Endoscopic Management of Primary Acquired Cholesteatoma.

Endoscopic ear surgery is increasingly accepted as a primary modality for cholesteatoma surgery. A major advantage is the enhanced visualization of the middle ear in traditionally poorly accessible locations by the microscope. We discuss novel techniques for selective mastoid obliteration when a canal wall down mastoidectomy is necessary. Postoperatively, indications for non-echo planar diffusion-weighted imaging MRI versus second-look surgery are discussed. Finally, outcome data for endoscopic versus microscopic ear surgery are reviewed, which show equivalent outcomes regarding residual and recurrent disease, similar rates of complications, decreased pain, and shorter healing time.

The Endoscopic Management of Congenital Cholesteatoma.

Congenital cholesteatoma is a rare, primarily pediatric disease that presents in otherwise healthy ears. Typically, this disease is found in a well-defined sac in the middle ear, making it particularly suited for removal through transcanal endoscopic ear surgery. This article reviews the ways in which endoscopy can be applied to the surgical management of congenital cholesteatoma and provides a guide based on congenital cholesteatoma stage and extent. Outcomes have shown similar rates of residual disease in total endoscopic ear surgery compared with operative microscopy.

Principles of Pediatric Endoscopic Ear Surgery.

The article describes the unique benefits and challenges of transcanal (and transmastoid) endoscopic ear surgery (EES) for management of middle ear disease in children. It provides a rationale for EES in children and describes differences in anatomy between the pediatric and adult ear. The basic principles of EES, from operating room layout, choice of surgical instruments, and tips and pearls to avoid complications specific to the endoscope, are reviewed. Finally, techniques and outcomes in pediatric EES for tympanic membrane perforation, congenital cholesteatoma, and acquired cholesteatoma are summarized.

Office-Based Otology Procedures.

Endoscopy has changed the practice of otology in both operative and clinic settings. Endoscopes increase the visibility of anterior tympanic perforations expanding the criteria for in-office repair. Endoscopic myringoplasty techniques using tissue-engineered grafts and porcine-based extracellular grafts are described. Endoscopic inspection of deep retraction pockets is a new important tool for pre-operative surgical assessment. This section also discusses the use and potential benefits of intratympanic injections for sudden sensorineural hearing loss and Meniere's disease.

Outcomes of Adopting Endoscopic Tympanoplasty in an Academic Teaching Hospital.

OBJECTIVES: To compare the outcomes of endoscopic versus microscopic tympanoplasty during the initial period of a surgeon adopting the new endoscopic technique and teaching the surgical approach to residents assisting in surgery. METHODS: Retrospective medical chart review of 60 consecutive operations for repair of isolated tympanic membrane perforations from 2011 to 2016 performed by a single surgeon assisted by residents in an academic teaching hospital. The outcomes of 20 ears repaired microscopically before the senior author adopted endoscopic ear surgery (Group A) were compared with the outcomes of the first 20 ears that were attempted with endoscopic surgery (Group B) and the next 20 ears performed endoscopically (Group C). Sixty ear operations were performed on 52 patients as 8 patients had bilateral ear surgery. RESULTS: The tympanic membrane closure rate was 80% for Group A, 80% for Group B, and 95% for Group C. Mean air-bone gap improvement was 12.8 dB in Group A, 8.3 dB in Group B, and 12.1 dB in Group C. Mean duration of surgery was 99.2 minutes in Group A, 91.3 minutes in Group B, and 90.5 minutes in Group C. In Group B, 20% of the ears (4/20) were converted to a microscopic approach; in Group C, none required conversion. CONCLUSIONS: Maintenance of good outcomes and similar results can be maintained during a surgeon's transition to adopting endoscopic tympanoplasty and teaching it to residents.

Endoscopic Anatomy of the Tensor Fold and Anterior Attic.

Objectives The objectives of the study were to (1) study the anatomical variations of the tensor fold and its anatomic relation with transverse crest, supratubal recess, and anterior epitympanic space and (2) explore the most appropriate endoscopic surgical approach to each type of the tensor fold variants. Study Design Cadaver dissection study. Setting Temporal bone dissection laboratory. Subjects and Methods Twenty-eight human temporal bones (26 preserved and 2 fresh) were dissected through an endoscopic transcanal approach between September 2016 and June 2017. The anatomical variations of the tensor fold, transverse crest, supratubal recess, and anterior epitympanic space were studied before and after removing ossicles. Results Three different tensor fold orientations were observed: vertical (type A, 11/28, 39.3%) with attachment to the transverse crest, oblique (type B, 13/28, 46.4%) with attachment to the anterior tegmen tympani, and horizontal (type C, 4/28, 14.3%) with attachment to the tensor tympani canal. The tensor fold was a complete membrane in 20 of 28 (71.4%) specimens, preventing direct ventilation between the supratubal recess and anterior epitympanic space. We identified 3 surgical endoscopic approaches, which allowed visualization of the tensor fold without removing the ossicles. Conclusions The orientation of the tensor fold is the determining structure that dictates the conformation and limits of the epitympanic space. We propose a classification of the tensor fold based on 3 anatomical variants. We also describe 3 different minimally invasive endoscopic approaches to identify the orientation of the tensor fold while maintaining ossicular chain continuity.

Vestibular dysfunction after cochlear implantation.

OBJECTIVE: To determine the prevalence, symptom characteristics, and potential risk factors for vestibular symptoms after cochlear implantation. STUDY DESIGN: Case-control study design embedded within an ongoing cohort of patients undergoing implantation. SETTING: Academic medical center cochlear implant research program funded by the National Institutes of Health. PATIENTS: Seventy five eligible consecutive patients undergoing cochlear implantation. INTERVENTION: Medical record review. MAIN OUTCOME MEASURE: Recorded symptoms of vestibular symptoms after cochlear implantation. Subjects with vestibular symptoms were considered case subjects; those without vestibular symptoms were considered control subjects. RESULTS: Twenty-nine of 75 (39%) patients experienced dizziness postoperatively. Four patients experienced a single, transient acute vertigo attack occurring less than 24 hours after surgery. The majority, 25 patients, experienced delayed, episodic onset of vertigo. The median (interquartile range) time of delayed onset was 74 (26-377) days after implantation. Delayed dizziness manifested as spontaneous episodic or positional vertigo. Preoperative dizziness, age at implantation, and age at onset of hearing loss were significantly greater in the dizzy group. Preoperative electronystagmography did not differentiate between groups. CONCLUSIONS: Thirty-nine percent (29/75) of subjects with implants were dizzy after implantation. The majority of subjects experienced dizziness in a delayed episodic fashion. Dizziness was not related to implant activation. It seemed that delayed dizziness was not related to immediate surgical intervention but could result from chronic changes occurring in the inner ear; there was some suggestion this could take the form of endolymphatic hydrops.

Endolymphatic sac enhancement: reversal of pathogenesis.

As this article and many other publications have indicated, many thousands of patients with incapacitating intractable progressive Meniere's disease have had their lives restored through endolymphatic sac enhancement surgery. This is the only nondestructive procedure for Meniere's disease that has stood the test of time. Destructive procedures such as labyrinthectomy (chemical or physical) and vestibular nerve section are reserved for rare cases of failure or recurrence after sac enhancement, despite revision of the enhancement. There is much evidence to support the concept that endolymphatic sac enhancement reverses or enhances the pathogenesis of Meniere's disease. With additional clinical and molecular biologic research, endolymphatic sac enhancement will continue to improve and become more efficacious in the new millennium.