Endoscopic ear surgery - a complement to microscopic ear surgery

Abstract

Wullstein, the founder of modern microscopic ear surgery, already used an oto-endoscope intraoperatively. However, it is only after the recent development of modern video-endoscopy with high-definition, 4K, and 3‑dimensional imaging that endoscopically guided surgery of the middle ear is gaining some importance. Key ventilation routes like the isthmus tympani and the epitympanic diaphragm can be visualized far better using an endoscope than with a microscope. Going through the external meatus, surgery of middle ear pathologies is possible without external incision. This type of primary endoscopic ear surgery has to be distinguished from secondary endoscopic ear surgery, where standard microscopic ear surgery is supplemented by endoscopic surgery. Having to hold the endoscope in one hand, surgery has to be performed single-handedly, which is awkward. In cases of extensive bone removal or excessive bleeding, the view through the endoscope lens is obscured; therefore; the endoscope cannot fully substitute the microscope. It is, however, an interesting adjunct to microscopic ear surgery.

Keywords: Cholesteatoma; Endoscopic surgical procedures; Middle ear; Middle ear surgery; Tympanoplasty; Video-assisted surgery.

Fig. 1

Setup for endoscopic ear surgery. a The ready-to-use microscope can be seen in the upper left corner. b The left hand holds the endoscope, while the right hand performs the surgery

Fig. 2

Endoscopic middle ear anatomy. ST sinus tympani, STS subtympanic sinus, RW round window, star posterior sinus. (Figure modified from [12] with permission from Elsevier)

Fig. 3

Endoscopic middle ear surgery in a patient with epitympanic dysventilation. a Epitympanic cholesteatoma with an otherwise normal tympanic membrane. b Mucosal folds obstructing the isthmus tympani. c Complete epitympanic diaphragm. d Dissection of the anterior malleolar fold to open up the epitympanic space for ventilation via the supratubal recess. SPT stapedius tendon, SH stapes head, ED epitympanic diaphragm, PE pyramidal eminence