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.

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.

Features Associated With High Risk of Recurrence in Saccular Laryngeal Cysts: A Systematic Review and Qualitative Synthesis.

INTRODUCTION: Saccular cysts are rare benign anomalies of the larynx (1.5% of laryngeal anomalies) determined by dilatation of the laryngeal saccule. They can be congenital or acquired. Clinical manifestation depends on the site of the cyst and the age of the patient. Children frequently have stridor and dyspnea, while adults usually complain of dysphonia.The therapeutic approach can be surgical or nonsurgical (needle aspiration or drainage).However, guidelines on the management of this disease are lacking in the literature.This systematic literature review was conducted through an interferential analysis with the aim of detecting the association between clinical, diagnostic, and operative factors and the recurrence of saccular cysts. MATERIALS AND METHODS: This systematic literature review was evolved following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 checklist statement Papers published up to August 2023 containing relevant clinical data were searched in Embase/PubMed, Web of Science, Scopus, and Cochrane database. Full texts lacking information on the patient's data, clinical, radiological, and/or histological diagnosis of saccular cysts of the larynx were excluded. Articles with follow-up inferior to 6 months and not reporting any treatment of the cyst were excluded, too. Data concerning signs and symptoms, cyst characteristics, and the type of treatment were described, and the risk of recurrence was studied in association with these features. A qualitative synthesis of the results was performed. RESULTS: Ninety-eight articles were screened. One hundred two patients were involved in the analysis. The articles with low or intermediate risk of bias were 22 (8 case reports and 14 case series) and they were included in the statistical analysis. Median age was 25 years (range 0-81). Saccular cysts were congenital (46/102, 45%) of cases acquired (56/102, 55%). Relying on the available data, all patients were symptomatic, with stridor as the main symptom (59%). Surgical approach was performed in 85% of cases, while drainage or needle aspiration of the cyst was the treatment of choice in the remaining 25% of cases. Twenty-four percent of patients had recurrence of the disease within 3 months. Median age at recurrence was 9 years. Cysts characteristics, preoperative management, and type of treatment were associated with an increased risk of disease recurrence (P < 0.05). CONCLUSIONS: Saccular cysts are rare congenital or acquired laryngeal diseases. Data regarding their management and factors associated with the risk of recurrence are still limited. Congenital cysts treated conservatively have a higher risk of recurrence than acquired cysts treated by open surgical techniques or by microlaryngoscopy. A better knowledge of factors associated with a higher risk of recurrence could help choose the best treatment.

Multilayer Anterior Skull Base Reconstruction with Cortical Rib Bone Graft: Preliminary Experience.

OBJECTIVE: During the past decades, different methods have been described for anterior skull base reconstruction. Regarding larger skull base defects, few investigators have described the use of bone grafts to foster support and prevent frontal lobe sagging, herniation, or falling. The aim of this study is to describe the use of a rib bone graft, which could be an option in these cases due to its rigidity and dimensions. METHODS: We retrospectively collected preoperative, intraoperative, and postoperative data at the last follow-up of 10 patients who underwent multilayer anterior skull base reconstruction, including rib bone graft, for large anterior cranial base defects at 2 tertiary care academic hospitals. RESULTS: Eight patients underwent endoscopic craniectomy for sinonasal malignancies, and the other two underwent transnasal endoscopic surgery for congenital meningoencephalocele. Anterior skull base defects measured on average 3.8 cm ± 0.9 SD antero-posteriorly (range 2.5-5 cm) and 2.3 ± 0.9 SD latero-laterally (range 0.9-4 cm). Multilayer reconstruction was performed in all cases, including a rib bone graft positioned as intracranial extradural layer. No patient experienced thoracic complications during the postoperative period. No side effects related to the bone graft or meningoencephalocele occurrence were reported after a mean follow-up of 8.0 ± 6.3 months. CONCLUSIONS: The use of a cortical rib bone graft could be a safe and effective option in skull base reconstruction when managing large defects after cancer removal.

