International Survey of Operative Practices for Otologists and Neurotologists During the COVID-19 Crisis.

OBJECTIVE: To investigate the influence of the COVID-19 pandemic on operative practices of otology and neurotology providers internationally. STUDY DESIGN: Cross-sectional survey. METHODS: A 78-question survey was distributed to otologists and neurotologists between May 12, 2020 and June 8, 2020 to assess the impact of the pandemic on surgical practices. Sections within the survey delineated time periods: prior to the crisis, onset of the crisis, during the crisis, postcrisis transition. RESULTS: Of 396 survey respondents, 284 participants from 38 countries met inclusion criteria.Respondents were 16.9% female and 82.4% male, with a most common age range of 40 to 49 years (36.3%). 69.8% of participants had been in practice for over 10 years and most respondents worked in an academic medical center (79.2%). The average operative weekly caseload was 5.3 (SD 3.9) per surgeon prior to the crisis, 0.7 (SD 1.2) during the COVID-19 crisis, and 3.5 (SD 3.3) for those who had begun a postcrisis transition at the time of survey administration (p < 0.001). 71.5% of providers did not perform an elective otologic or neurotologic operative procedure during the initial crisis period. 49.8% reported modifying their surgical technique due to the COVID-19 pandemic. Use of powered air-purifying respirators and filtering facepiece 2 or 3 (FFP2/FFP3) respirators were in minimal supply for 66.9% and 62.3% of respondents, respectively. CONCLUSION: The COVID-19 pandemic impacted the otology and neurotology community globally, resulting in significant changes in operative volume and case selection. Modification of surgical technique and shortages of personal protective equipment were frequently reported.

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.

Endoscopic transtympanic Eustachian tube dilatation: An overview of evaluation methods and dilatation technique.

Endoscopic technique in patients undergoing chronic ear surgery allows visualization of protympanic (proximal) segment of the Eustachian tube (ET). The proximal cartilaginous ET is a common site of anatomical Obstruction in chronic otitis media and it is this proximal end of ET that is being observed, instrumented and dilated with transtympanic methods. The aim of this article is to discuss our approach to the assessment of the Eustachian tube using opening pressure measurement, endoscopic assessment of the protympanic segment of ET and Valsalva CT. And also to discuss detailed technique of transtympanic Eustachian tube dilatation.

An overview of endoscopic ear surgery in 2018.

OBJECTIVE: To provide an overview of Endoscopic Ear Surgery, its development, principles, and penetration in otology practice in 2018. DATA SOURCE: PubMed review of literature and cross-sectional email survey of otologists. METHODS: We reviewed all PubMed published articles on use of endoscopy in practice of otology over the last 50 years. Articles were categorized based on date of publication and pattern of utilizing the endoscope. We also conducted two identical email surveys in 2010 and 2018 of otologists on the use of endoscope and tabulated and compared results. RESULTS: The number of publications on use of endoscope has increased from 6 in 1990 to an accumulated total of 451 in 2018. There has been a clear shift in the area of interest away from diagnostic endoscopy, to endoscope-assisted surgery, and lately, to transcanal endoscopic ear surgery (TEES). Survey results further documented the increased awareness of the value of the endoscope and its increased use in clinical practice. CONCLUSION: TEES has gained traction as a subject of research interest and in clinical practice and has lately dominated the discussion on the use of endoscope in otology. LEVEL OF EVIDENCE: NA.

Comparison of short nozzle and long nozzle spray in sinonasal drug delivery: a cadaveric study.

