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Sang-Yoon Han, MD; Doh Young Lee, MD, PhD; Juyong Chung, MD and Young Ho Kim, MD, PhD
Objectives: Recently, the endoscope has been increasingly introduced for middle-ear surgery. To evaluate the postopera-
tive outcomes of endoscopic ear surgery (EES) in pediatric patients, we did a qualitative analysis with a systematic review and
quantitative analysis with meta-analysis of available literature.
Methods: Studies reporting the comparative surgical outcomes of EES in pediatric patients were systematically reviewed
by searching the MEDLINE, PubMed, and Embase databases from database inception through 2017. The selected articles
included clinical studies conducted with at least 30 subjects and at least one postoperative parameter, including residual or
recurrent cholesteatoma and graft success in tympanoplasty. Two investigators independently reviewed all studies and
extracted the data using a standardized form. A meta-analysis was performed using a random-effects model and qualitative
review was performed on the smaller studies.
Results: Ten studies were identified as appropriate for quantitative meta-analysis and 19 studies for qualitative analysis.
In the meta-analysis, residual or recurrence rate of cholesteatoma was significantly lower in the EES group than in the micro-
scopic ear surgery (MES) group (odds ratio [OR]: 0.56, 95% confidence interval [CI]: 0.38-0.84, P = .005). The graft success
rate of tympanoplasty was not statistically different between EES and MES groups (OR: 0.72, 95% CI: 0.41-1.26, P = .249). In
the qualitative analysis, most of the studies reported similar audiological outcomes after tympanoplasty and success rate of
cholesteatoma removal between the two groups.
Conclusions: It appears that EES reduces the risk of residual cholesteatoma in children and that the success of perfora-
tion closure is equivalent to MES.
Laryngoscope, 00:1–9, 2018
COM = chronic otitis media; EES = endoscopic ear surgery; F/U = follow up; MES = microscopic ear surgery.
3
Han et al.: Pediatric Endoscopic Ear Surgery
Fig. 1. PRISMA flow diagram outlining the study design. PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
[Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
Marchioni et al. (2017) Retrospective Cholesteatoma 12 (6/6) 4 (2–7) 54.5 RCR 0.0
33
cohort
D’Eredita et al. (2017) 24 Case series Cholesteatoma 12 3.5 (1.5–6) 7 RCR/hearing gain 0.0/equivocal
Sarcu et al. (2016) 37 Case series Cholesteatoma 42 1–16 >15 RCR 16.7
Landegger et al. (2016) Case series Cholesteatoma/ 5 5 (6–12) 6 RCR 0.0
32
CHL
Huang and Sun (2016) Case series Cholesteatoma 2 — 6 RCR 0.0
34
Huang and Sun (2016) Case series Cholesteatoma 13 6.9 ± 4.3 6–24 RCR/graft failure 0.0/0.0
26
/COM
Ito et al. (2015) 29 Case series Cholesteatoma/ 31 7.6 (2–13) — RCR/graft failure/ 6.3/0.0/10.4 dB
COM/CHL hearing gain
Kobayashi et al. (2015) Case series Cholesteatoma 12 3 (1–16) 48 RCR 8.3
31
Kanotra and James Case series Cholesteatoma 27 6.9 (3–15) 0 IDRC 18.5
(2012) 30
Good and Isaacson Case series Cholesteatoma 29 — — IDRC 24.0
(1999) 25
Rosenberg et al. (1995) Case series Cholesteatoma 10 11.1 25.4 RCR 50.0
36
De Zinis et al. (2017) 8 Case series COM 10 10 (6–14) — Graft failure/hearing 0.0/6 dB
gain
Akyigit et al. (2017) 21 Case series COM 32 13.9 (8–17) 23.3 Graft failure/hearing 6.3/10.5 dB
gain
Isaacson and Harounian Case series COM 31 6 (3.5–17) — Graft failure 12.9
(2017) 28
Awad et al. (2015) 22 Case series COM 80 11 (5–17) 6 Graft failure/hearing 13.0/23.7 dB
gain
Migirov and Wolf (2015) Case series COM 22 10.7 (5–16) 12 Graft failure/hearing 13.6/14.6 dB
35
gain
Carter et al. (2017) 23 Case series CHL 21 8.0 25.2 Graft failure/hearing 0.0/12.4 dB
(4–15.8) gain
Zhu et al. (2016) 38 Case series CHL 8 10.1 (6–12) 6 Hearing gain 18.9 dB
Isaacson et al. (2015) 27 Case series CHL 8 6–18 Hearing gain Improved
Cholesteatoma Cholesteatoma 194
COM COM 219
CHL CHL 72
Total 406
CHL = conductive hearing loss; COM = chronic otitis media; EES = endoscopic ear surgery; F/U = follow up; IDRC = intraoperative detection of residual
cholesteatoma; RCR = residual cholesteatoma or recurrence.