Acquired bilateral facial palsy: a systematic review on aetiologies and management.

OBJECTIVE: To systematically review the published cases of bilateral facial palsy (BFP) to gather evidence on the clinical assessment and management of this pathology. METHODS: Following PRISMA statement recommendations, 338 abstracts were screened independently by two authors. Inclusion criteria were research articles of human patients affected by BFP, either central or peripheral; English, Italian, French or Spanish language; availability of the abstract, while exclusion criteria were topics unrelated to FP, and mention of unilateral or congenital FP. Only full-text articles reporting the diagnostic work-up, the management, and the prognosis of the BFP considered for further specific data analysis. RESULTS: A total of 143 articles were included, resulting a total of 326 patients with a mean age of 36 years. The most common type of the paralysis was peripheral (91.7%), and the autoimmune disease was the most frequent aetiology (31.3%). The mean time of onset after first symptoms was 12 days and most patients presented with a grade higher than III. Associated symptoms in idiopathic BFP were mostly non-specific. The most frequently positive laboratory exams were cerebrospinal fluid analysis, autoimmune screening and peripheral blood smear, and the most performed imaging was MRI. Most patients (74%) underwent exclusive medical treatment, while a minority were selected for a surgical or combined approach. Finally, in more than half of cases a complete bilateral recovery (60.3%) was achieved. CONCLUSIONS: BFP is a disabling condition. If a correct diagnosis is formulated, possibilities to recover are elevated and directly correlated to the administration of an adequate treatment.

A Systematic Review of Diagnostic and Prognostic Biomarkers for Head and Neck Cancer of Unknown Primary: An Unmet Clinical Need.

Head and neck cancer of unknown primary (HNCUP) is defined as cervical lymph node metastases without a detectable primary tumor. The management of these patients presents a challenge to clinicians since guidelines in the diagnosis and treatment of HNCUP remain controversial. An accurate diagnostic workup is fundamental for the search for the hidden primary tumor to allow the best adequate treatment strategy. The purpose of this systematic review is to present the currently available data about the diagnostic and prognostic molecular biomarkers for HNCUP. Systematic research in an electronic database was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol and identified 704 articles, of which 23 studies were selected and included in the analysis. Fourteen studies investigated HNCUP diagnostic biomarkers and focused on the human papilloma virus (HPV) and the Epstein-Barr virus (EBV) due to the strong associations with oropharyngeal cancer and nasopharyngeal cancer, respectively. HPV status was shown to possess prognostic value, correlating with longer disease-free survival and overall survival. HPV and EBV are the only available HNCUP biomarkers, and they are already used in clinical practice. A better characterization of the molecular profiling and the development of tissue-of-origin classifiers are necessary to improve the diagnosis, staging, and therapeutic management of patients with HNCUP.

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.

Oncological and Functional Outcomes for Horizontal Glottectomy: A Systematic Review.

Horizontal glottectomy (HG) is a particular type of partial laryngectomy indicated for exclusive glottic tumor with anterior commissure involvement. The purpose of this study is to systematically review the literature about functional and oncological outcome of HG. This systematic review adhered to the recommendations of the PRISMA (Preferred Reporting Items of Systematic Reviews and Meta-analysis) 2009 guidelines. Articles mentioning patients undergoing HG for laryngeal squamous cell carcinoma were included. A total of 14 articles were selected and reviewed from 19 identified. The whole study population consisted of 420 patients who underwent HG. Three hundred and thirty-nine patients out of 359 were staged as T1. The range of post-operative follow-up was 5 months to 10 years. Fifty-five recurrences were experienced, being local, regional and distant in 35, 12 and 8 patients, respectively. Laryngeal preservation rate was 93.6%. Nasogastrict tube was removed on average after 10.1 days. The tracheostomy was maintained for 11.3 days. Mean hospitalization lasted for 11.7 days. According to the results of this systematic review, HG is an oncologically safe surgical option for T1a-T1b glottic tumors with oncological outcomes comparable to other treatment. HG could be a good therapeutical choice whenever poor laryngeal exposure and/or patient's refusal of radiotherapy are encountered, or when patient's medical history represents a contraindication for radiation therapy.

