[Management of 242 patients with middle ear cholesteatoma by otoendoscopic surgery and the postoperative effect analysis].

Objective: To summarize and discuss the characteristics of endoscopic approach to manage the middle ear cholesteatoma, and to evaluate the operative safety and outcomes based on the data from the multicenter study. Methods: The data of 242 cases diagnosed with the middle ear cholesteatoma and received operation through endoscopic approach between June 2016 and June 2017 in six tertiary hospitals in China were analyzed in this work. There were 130 males and 112 females, with the age ranging from 3 to 72 years old. We evaluated the strategy about how to manage the cholesteatoma, discussed the detailed techniques about how to remove the cholesteatoma and to improve the efficiency under endoscopic visualization. Meanwhile, the recurrence rate and residual rate of cholesteatoma as well as the complications in endoscopic approach were summarized. Results: A total of 158 cases were operated in exclusively endoscopic transcanal approach, 72 cases operated in combined approach, and 12 cases operated majorly under microscope and minorly under endoscope. 219 cases were operated in one stage surgery, 23 cases received second look. In the second look, 3 cases were detected with residual cholesteatomas. Among them, 2 cases were found by MRI-DWI examination after the first-stage operation. With endoscopic examination after operation, 17 cases showed retracted pocket recurrence (7%,17/242). With introduction of endoscope in cholesteatoma, 153 cases were achieved canal wall-up operation (63%, 153/242). The complications in endoscopic approach included chord tympani never injury in 27 cases, skin injury of ear canal in 11 cases, tinnitus in 13 cases, vertigo in 7 cases, external ear canal stenosis in 1 case. Conclusions: Using otoendoscope in cholesteatoma surgery would help keeping the normal structures of middle ear as much as possible, benefit to remove the hiding pathologies, help reducing residual cholesteatoma and lowering the rate of canal wall-down operation as well. This study showed good safety of otoendoscopic cholesteatoma surgery, however, strict evaluation of indication and quite good surgical techniques and skills are necessary for avoiding unexpected complication.

The Eustachian Tube as a Landmark for Early Identification of the Abducens Nerve During Endonasal Transclival Approaches.

BACKGROUND: Expanded endonasal approaches have the potential to injure the abducens nerve (cranial nerve [CN] VI). The nerve's root entry zone (REZ) and cisternal segment (CS) are particularly prone to injury during the clivus resection and dural incision of transclival approaches. OBJECTIVE: To investigate the role of the eustachian tube (ET) as a surgical landmark for the REZ and CS of CN VI. METHODS: Transclival expanded endonasal approaches were performed bilaterally in 6 fresh-frozen cadaveric specimens (12 sides). Anatomic relationships between ET and CN VI were documented with neuronavigation. RESULTS: The mean vertical distance from the inferior brainstem point to the horizontal projection of CN VI REZ, CS midpoint, and interdural segment (ID) were 26.38 mm (95% confidence interval [CI] 17.36-35.4), 38.61 mm (95% CI 25.61-51.61), and 42.68 mm (95% CI 30.14-55.22), respectively. The relative vertical distance from the ET to the horizontal projections of the REZ, CS midpoint, and its ID were 6.43 mm (95% CI 3.25-9.61), 18.66 mm (95% CI 11.52-25.8), and 22.72 mm (95% CI 16.02-29.42), respectively. In the axial plane the angles between the ET and (1) the REZ and its midline horizontal projection point, (2) the midpoint and its midline horizontal projection point, and (3) ID and its midline horizontal projection point were 9.81 ± SD 5.20°, 18.50 ± SD 4.87°, and 24.71 ± SD 6.21°, respectively. CONCLUSION: The ET may serve as a constant landmark to reliably predict the position of the REZ and CS of CN VI.

Comparison of transcanal endoscopic tympanoplasty with sterile acellular dermal allograft to conventional endaural microscopic tympanoplasty with tragal perichondrium.

