brief study of endoscopy use in ear surgery ,and how it can supplement microscopic ear surgery

1. ENDOSCOPE
ASSISTED MIDDLE
EAR SURGERY
BY
RAMA RAJU

2. •“ endoscopy is an adjunct to
microscope but never a substitute”

3. Endoscopes offer the surgeon the :
• capability of wide field visualization with
minimal exposure,
• looking behind the obstructions or overhangs
and
• peering into recesses with much less
requirement for surgical exposure than
demanded by conventional techniques.

4. • endoscopes help in angled vision at tip
allowing off line-of-site visualization
Off Line-of-Sight Structures:
• Middle ear Epitympanic recess
• Facial recess
• Sinus tympani
• Eustachian tube
• Hypotympanum

5. MIDDLE EAR ENDOSCOPY –
POTENTIAL INDICATIONS:
• Unexplained conductive hearing loss
• Trauma
• Cholesteatoma
• Perilymph fistula
• Follow-up (second look) cholesteatoma

6. FACIAL RECESS:
• Shallow depression
on the posterior
wall of tympanic
cavity
Relations:
Medial wall : PE,
vertical segment
of FN
Lateral wall : bony
annulus

7. SINUS TYMPANI:
• Relations:
Sup- ponticulus
Inf- subiculum
Lat – mastoid
segment of facial
nerve

8. SUPRA TUBAL RECESS:

9. ST CLASSIFICATION WITH ENDOSCOPY:
• Classical shape:
medial to the facial nerve and to
the pyramidal process
• Confluent shape: absent ponticulus
• Partitioned shape: when a ridge of
bone extending from the third
portion of the facial nerve to the
promontory area is present,
separating the sinus tympani into
two portions (superior and
inferior)
• Restricted shape: when a high
jugular bulb is present thus
reducing the size of ST

10. TRANSTYMPANIC ENDOSCOPY
• Endoscopy through
perforation /myringotomy
for a limited middle ear
exploration.
TECHNIQUE:
• Position- supine
• Local anaesthetic- phenol
solution
• Myringotomy incision : at
site of pathology (PLF-half
way b/w RWN shadow and
distal end of long process of
incus

11. ENDOSCOPY IN CHRONIC EAR
SURGERY
• As a adjuvant for removal of cholesteatoma
• For cholesteatoma in deep recesses
• For ds limited to aditus ,antrum ,ST,FR
(mastoidectomy avoided)
• Perform intact canal wall mastoidectomy
+endoscopy(avoids canal wall down technique)
• Used if firm adhesions of cholesteatoma sac to
recesses , blind elevation results in tearing the
matrix and residual ds,
• Lessen the need for second look procedure

12. • Thomassin et .al:
Only canal wall up procedure: 47.7% has
residual procedure and planned for second
stage procedure
Canal wall up+endoscopic removal: only 5.5%
required second stage procedure , results
are on par with canal wall down procedure

13. DISADVANTAGES:
• One handed surgery
• Bleeding hard to manage
• Passing instruments past endoscope
• Fogging
• Cannot be very helpful if disease involves
mastoid antrum

14. ENDOSCOPIC TYMPANOPLASTY
MOSTLY DONE IN
• Anterior perforation / anterior bony overhang
• Marginal perforation

15. ENDOSCOPIC ASSISTANCE IN
STAPEDOTOMY:
• Anterior crus and anterior part of foot
plate better visualised using endoscope
than microscope

16. PERILYMPH FISTULA
EXPLORATION:
• ME endoscopy proably improve the ability to
identify true peri-lymph fistula and reduce the
number of false positive examination whereas
open surgical exploration cannot eliminate the
artefactual pooling of infilitrated anaesthetics and
surgery induced transudates

17. ENDOSCOPY OF EAC AND T.M
• Photo documentation
• T.M and medial E.A.C (canal
stenosis/obstruction)
• Bony canal defects
• Recesses
• To determine depth and presence of
cholesteatoma in retraction pockets