Digital image enhancement may improve sensitivity of cholesteatoma detection during endoscopic ear surgery.

OBJECTIVES: This study investigates the possible benefits and limitations of the digital image enhancement systems provided by Storz Professional Image Enhancement System (SPIES) during endoscopic ear surgery (EES) for cholesteatoma. An increased detection of cholesteatoma residuals during the final steps of endoscopic surgery using DIE technology was hypothesized. DESIGN: Cross-sectional study. SETTING: Tertiary referral hospital. METHODS: A total of 10 questionnaires of 18 intraoperative pictures with equal numbers of cholesteatoma and non-cholesteatoma images, each presented in three different image-enhancing modalities (Clara, Spectra A, Spectra B), were generated. Fifty-one experienced ear surgeons participated to the survey and were randomly assigned to a questionnaire and completed it at two time points. The experts were asked to rate for each picture whether cholesteatoma was present or not. The answers were compared with the histopathological reports. RESULTS: Clara showed the highest accuracy in cholesteatoma detection, followed by Spectra A and lastly Spectra B. In contrast, Spectra B showed the highest sensitivity and Clara the highest specificity, while Spectra A was placed in the middle for both values. Using the Spectra B modality, most responses agreed across the two time points. Ear surgeons assessed the usefulness, as well as preference among image modalities for cholesteatoma surgery, in the following order: Clara, Spectra B, Spectra A. CONCLUSION: Digital enhancement technologies are applicable to EES. After complete cholesteatoma removal, Spectra B showed the highest sensitivity in the detection of cholesteatoma residuals as compared with Clara and Spectra A. Thus, Spectra B may be recommended to avoid missing any cholesteatoma residuals during EES.

Diagnostic and Prognostic Value of microRNAs in Patients with Laryngeal Cancer: A Systematic Review.

Laryngeal squamous cell cancer (LSCC) is one of the most common malignant tumors of the head and neck region, with a poor survival rate (5-year overall survival 50-80%) as a consequence of an advanced-stage diagnosis and high recurrence rate. Tobacco smoking and alcohol abuse are the main risk factors of LSCC development. An early diagnosis of LSCC, a prompt detection of recurrence and a more precise monitoring of the efficacy of different treatment modalities are currently needed to reduce the mortality. Therefore, the identification of effective diagnostic and prognostic biomarkers for LSCC is crucial to guide disease management and improve clinical outcomes. In the past years, a dysregulated expression of small non-coding RNAs, including microRNAs (miRNAs), has been reported in many human cancers, including LSCC, and many miRNAs have been explored for their diagnostic and prognostic potential and proposed as biomarkers. We searched electronic databases for original papers that were focused on miRNAs and LSCC, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. According to the outcome, 566 articles were initially screened, of which 177 studies were selected and included in the analysis. In this systematic review, we provide an overview of the current literature on the function and the potential diagnostic and prognostic role of tissue and circulating miRNAs in LSCC.

Expanded transcanal transpromontorial approach for acoustic neuroma removal.

Axial sections from preoperative magnetic resonance imaging without contrast, showing a cone-shaped lesion of the internal auditory canal, extending toward the most lateral part of the cerebello-pontine angle. (A) T1-weighted high-resolution isotropic volume excitation (THRIVE) sequence; (B) T1-weighted sequence; (C) Fluid attenuated inversion recovery (FLAIR) sequence. Laryngoscope, 133:282-286, 2023.

Vestibular schwannoma removal through expanded transcanal transpromontorial approach: a multicentric experience.