The aim of this study is to compare the delivery site of topical drugs using the short nozzle and the long nozzle. Fourteen fresh frozen cadaver heads were obtained. All cadaver specimens underwent bilateral endoscopic wide maxillary antrostomy, frontal sinusotomy, and complete sphenoethmoidectomy. The right nasal cavity of each cadaver was sprayed with radiolabeled saline using the short nozzle (short nozzle group), while the left nasal cavity was sprayed using the long nozzle (long nozzle group). The distribution of radioactive saline within the sinus cavities was determined using single-photon emission computed tomography/computed tomography. The distribution of the radiolabeled saline in reference with the maxillary line, vestibule, maxillary, ethmoid, sphenoid, and frontal sinus was compared between the 2 groups using Fisher exact test. The number of specimens that demonstrated radioactivity above the maxillary line is higher in the long nozzle group (14 cadavers, 100%) compared to short nozzle group (9 cadavers, 64.3%; p = .02). There are fewer specimens that demonstrated deposition of radioactive saline in the vestibule in the long nozzle group (6 cadavers, 42.86%) compared to short nozzle group (13 cadavers, 92.86%; P = .006). Compared to short nozzle group, there are more specimens demonstrating radioactivity in the maxillary, ethmoid, sphenoid, and frontal sinus in the long nozzle group, but the differences were not statistically significant (p = 0.241, 0.347, 0.126, 0.5). Compared to short nozzle, long nozzle more frequently delivers intranasal drugs beyond the maxillary line and less frequently in the vestibule. These findings support the hypothesis that the use of long and narrow nozzle, instead of the conventional short nozzle, can improve sinonasal drug delivery in post-endoscopic sinus surgery nose.

Feasibility and Safety of Transtympanic Balloon Dilatation of Eustachian Tube.

OBJECTIVE: Assess safety and feasibility of transtympanic dilatation of proximal (tympanic-end) of the cartilaginous segment of the Eustachian tube in patients undergoing surgery for chronic ear disease. STUDY DESIGN: Case series. SETTING: Tertiary care hospital. SUBJECT AND METHODS: We reviewed the charts of 40 consecutive patients undergoing chronic ear surgery in our practice with manometric evidence of obstruction who underwent attempted transtympanic dilatation of proximal (tympanic-end) segment of the Eustachian tube. A range of outcome measures were reported that included pre and postdilatation opening pressure measurement of the Eustachian tube, closure of perforation, audiometric data, and complications. RESULTS: Dilatation of proximal (tympanic-end) of the cartilaginous segment of the Eustachian tube was technically feasible in 37 of 40 patients (93%). Postdilatation inspection of protympanum showed increased aperture in all dilated tubes. Opening pressure of Eustachian tube declined in 36 of 37 patients (97%). Residual perforation was evident in 5 of 40 patients (12%). No facial nerve or carotid complications were observed. Two patients had severe dizziness (5%) with one patient sustaining severe cochlear loss. CONCLUSION: Transtympanic dilatation increases the patency of the Eustachian tube immediately after instrumentation. No carotid complications were observed. Continuous endoscopic control is essential to avoid subluxation of stapes. Further study of this technique is warranted to identify its role, if any, in chronic ear surgery.

Safety of Carotid Canal during Transtympanic Dilatation of the Eustachian Tube: A Cadaver Pilot Study.

To assess the safety of Transtympanic balloon dilatation of the cartilaginous proximal Eustachian tube under endoscopic guidance as it relates to the integrity of the carotid canal in cadaver model. Endoscopic guided Transtympanic dilatations of the cartilaginous proximal end of the Eustachian tube were performed in 15 ears of 8 fresh frozen cadaver heads. CT scans were done before and after dilatation. Images were reviewed by two otologists and one radiologist. Balloon catheter placement and dilatation of the proximal Eustachian tube was feasible in all specimens. Endoscopic examination post dilatation showed a consistent increase in the aperture of the proximal cartilaginous tube in all ears. Review of CT images after dilatation showed no evidence of trauma to the carotid canal in all ears instrumented. Endoscopically guided Transtympanic dilatation of the proximal Eustachian tube is not associated with damage to the carotid canal in cadaver model. Level of Evidence: 4.

The Epitympanum Revisited: Endoscopic Anatomy.

