Endoscopic mastoid sugery with tympanoplasty


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Transcanal endoscopic mastoid Surgery with tympanoplasty for cholesteatoma and its related pathology of mastoid antrum - Dr. Sheikh Shawkat Kamal

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Endoscopic mastoid sugery with tympanoplasty

  1. 1. TEMS with Tympanoplasty for the management of cholesteatoma and its related lesions of mastoid antrum by Dr. Sheikh Shawkat Kamal Transcanal endoscopic mastoid surgery with tympanoplasty for the management of cholesteatoma and its related lesions of mastoid antrum Author Dr. Sheikh Shawkat Kamal MBBS, FCPS Consultant ENT Surgeon Surgiscope Hospital Chittagong, Bangladesh Tel: 880-01711406943 E-mail- drjoyent@yahoo.com This article is free to share among the interested readers providing with out any change and should not be published in any journal. Questions or suggestions regarding the article will be highly appreciated by the author.Abstract:Objective: To describe and to evaluate a newly designed transcanal endoscopic mastoid surgical procedure for the management of cholesteatoma inmastoid antrum.Study design: Cross sectional study from January 2009 to January 2011.Setting: Private tertiary care hospitalPatients: Patients having cholesteatoma clinically with presence of soft tissue shadows in their preoperative CT scan of mastoid antrum were onlyselected. Patient with cholesteatoma in and around mastoid tip or having stenosed external auditory canal were excluded from this study.Interventions: Transcanal endoscopic mastoid surgery (TEMS) involved exclusive endoscopic exploration of mastoid antrum after removal of selectedpart of posterior meatal wall. Thereafter the TEMS was ended either by reconstructing the gap of posterior meatal wall with tympanoplasty (Closed –TEMS with tympanoplasty) or by widening of the initial passage to mastoid antrum with tympanoplasty (Open- TEMS with tympanoplasty).Main outcomes measure: Assessment of the feasibility and efficacy of transcanal endoscopic mastoid surgical approach for visualization and removal ofcholesteatoma or related pathology from mastoid antrum.Results: The study was done on 23 patients (19 adult cases and 4 child cases) age ranging from 9 years to 54 years with maximum 2 years follow-up. Alladult patients (19 cases) got their surgery under local anesthesia and perceived intra-operative pain sensation mostly scored grade 2 (74%) in numericalpain scale. Initially out of 23 cases open - TEMS with tympanoplasty was done in 9 cases and closed- TEMS with tympanoplasty was done in 14 cases. Inall cases mastoid antrum was found completely visible and endoscopically accessible for effective excision of cholesteatoma. After one year of follow upsecond look surgery was done through transcanal route only in 2 closed TEMS cases having soft tissue shadow in postoperative CT scan with bad auralsymptoms. Commonest cholesteatoma nesting site in residual cases was retrotympanum. No facial palsy was observed in any case. Mastoid cavity in canalwall down cases was found small and mostly clean. Postoperative bone conduction thresholds remained static in all cases.Conclusion: Transcanal endoscopic mastoid surgery (TEMS) has been found to be an efficient new approach for the management of cholesteatoma and itsrelated lesions extensive up to mastoid antrum.22nd April, 2011 -1-
  2. 2. TEMS with Tympanoplasty for the management of cholesteatoma and its related lesions of mastoid antrum by Dr. Sheikh Shawkat KamalIntroduction: Nasoendoscope of 0 and 30 degree of 4mm outer diameter and otoendoscope of 0 and 30 degree of 2.7 mm outer “The least the surgery disturbs the normal anatomy, the diameter were used. Karl Storz’s fiberoptic light source withbest its outcome will be” - the strategy behind the better 150 volt light and camera model Telecom 90 were used foroutcomes of all kinds of minimal invasive surgery. The sole endoscopic video system. For cutting the posterior meatal wallinstrument that has made the operative procedure less invasive electrical drill machine (Saeshin micromotor model Strongis the rigid rod-lens endoscope introduced to the medical field 90/90N) with cutting drill bur of 1.5-2 mm tip diameter sizeby renowned British physicist Harold Horace Hopkins. The were used. Some custom made instruments such as curvedcomplementary use of endoscope in otology in addition to sucker nozzles, angled ring curettes were also used along withmicroscope has already shown its superior role in detecting the 1,2,3,4,5 traditional middle ear instruments. Preoperative CT scan ofhidden cholesteatoma . Middle ear surgery purely under temporal bones and pure tone audiogram were performed in allendoscopic guidance is a growing concern among the cases.otologists. Transcanal endoscopic myringoplasty, stapedotomy Intramuscular injection of pethidine and promethazineor management of attic cholesteatoma is now being practicing had been used as premedication for all cases. While performingas new preservative