VIDEO - Case 1 - transcanal endoscopic ear surgery (EES) for left ear attic cholesteatoma



minimally invasive transcanal endoscopic ear surgery (EES) for pediatric and adult middle ear disease

One of the important benefits of an endoscope compared to the microscope is the wide-field view of the middle ear afforded by the location of the light source at the tip of the endoscope and the availability of angled lenses.

In many cases of pediatric ears even with small ear canals, a large incision or cut behind the ear can be avoided during tympanoplasty or cholesteatoma surgery.

The image below was taken using 3mm 0 degree, 14cm long endoscope placed through the left ear external auditory canal. The panoramic view of the tympanic membrane (eardrum) provides the surgeon with a high definition view of the entire ear using a transcanal approach.

The modern era of otoendoscopy was pioneered by Dennis Poe MD and endoscopic ear surgery (EES) has been the focus of Muaaz Tarabichi MD at the American Hospital in Dubai for over 20 years. We are indebted to the work of Dr Poe, Dr. Tarabichi, and the entire International Working Group on Endoscopic Ear Surgery (IWGEES).

At the Massachusetts Eye and Ear Infirmary both pediatric and adult otologists perform endoscopic ear surgery in hundreds of children and adults with routine and complex middle ear disease.

BOTH microscopic and endoscopic ear surgery are complementary approaches that are used alone or together to ensure that our patients in Boston receive the best possible surgical outcomes.

Our active program on EES at MEEI and Harvard Medical School is committed to 1) determining the clinical and radiologic indications for EES in children and adults, 2) understanding the surgical and audiologic outcomes following EES, 3) improving instrumentation for EES, 4) developing novel teaching tools to enhance the educational experience of residents, fellows, and surgeons in practice when learning EES, and 5) offering Harvard CME courses on endoscopic ear dissection.

Middle ear procedures that employ a rigid endoscope for visualization may reduce the need to drill for enhanced exposure to the operative field. In contrast, the traditional otologic operating microscopes typically require larger portals (e.g. post-auricular or endaural approaches) to enable adequate passage of light for intraoperative visualization and follow-up surveillance in clinic.

The image below was taken using a 0 degree endoscope following the elevation of the tympanomeatal flap, revealing the left middle ear, the three ossicles (malleus or hammer, incus or anvil, and stapes or stirrup), the cochlea, the round window, and the facial nerve. A microscopic view would not provide the same view without significant bone removal.

The clinical indications for this powerful technique are currently evolving in the literature and the use of rigid endoscopes to perform ear surgery (rather than just to visualize the middle ear) is increasing and primed to expand as refined instrumentation and operative approaches become available.

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CASE NO. 1: 55 year old woman who presented with progressive left ear (aural) fullness and hearing loss.

The image below shows her left ear with 0 degree endoscopy. An attic retraction pocket is defined by the black arrows collecting keratinaceous debris, and represents a small cholesteatoma.

The preoperative audiogram showed a conductive hearing loss in both ears, worse in the left ear. The blue line represents sound detection in the left ear and the red line represents sound detection in the right ear.

The right ear was found to have an otitis media with serous effusion and this was addressed with a myringotomy and tympanostomy tube placement in the office.

Computed tomography (CT) scans of the left ear temporal bone revealed a soft tissue process involving Prussak's space and the epitympanum (attic).

The left ear axial CT scan below shows a soft tissue density of the epitympanum abutting the ossicular heads of the malleus and incus.

The left ear coronal CT scan below shows a soft tissue density filling Prussak's space and extending into the attic. There is also erosion of the lateral wall of the epitympanum (or attic), a finding often seen in middle ear cholesteatoma.

 

This patient elected to undergo a left ear transcanal endoscopic ear surgery (TEES or EES) with resection of an attic cholesteatoma. The tympanic membrane (eardrum) was reconstructed with a small perichondrium and cartilage graft taken from the conchal bowl.

Avoiding the tragus cartilage reduced the concern of a visible scar and allows one to use "earbuds" when listening to music without them falling out easily, a problem seen in some cases where a large tragal cartilage graft is taken.

The incus and malleus head were removed in order to successfully resect the retraction pocket and cholesteatoma.

The incus was reshaped as an "incus interposition" graft, and then placed back into the middle ear to restore ossicular continuity.

Surgery took about two hours. She was sent home several hours after her procedure.

SEE SURGICAL VIDEO HERE

 

   
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