The protocol followed the guidelines of the local institution's human research ethics committee and was approved by the local institutional review board (KEK-BE 2019-00555). All operations were performed in general anesthesia under controlled hypotension in anti-Trendelenburg positioning with standard otological instruments.
1. Preparation of the surgical site
2. Exclusive transcanal endoscopic approach
3. Middle ear exploration
4. Reconstruction of the ossicular chain and scutum
5. Wound closure
A total of 43 consecutive cases of exclusive endoscopic cholesteatoma surgery were analyzed for this study. One surgeon performed all operations; cases needing conversion to a microscopic or combined approach were excluded. Preoperative computed tomography suspected an epitympanal cholesteatoma extension in every case. The mean age (±standard deviation) at the surgery date was 37.36 years (±15.64 years). Seven cases (16.3%) were revision surgeries, thirty-six cases (83.7%) were patients undergoing first cholesteatoma removal. The left side was operated in 26 cases (60.5%), the right side in 17 cases (39.5%).
Surgical Results
All operations were completed without significant complications like facial nerve palsy or postoperative sensorineural hearing loss, as illustrated in Figure 1. Cartilage was used as grafting material in 38 cases (88.4%) and fascia in 5 cases (11.6%). The graft intake rate (GIR) was 90.7% showing 3 cases of postoperative perforations (7.3%). The mean follow-up was 17.4 months (±10 months), with 40 cases (93%) having no recurrent cholesteatoma at the last follow-up.
Audiological Results
Each patient underwent standard audiological testing before and after surgery. One patient was already deaf before surgery; thus, no hearing improvement was expected. Two more patients had no postoperative audiogram. Preoperative air bone gap (ABG) of 23.8 dB ± 12.6 dB improved significantly (paired t-test with p = 0.0005) to a postoperative ABG of 18.2 dB ± 10 dB after surgery. The detailed surgical results are presented in Table 1.
Figure 1: Overview of the essential surgical steps. Please click here to view a larger version of this figure.
Age | 37.4 years (14-80 years) | ||
Side | 26 left side | 17 right side | |
Revision surgery | 36 primary surgery | 7 revision surgery | |
Grafting sucess | 39 successful | 3 perforations | 1 missing follow up |
Grafting material | 38 cartilage | 5 fascia | |
Recidive | 40 without recidive | 3 with recidive | |
Mean ABG | 23.8 ± 12.6 dB preoperative | 18.2 ± 10 dB postoperative |
Table 1: Detailed surgical results.
Antifog Solution | Karl Storz | N/A | |
Epinephrine 1 mg/mL | Dr. Bichsel AG | N/A | |
Gelatinous sponge (Gelfoam) | Pfizer | N/A | |
HOPKINS Optic 0° | Karl Storz | 7220AA | |
HOPKINS Optic 30° | Karl Storz | 7220BA | |
HOPKINS Optic 45° | Karl Storz | 7220FA | |
HOPKINS Optic 70° | Karl Storz | 7220CA | |
Image 1S 4K | Karl Storz | TH120 | |
ME 102 | KLS Martin | N/A | |
Monitor 32" 4K/3D | Karl Storz | TM350 | |
NIM-Neuro 3.0 | Medtronic | N/A | |
OsseoDuo | Bien Air | N/A | |
Otosporin (polymyxin, neomycin, hydrocortison) | GlaxoSmithKline | N/A | |
Piezosurgery device | Mectron | N/A | |
PM2 Line Drill | Bien Air | N/A | |
Povidone-iodine (Betadine) | Mundi-Pharma | N/A | |
Ringer Solution | B. Braun | N/A | |
Standard otological instruments | Karl Storz | N/A | |
Steel and diamand burrs | Bien Air | N/A | |
Syringe Injekt Solo 10 mL | B. Braun | N/A |
Implementation of endoscopes in cholesteatoma surgery resulted in considerable changes in the management of cholesteatoma in the last two decades. Compared to the microscopic approach with an excellent but straight-line view and limited illumination, the introduction of endoscopes provides a wide-angled panoramic view. Moreover, angled lenses allow the surgeon to visualize the middle ear and its hidden recesses through a transcanal, minimally-invasive approach. The endoscope enables the surgeon to remove limited cholesteatoma of the middle ear and its recesses using an exclusive endoscopic technique by taking advantage of these benefits. This reduces the rate of residual disease and sparing external incisions and excessive temporal bone drilling as in a transmastoid approach. Since transcanal endoscopic access is mainly a one-handed technique, it implies the need for specific procedures and technical refinements. This article describes a step-by-step guide as a surgical manual for endoscopic removal of epitympanic cholesteatoma. Different techniques for cholesteatoma dissection and bone removal for epitympanectomy, including curettage and powered instruments such as drills and ultrasonic devices with their outcomes, are discussed. This may offer ear surgeons insight into technical refinements and the latest technological developments and open the horizon for different techniques.
Implementation of endoscopes in cholesteatoma surgery resulted in considerable changes in the management of cholesteatoma in the last two decades. Compared to the microscopic approach with an excellent but straight-line view and limited illumination, the introduction of endoscopes provides a wide-angled panoramic view. Moreover, angled lenses allow the surgeon to visualize the middle ear and its hidden recesses through a transcanal, minimally-invasive approach. The endoscope enables the surgeon to remove limited cholesteatoma of the middle ear and its recesses using an exclusive endoscopic technique by taking advantage of these benefits. This reduces the rate of residual disease and sparing external incisions and excessive temporal bone drilling as in a transmastoid approach. Since transcanal endoscopic access is mainly a one-handed technique, it implies the need for specific procedures and technical refinements. This article describes a step-by-step guide as a surgical manual for endoscopic removal of epitympanic cholesteatoma. Different techniques for cholesteatoma dissection and bone removal for epitympanectomy, including curettage and powered instruments such as drills and ultrasonic devices with their outcomes, are discussed. This may offer ear surgeons insight into technical refinements and the latest technological developments and open the horizon for different techniques.
Implementation of endoscopes in cholesteatoma surgery resulted in considerable changes in the management of cholesteatoma in the last two decades. Compared to the microscopic approach with an excellent but straight-line view and limited illumination, the introduction of endoscopes provides a wide-angled panoramic view. Moreover, angled lenses allow the surgeon to visualize the middle ear and its hidden recesses through a transcanal, minimally-invasive approach. The endoscope enables the surgeon to remove limited cholesteatoma of the middle ear and its recesses using an exclusive endoscopic technique by taking advantage of these benefits. This reduces the rate of residual disease and sparing external incisions and excessive temporal bone drilling as in a transmastoid approach. Since transcanal endoscopic access is mainly a one-handed technique, it implies the need for specific procedures and technical refinements. This article describes a step-by-step guide as a surgical manual for endoscopic removal of epitympanic cholesteatoma. Different techniques for cholesteatoma dissection and bone removal for epitympanectomy, including curettage and powered instruments such as drills and ultrasonic devices with their outcomes, are discussed. This may offer ear surgeons insight into technical refinements and the latest technological developments and open the horizon for different techniques.