ENDOSCOPIC EAR SURGERY

Introduction
Otologic surgery has progressed rapidly
over the past century
 Before1920’s; loupes/without
microscope assistance
 1950’s; refinement of the
binocular microscopes
 Late 60’s; use of microscope to
visualize middle ear was introduced
 1990’s; endoscopes incorporated in middle
ear surgery
Introduction to EES
 Microscopic techniques, introduced in late
1950’s changed the character and outcome
of ear surgery.
 Endoscope offers a same ‘game changing’
impact.
 By using endoscopes, the improved access to
the tympanic cavity and proximal Eustachian
tube has allowed us to have a better
understanding of the primary disease
process : impaired ventilation.
HISTORY OF
OTOMICROSCOPY &
ENDOSCOPIC EAR
SURGERY
 History of Otomicroscopy
Otologic surgery has progressed rapidly over the
past century

 Carl Olof Nylen 1921; The monocular

microscope was first applied in ear surgery.
 Gunnar Holmgren 1922; developed the first
binocular microscope for use in ear surgery.
 Otologists of that era in the first half of the
20th century mostly used
loupes for visualization.
 History of Otomicroscopy
Otologic surgery has progressed rapidly over the
past century

 1953, Carl Zeiss in collaboration with physicist Hans

Littman adapted and redesigned the ear microscope.
 1950’s- The Zeiss OPMI-1 microscope became
widely available and revolutionized otologic surgery.
HISTORY OF ENDOSCOPIC EAR
SURGERY
 Paralleling the introduction of
endoscopes for sinus surgery in the
1990s, otology is facing a similar
paradigm shift.
 “Otoendoscopy” (The use of endoscopy
to visualize the ear) was introduced in
the late1960s.
 Poor image resolution at that time, in
comparison to the operative
microscope limited its application.
 SURGER
Ear Endoscopy
Y from the 1960s to the
1980s
 Mer and colleagues in 1967: examined cadaver’s
ears & living animals’ ears through an iatrogenic
myringotomy.
 Nomura 1982: The first myringotomy was
published
- used an angled rigid endoscope and called it
the needle otoscope. Nomura’s focus was on
middle ear photography.

 1989, Kimura and colleagues in Japan: used an

ultrathin fiberscope that was inserted in living
patients under LA through the eustachian tube
orifice in Nasoph.
 SURGER
Ear Endoscopy
Y from the 1960s to the
1980s
Early endoscopic views of the middle ear,
1967.

(From Mer SB, Derbyshire AJ, Brushenko A, et al. Fiberoptic

endotoscopes for examining the middle ear. Arch Otolaryngol
1967;85(4):387–93)
 HISTORY OF ENDOSCOPIC EAR
SURGERY
Endoscopy Ear Surgery in the 1990’s
The true beginnings of EES took place in the
1990’s.
Otologic surgeons started to use endoscopic approaches
not only for inspection but also to guide intervention.
 McKennan in California – Second look Mastoidectomies
(Transcutaneous Mastoidoscopy) – to avoid another
postauricular incision during second-look surgery for
cholesteatoma.
 Rosenberg and Silverstein – investigated this
mastoidoscopy approach further by first examining the
mastoid endoscopically via a postauricular keyhole
approach then formally opening the mastoid via the
postauricular approach.
One advantage of ear endoscopy over binocular
otomicroscopy is the wide field of view
Microscopic and endoscopic views of the right middle ear.

Daniel Lee, MD
Massachusetts Eye and Ear Infirmary
Harvard Medical School
 HISTORY OF ENDOSCOPIC EAR
SURGERY
Endoscopy Ear Surgery in the 1990’s
Muaaz Tarabichi – embraced the endoscope
as a sole mode of visualization for ear surgery,
and by the late 1990s published an important
series on the endoscopic management of
cholesteatoma.
Tarabichi M – Endoscopic management of Acquired
Cholesteatoma. Am J Otol. 1997; 18: 5444-5449

 38 adults with acquired

cholesteatoma
 36 underwent transcanal EES
 29/30 disease free at 1 year
 10/13 disease free at 2 years
 4/6 disease free at 2 years (on surgical
exploration)
Transcanal Endoscopic resection of
Cholesteatoma is safe and effective.
 Tarabichi M – Endoscopic management of Acquired
Cholesteatoma. Am J Otol. 1997; 18: 5444-5449.

