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Otology & Neurotology

38:e41–e45 ß 2017, Otology & Neurotology, Inc.

Transcanal Endoscopic Ear Surgery for Middle Ear Cholesteatoma


Eran Glikson, Ruth Yousovich, Jobran Mansour, yMichael Wolf, yLela Migirov,
and yYisgav Shapira
Department of Otolaryngology, Head and Neck Surgery, Sheba Medical Center, Tel-Hashomer; and ySackler Faculty of Medicine,
Tel Aviv University, Tel Aviv, Israel

Objective: To evaluate the clinical parameters, outcomes, Results: Sixty operations (56 patients, mean age ¼ 43.6)
and complications of transcanal endoscopic ear surgeries for were included.
middle ear cholesteatoma. Six operations (10%) were performed under local anesthesia.
Study Design: Retrospective study. The most common sites of cholesteatoma involvement were:
Setting: Tertiary university-affiliated medical center. posterior epitympanum (n ¼ 51, 91%), anterior epitympanum
Patients: Adult patients (age >18) who underwent transca- (n ¼ 19, 33.9%), posterior mesotympanum (n ¼ 13, 23.2%),
nal endoscopic ear surgeries for cholesteatoma, between and sinus tympani (n ¼ 11, 19.6%). Intraoperative ossicular
March 2009 and March 2015. chain reconstruction was performed in 18 (30%) cases.
Intervention: Transcanal endoscopic surgery was indicated Our overall residual and recurrence rates were 10% (n ¼ 6)
when the cholesteatoma did not extend posterior to the and 8.3% (n ¼ 5), respectively, with mean duration of follow
anterior limb of the lateral semicircular canal. Rigid endo- up of 35 months. The most common sites of residual disease
scopes 4 and 2.7 mm in diameter, 0, 30, 45, and 70 degrees were the mastoid cavity/antrum (n ¼ 3, 50%), tympanic
were used with angled picks, suction, and forceps. cavity, and posterior mesotympanum. Overall minor and
Preoperative assessment included high-resolution computed tom- major complication rates were 16.6 and 6%, respectively.
ography of the temporal bones and/or non echo-planar diffusion- Conclusions: Transcanal endoscopic ear surgery was found
weighted magnetic resonance imaging and pure-tone audiometry. to be an acceptable and safe technique for the exposure and
Main Outcome Measures: Residual or recurrent disease eradication of middle ear and/or attic cholesteatoma. Key
was diagnosed by clinical examination and/or magnetic Words: Cholesteatoma—Endoscopic ear surgery—Middle
resonance imaging findings consistent with cholesteatoma. ear and attic—Transcanal.
Intra- and postoperative complications, pre- and postopera-
tive audiometric results were recorded. Otol Neurotol 38:e41–e45, 2017.

Traditional surgical techniques for middle ear choles- recurrence rates for transmeatal atticotomy reach 25%
teatoma that involves the mastoid cavity include canal (range, 0–50%) (9–14).
wall down (CWD) and canal wall up (CWU) mastoidec- Endoscopic middle ear surgery was introduced into
tomy. The advantages and disadvantages of these otology in the 1990s (15) and has significantly changed
approaches are well described (1–4). surgical, anatomic, and physiologic concepts. Transcanal
The overall rate of residual cholesteatoma reaches 7% primary endoscopic ear surgery (EES) is indicated for
(range, 2–21%) and 22% (range, 15–27%) for CWD and cholesteatoma confined to the tympanic cavity without
CWU mastoidectomy, respectively, and the recurrence involving the mastoid (16).
rates reach 5% (range, 0–10%) and 25% (range, 9–70%), The endoscope provides better visualization of middle
respectively (5–8). ear subsites, (i.e., anterior and posterior epitympanic
The optimal technique for extirpation of cholesteato- spaces, sinus tympani, posterior mesotympanum, eusta-
mas limited to the attic or mesotympanum is also under chian tube opening, and hypotympanic cells). We, there-
debate. Though these lesions are regarded accessible fore, hypothesize that the use of the endoscope for middle
through more conservative transmeatal approach, the ear cholesteatoma surgery will be associated with a lower
rate of residual disease.
The present study examines this hypothesis and
Address correspondence and reprint requests to Eran Glikson, M.D., presents our experience with transcanal endoscopic ear
Department of Otorhinolaryngology–Head and Neck Surgery, Chaim surgery for middle ear cholesteatoma.
Sheba Medical Center, Tel Hashomer, 5262100, Israel;
E-mail: Eran.Glikson@sheba.health.gov.il MATERIALS AND METHODS
Funding: None.
The authors disclose no conflicts of interest. We conducted a retrospective chart review of patients who
DOI: 10.1097/MAO.0000000000001395 underwent endoscopic ear surgeries for cholesteatoma between