PURPOSE: Expanded Transcanal Transpromontorial Approach (ExpTTA) is an endomicroscopic technique that allow surgical excision of small and symptomatic neuromas limited to the internal auditory canal (IAC) or minimally invasive the cerebellopontine angle (CPA). ExpTTA is a safer alternative to the exclusive endoscopic technique as it allows a wider surgical field and better management of the auditory porus and CPA. METHODS: We report a retrospective case series of 34 patients who underwent ExpTTA between 2017 and 2022 at the ENT Departments of the University Hospital of Modena, Bologna and Verona. Tumor size was defined according to the Koos staging and hearing function was classified according to the AAOHNS. A clinical evaluation of facial nerve (FN) function was performed using the House and Brackman scale (HBs). RESULTS: Our cohort consists of 34 patients. At time of surgery all patients had a normal preoperative facial function. Gross total resection was achieved in all patients, without intraoperative complications, and FN continuity was preserved in all cases. No major complications were observed. Regarding post-operative FN function, at hospital discharge ten patients had impairment equal or greater than IV grade according to H&Bs. At 6 months after surgery only two patients presented with moderate/severe facial paralysis (grade IV H&Bs) and finally at 12-month follow-up all patients had a satisfactory recovery of nervous function (grade < III H&Bs). CONCLUSIONS: ExpTTA is a safe and effectively technique for treatment of small VS (Koos I, II and selected cases of Koos III) with low postoperative morbidity.

"Hot" vs "Cold" endoscopic stapes surgery: a matched case-control study.

PURPOSE: To compare hearing results and complication rates between two groups of patients operated on by endoscopic stapes surgery (ESS) for otosclerosis, either with CO2 fiber laser or microdrill. METHODS: A case-control study was performed. All consecutive cases of CO2 fiber laser ESS operated at a single center during the period 2017-2020 (case group) were matched to a control group of patients operated by traditional technique, according to year of surgery, preoperative mean air-bone gap, sex and age. Audiological data from preoperative and postoperative examinations and complication rates were compared. RESULTS: 46 cases were included. Mean operative time was significantly longer in the laser cohort (65 min) than in the drill one (45 min) (p = 0.003). Similar results were found in the two groups regarding the mean postoperative BC-PTA. The high-frequency bone conduction resulted significantly higher in the laser group (p = 0.002), suggesting an overclosure effect in the laser group. Consistently, a significant improvement of the BC-PTA threshold at 2000 Hz postoperatively was found in the laser group (p = 0.034). The postoperative AC-PTA significantly improved in both groups at all frequencies (p < 0.05), except for the AC threshold at 8 kHz. Similar rates of complications were found in the two groups. CONCLUSION: This study is the first to compare hearing results and complications between CO2 fiber laser and microdrill in ESS. Our results demonstrated similar functional outcomes between the two groups, confirming ESS as safe and effective, regardless of the technique used.

Assessment of a novel patient-specific 3D printed multi-material simulator for endoscopic sinus surgery.

Background: Three-dimensional (3D) printing is an emerging tool in the creation of anatomical models for surgical training. Its use in endoscopic sinus surgery (ESS) has been limited because of the difficulty in replicating the anatomical details. Aim: To describe the development of a patient-specific 3D printed multi-material simulator for use in ESS, and to validate it as a training tool among a group of residents and experts in ear-nose-throat (ENT) surgery. Methods: Advanced material jetting 3D printing technology was used to produce both soft tissues and bony structures of the simulator to increase anatomical realism and tactile feedback of the model. A total of 3 ENT residents and 9 ENT specialists were recruited to perform both non-destructive tasks and ESS steps on the model. The anatomical fidelity and the usefulness of the simulator in ESS training were evaluated through specific questionnaires. Results: The tasks were accomplished by 100% of participants and the survey showed overall high scores both for anatomy fidelity and usefulness in training. Dacryocystorhinostomy, medial antrostomy, and turbinectomy were rated as accurately replicable on the simulator by 75% of participants. Positive scores were obtained also for ethmoidectomy and DRAF procedures, while the replication of sphenoidotomy received neutral ratings by half of the participants. Conclusion: This study demonstrates that a 3D printed multi-material model of the sino-nasal anatomy can be generated with a high level of anatomical accuracy and haptic response. This technology has the potential to be useful in surgical training as an alternative or complementary tool to cadaveric dissection.