approach with significant success. In this the surgery under local anesthesia, external auditory canal andperspective the exploration of mastoid antrum entirely by pinna were anesthetized through usual nerve-block techniqueendoscope could be an exiting and challenging experience for by using injection 0.5% bupivacaine and 2% lignocaine withthe surgeons. adrenaline (1: 2, 00,000). Hypotensive anesthetic procedure The transcanal endoscopic mastoid surgery (TEMS) is a was conducted for surgery under general anesthesia.new approach for the management of middle ear All the surgical procedures were done only throughcholesteatoma. Here the exploration of mastoid antrum was transcanal route under endoscopic guidance.done purely under guidance of endoscope through the external An anterior based tympano-meatal flap involving theauditory canal after removing a selected part of posterior tympanic membrane and few millimeter of posterior meatalmeatal wall. The endoscopic wide angled image increases the skin was elevated. Thereafter a wide inferior based posteriorvisibility as well as the control over hidden pathologies of meatal skin flap involving the skin over the bony meatus wasmiddle ear compartments. The use of transcanal route to elevated. If incus was found intact then its long process wasmastoid antrum with minimal dissection under endoscopic separated from head of stapes before starting the bony works.guidance makes the procedure truly less invasive. Good grip topathological part with less disturbance of the normalityincreases the chances of the better outcome of the surgery.With this hope the present study was planed.Patients and methods: The study was conducted on total 23 patients (19 adultsand 4 children) age ranging from 9 years to 54 years in aprivate tertiary care hospital named ‘Surgiscope hospital’situated in Chittagong, Bangladesh. The duration of the studywas from January 2009 to January 2011. Patients havingcholesteatoma clinically with soft tissue shadows in their Figure 1: Picture is showing the design of bony dissection onpreoperative CT scan of mastoid antrum were only selected posterior meatal wall. Inner black dots indicate the area that has towhere as patients with cholesteatoma in and around mastoid tip be dissected out during initial exploratory attico-antrostomy. Outer red dots indicate the area that has to be dissected down during open-or having stenosed external auditory canal were excluded from TEMS procedure. The posterior extension of this area depends upon complete visualization of mastoid antrum or adequate endoscopicthis study. All the cases received surgical treatment for their accessibility of entire antrum. Vertical thick blue colored areamastoid pathology by the author only. indicates the area of posterior bony wall of the tympanic cavity.22nd April, 2011 -2-
  3. 3. TEMS with Tympanoplasty for the management of cholesteatoma and its related lesions of mastoid antrum by Dr. Sheikh Shawkat Kamal A design was preplanned for bony dissection of posterior If cholesteatoma or only huge granulation tissues were foundmeatal wall (figure 1). Bony dissection was done mostly by entirely involving the mastoid antrum or gone beyond of it intocutting bur and occasionally by curettes (figure 2). The bur was surrounding air cells or if the patient had poor socioeconomicallowed to rotate at 30,000 RMP for not more then condition – then the open TEMS with tympanoplasty wasapproximately 20 seconds at a time. Intermittent saline water considered. All the granulation tissues along with mucosa ofirrigation and suction clearance was employed in between bony mastoid antrum were stripped out by ring curate (figure 4).works. Initially a narrow strip of bone was removed from Then the initial surgical passage to mastoid antrum wasscutum and posterior bony meatal wall and continued until the widened by dissecting the over hanged bone inFigure 2: Subsequent pictures are showing the bony dissection of posterior meatal wall by cutting drill bur.Figure 3: Pictures show different steps of exploratory attic-antrostomy. In picture1, ‘Ad’ indicates the addidus ad antrum, ‘I’ indicates the body ofincus and ‘C’ indicates the cholesteatoma matrix. Picture 2 shows the removal of incus. Picture 3 shows final scenario of attic-antrostomy withpresence of huge granulation tissues in mastoid antrum (An).visualization of distal end of cholesteatoma matrix or the part posterior lateral direction with cautious steps around posteriorof mastoid antrum. Removal of present incus was done. This wall of tympanic cavity (figure 5,6) . Head of malleus frominitial removal of bony strip was named exploratory attico- epitympanum was removed. Remaining part of scutum wasantostomy (figure 3). After taking a thorough assessment of the lowered down. Healthy looking mastoid air cells were alwaysextension of cholesteatoma and of its surrounding inflamed tried to be kept preserved.granulation tissues, the decision of the final destination of the In all cases the defect of tympanic membrane wassurgical procedure