Middle Ear Surgery: what can we

do with endoscopic approach

Anatomy of Ear
Understanding physiology of
middle ear
 Understanding physiology of
middle ear
• What is the most important middle ear
mucosa function ?

Gas exchange

• Without “air” filled space, sound conduction

will be compromised !
Understanding physiology of
middle ear
The exchange of gas
between the middle ear
cleft and vascular space.
Understanding physiology of
middle ear
 Understanding physiology of
middle ear
• Is mucosa gas exchange enough for
maintaining middle ear chamber homeostasis
?

Normal ventilation is mandatory

• Including: normal Eustachian tube function &

middle ear compartments ventilation.
 Understanding physiology of
middle ear

Comparative histology of the two compartments. a: Anteroinferiorly the

mucosa is ciliated pseudostratified epithelium that is populated by numerous
mucous secreting cells and covered with cilia. b: The posterosuperior mucosa
is a thin layer of simple cuboidal cells, thin stroma, and blood vessels that lie
in much closer proximity to the surface and therefore to the interface with
the air-filled mastoid cavity.
What is CHRONIC OTITIS MEDIA ?

Middle ear mucosa disease

Pathological Changes in the Middle Ear
Cleft in COM
• Granulation Tissue
– The most common sites: epitympanum,
mesotympanum, round window niche, and
mastoid antrum.
– With maturation, granulation tissue becomes
more fibrous and less cellular, with increased
collagen and reticular formation.
Pathological Changes in the Middle Ear
Cleft in COM

Histopathologic examination of the left ear showed the retraction of the pars
flaccida (arrow), a pathology associated with fibrocystic changes, and
granulation tissue in the attic and mesotympanum (*).
Pathological Changes in the Middle Ear
Cleft in COM
• Biofilms
– Definition: structured communities of
microorganisms embedded in an
extrapolysaccharide matrix.
– Haemophilus influenzae, Streptococcus
pneumoniae, and Pseudomonas aeruginosa, have
been shown to form biofilms.
– important role in the establishment of COM that is
resistant to medications and for which surgical
intervention is often required.
 The objectives of middle ear surgery
1. Removal of middle ear mucosa diseased.

2. Regain normal ventilation within middle ear

compartments.

3. Tympanic membrane perforation closure.

SAFE & DRY Ear !!!

Why do we use endoscope for middle
ear surgery ?
• Limited access area of middle ear with
microscope:
– Protympanum
– Hypotympanum
– Retrotympanum
• Un-accessible area of middle ear with
endoscope:
– Mastoid air cells beyond the antrum.
Advantage of endoscopic approach

Remember that It is true when you don’t need

to remove the mastoid air cells mucosa !!!
Disadvantage of microscopic approach
Accessible area of middle ear
Endoscopic or microscopic approach ?
Extension of the diseased mucosa or cholesteatoma
beyond (posterior to) the mastoid antrum

How to know it / how to detect it ?

• High resolution CT scan

• Macroscopic appearance of tympanic cavity
mucosa
 Conclusions
• Understanding the expansion of the middle
ear mucosa disease or cholesteatoma in each
case is very important.

• Whenever possible, always prepare both

modality ready to use during surgery to
prepare all possibility of difficult situations.
 Conclusions
• High resolution CT scan of temporal bone is
mandatory to detect mastoid air cells
involvement.

• Beyond the never ending debate in regard to

which one is better, the most important is
how to remove the disease as completely as
possible. Using combination of both method is
the best of choice.