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e42 E. GLIKSON ET AL.

March 2009 and March 2015 in the Department of Otolaryng- TABLE 1. Study group characteristics
ology and Head and Neck Surgery at the Sheba Medical n ¼ (%)
Center—a tertiary referral center. Total 56 (60 operations)
The inclusion criteria were:
Male 33 (59%)
Female 23 (41%)
1) Transcanal endoscopic approach.
Primary surgery 45 (75%)
2) Cholesteatoma surgeries.
Previously operated (revision cases) 15 (25%)
3) Age over 18 (adults).
4) Postoperative follow up period of over 12 months. EES 6
5) Cholesteatoma involving the middle ear and/or attic, Microscopic atticotomy 5
without mastoid extension. Mastoidectomy 7
Mean age (yr) 42.7
Transcanal endoscopic surgery was indicated when the Affected side
cholesteatoma did not extend posterior to the anterior limb Right 41 (68%)
of the lateral semicircular canal (LSCC). Left 19 (32%)
Rigid endoscopes (Hopkins telescope; Karl Storz, Tuttlin-
gen, Germany) 4 mm in diameter, 0, 30, 45, and 70 degrees were EES indicates endoscopic ear surgery.
used routinely for all the procedures with a three-chip video
camera (Karl Storz) and 20-inch high-resolution monitor. Endo- excluded due a short postoperative follow up (<12 mo).
scopes 2.7 mm in diameter were used only when necessary Altogether, 60 operations (56 patients) were included.
owing to the limited view they provide. The study group consisted of 33 men and 23 women. The
Illumination was provided by a xenon cold light source main characteristics of our group are noted in Table 1. Mean
connected to a fiber-optic light cable with average light inten-
patient age was 43.6 years (range, 19–75 yr). Approxi-
sity of 50%. A special set of microendoscopic instruments
(angled picks, suction and forceps [Karl Storz]) were used in mately, 75% of cases underwent primary surgery while the
addition to the routine otologic micro instruments. rest were revision cases. In the previously operated group,
Facial nerve monitoring was used in all surgeries. mean time from the previous surgery was 5.4 years. Pre-
Preoperative assessment included high-resolution computed dominance of right sided lesions was noted (68%).
tomography (CT) of the temporal bones and/or non echo-planar
diffusion-weighted magnetic resonance imaging (non-EPI DWI Surgery
MRI) and pure-tone audiometry. Six operations (10%) were performed under local
Our standard postoperative follow up recommendations anesthesia while the rest were performed under general
include repeated clinical examinations (at 2 wk and at 2, 6, anesthesia. Local anesthesia was chosen when the patient
and 12 mo after surgery), audiologic assessment 2 to 4 months
postsurgery, and performance of non-EPI DWI MRI at approxi-
