative, time and cost-effective technique, which can be used for reporting purposes using a simple smart phone and a basic data pack with no additional manpower.

Deep Learning Techniques for Ear Diseases Based on Segmentation of the Normal Tympanic Membrane.

OBJECTIVES: Otitis media is a common infection worldwide. Owing to the limited number of ear specialists and rapid development of telemedicine, several trials have been conducted to develop novel diagnostic strategies to improve the diagnostic accuracy and screening of patients with otologic diseases based on abnormal otoscopic findings. Although these strategies have demonstrated high diagnostic accuracy for the tympanic membrane (TM), the insufficient explainability of these techniques limits their deployment in clinical practice. METHODS: We used a deep convolutional neural network (CNN) model based on the segmentation of a normal TM into five substructures (malleus, umbo, cone of light, pars flaccida, and annulus) to identify abnormalities in otoscopic ear images. The mask R-CNN algorithm learned the labeled images. Subsequently, we evaluated the diagnostic performance of combinations of the five substructures using a three-layer fully connected neural network to determine whether ear disease was present. RESULTS: We obtained the receiver operating characteristic (ROC) curve of the optimal conditions for the presence or absence of eardrum diseases according to each substructure separately or combinations of substructures. The highest area under the curve (0.911) was found for a combination of the malleus, cone of light, and umbo, compared with the corresponding areas under the curve of 0.737-0.873 for each substructure. Thus, an algorithm using these five important normal anatomical structures could prove to be explainable and effective in screening abnormal TMs. CONCLUSION: This automated algorithm can improve diagnostic accuracy by discriminating between normal and abnormal TMs and can facilitate appropriate and timely referral consultations to improve patients' quality of life in the context of primary care.

Evaluation of Ear in Otologically Asymptomatic Patients of Chronic Rhinosinusitis.

Background: The aim of the study was to evaluate the ear in otologically asymptomatic patients of chronic rhinosinusitis and summarize the otological and audiological findings. Methods: This is a cross sectional study conducted in the Department of Otorhinolaryngology - Head & Neck Surgery, Jaipur Golden Hospital, New Delhi, from January 2019 to October 2019. 80 cases aged between 15 and 55 years with Chronic rhinosinusitis were included in the study. Detailed clinical examination and history was carried out followed by Diagnostic nasal endoscopy and Otoendoscopy. All the data collected was statistically analyzed. Results: In patients of Chronic rhinosinusitis, Nasal obstruction was the most common complaint. Out of 80 patients 47 had abnormal Tympanic Membrane finding in one or the other ear, among them Tympanosclerotic patch was the most common finding. Co-relation between Diagnostic nasal endoscopy in right and left ipsilateral nasal cavity and tympanic membrane showed statistically significant association between nasal polyp and presence of abnormal tympanic membrane. Statistically significant association between duration of chronic rhinosinusitis and presence of abnormal tympanic membrane finding on otoendoscopy was found. Conclusion: chronic rhinosinusitis affects the ears slowly and silently. Hence, the ears should always be proactively evaluated in every patient of chronic rhinosinusitis to diagnose inevident disease in ears and if necessary, initiate timely preventive and therapeutic intervention.

Tympanic Membrane Pneumatocele from Auto-insufflation.

OBJECTIVE: The differential of an external auditory canal mass is broad. One rare potential cause is a pneumatocele of the tympanic membrane, which has only been described 1 other time in the literature. This report serves to describe the second case of this pathology, including its unique presentation, and benign clinical course. METHODS: Case report. RESULTS: A case is discussed in which a pneumatocele of the tympanic membrane was incidentally identified during evaluation of contralateral otologic pathology. The etiology was suspected to be habitual auto-insufflation. After cessation of this practice, the pneumatocele was noted to resolve without further intervention. CONCLUSION: A tympanic membrane pneumatocele represents a rare cause of an external auditory canal mass. The diagnosis can be made clinically via history, palpation, and otoscopy during auto-insufflation, potentially avoiding further diagnostic testing. Depending on the etiology, resolution can occur after lifestyle modification; however, further interventions may definitively treat the condition if so required.

Endoscopic Transcanal Myringoplasty-Smart Myringoplasty for Nex Gen ENT Surgeons: Our Experience.

Otolaryngology is one of the branch where endoscopes is being widely used nowadays to perform different surgeries. Ear surgeries are of special interest among the ENT surgeons. It has several advantages compared to the microscopes. 60 patients underwent endoscopic transcanal myringoplasty by the postgraduate residents under direct supervision of same consultants, using temporalis facia graft. The overall success rate in terms of graft uptake was 86.67% and the AB gap closure of < 10 dB in 63.3% of cases and 10-20 dB in 33.3%. Endoscopic myringoplasty was found to be equally effective, less morbid and very cost effective than the microscopic myringoplasty. This was applicable irrespective of the size of the perforation and condition of the middle ear (dry/wet) in our centre.