was then planed. repaired either by tragal cartilage with perichondrium or by If cholesteatoma was found partly involving the mastoid temporalis fascia (Figure 7). In few cases ossiculoplasty wasantrum with having a very few or no granulation tissue in done with autologous sculptured incus. The previously elevatedsurrounding mucosa then the closed- TEMS with meatal skin flap was then repositioned.tympanoplasty was decided to end the up the procedure. Pieces of gelfoam were placed over the graft and flap toRemoval of cholesteatoma along with granulation tissue was stabilize them. Thereafter the external auditory canal (EAC)then carried out keeping the healthy mucosa undisturbed. and newly formed mastoid cavity (in case of canal wall down)Reconstructing the posterior meatal wall was done with was filled with 5% povidone iodine ointment. A piece of cottoncomposite graft of tragal cartilage with perichondrium. ball was kept outside the EAC to prevent the out pouring of22nd April, 2011 -3-
  4. 4. TEMS with Tympanoplasty for the management of cholesteatoma and its related lesions of mastoid antrum by Dr. Sheikh Shawkat Kamalointment. The skin wound of graft harvesting site was closed tissue shadow in CT radiogram with bad aural symptoms werewith 3/0 chromic catgut sutures. only subjected to second look operation. Second look operations were done through transcanal route after elevating the posterior meatal composite flaps consisting of tympano- meatal skin with cartilage graft.Figure 4: Picture is showing the removal of granulation tissues byring curate from mastoid antrum. Figure 6: Picture of the exposed mastoid antrum (A). Lower down of over hanged bones (black arrow) near the posterior bony wall of tympanic cavity (thick blue line) should be done cautiously since it lodges the mastoid segment of facial nerve. ‘S’ indicates the position of lateral semicircular canal.Figure 5: Showing the direction of dissection to enlarge thepassage to mastoid antrum. Dissection along the posterior and lateraldirection (green arrow) is the ideal way to enlarge the approach tomastoid antrum. Faulty dissection in posterior direction (yellowarrow) might have the risk of injuring the semicircular canal or duraof posterior cranial fossa. All the cases done under local anesthesia were dischargedafter 6 to 8 hours of observation. Cases done under general Figure 7: Picture of the end scenario of open TEMS withanesthesia were kept for 24 hours observation. Cotton ball tympanoplasty. Meatal skin flap (MF) and tympanomeatal flap (TMF) are repositioned. Myringoplasty is done with temporalis fasciaplaced in external auditory meatus was changed with fresh dry graft (G). ‘A’ indicates the mastoid antrum.one whenever it got soaked and was advice for change as perneeded. Results: Stitches of surgical wound of graft harvesting site were Soft tissue shadows in preoperative CT scan of total 23removed on 5th postoperative day. Wet debris in EAC was cases of mastoid antrum later intra-operatively revealed ascleaned. A topical antibiotic drop was then started to apply into presence of cholesteatoma in mastoid antrum either partly orEAC several times a day for nest 15 to 20 days. Periodic aural entirely in 19 cases (83%) and only as presence of hugedressing was employed as needed. Pure tone audiogram was infected granulation tissues in entire mastoid antrum in 4 casesdone on 3rd month following operation. Postoperative CT scan (17%). Intra-operatively cholesteatoma was also found nestingof temporal bone was done only in closed TEMS cases after 1 13 cases in facial recess, 10 cases in sinus tympani, 6 cases inyear of their operation. Temporal bones having suspected soft supratubal recess and 8 cases in between ossicles.22nd April, 2011 -4-
  5. 5. TEMS with Tympanoplasty for the management of cholesteatoma and its related lesions of mastoid antrum by Dr. Sheikh Shawkat Kamal The TEMS for entire adult patients (19 out of 23 cases) Discussion:were done under local anesthesia. General anesthesia was only Incorporation of endoscope in the armamentarium ofconsidered for the children (4 out of 23 cases). The perception middle ear surgery in addition to microscope has significantlyof intra-operative pain sensation among the patients having reduced the incidence of residual cholesteatoma in primarytheir surgery under local anesthesia was measured in numerical surgery and thus has made possible to choose canal up mastoidpain rating scale and was found grade 2 in 14 cases (74%), procedures more confidently 6,7,8 . Several authors had alreadygrade 3 in 4 cases (21 %) and grade 5 in 1 case (5%). experienced the efficacy of endoscopic management of attic In every case the entire mastoid antrum could be cholesteatoma with promising results 9,10,11,12 . Although thecompletely visualized (100%) and could be attempted for total success stories on transcanal endoscopic management of atticclearance of lesions with confidence under endoscopic cholesteatoma were found piling up in publications butguidance. The average duration of operation