was considered to be appropriately compliant with a very
mately 1 year postsurgery. limited disease. Mean length of surgery was
Recurrent cholesteatoma was defined as a lesion arising in a 2.2  0.6 hours. Mean postoperative hospitalization
new retraction pocket diagnosed otoscopically. Residual dis- period in our institution was 1.7  0.9 days.
ease was defined as cholesteatoma diagnosed by non-EPI DWI
MRI behind an intact tympanic membrane. Cholesteatoma Extension
Complications were divided into major and minor. Minor Cholesteatoma was found in 56 cases (93%). The other
complications were defined as those resolving spontaneously or four cases’ findings were a grade 4 retraction pocket
with conservative therapy. Major complications were defined as without cholesteatoma.
those necessitating revision surgeries or resulting in permanent The sites of cholesteatoma involvement are noted in
sequelae. We further divided the complications as those that
occurred intraoperatively or postoperatively.
Figure 1. The most common site of involvement was the
Changes in hearing levels were defined as significant when the posterior epitympanum (n ¼ 51, 91%), followed by the
postoperative pure tone averages of air/bone thresholds at 500, anterior epitympanum (n ¼ 19, 33.9%), posterior meso-
1000, 2000, and 3000 Hz increased or dropped more than 10 dB. tympanum (defined as the area along the posterior wall
of the middle ear lateral to the pyramidal eminence)
Statistical Analysis (n ¼ 13, 23.2%), and sinus tympani (defined as the area
Continuous variables are displayed as mean  standard devi- along the posterior wall of the middle ear medial to the
ation and categorical variables are presented as number and pyramidal eminence) (n ¼ 11, 19.6%). Eustachian tube and
percent in each group. supra-tubal recess involvement were less common.In two
The mean and standard deviation of each measurement were surgeries, cholesteatoma was found to extend posterior to
determined. Relative risk and x2 test were used to analyze the LSCC into the mastoid cavity and, therefore, conversion
association between disease site and recurrence and were to retro-auricular microscopic approach was needed.
considered significant at p < 0.05 (two tailed). None of our cases presented with facial nerve weak-
ness, although the fallopian canal was eroded in 13
RESULTS (21.6%) cases. The Chorda tympani nerve was involved
in 43.3% of cases.
A total of 146 EES were performed for middle ear Seventy one percent (n ¼ 43) of our patients showed
cholesteatoma, of whom there were 71 operations described ossicular chain involvement. Incus, malleus, and stape-
as exclusive transcanal in adult patients. Eleven cases were dial suprastructure erosion were found in 24 (55.8%), 6