 The main contribution of the endoscope in my experience

has not been a technical one, but rather the different
perspective of cholesteatoma and cholesteatoma surgery
that it afforded me.
 Cholesteatoma is a manifestation of advanced retraction
of the tympanic membrane, with the sac advancing into
the tympanic cavity proper and then on to its extensions
(ST,FR,HyT). Only in advanced cases, it proceeds further
to mastoid cavity proper.
 The endoscope allowed a better understanding of
cholesteatoma and the way it travels through the
temporal bone
 Therefore, the most logical approach to
 HISTORY OF ENDOSCOPIC EAR
SURGERY
Endoscopy Ear Surgery in the 2000’s
 During this decade, more investigators and
otologic surgeons explored the potential benefits
of endoscopic techniques.
 Number of publications in peer-reviewed journals
dramatically increased.
 Otologic surgeons tried their hands at performing
a variety of classic otologic procedures
endoscopically and reported their experiences as
well as technical tips and limitations.
 Video clips of various endoscopic ear surgeries
could be found on different websites and on
YouTube.
 HISTORY OF ENDOSCOPIC EAR
SURGERY
Endoscopy Ear Surgery in the 2000’s
 The International Working Group on Endoscopic Ear
Surgery (IWGEES) formed as a consortium of otologists
interested in endoscopic ear surgery. The group promotes
endoscopic ear surgery and provides educational
materials and seminars.
Dr. Nirmal Patel
Daniel Lee, MD
Massachusetts Eye and Ear Infirmary
Harvard Medical School
João Flávio Nogueira Assistant Professor ENT
Universidade Estadual do Ceará – UECE
Director Sinus & Oto Centro Fortaleza, Brazil.
RATIONALE FOR
ENDOSCOPIC EAR
SURGERY
Rational for EES
 The operative microscope, pioneered in the
1950s & 1960s, is essential for otologic
surgery as it provides
1. excellent illumination,
2. depth perception and magnification,
3. binocular vision,
4. ability to work with 2 hands, and
5. capacity to capture HD images and video.
 Despite these advantages, the microscope is
limited when constrained by small surgical
corridors: the External Auditory Canal.
Transcanal microscopic Transcanal endoscopic
view is limited by view is wider than
size of speculum. the microscope.
Rational for EES
 In cases with a small surgical corridor,
additional soft tissue incisions (endaural or
postauricular) or bone removal (canalplasty,
atticotomy, removal of ossicles, and canal up
or down mastoidectomy) are sometimes
needed to access middle ear disease.
 This is especially true when
 the EAC is small,
 when there is a prominent anterior bony overhang
&
 when the middle ear disease extends to the attic,
Rational for EES
 The endoscope allows for excellent
visualization of the entire tympanic
membrane, middle ear because
 A wide-angle lens &
 Illumination emerges from the distal tip.

 With the introduction of 3-CCD camera systems

and wide-format digital displays, endoscopes
now provide an immersive and high-fidelity
visual experience for the surgeon that is also
shared by observers in the operating room.
 Main Advantages of EES

1. Using the ear canal as the natural conduit to the

tympanic cavity
2. High quality resolution and magnification
3. Restoring normal middle ear & mastoid ventilation
routes
4. Preserving as much normal anatomy as possible
by minimizing unnecessary dissection of bone and
soft tissue
5. Decreasing the need for drilling
6. Avoidance of postauricular approaches and
minimizing damage to neurovascular structures
Philosophy (of the experts) in
EES

David D. Pothiar
Toronto General
Hospital
Drawbacks of EES include;

Challenging one handed dissection
without suction in other hand

Lack of 3 dimensional view – reliance on
motion parallax to assess depth
perception

