Techniques of Endoscopic Ossiculoplasty.

The utilization of endoscopes in modern otology has evolved from diagnostic purposes to the development of exclusive endoscopic ear surgery. This technique offers a panoramic view of the middle ear and provides an optimal magnification of the oval window region, the stapes' suprastructure, and the footplate, allowing great precision in prosthesis positioning during ossiculoplasty (OPL). Various techniques for ossicular chain reconstruction have been described in the literature. Either autologous or synthetic materials can be used for reconstruction. The use of a patient's own tissue minimizes the risk of implant rejection or extrusion of the prosthesis through the tympanic membrane. On the other hand, synthetic materials like titanium are light and rigid and do not require time-consuming prosthesis remodeling. The main objective of this article is to present a comprehensive step-by-step guide that serves as a surgical manual for exclusive endoscopic OPL. This guide will explain various forms of OPL using synthetic and autologous materials. The goal is to provide a comprehensive understanding of the various surgical techniques and support the integration into clinical practice.

To detach or not to detach the umbo in type I tympanoplasty: functional results.

PURPOSE: To compare the audiological outcomes, tympanic membrane (TM) healing rates and complication rates in patients undergoing endoscopic underlay and over-under tympanoplasty type I (TTI). METHODS: The study includes 95 patients who underwent endoscopic TTI in the period between 2018 and 2023: 56% of the patients had the underlay technique and 41% had the over-under technique. Data regarding pre- and postoperative hearing, perforation characteristics, surgical procedures, graft types and complications were retrospectively analyzed. Audiometrical assessment included air conduction (AC) and bone conduction (BC) pure tone averages (PTA) and air-bone gap (ABG), pre- and postoperatively. RESULTS: Both underlay and over-under techniques significant improved AC PTA, with a mean ABG improvements of 5.9 dB and 7.2 dB, respectively. There was no significant difference in BC PTA between pre- and post-operative, indicating no inner ear damage in both techniques. The over-under technique showed a significantly higher TM closure rate (94.4%) compared to the underlay technique (80.6%). Complications were rare, with only one case of TM lateralization requiring revision surgery. CONCLUSIONS: Endoscopic TTI is an effective treatment in improving auditory function in chronic middle ear diseases. In our cohort, the detachment of the umbo does not negatively influence the postoperative hearing results and does not increase rate of complications. Moreover, the over-under technique demonstrates superior TM closure rates, making it a valuable option for specific cases. However, future prospective studies with larger sample sizes and longer term follow-up are needed to validate these findings and provide more comprehensive insights.

Video Learning of Surgical Procedures: A Randomized Comparison of Microscopic, 2- and 3-Dimensional Endoscopic Ear Surgery Techniques.

BACKGROUND: Video learning of surgical procedures helps trainees gain an initial understanding of the complex anatomy and the surgical procedure. Because no comparative studies have yet examined which microsurgical approach to the middle ear is most suitable for video learning, the authors investigated objective and subjective outcomes for medical trainees observing microscopic, 2-dimensional (2D) endoscopic, and 3- dimensional (3D) endoscopic ear surgeries. METHODS: Sixty-two medical students (min. 3rd year) from the University Hospital of Bern watched three standardized videos of a type I tympanoplasty surgery recording, conducted with a microscope, a 2D endoscope, and a 3D endoscope, respectively. The authors measured participants' learning outcome, eye movements, cognitive load, and subjective preferences. RESULTS: Of the 62 participants included in the study, 14 were male (22.58%), and mean age was 24.44 years (range: 21-29). Learning outcome was highest after watching the 3D endoscopic video (mean [SD], 59.48% [20.57%]). Differences in score were statistically significant: 2D endoscopic video (mean difference: -6.56%, 95% CI: -13.02 to -0.10%), microscopic video (mean difference: -13.82%, 95% CI: -20.27 to -7.36%). Participants showed lowest average eye fixation duration when watching the 3D endoscopic video (mean [SD], 307 ms [109 ms]), with statistically significant differences to the 2D endoscopic video (mean difference: -139 ms, 95% CI: -185 to -93 ms), and the microscopic video (mean difference: -264 ms, 95% CI: -310 to -218 ms). Participants reported lowest cognitive load for the 2D and 3D endoscopic videos. Ratings on discomfort, usability, naturalness, depth perception, and image quality were in favor of the 3D endoscopic video. CONCLUSION: The 3D endoscopic technique offers many advantages for video learning in terms of knowledge gain, visual field exploration, and subjective evaluation. To optimize learning effects in trainees, the authors recommend the use of endoscopes in middle ear surgery and, if available, using 3D technology.

Outcome of Salvage Therapy in Isolated Regional Recurrence in Head and Neck Squamous Cell Carcinoma.

OBJECTIVES/HYPOTHESIS: Head and neck squamous cell carcinoma (HNSCC) has a high tendency for regional lymphatic spreading. Nevertheless, isolated regional lymph node recurrences are rare, and only limited data regarding its management are available. The aim of this study was to describe treatment modalities and outcomes, and to identify prognostic factors. Study Design Retrospective cohort study. METHODS: The records of all patients (n = 498) with tumor persistence or recurrence after curatively intended treatment for HNSCC were retrospectively reviewed. Patients with synchronous secondary tumors at initial presentation, tumor persistence, local or locoregional recurrence, and systemic metastases were excluded. RESULTS: A total of 76 patients were included. The rate of occult additional metastasis in radiologically uninvolved neck compartments during salvage neck dissection was 25%. The salvaged patients showed a 37.5% 5-year recurrence-free survival (RFS). Multivariate analysis revealed initial stage IVA-B (hazard ratio [HR]: 4.16, P < .01), extracapsular spread (HR: 3.71, P = .04), higher involved/total lymph node ratio (HR: 6.79, P < .01), and soft-tissue infiltration (HR: 3.27, P < .01) as independent adverse prognostic factors for RFS. Moreover, univariate data analysis identified recurrent stage rcN2-3; clinical involvement of the neck levels IV, V and/or VI; and smoking as adverse risk factors for RFS. CONCLUSIONS: This study identifies initial stage IVA-B, extracapsular spread, higher involved/total lymph node ratio, and soft-tissue infiltration as independent adverse prognostic factors for RFS following isolated regional recurrences. The incidence of occult additional metastasis of radiologically uninvolved levels during salvage neck dissections was high (25%). Therefore, superselective or selective neck dissection would not have been the adequate type of salvage surgery. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:67-72, 2021.