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TRANSCANAL ENDOSCOPIC EAR SURGERY e43
TABLE 3. Cholesteatoma residual and reccurence sites
n (%)
Total 6
Mastoid antrum/cavity 3 (50%)
Round window niche 1 (16.6%)
Residual Tympanic cavity (around ossicular 2 (33.3%)
chain)
Sinus tympani 1 (16.6%)
Posterior mesotympanum 2 (33.3%)
Total 5
Epitympanum 4 (80%)
Recurrence Tympanic cavity (around ossicular 1 (20%)
chain and tympanic membrane)
FIG. 1. Sites of cholesteatoma involvement. Facial recess 1 (20%)

(13.9%), and 13 (30.2%) cases, respectively. The rest of 1 month. There were two cases of surgical site infection: one
cases (n ¼ 13) were ossicles covered by cholesteatoma of a tragal graft harvest site and one of the external ear canal.
matrix without significant erosion. Major postoperative complication rate was 6% (n ¼ 4).
This includes three cases of permanent SNHL, including
Complications the previously mentioned case of labyrinthitis and two
Our complications are listed in Table 2. patients with extensive disease involving the oval/round
window. In two SNHL, the bone conduction thresholds
Intraoperative decreased by 15 to 25 dB with a decrease in word
In our cohort the overall intraoperative complication recognition score (WRS) of 20 to 30%. The third was
rate was 5% (n ¼ 3)—all were minor complications. There a profound SNHL. One patient developed protrusion of
were two cases of stapes footplate fracture: one of these the ossicular chain reconstruction prosthesis that necessi-
patients developed transient postoperative vertigo without tated surgical intervention.
sensorineural hearing loss (SNHL) and the other was Among the patients who underwent surgery under
asymptomatic. The mechanism of injury was direct trauma local anesthesia, there were no complications.
to the stapes with the endoscope during surgery. These Our overall minor and major complication rates were
cases were among our departments’ first operations and 16.6 and 6%, respectively.
are, therefore, probably related to our ‘‘learning curve.’’ In
addition there was a single case of tympanic membrane Follow-up
perforation which was primarily repaired. Our cohort’s mean duration of follow up was 35
months (range, 12–72 mo). An intact tympanic mem-
Postoperative brane was found in 88% of cases.
Our postoperative minor complication rate was 11.6% The overall residual and recurrence rates in our study
(n ¼ 7): there were two cases of transient vertigo and two were 10% (n ¼ 6) and 8.3% (n ¼ 5), respectively.
cases of labyrinthitis, one of which developed permanent Our patients’ sites of residua and recurrence are listed in
SNHL. One patient in whom no intraoperative facial nerve Table 3. The most common sites of residual disease were
injury was noted, developed transient mild facial nerve the mastoid cavity/antrum (n ¼ 3, 50%), tympanic cavity
paresis on postoperative day 3 and was treated with oral (n ¼ 2, 33.3%), and posterior mesotympanum (n ¼ 2,
prednisone. Complete facial nerve recovery was noted after 33.3%). Residual disease in the sinus tympani was found
in one case (16.6%). Most recurrences occurred in the
TABLE 2. Complications epitympanum (n ¼ 4, 80%). Involvement by cholestea-
n (%) toma of the posterior mesotympanum (relative risk
Intraoperative 3 (5%) [RR] ¼ 1.71, confidence interval [CI] 0.56–5.18) and
Fracture of stapes footplate 2 (3.3%) the oval window niche (RR ¼ 1.6, CI 0.43–5.9) correlated
Tympanic membrane perforation 1 (1.6%) with increased risk for recurrence, however these results
Postoperative 11 (18%) did not reach statistical significance.
Minor complications 7 (11.6%) Five of 11 patients with recurrence/residua underwent
Transient vertigo 2 (3.3%) revision EES, all with epitympanic disease. The rest
Transient facial nerve weakness 1 (1.6%) underwent radical/modified radical mastoidectomy
Labyrinthitis 2 (3.3%) (n ¼ 4), or CWD mastoidectomy with reconstruction of
Surgical site infection 2 (3.3%) the posterior wall and obliteration (MAPRO, n ¼ 2) (17).
Major complications 4 (6.6%)
Protrusion of the ossicular chain reconstruction 1 (1.6%)
prosthesis
Hearing Evaluation
Sensori-neural hearing loss 3 (5%) The mean preoperative air conduction pure tone aver-
age (AC-PTA) was 43.4 dB. A total of 52 patients (86%)

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e44 E. GLIKSON ET AL.

