Describe the history, rationale, indications and technique of endoscopic ear surgery.

1. Endoscopic
Ear Surgery
Dr. Ausaf A. Khan
ENT/Head & Neck Surgery
HCM&D. Hamdard University

2. ENDOSCOPIC
EAR SURGERY
Prof. Dr. Ausaf Ahmed khan
Professor and Head of Department
Hamdard College of Medicine &
Dentistry
Hamdard University Hospital
Karachi, Pakistan.

3. 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

4. Introduction to EES
 Endoscopic Ear Surgery (EES – the use of
endoscopes to perform otologic surgery) has
become, in experienced hands, a safe and
reasonable approach for a variety of indications in
ear surgery.
 The endoscope is slowly emerging as
 a valuable adjunct to the operative microscope &
 the sole means for visualization and performing
many routine and complex otologic procedures for
experienced surgeons in selected centers in US &
elsewhere.
The Endoscope is NOT meant to replace the
microscope in all patients, but may serve a
specialized purpose in select cases.

5. 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.

7. CONTENTS
History of Endoscopic Ear Surgery
Rationale for use of the endoscope in ear
surgery
Terminology
How to get started
Relevant instrumentation for EES
Surgical ergonomics & OR setup
Indications, C/I & safety considerations
Endoscopic tympanoplasty steps
Techniques to incorporate EES in practice
Pearls and pitfalls/Technical tips/Promotional
tips
10-commandments for the novice surgeons
Summary

8. HISTORY OF
OTOMICROSCOPY &
ENDOSCOPIC EAR
SURGERY

9. 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.

10. 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.

11. 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.

12. HISTORY OF ENDOSCOPIC EAR
SURGERY
Ear Endoscopy 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.

13. HISTORY OF ENDOSCOPIC EAR
SURGERY
Ear Endoscopy from the 1960s to the
1980s
(From Mer SB, Derbyshire AJ, Brushenko A, et al. Fiberoptic
endotoscopes for examining the middle ear. Arch Otolaryngol
1967;85(4):387–93)
Early endoscopic views of the middle ear,
1967.

14. 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.

15. One advantage of ear endoscopy over binocular
otomicroscopy is the wide field of view

16. Microscopic and endoscopic views of the right middle ear.
Daniel Lee, MD
Massachusetts Eye and Ear Infirmary
Harvard Medical School

17. 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.

19. 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.

20.  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 cholesteatoma is
Tarabichi M – Endoscopic management of Acquired
Cholesteatoma. Am J Otol. 1997; 18: 5444-5449.

21. Right ear: Note the retraction and
cholesteatoma. H: Handle of malleus

23. 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.

24. 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.

25. Dr. Nirmal Patel

26. Daniel Lee, MD
Massachusetts Eye and Ear Infirmary
Harvard Medical School

27. João Flávio Nogueira Assistant Professor ENT
Universidade Estadual do Ceará – UECE
Director Sinus & Oto Centro Fortaleza, Brazil.

28. RATIONALE FOR
ENDOSCOPIC EAR
SURGERY

29. 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.

30. Transcanal microscopic
view is limited by
size of speculum.
Transcanal endoscopic
view is wider than
the microscope.

31. 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,

32. 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.

37. 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

38. Philosophy (of the experts) in
EES
David D. Pothiar
Toronto General
Hospital

39. 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

40. Basic differences between
endoscopic
and microscopic ear surgery
Endoscope Microscope
Number of hands
available for dissection
One handed
(optional 2-handed)
Two handed
Typical surgical approach Transcanal (can be
postauricular for
combined cases as
well as via the antrum
following CWU
mastoidectomy
Transcanal with
speculum +- endaural
incision or postaural
Resolution High High
Binocular vision No Yes
Field of vision Wide Narrow
Ability to look around
corners
Yes (0-70degrees) No

41. 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

42. HOW TO GET STARTED

43. 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

45. 4.0 mm
3.0 mm

46. A basic otology Instrument set for Middle ear surgery

47. Panetti Endoscopic Instrument set for Middle ear surgery

49. Surgical ergonomics & OT
setup

51. Hand positioning and
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.

52. 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.

53. Indications for Endoscopic Ear
Surgery
 External ear
 Exostosis
 Canalplasty
 Debridement & Bx.
 EAC cholesteatoma
 Middle ear
 Myringotomy
 Myringo/Tympanoplasty
 Ossiculoplasty
 Cholesteatoma
 Tumors (glomus)
 Stapedectomy
 Inner ear/Skullbase
 Intracochlear
schwannoma
 Small symptomatic
neoplasm of IAC fundus
or facial N.
 Petrous apex cyst
 Perilymph fistula repair
 Middle cranial fossa
 SCC dehiscence repair
 Post. Fossa/CP angle
 Identification of residual
schwannoma in IAC

54. Contraindications & potential
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
approaches.
Contraindications & potential
complications

55. 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.

56. 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.

57. 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

58. 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.

59. 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
A 3-step process to introduce EES into
your surgical practice

60. FEW
SURGICAL
STEPS IN
ENDOSCOPIC
TYMPANOPLASTY

67. PROMOTIONAL TIPS
TECHNICAL TIPS
MEEI 10 COMMANDMENTS

68. 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

69. TECHNICAL TIPS
Success in EES comes form the accumulation of many tiny 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

70. 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
TECHNICAL TIPS
Success in EES comes form the accumulation of many tiny tips &
pearls

71. 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
4. The light source should be no greater than
50%.

72. 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”.
10. Finally, keep practicing and expect setbacks.
The MEEI “10
Commandments”
of EES for the novice surgeon

73. Time
3 hours
3 hours
2.3 hours
2.3 hours
2 hours
Microscope Case
Endoscope Case
David D. Pothiar
Toronto General
Hospital

74. The LEARNING curve
microscope
endoscope
David D. Pothiar
Toronto General
Hospital

75. The BENEFIT curve
microscope
endoscope
David D. Pothiar
Toronto General
Hospital

77. 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

78.  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

79. Gunner
Holmgren
(1875-1954)
father of
fenestration
surgery.
Raymond
Carhart
(1912-1975)
first described
Carhart notch.
Julius
Lempert
(1890-1968)
developed
one-stage
fenestration
surgery.
Samuel
Rosen
(in 1953)
proposed
stapes
mobilization.
John
Shea Jr.
(1924-2015 )
father of
modern stapes
surgery.
John W.
House
President -
House Ear
Institute.
We are all dwarfs seated on Giant’s shoulder.
If we can see far this is not because we are tall,
this is because we are seated on Giant’s shoulder.
Iftikhar
Salahuddin
The Aga Khan
University
Hospital.