However, we cannot overlook the following limita- A few techniques to overcome the limitations of EES
tions. First, it is basically a one-handed technique, were developed. The double-handed technique supported
because the other hand is used to grip the endoscope. by the endoscope-holding system was introduced in pre-
Therefore, it may be very difficult in special conditions, liminary studies.8,48–50 This technique increased the
such as massive bleeding. Preyer suggested that EES effectiveness of the surgery over that of the one-handed
cannot fully substitute for the use of a microscope because EES if the stability of the holding system was guaran-
of the limitation associated with the single-hand tech- teed. Furthermore, ear endoscopy may be used for total
nique.46 Second, EES is associated with a potential risk EES or observation of the middle ear before and after
of damage to the surrounding structures not included in MES. Observational practices of ear endoscopy in the con-
the visual field, such as ossicles, nerves (including facial ventional MES before the start of full-scale total EES will
nerves and the chorda tympani nerve), and other sur- assist beginners in learning the surgical skills of EES.
rounding tissues.9 EES in pediatric patients with a nar- This study demonstrated that the control rate of
row ear canal requires great care. Third, the heat of the residual cholesteatoma after EES was higher than that of
endoscope light may induce thermal damage to inner-ear MES and the graft success rate after EES was similar to
structures. Therefore, the brightness of the light source that of MES in qualitative studies. The graft-failure rate
should be adjusted during the surgical preparation.40,47 ranged from zero to 13.6%, which was similar to that of
MES.51,52 The recurrence rate of cholesteatoma after EES sensitivity or subgroup analysis in the present study.
in this study was similar to that of MES (4%–15%).53 A Although residual and recurrent cholesteatoma should
few studies evaluated the efficacy of EES for intraopera- be analyzed separately, having so few studies made it
tive detection of residual cholesteatoma.25,30 In these difficult to perform subgroup analysis. Moreover,
studies, 18.5% to 24.0% of residual cholesteatoma cases because of the lack of information about follow-up
were detected with endoscopes during MES. Although periods and timing of recurrences, a survival analysis
EES showed results similar to or better than those of using a time variable was not possible. Second, the stage
MES in a few situations, no large cohort studies were of cholesteatoma or size of the perforated tympanic
available to date. Therefore, a significant publication bias membrane was not reported in most studies, complicat-
may be present, suggesting that the worst outcomes of ing the analysis of factors affecting the extent of dis-
EES were not reported. Interestingly, there was no report eases. The residual or recurrence rate according to the
of significant complications after EES in this review. Fur- stage of cholesteatoma and graft-success rate based on
ther studies are needed to investigate the surgical prob- the size of the perforated tympanic membrane need to
lems or complications in patients who underwent EES, be further investigated. Third, a publication bias was
especially in pediatric EES cases. Additional studies with observed in most of the risk-factor analyses. Among the
larger cohorts are needed for clarification. studies included in this meta-analysis, an epidemiologic
Compared with previously published systemic analysis may compromise the consistency of the included
reviews of EES, this study was designed for only pediatric articles and results. Fourth, studies in languages other
patients. Presutti et al. and Kozin et al. performed sys- than English were excluded; they might have reported
tematic reviews targeting all ages for EES.54,55 Therefore, different results. Last, demographic factors such as age
their results may have heterogeneity for age in EES. In were not adjusted, although age may contribute to the
the present study, we selected only pediatric patients to success of EES. Despite limitation of possible heteroge-
investigate the efficacy of EES in children with a narrow neity and bias in this study, its results may facilitate
surgical field. decision-making and outcome prediction for EES. Fur-
This study has a few limitations. First, only a few ther clinical and basic studies are needed to elucidate
published articles reported the quantitative analysis of the factors related to successful treatment outcomes of
EES compared with other techniques; this precluded EES in pediatric patients.