Lack of exposure to these techniques
during surgical training
 Limited instrumentation
 Basic differences between
endoscopic
and microscopic ear
Endoscope Microscope
surgery
Number of hands One handed Two handed
available for (optional 2-handed)
dissection
Typical surgical approach Transcanal (can be Transcanal with
postauricular for speculum +-
combined cases as endaural incision or
well as via the antrum postaural
following CWU
mastoidectomy
Resolution High High
Binocular vision No Yes
Field of vision Wide Narrow
Ability to look around Yes (0-70degrees) No
corners
 Terminology of EES
OTOENDOSCOPY It involves the use of rigid (or
flexible) endoscope for inspection of the outer ear,
middle ear, mastoid, or lateral skull base.
E.E.S It involves the use of the endoscope for
simultaneous visualization and dissection of the
outer ear, middle ear, and mastoid. This applies to
transcanal, transmeatal (canal wall down cavity),
trans-mastoid, and transcranial lateral skull base
approaches.
TRANSCANAL- E.E.S (TEES) It refers to EES
techniques in which the EAC is used as the primary
surgical portal to access the TM, middle ear, and in
very specialized cases, the inner ear and lateral
HOW TO GET STARTED
EES Instruments
If you have FESS sinuscopes and a middle
ear instruments tray you are ready to
start…

 Rigid sinus endoscopes

 A light source
 A HD 3-CCD Camera
 A HD video monitor
 Basic otological surgical instruments set
 Few specialized instruments
4.0 mm
3.0 mm
A basic otology Instrument set for Middle ear surgery
Panetti Endoscopic Instrument set for Middle ear surgery
Surgical ergonomics &
OT setup
 Hand positioningand
placement of the endoscope
 A standard otologic chair that has armrests
is essential for EES. Both forearms and
elbows should rest on the table, patient
shoulder, or armrest to maintain wrist stability
and minimize fatigue.
 The endoscope may be held in a similar
fashion as during sinus surgery, with the hand
placed partly along the shaft and camera
head.
 The endoscope should be stabilized
gently along the cartilaginous meatus.
 Left vs. right ear cases
 For the right-handed surgeon, it is
recommended to start with left-sided EES cases
as dissection of routine and complex middle
ear disease is much easier than the right ear.

 Use dominant hand for dissection in both left

and right ear cases.
 Indications for Endoscopic Ear
Surgery
 External ear  Inner ear/Skullbase
 Exostosis  Intracochlear
 Canalplasty schwannoma
 Debridement & Bx.
 Small symptomatic
neoplasm of IAC fundus
 EAC cholesteatoma
or facial N.
 Middle ear  Petrous apex cyst
 Myringotomy  Perilymph fistula repair
 Myringo/Tympanoplasty  Middle cranial fossa
 Ossiculoplasty  SCC dehiscence repair
 Cholesteatoma
 Post. Fossa/CP angle
 Tumors (glomus)
 Identification of residual
 Stapedectomy
schwannoma in IAC
Contraindications & potential
Contraindications & potential
complications
complications
 No known absolute contraindications to EES.
 Any otologic case that may be performed via microscopic
techniques may be assisted by the use of an
endoscope.
 Potential complications of EES are identical to that of
traditional microscopic ear surgery;
 Direct damage to ossicles

 Direct damage to facial nerve

 Heat damage to inner ear

 Heat damage to facial nerve

 There is no reason to believe that complications for

EES are higher than microscope-based
 Safety considerations specific to
EES
 Potential of thermal injury from tip
of endoscope:
 Power of light source no greater than
50% and
 A safe distance of >5 mm from inner ear
structures