In contrast to other means of studying the epitymapnum, the endoscope allows unparallel access without disruption of anatomy. The aim of this study is to delineate the anatomy of the epitympanum through transcanal endoscopy. Systematic dissection of anatomic specimens. We performed systematic endoscopic dissection of 20 ears in 10 fresh frozen anatomical specimens. A detailed flow sheet was filled up documenting the status of the lateral attic folds, the tensor fold, the cog and the tensor folds, the supratubal recess, and the patency of the anterior and posterior isthmus. None of the ears showed indication of previous chronic otitis media. The lateral incudomallear fold was intact in all but one ear. The lateral mallear fold was intact in all specimens. The tensor fold was complete in 16 ears and partial in four. Two of these ears belonged to the same specimen. The epitympanic diaphragm was complete in 15 out of 20 ears in 10 anatomic specimens. The endoscope allows for assessment of the attic anatomy and integrity of the diaphragm without undue disruption of anatomy. The epitympanic diaphragm is present in the majority of healthy ears and can in theory serve as the anatomic basis for the isolated attic retraction.

Endoscopic Anatomy of the Protympanum.

The protympanum, a final common pathway between the tympanic cavity and external environment, is gaining relevance due to the ease and completeness of visualization with angled endoscopes. Two primary conformations are described, quadrangular and triangular, and new anatomic structures such as the protiniculum, subtensor recess, and protympanic spine are defined. Surgical relevance of the protympanum is described with respect to ventilation, cholesteatoma, cerebrospinal fluid leak, otic neuralgia, and surgical access to the eustachian tube.

The Role of Transtympanic Dilatation of the Eustachian Tube During Chronic Ear Surgery.

Endoscopic technique allows visualization of the protympanic segment of the eustachian tube in patients undergoing chronic ear surgery. Balloon dilatation of the area can be undertaken with clear widening of the obstructed areas. This article discusses the authors' approach and experience with transtympanic dilatation of the eustachian tube. It includes case selection, technique, immediate postprocedure evaluation, and results, with multiple case presentations and videos.

Preoperative and Intraoperative Evaluation of the Eustachian Tube in Chronic Ear Surgery.

This article discusses the authors' approach to the assessment of the eustachian tube using opening pressure measurement, endoscopic assessment of the protympanic segment of the eustachian tube, and Valsalva computed tomography. A possible algorithm for the evaluation of eustachian tube obstructive disorders is detailed both preoperatively and intraoperatively.

Principles of endoscopic ear surgery.

PURPOSE OF REVIEW: The aim of this review is to study the rationale, limitations, techniques, and long-term outcomes of endoscopic ear surgery. RECENT FINDINGS: The article discusses the advantages of endoscopic ear surgery in treating cholesteatoma and how the hidden sites like facial recess, sinus tympani, and anterior epitympanum are easily accessed using the endoscope. SUMMARY: Transcanal endoscopic approach allows minimally invasive removal of cholesteatoma with results that compare well to traditional postauricular tympanomastoidectomy.

Endoscopic cochlear implantation: Call for caution.

OBJECTIVES/HYPOTHESIS: To assess whether transcanal endoscopic access to the basal turn of the cochlea for cochlear implantation is appropriate. STUDY DESIGN: Case series study. METHODS: We reviewed 100 consecutive computed tomographic studies of the sinuses and temporal bone in our institution. We excluded studies that demonstrated evidence of congenital anomalies, chronic ear disease, or inadequate visualization of the cochlea. On axial sections, the angles of the basal turn of the cochlea and of the ear canal in reference to the sagittal plane were recorded as a function of age. RESULTS: Eighty-four studies were included and 16 were excluded. There was significant variability in the relationship between the ear canal and the basal turn of the cochlea in reference to the sagittal plane. A clear majority of images demonstrated the basal turn of the cochlea to align with a more posterior angle than that of the ear canal. CONCLUSION: The trajectory provided by posterior tympanotomy aligns more favorably with the basal turn of the cochlea than transcanal access. Endoscopic technique, primarily an ear canal intervention, may not be useful in cochlear implant surgery. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:689-692, 2016.