OBJECTIVES: This study aimed to compare the outcome of endoscopic tympanoplasty with sterile acellular dermal allograft (ADA) and conventional endaural microscopic tympanoplasty with tragal perichondrium. METHODS: This was a retrospective comparative study of 53 patients (25 males and 28 females) with tympanic membrane perforation who underwent type I tympanoplasty in the department of otorhinolaryngology at a tertiary medical center from March 2011 to April 2017. The subjects were classified into two groups; transcanal endoscopic tympanoplasty with ADA (TET, n=26), conventional endaural microscopic tympanoplasty with autologous tragal perichondrium (EMT, n=27). Demographic data, perforation size of tympanic membrane at preoperative state, pure tone audiometric results preoperatively and 3months postoperatively, operation time, sequential postoperative pain scale, and postoperative graft failure rate were evaluated. RESULTS: The perforation size of the tympanic membrane in TET and EMT group was 22.3±10.9% and 23.5±9.7%, respectively (P=0.143). Mean operation time of EMT (92.3±16.5min) was longer than that of the TET (65.3±20.5min) with a statistical significance (P=0.004). Graft success rate in the TET and EMT group were 92.3% and 96.3%, respectively; the values were not significantly different (P=0.610). Pre- and postoperative audiometric results including bone and air conduction thresholds and air-bone gap were not significantly different between the groups. In all groups, the postoperative air-bone gap was significantly improved compared to the preoperative air-bone gap. Pain in the immediate postoperative and day 1 after surgery were significantly less in the TET group. CONCLUSION: With human cadaveric ADA, minimal invasive endoscopic tympanoplasty can be achieved with similar postoperative results and less pain.

Management of Bleeding in Exclusive Endoscopic Ear Surgery: Pilot Clinical Experience.

Objective Transcanal exclusive endoscopic ear surgery requires the management of the endoscope and the surgical instruments in the external auditory canal. Bleeding in this narrow space is one of the most challenging issues, especially for novice endoscopic ear surgeons. We aim to assess the severity and occurrence of bleeding and describe strategies to control the bleeding during endoscopic ear surgery. We hypothesize that bleeding is reasonably controllable in endoscopic ear surgery. Study Design Case series with chart review. Setting Tertiary referral center. Subjects and Methods We retrospectively assessed 104 consecutive cases of exclusive endoscopic ear surgery at the University Hospital of Modena, Italy. The surgical videos and the patient charts were carefully investigated and analyzed. Results Hemostatic agents included injection of diluted epinephrine (1:200,000, 2% mepivacaine), cottonoids soaked with epinephrine (1:1000), mono- or bipolar cautery, washing with hydrogen peroxide, and self-suctioning instruments. The localization of bleeding in the external auditory canal was most frequently the posterior superior part, and inside of the middle ear, it was the pathology itself. Statistical analysis revealed significant differences comparing the mean arterial pressure and the type of intervention among bleeding scores. Conclusion The management of bleeding in endoscopic ear surgery is feasible through widely available hemostatic agents in reasonable frequency. This study gives an instructive overview on how to manage the bleeding in the exclusive endoscopic technique. Even the highest bleeding scores could be managed in an exclusively endoscopic technique.

Transcanal surgery for vestibular schwannomas: a pictorial review of radiological findings, surgical anatomy and comparison to the traditional translabyrinthine approach.

The most popular approaches for vestibular schwannoma (VS) removal are retrosigmoid, middle cranial fossa and translabyrinthine (TL). All require a certain degree of invasivity, bone removal, or brain manipulation. Recently, the authors described the transcanal transpromontorial approaches (TTA), which allow the inner ear to be accessed directly through the external auditory canal (EAC), either with a microscopic (Expanded TTA, or ExpTTA) or even an exclusive endoscopic technique (Endoscopic TTA, or EndoTTA). The advantages compared to traditional approaches are a direct view of the internal auditory canal (IAC) from lateral to medial, very little or no superficial tissue dissection and very little petrous bone drilling. In summary, from an anatomical point of view, they could be considered to be minimally invasive approaches. The radiologic outcome and the anatomical correspondence of these new approaches are described so as to share with the readers the possible radiologic findings and to compare and differentiate them from classic transpetrous approaches such as the TL approach. LEVEL OF EVIDENCE: 4.

Transcanal endoscopic myringoplasty: a case series in a university center / Miringoplastia endoscópica transcanal: série de casos em um serviço universitário

ABSTRACT INTRODUCTION: Transcanal myringoplasty has the advantages of demanding lower operative time and minimal external incisions. It can be performed using the microscopic or endoscopic approach. In the last decade, the use of endoscopes in ear surgery has increased significantly. This technique may allow "around the corner" visualization of small recesses, through narrow spaces, without the aid of canalplasty in unfavorable ear canals. OBJECTIVE: To describe a case series of transcanal endoscopic myringoplasty performed in a university service. The characteristics, advantages, and disadvantages of this technique are also discussed. METHODS: A case series study, based on the chart review of patients submitted to transcanal endoscopic myringoplasty in the period from January of 2012 to October of 2014. RESULTS: Data from 22 patients were analyzed. Tympanic perforation closure three months after surgery was observed in 86.4% of all patients. There was statistically significant improvement in pure tone average thresholds after surgery (p < 0.001). CONCLUSION: Transcanal endoscopic myringoplasty is a feasible, safe, and effective procedure; it can be an alternative to microscopic surgery.