Primary mucosal melanoma of the larynx: systematic review of the literature and qualitative synthesis.

PURPOSE: Primary mucosal melanoma of the larynx (PLM) is a rare entity among head and neck cancers. Due to its rarity, clear protocols of management are not available. A deeper knowledge of the clinical and biological behaviour of PLM is strongly needed. METHODS: According to PRISMA process, we searched through electronic databases case reports, case series and review articles providing relevant clinical data. The survival analysis was performed with Kaplan-Meier survival curves, using disease free survival (DFS) and overall survival (OS) as endpoints. RESULTS: 1074 articles were initially screened, of which 37 studies describing 44 PLM cases were selected and included in the analysis. Mean age was 59.7 years with a mean follow-up time of 25.4 months. The most common symptom at presentation was hoarseness (52%), while the most involved laryngeal subsite was supraglottic region (62%). Most patients presented with an advanced stage. Tumour (T) and node (N) status at presentation did not influence OS nor DFS, whereas distant metastases (M) status resulted significantly associated with the reduction of OS and DFS time (Mantel-Cox: p < 0.0001 and p = 0.001, respectively). The laryngeal subsite and the type of surgery performed did not significantly impact on OS and DFS. CONCLUSIONS: Treatment for PLM remains debated. Surgery with safe margins is recommended due to the high rates of local recurrence. Systemic therapy is advised for metastatic disease. However, the prognosis remains poor even after radical resection or targeted therapy.

Surgical Training on Ex Vivo Ovine Model in Otolaryngology Head and Neck Surgery: A Comprehensive Review.

Background: Nowadays, head and neck surgical approaches need an increased level of anatomical knowledge and practical skills; therefore, the related learning curve is both flat and long. On such procedures, surgeons must decrease operating time as much as possible to reduce the time of general anesthesia and related stress factors for patients. Consequently, little time can be dedicated for training skills of students and young residents in the operating theater. Fresh human cadavers offer the most obvious surrogate for living patients, but they have several limitations, such as cost, availability, and local regulations. Recently, the feasibility of using ex vivo animal models, in particular ovine ones, have been considered as high-fidelity alternatives to cadaveric specimens. Methods: This comprehensive review explores all of head and neck otolaryngology applications with this sample. We analyzed studies about ear surgery, orbital procedures, parotid gland and facial nerve reanimation, open laryngeal and tracheal surgery, microlaryngoscopy procedures, laryngotracheal stenosis treatment, and diagnostic/operative pediatric endoscopy. For each different procedure, we underline the main applications, similarities, and limitations to human procedures so as to improve the knowledge of this model as a useful tool for surgical training. Results: An ovine model is easily available and relatively inexpensive, it has no limitations associated with religious or animal ethical issues, and it is reliable for head and neck surgery due to similar consistencies tissues and neurovascular structures with respect to humans. However, some other issues should be considered, such as differences about some anatomical features, the risk of zoonotic diseases, and the absence of bleeding during training. Conclusion: This comprehensive review highlights the potentials of an ex vivo ovine model and aims to stimulate the scientific and academic community to further develop it for other applications in surgical education.

Step-by-Step Stapedotomy through Transcanal Exclusive Endoscopic Approach.