 Use of 0 scopes is encouraged until

comfort is gained using highly angled
scopes i.e. 30 and 45.
Before you begin EES
 Visit the IWGEES website
 www.iwgees.org
 Look at the video clips
 Visit the SEES website
 www.sydneyendoscopyear.com
 Read the SEES dissection guide, watch the
videos
 Visit an IWGEES member
 Attend 1 (or two) Hands-on dissection
course.
 EES courses
 Harvard, USA
 Vanderbilt, USA
 St. Louis MI, USA
 Glasgow
 Toronto, Canada
 Sydney, Australia
 Bern, Switzerland
 Cape town, SA
 Fortaleza, Brazil
 Modena, Italy
 Nice, France
 Yamagata, Japan
 Dubai, UAE
 Alexandria, Egypt
 Jeddah, Saudi Arabia
A 3-step process to introduce EES into
your surgical practice
1. Use the endoscope during chronic
ear surgery after the microscope-
based dissection to
a) Look for hidden disease.
b) Examine the retrotympanum,
epitympanum, and
hypotympanum with a 30° endoscope.
c) Examine the antrum through the ear canal with a
30° endoscope.
d) Assess the ossicular chain and round window.
A 3-step process to introduce EES into
your surgical practice
2. Perform an easy transcanal
procedure, including
a) Endoscopic examination under anesthesia of EAC
and TM before microscope dissection to document
abnormality.
b) Cerumen removal.
c) Myringotomy & PE tube placement.
d) Myringoplasty.
3. Use the microscope to begin the
tympanomeatal flap; then complete
elevation with EES techniques
a) Switch to a 0° endoscope before dissection of the
FEW
SURGICAL
STEPS IN
ENDOSCOPIC
TYMPANOPLAST
Y
PROMOTIONAL
TIPS TECHNICAL
TIPS
MEEI 10
COMMANDMENTS
 Promotional tips
 No soft tissue injury
 No head bandage/dressing
 No scar
 No removal of Sutures
 Day-case
 Minimum requirement of
analgesia
 Good view, recording
 Everyone is engaged
 Good educational tools
 TECHNICAL
Success in EES comes form the accumulation of many tiny tips
TIPS & pearls

1. Inject the EAC and surrounding tissues

thoroughly
2. Place cottonoids with 1:1000 adrenaline in EAC
during preparation of case
3. While you are waiting
1. Trim EAC hairs
2. Clean debris and cerumen
4. Placing the endoscope in the EAC is critical each
time
1. Use instruments to push tragus forward
2. Place in canal under screen view
 TECHNICAL
Success in EES comes form the accumulation of many tiny tips
TIPS & pearls

5. Raising the tympanomeatal flap is often the most

difficult part: Once you reach the MEar, everything
settles down
6. Make the tympanomeatal flap more lateral than you
might expect
7. Raise the flap with a cottonoid +/- suction elevator
8. Be liberal with the cottonoids
9. Irrigate
10. 5 minutes ‘by the clock’ will solve almost every
bleed
11. Take your time
 The MEEI “10
Commandments”
of EES for the novice
surgeon

1. Participate in an EES course and

practice EES in a temporal bone
laboratory.
2. Essential EES surgery equipment: includes
0 and 30 endoscopes, 3-CCD HD camera,
HD monitor, and standard otologic instrument
set.
3. Discuss with OR team, anesthesiologist
& ancillary staff, the setup for EES
before beginning any case
 The MEEI “10
Commandments”
of EES for the novice
surgeon

6. Trim ear canal hair before the start of

EES cases.
7. Avoid using endoscope holders
8. Initial cases of EES; use the endoscope
to look for hidden disease after using the
microscope and then transitioning to “easy”
procedures
9. For angled endoscopes; use two hands
to introduce the endoscope into canal
and middle ear: be aware of “blind spots”.
 Time

3 hours

2.3 hours

3 hours

2.3 hours

2 hours

Microscope Case David D. Pothiar

Toronto General
Endoscope Case
Hospital
The LEARNING curve

microscope

endoscope

David D. Pothiar
Toronto General
Hospital
The BENEFIT curve

microscope

endoscope

David D. Pothiar
Toronto General
Hospital
Summary
 Advancing technique with many
historical precedents
 Excellent tool for CSOM
 Advances in anatomy of relevant
structures
 Expanding indications
 Early days
 Rapidly developing field
 Requires commitment and practice
 A truth passes through three
stages. First it is ridicule. Second
it is violently opposed. Third it is
accepted as being self evident
- Arthur Schopenhauer
 We are all dwarfs seated on Giant’s shoulder.
If we can see far this is not because we
are tall, this is because weare seated on
Giant’s shoulder.

Gunner Raymond Julius Samuel John John W. Iftikhar

Holmgren Carhart Lempert Rosen Shea Jr. House Salahuddin
(1875-1954) (1912-1975) (1890-1968) (in 1953) (1924-2015
father of first described developed proposed ) President - The Aga Khan
fenestration Carhart one-stage stapes father of House University
surgery. notch. fenestration mobilization. modern stapes Ear Hospital.
surgery. surgery. Institute.