Site of eustachian tube obstruction in chronic ear disease.

OBJECTIVE: Assess the patency of the proximal and distal segments of the Eustachian tube in patients undergoing surgery for chronic ear disease. STUDY DESIGN: Case study with control group. METHODS: All consecutive patients presenting for surgery for chronic ear disease in our practice over 14 months underwent preoperative Valsalva computed tomography (CT), and an attempt was made intraoperatively using angled rigid scopes to evaluate obstruction of the protympanic segment of the Eustachian tube. Endoscopic examination of the same segment in 19 cadaver ears served as a control group. RESULTS: Preoperative Valsalva CT showed patency of the distal one-third of the Eustachian tube in 51 of 53 ears. Intraoperative endoscopy allowed visualization of the protympanic opening of the Eustachian tube in 31 of 53 ears; 21 of 31 ears showed obstruction of the protympanic opening of the Eustachian tube. CONCLUSION: A clear obstruction was more likely to be present in the protympanic opening of the Eustachian tube in the patient population undergoing surgery for chronic ear disease than in the cadaver control group, and was equally likely to be present in the distal cartilaginous tube in patients as in the control population. LEVEL OF EVIDENCE: 4.

Transtympanic dilatation of the eustachian tube during chronic ear surgery.

CONCLUSION: Evaluation of the protympanic segment of the eustachian tube is feasible during chronic ear surgery. Balloon dilatation of that segment yields a bigger aperture. OBJECTIVE: To evaluate the feasibility of visualization and balloon dilatation of the protympanic segment of the eustachian tube during chronic ear surgery. METHODS: This study was carried out on a consecutive case series. All patients undergoing surgical treatment for cholesteatoma or tympanic membrane perforation over a 6-month period of time at a tertiary hospital were evaluated intraoperatively for the ability to visualize the protympanic segment of the eustachian tube, perform balloon dilatation, and then perform visual inspection of the effect of dilatation. RESULTS: A total of 21 chronic ear procedures were performed; visualization of the protympanic segment was feasible in 12 ears, obstruction was identified in 7 ears, and dilatation was undertaken. Immediate assessment showed increased aperture of the tube in all patients when compared with predilatation findings.

Visualization of the eustachian tube lumen with Valsalva computed tomography.

OBJECTIVES/HYPOTHESIS: Assess the feasibility of using the Valsalva maneuver to visualize the cartilaginous eustachian tube lumen with computed tomography (CT) in subjects with no ear disease. STUDY DESIGN: Prospective case series study. METHODS: Thirty-eight consecutive patients undergoing CT of the sinuses for nose-related complaints with normal radiographic findings consented for a CT of the temporal bone while performing the Valsalva maneuver. Multiplanar reconstruction was performed along the axis of the tube. Images were assessed for visualization of the whole length of lumen of the tube, or partial visualization with ratio of visualized to nonvisualized segments. RESULTS: The Valsalva maneuver allowed visualization of the whole length of the tube in 27/76 (35%) ears examined. It consistently visualized the distal one-third of the cartilaginous tube in 71/76 (94%) ears. Paradoxical collapse of the eustachian tube was present in three ears along with evidence of poor Valsalva technique. CONCLUSIONS: Valsalva CT consistently allows visualization of the lumen of the distal one-third of the eustachian tube in a majority of patients with no eustachian tube-related complaints. This technique might be helpful in localizing eustachian tube pathology in patients with obstructive tube symptoms.

Transcanal endoscopic management of cholesteatoma.

A detailed and comprehensive discussion of transcanal endoscopic management of cholesteatoma is presented. After a presentation of the anatomy of the area, the rationale, advantages and limitations, technique, and long-term results of each technique are presented. A case presentation follows each technique. Techniques presented are: endoscopic transcanal management of limited cholesteatoma, endoscopic open cavity management of cholesteatoma, and expanded transcanal access to middle ear and petrous apex.