In recent years there has been an increasing trend in the use of the endoscope to treat a variety of middle ear pathologies, including otosclerosis. Several studies comparing traditional microscopic and endoscopic stapes surgery have reported similar hearing results and an overall low rate of complications. The endoscope has unraveled its full potential in demanding settings of stapes surgery, such as unfavorable anatomy of the oval window niche or revision cases. Reduced manipulation of the chorda tympani and low rate of post-operative dysgeusia are further benefits to mention for endoscopic stapes surgery. Being a one-handed technique, management of bleeding, positioning, and crimping of the prosthesis may be challenging for novice endoscopic surgeons, so some training in endoscopic ear surgery is recommended before performing endoscopic stapedotomy. The problem of sharing the surgical field between the endoscope and the operating instruments could be easily overcome if proper instruments positioning is understood. One-handed bleeding control in the narrow space of the ear canal may represent an issue during the elevation of the tympano-meatal flap, possibly discouraging the surgeon since the preliminary steps of surgery. Following appropriate technique to raise the flap and the collaboration with the anesthesiology team in keeping the blood pressure low guarantee an adequate bleeding control in most cases. The aim of this article is to describe the entire surgical procedure of a transcanal exclusive endoscopic stapedotomy, from operating room set up and patient positioning to post-operative care. A step-by-step description of the surgical maneuvers with technical hints is reported, to guide the surgeon across the procedure and allow any ear surgeon to perform stapes surgery endoscopically.

Disease-specific quality of life and psychological distress after endoscopic tympanoplasty.

PURPOSE: To assess the postoperative quality of life (QoL) of patients operated on for chronic otitis media (COM) and cholesteatoma by endoscopic approach, with respect to disease-specific complaints and psychological distress, using two validated questionnaires: Chronic Ear Survey (CES) and Depression Anxiety Stress Scale-21 (DASS-21). METHODS: Eighty-five consecutive patients operated on for cholesteatoma and COM by endoscopic tympanoplasty from March 2018 to February 2020 filled in CES and DASS-21, within one month prior to surgery. A second administration of each questionnaire was performed at the yearly postoperative evaluation. A multivariate analysis using a linear regression model was performed to evaluate the role of the different variables associated with the questionnaires' subscales and overall scores. RESULTS: A significant improvement was achieved in all CES and DASS-21 subscales after endoscopic tympanoplasty. No patient showed a DASS-21 score compatible with a psychological distress both at the pre- and postoperative assessments. At multivariate analysis, the only significant factors associated with postoperative improvement in CES scores were preoperative DASS-21 "depression" score and months of follow-up. CONCLUSION: Endoscopic tympanoplasty shows significantly improved QoL as assessed by disease-specific and psycho-emotional questionnaires. A subjective favourable effect of fully endoscopic ear surgery was demonstrated.

Suprameatal-transzygomatic root endoscopic approach to the geniculate ganglion: an anatomical and radiological study.

PURPOSE: To describe the suprameatal-transzygomatic root endoscopic approach (STEA) to the geniculate ganglion (GG), the labyrinthine facial nerve (FN) and epitympanum. METHODS: The feasibility and limits of the STEA, maintaining the integrity of the ossicular chain, were analysed. Ten human cadaveric ears were dissected. Step-by-step description of the technique and relevant measurements were taken during the approach. The visualization and surgical working field on the anterior and posterior medial epitympanum, GG, greater superficial petrosal nerve, the labyrinthine FN and suprageniculate area were evaluated. The range of motion through the approach and the rate of the decompression of the GG and the labyrinthine portion of the FN were assessed as well. CT-scan measurements were compared with those obtained during the dissection. RESULTS: A complete exploration of the epitympanum was possible in every specimen. Decompression of the GG and first portion of the FN was achieved without any trauma to the ossicular chain in nine ears. The endoscope movements were mainly limited by the distance between bony buttress-short process of the incus-tegmen. The working space, during GG and labyrinthine FN decompression, was limited by the distance between malleus head-medial epitympanic wall and malleus head-GG. Radiologic measurements were consistent with those obtained during the dissections. CONCLUSION: The STEA is a promising minimally invasive approach for decompression of the GG and FN's labyrinthine portion. The applications of this corridor include the exploration and surgery of the medial epitympanum, preserving the ossicular chain.