Resumo Introdução: A miringoplastia realizada por via transcanal possui como vantagens a maior rapidez do procedimento e menor incisão externa, podendo ser realizada com auxílio de microscópio ou endoscópio. Na última década tem sido observado um aumento do uso de endoscópios na cirurgia otológica. Essa técnica pode permitir melhor visibilização de espaços encobertos e estreitos, sem necessidade canaloplastia em meatos desfavoráveis. Objetivo: Descrever uma série de casos de miringoplastia endoscópica transcanal, em um serviço universitário, discutindo suas particularidades, vantagens e desvantagens. Método: Estudo de série de casos, baseado na revisão de prontuários dos pacientes submetidos a miringoplastia com uso exclusivo de endoscópio rígido, no período de Janeiro de 2012 a Outubro de 2014. Resultados: Foram analisados os dados de 22 pacientes. Na otoscopia pós-operatória, foi observado fechamento da perfuração timpânica em 86,4% dos pacientes, após 3 meses da intervenção. Para a amostra estudada, foi observada melhora funcional estatisticamente significante da média dos limiares tonais (PTA) após a cirurgia (p < 0,001). Conclusão: A miringoplastia endoscópica transcanal é um procedimento seguro, factível e efetivo, podendo ser realizado como alternativa à cirurgia microscópica.

Transcanal endoscopic myringoplasty: a case series in a university center.

INTRODUCTION: Transcanal myringoplasty has the advantages of demanding lower operative time and minimal external incisions. It can be performed using the microscopic or endoscopic approach. In the last decade, the use of endoscopes in ear surgery has increased significantly. This technique may allow "around the corner" visualization of small recesses, through narrow spaces, without the aid of canalplasty in unfavorable ear canals. OBJECTIVE: To describe a case series of transcanal endoscopic myringoplasty performed in a university service. The characteristics, advantages, and disadvantages of this technique are also discussed. METHODS: A case series study, based on the chart review of patients submitted to transcanal endoscopic myringoplasty in the period from January of 2012 to October of 2014. RESULTS: Data from 22 patients were analyzed. Tympanic perforation closure three months after surgery was observed in 86.4% of all patients. There was statistically significant improvement in pure tone average thresholds after surgery (p<0.001). CONCLUSION: Transcanal endoscopic myringoplasty is a feasible, safe, and effective procedure; it can be an alternative to microscopic surgery.

The utility of minimally invasive transcanal endoscopic approach for removal of residual/recurrent cholesteatoma: preliminary results.

To investigate the feasibility of applying the transcanal endoscopic approach (TEA) for surgical treatment of residual/recurrent cholesteatoma and present the preliminary results of 17 revision procedures that were carried out with this minimally invasive approach. The records of 17 patients (aged 5-76 years) who underwent transcanal revision procedure using rigid 3-mm diameter, 0°, 30° and 45° endoscopes between 2009 and 2012 were retrospectively reviewed. A wide posterior tympanomeatal flap was elevated via the external auditory canal and then transposed inferiorly in cases of cholesteatoma situated in the middle ear under a tympanic membrane. In certain cases, cholesteatoma was assessed and removed using the endoscopes directly from the radical cavity or from the mastoid cavity remaining after a canal-wall-down procedure. Six patients had originally undergone the canal-wall-up mastoidectomy, 6 patients had a canal-wall-down mastoidectomy and 5 patients had radical mastoid cavities. The interval between the previous and the index surgery ranged between 1 and 6 years. The attic was the most common site involved with cholesteatoma, followed by the tympanic portion of the facial nerve, sinus tympani, mastoid, supratubal recess, promontory, round and oval windows. The size of residual/recurrent lesion varied between 3 and 15 mm. The patients were followed up 26-67 months (mean 52.1 months). The single recurrence (a 4-mm pearl over the tympanic portion of the facial nerve) was eradicated by a transcanal re-revision 1 year following the index surgery. Minimally invasive TEA can be successfully applied in carefully selected patients with endoscopically accessible cholesteatoma subsequent to various types of mastoidectomy.

Cochlear schwannoma removed through the external auditory canal by a transcanal exclusive endoscopic technique.

Surgical approaches to the inner ear and internal auditory canal (IAC) are widely known and extensively recorded. The most popular can be classified as retrosigmoid, transmastoid-translabyrinthine, and middle cranial fossa approaches. For the first time, an exclusive endoscopic approach to the IAC is described here, used to remove a cochlear schwannoma involving both the IAC and labyrinth. The operation provided a direct transcochlear intradural approach from lateral to medial and from external to internal auditory canal, without any external incision. The pathology was totally removed, and the postoperative outcome of the facial nerve was grade II (House-Brackmann grading system) at 3-month follow-up.