Sharing in-office otoendoscopy recordings may improve patient satisfaction: A prospective cohort study.

OBJECTIVE: Evaluate the impact of sharing otoendoscopy exams on patient satisfaction in the outpatient clinical setting. METHODS: Randomized, prospective cohort study. Consecutive adults presenting to otology clinic at one tertiary referral center were randomized into two groups: standard microscopy (SM) and video otoendoscopy (VO). The SM group had ears examined using a standard, otomicroscope; the VO group had ears examined using a 0° rigid endoscope connected to a video tower. All subjects were counseled on their exam findings in a routine manner; the VO group was concurrently shown a recording of their ear exam. All subjects completed the 18-item Patient Satisfaction Questionnaire (PSQ-18) at the conclusion of their clinic visit. RESULTS: The SM group consisted of 27 patients and VO group consisted of 23 patients. VO subjects reported higher PSQ-18 scores compared to SM subjects within the domains of communication (p = 0.04) and technical quality (p = 0.005). On linear regression models, demographic factors and positive exam findings were not predictive of patient satisfaction. CONCLUSIONS: Sharing otoendoscopy recordings may be a valuable tool that can improve patient satisfaction. PRACTICE IMPLICATIONS: Clinicians should consider sharing recordings of otoscopic exams with patients, particularly when faced with the possibility of surgery.

Mongolian Gerbils as a Model for the Study of Cholesteatoma: Otoendoscopic as a Diagnostic Tool.

Introduction Cholesteatoma is a disease with significant clinical impact but is incompletely understood. The challenge of performing studies with long-term follow-up in humans is a factor that has restricted the advance of knowledge in this field. Thus, the use of animal models is highly pertinent, and the Mongolian gerbil model has emerged as one of the most useful. Objective The present study aims to evaluate, through serial otoendoscopies, the development and characteristics of pars flaccida retraction pocket and cholesteatoma in Mongolian gerbils after obliteration of the eustachian tube and compare it with the control group. Methods Forty Mongolian gerbils were divided into two groups of 20 animals each. In the intervention group, the animals were followed with serial otoendoscopies after eustachian tube obliteration. In the control group, the animals were only followed through serial otoendoscopies. Results At the end of the 16-week follow-up, cholesteatoma was present in 13 of 38 (34.2%) ears in the intervention group, and in 7 of 34 (20.6%) in the control group ( p = 0.197). When we considered cholesteatoma and its potential precursor, pars flaccida retraction pocket, in a combined way, we verified it in 23 of 38 (60.8%) in the intervention group and in 11 of 34 (32.3%) in the control group ( p = 0.016). Conclusions Over the 16 weeks of follow-up, serial otoendoscopies enabled us to evaluate the formation and development of pars flaccida retraction pockets and cholesteatomas in Mongolian gerbils and proved to be an excellent diagnostic tool.

[Guiding opinions on clinical application of OTO'VIEW technology].

The application of endoscopy technology has promoted the continuous progress and perfection of otology, but the inherent limitations of traditional otoendoscopy technology have also been highlighted, which limits its comprehensive application in clinical practice. To overcome these limitations, we combined clinical needs with basic research, to make a pioneering exploration of the existing otoendoscopy technology. This pioneering OTO'VIEW technology applies the plasma technology innovatively to the traditional continuous perfusion mode otoendscopy technology. This paper comprehensively introduces the development, application, existing problems and possible solutions of OTO'VIEW technology in clinical application.

A case report of otoendoscopic radiofrequency resection of squamous cell carcinoma of the external auditory canal.

Squamous cell carcinoma is the most common pathological type of external and middle ear malignancy. Squamous cell carcinoma of the external auditory canal and middle ear is closely associated with long-term chronic inflammatory irritation. The patient was admitted with a major complaint of a "stuffy feeling in the left ear for more than three months." The results of the otoendoscopic examination were as follows: The left external auditory canal was filled with a granuloma-shaped mass with an unsmooth surface that showed obvious oozing of blood. The tympanic membrane was not visible. After the completion of the relevant examinations, radiofrequency resection of the external auditory canal mass was performed under otoendoscopy and the wound healed well with postoperative dressing changes. Pathological results revealed a well-differentiated keratinizing cutaneous squamous cell carcinoma and there was no recurrence throughout the next 5 years after the operation. Proper preoperative evaluation and the correct selection of surgical approaches can be of great importance. The primary complication of ear squamous cell carcinoma was local recurrence with a low incidence of metastasis. Early and complete resection was determined to be the optimal course of treatment.