Marchioni et al. Congenital (all) TEES/3/0 TEES/1/0 TEES with CWU with — — —
(2017) ossiculoplasty/5/0, EES/2/0
EES with CWU/2/0
D’Eredita et al. — –/7/– –/4/– –/1/– — — — —
(2017)
Landegger et al. Congenital (1), acquired Oval window (1)
(2016) (2)
Sarcu et al. (2016) Congenital (7), acquired — — — — — Oval window Oval window (3),
(35) (2), pyramidal eminence
stapes (1) (2),
sinus tympani (2)
Ito et al. (2015) Congenital (13), acquired — — — — — —
(3)
Kobayashi et al. Congenital TEES TEES TEES T3/1/1 — ASQ (7), PSQ+PIQ (2), Horizontal —
(2015) closed (7), TI/7ear/0 TI/4/0 ASQ+AIQ (1), ASQ+PSQ (1), portion
congenital open ASQ–difficult to endoscopic of FN and
(5), open type surgery facial recess
recur (1)
Kanotra (2012) — –/39.2%/– –/35.7%/– –/25.0%/– — — — Sinus tympani (4),
anterior
epitympanum (1)
Rosenberg et al. — — — — — — Stapes crura, —
(1995) epitympanum
AIQ = anterior inferior quadrant; ASQ = anterior superior quadrant; CWU = canal wall up mastoidectomy; EES, endoscopic ear surgery; FN = facial nerve; IDRC = intraoperative detection of residual choles-
teatoma; N = number; PIQ = posterior inferior quadrant; PSQ = posterior superior quadrant; RCR = residual cholesteatoma or recurrence; TEES = transcanal endoscopic ear surgery.
7
Han et al.: Pediatric Endoscopic Ear Surgery
TABLE IV.
Summary of Studies of EES for Chronic Otitis Media That Had Data on Perforation Site, Size, Recurrence Site, and Audiometric Results
Study Perforation Site/N/SR, % Perforation Size/N/SR, % TM Graft Audiometry Results
Awad et al. Central/30/90, anterior/20/95, >50%/25/92, ≤ 50%/55/85 Tragal cartilage 1–10 years old ABG: pre, 30.5
(2015) inferior/16/88, posterior/9/78, dB/post, 8.0 dB; 11–17 years old
marginal/5/60 ABG: pre, 35.5 dB/post, 10.5 dB
Akyigit et al. Anterior/9/28.1, posterior/6/18.8, both ≥3 mm/12/100, Cartilage Pre ABG: 18.5 ± 6.29; post ABG:
(2017) (ant-post)/17/53.1 3–6 mm/20/93.7 7.96 ± 3.32; 0–10 dB ABG: pre 4
(12.5%), post 25 (78.1%); 11–20 dB
ABG: pre 16 (50%), post 7 (21.9%);
21–30 dB ABG: pre 12 (37.5%)
Carter et al. Pre PTA: 43.82 dB (range, 17.5–63.75);
(2017) post PTA: 31.38 dB (range,
15–66.25); AC gain: 11.65 dB
(range, –10 to 36.25); ABG gain:
10.19 dB (range, –11.25 to 28.75)
Ito et al. Large/5/100, Hearing level was 28.2 14.1 dB;
(2015) moderate/4/100, ABG was 8.6 8.3
adhesive/2/100
Migirov et Anterior/14/100 (difficulty to approach Large/13/100, Chondro-perichondrial Pre AC: 32.8 dB (range, 10–51.3); post
al. (2015) due to overhanging, narrowness); medium/8/100, flap AC: 18.2 dB (range, 5–35)
central/2/100; posterior marginal/6/100 small/1/100
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17. James AL. Endoscope or microscope-guided pediatric tympanoplasty? Com-
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