presented with hearing loss (HL) of any degree, 22 were emphasize this fact and the required ‘‘learning curve’’ of
pure conductive HL, and the rest were mixed type. The the surgeon. Nevertheless, the mean length of surgery in
mean word recognition score (WRS) was 93.1%. our cohort was similar to classic mastoidectomy oper-
The mean postoperative AC-PTA was 46.11 dB, and ations performed in our department.
the mean postoperative WRS was 87.7%. These did not In our series, we found a relatively high rate of
differ significantly from the preoperative scores. cholesteatoma involvement of the anterior epitympanic
space, sinus tympani, posterior mesotympanum, and
Hearing Reconstruction hypotympanum. These are all sites of potential residual
Intraoperative ossicular chain reconstruction was per- disease and were classically considered inaccessible by
formed in 18 cases (30%). In all others, the extent of transcanal approach.However, cholesteatoma was acces-
disease did not allow primary reconstruction. Partial sible and was easily removed using angled endoscopes
ossicular replacement prosthesis (PORP) was used in and instruments from the above mentioned sites.The fact
14 cases and total ossicular replacement prosthesis that only two cases were converted to transmastoid
(TORP) was used in four cases. approach due to posterior involvement show that pre-
In these patients, the mean overall preoperative air- operative assessment of the disease extension is usually
bone gap (ABG) was 26.8 dB (PORP ¼ 24.5 dB, accurate. On the other hand, if we add the three cases with
TORP ¼ 34.7 dB). The mean postoperative ABG after mastoid cavity/antrum residual disease, the rate of mas-
long-term follow up was 20.9 dB (PORP ¼ 19 dB, toid involvement is probably higher.
TORP ¼ 27.8 dB) (mean improvement of 5.9 dB). In a previous smaller study performed in our institution
that included only preliminary results of 30 EES (16)
DISCUSSION there were similar results of hearing and disease exten-
sion but with lower rates of ossicular chain involvement.
Despite the fact that cholesteatoma surgery is being Because cholesteatoma that is limited to the attic and
performed worldwide for decades, it continues to pose a middle ear cavity can be accessed through the external
challenge. The choice among well described surgical ear canal, transcanal atticotomy was introduced several
techniques depends on disease extension, surgeon’s own decades ago.The main advantages of a transcanal
experience, published data, and the institution’s resources. approach are: preservation of the external canal’s
Cholesteatoma surgery primarily aims to eradicate the posterior wall and, therefore, preserving its structure
disease process and provide the patient with a safe and and function and preservation of the mastoid bone lead-
healthy ear. One of the main problems regarding choles- ing to a decrease of possible intraoperative complications
teatoma removal is residual disease and/or recurrence. such as dural injury and intracranial complications.
Full exposure and visualization of the entire middle ear Relatively few reports of the surgical techniques and
spaces involved by cholesteatoma are sometimes limited success rates of transcanal atticotomy with use of the
when using microscopic vision. otologic microscope were previously described. This
Recently, the use of the endoscopes has led to new includes transmeatal (9,10,13) or retroauricular (11,12)
treatment options for middle ear pathologies. As approaches, several proposed reconstruction methods
described previously, the main advantage of the otologic and recently, combination with an endoscopic look for
endoscope is improved visualization and cholesteatoma complete eradication (14).
eradication in previously difficult to access locations The reported recurrence/residual rates for these pro-
such as the posterior mesotympanum, sinus tympani, cedures are approximately 26%, but these results vary
anterior epitympanic space, and the Eustachian tube considerably between different cohorts (range, 0–
(16,18–21). Therefore, it is hypothesized that this tech- 50%).Little or no information regarding complications
nique should reduce cholesteatoma recurrence. in these operations is provided.
According to our experience, other advantages of trans- In recent years several cohorts presented results of EES
canal EES are less painful surgery and shorter healing time (21,22). The reported cholesteatoma residual and recur-
compared with traditional surgeries (mean postoperative rence rates vary between 0 to 15.5% and 0 to 8.2%,
hospitalization period in our cohort is shorter than after respectively during follow up periods ranging from 11 to
transmastoid surgery in our department). Also, these pro- 43 months.One must consider the variability of postoper-
cedures can be performed under local anesthesia in select ative follow up protocols and diagnosis of residual/recur-
cases.The six patients who underwent EES under local rent disease between institutions. These variations may
anesthesia in our cohort had no complications. account for the wide range of results. Our recurrence and
Endoscopic surgery requires experience and specific residual rates fall within the high end of this range, and in
surgical skills (15,16,19,20). The surgeon is limited to our opinion are a close estimate of the accurate rates. Our
single handed instrument manipulation, while looking EES cohort’s overall recurrence/residual rate is lower than
into the surgical field indirectly through a 2-D monitor. In the reported rates for traditional microscopic approaches
inexperienced hands, the endoscopic approach can be such as: transcanal atticotomy and CWU mastoidectomy.
associated with complications due to direct trauma from Also, it is reasonable to assume that patients with loss
the tip of the endoscope to various middle ear structur- of follow up before 12 months had satisfying outcome
es.The two cases of stapes footplate fracture in our series with dry ears. This is because these patients did not seek

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TRANSCANAL ENDOSCOPIC EAR SURGERY e45

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