Tragus Perichondrium-Cartilage Island and Temporalis Muscle Fascia for Repairing Tympanic Membrane Perforation Under the Otoendoscope: A Randomized Controlled Trial.

OBJECTIVE: To compare the clinical effects of repairing tympanic membrane perforation (TMP) with the tragus perichondrium-cartilage island and temporalis muscle fascia (TMF) under the otoendoscope. METHODS: The clinical data of 84 patients (total 84 ears) with TMP repaired by otoendoscopy from March 2019 to April 2021 were analyzed. The patients were randomly divided into the control group (n = 42, TMF repair) and the experimental group (n = 42, perichondrium-cartilage island repair). The intraoperative blood loss, operation time, length of hospital stay, success rate of the TMP repair, mean air-conducted sound, and air-bone gap before and after surgery were compared between the two groups. RESULTS: The mean air-bone gap and mean air-conducted hearing threshold in the experimental group were significantly lower after surgery at all frequencies than those of the control group (all P < .05). The reduction of the mean air-conducted hearing threshold in the experimental group was significantly higher than that of the control group (P < .001). The surgery time of the experimental group was significantly shorter than the control group (78.04 ± 2.23 vs. 84.27 ± 1.67 minutes, P < .001). The success rate of the TMP repair was 95.24% (40/42) in the experimental group and 92.86% (39/42) in the control group, indicating that there was no significant difference in the success rate of TMP repair between the two materials (risk ratio = 1.75; 95% confidence interval: .31-12.04; P = .71). CONCLUSION: Repairs with the tragus perichondrium-cartilage island have a short operation time, high healing rate, and more significant postoperative hearing improvement, which makes it a more effective method of TMP repair.

Correlation Between Video-Otoendoscopy and Tympanograms of Patients with Acute Middle Ear Infections.

The tympanic membrane (TM) undergoes a number of pathological changes in middle ear disease which can be detected by a video-otoendoscope. Middle ear disease is also accompanied by changes in middle ear pressure which can be assessed by tympanometry. The objectives of this study were to find the correlation between video-otoendoscopy and tympanometry in acute middle ear infections and to deduce which of the two is more efficient and reliable for early diagnosis. 75 patients with AOM or OME were included over 1 year where each patient was followed for 21 days. Detailed history and clinical examination with videootoendoscope and tympanometry was done on each visit. Each TM was graded using OMGRADE scale. Symptoms and clinical findings consistent with acute otitis media were given a clinical score (CO Score). The results were collected and correlation between video-otoendoscopy and tympanometry was determined and their individual sensitivity, specificity and diagnostic accuracy was calculated. The sensitivity, specificity and diagnostic accuracy for tympanometry and video-otoendoscopy was calculated individually for each of the 4 visits and positive correlation between the 2 was found. Our study showed that tympanometry had a higher overall sensitivity than video-otoendoscopy. While, video-otoendoscopy showed a higher specificity than Tympanometry. Otoendoscopy is good for ruling out AOM/OME but cannot rule out persisting Middle Ear Effusion and Tympanometry is a better tool for detecting MEE but cannot differentiate well between AOM and OME. We found that tympanometry plus otoendoscopy together greatly increase the chances of detecting AOM and OME thus improving diagnostic accuracy, reducing financial costs associated with over or mis-diagnosis.

The Role for Microsurgery of the Ear.

Microscopic ear surgery (MES) has been used since the 1950s whereas endoscopic ear surgery (EES) was introduced in the mid-1990s. The advantages of MES should not be forgotten as surgeons turn their attention to new technology. These include depth perception, wide angle view, and the ability to operate with 2 hands. EES affords the ability to look around corners but needs a pristine field and is limited to single-handed surgery in a narrow field. Trainees should be taught both, and technique used should reflect the experience and abilities of the surgeon and the nature of the disease in the particular patient.

History of Endoscopic Ear Surgery.

The introduction of the microscope to ear surgery by Wullstein has been a transformative event in ear surgery. The ability to visualize disease and anatomy has resulted in more effective surgery and better functional outcomes. Many surgical disciplines have adapted the endoscope as the instrument of choice to access and correct internal pathology without disruption of overlying tissue. Multiple discussions and attempts at using the endoscope in ear surgery over the years have culminated in the development of transcanal endoscopic ear surgery. This article discusses the integration of the endoscope into the practice of otologic surgery.