was 3 hours literature on transcanal endoscopic exploration of mastoidranging from 2.30- 4.30 hours. antrum for cholesteatoma is very rare in the publications. Among 23 cases, closed-TEMS with tympanoplasty was Tarabichi M. did mention in his literature about his efforts todone in 14 cases (61%) and open-TEMS with tympanoplasty explore the mastoid but at the end he concluded this purewas done in 9 cases (41%) as a primary surgical procedure. In endoscopic approach unsuitable for mastoid pathology 13. Very19 cases out of 23, ears became dry and free of infection with recently Marchioni D. et el described their transcanalin 8 weeks. Rest of the 4 cases which were discharging endoscopic ‘centrifugal’ technique for management ofintermittently after initial surgery were found presence of cholesteatoma extensive to antrum and periantral cells withresidual cholesteatoma in 1 of closed- TEMS and tympanic favorable outcomes 14.membrane graft failure in 3 open TEMS cases. The closed- Transcanal endoscopic mastoid surgery involves theTEMS case having residual cholesteatoma was transformed in exploration of mastoid after removing the selected part of outerto open TEMS case. Ears having tympanic membrane graft attic wall and posterior meatal wall entirely under guidance offailure were successfully repaired by revision myringoplasty. endoscope. It preserves the cortical wall of mastoid intact. ForSuspected soft tissue shadows were found in postoperative CT being oriented with this new endoscopic dissection, fivescan of 4 out of 8 closed- TEMS cases at the end of their one cadaveric temporal bones had been dissected endoscopicallyyear follow up. Only 2 of them had bad aural symptoms like before this study. The observations from those cadavaricotorrhea, deep retraction and perforation of tympanic dissections helped to design the dissection plan on living cases.membrane. These two cases were only subjected to second look Some of those important observations were depicted here. Theoperation and were transformed into open TEMS cases after first concern was about the prediction of the exact location ofremoval of their residual diseases. The rest 2 cases were kept the part of posterior meatal wall which formed the lateral limitunder close observation. of the posterior bony wall of tympanic cavity. The posterior The cholesteatoma revealing sites in total 3 residual cases bony wall of tympanic cavity remained as almost unsightedwere sinus tympani in 3 cases (100%), facial recess in 2 cases area in between tympanic cavity and lower portion of mastoid(67%) and mastoid antrum in one case (33%). antrum before starting the dissection and prediction of its No facial nerve palsy was seen developed in this study. location was felt important to avoid injury to mastoid segmentNo injury was found in the skin of EAC. In follow up visits the of facial nerve that it contained (figure 1, 6, 8). In endoscopicmastoid cavities of open TEMS cases were found small. orientation it had been observed that the most possible site ofPostoperative bone conduction threshold remained static in all this area could be a few millimeters wide vertical areacases. Air-bone gap (AB gap) was found reduced in 14 cases. approximately 1-3 millimeters behind the posterior bonyOut of these 14 cases, average 10db gain was noticed in 5 cases annulus with an upper limit demarked by the upper level ofwhere ossiculoplasty was done. However in 3 out of 23cases oval window. The second concern was the direction ofAB gap was found increased. mastoid antrum in relation to external auditory canal. It had been observed that the angle between the long axes of these22nd April, 2011 -5-
  6. 6. TEMS with Tympanoplasty for the management of cholesteatoma and its related lesions of mastoid antrum by Dr. Sheikh Shawkat Kamaltwo structures was always below 90 degree (figure 9). So thedissection in faulty straight posterior direction has the risk ofinjuring the delicate structures present there such assemicircular canals or dura of posterior cranial fossa. The safedissection plane should be parallel to the posterior bony meatalwall running posterior and outward direction. The thirdconcern was about the mastoid cells in and around the mastoidtip. Endoscopic exploration of mastoid air cells in those areashad been found difficult and incomplete. So it had been decidedthat any mastoid pathology present below the level of the floorof bony external auditory canal depicted in preoperative CT Figure 9: Picture shows that the angle in between the axis ofscan should have been abandoned for endoscopic mastoid external auditory canal and mastoid antrum is always below 90 degree.surgery. The fourth concern was necessity of new instrumentsfor working in mastoid antrum. Endoscope offers wider-angle To overcome the difficulty of instrumentation in presenceview then the view produced by microscope. Traditional of narrow isthmus of EAC some new techniques had beenmiddle ear micro instruments usually failed to cover this wider invited. It was observed that if the tip of the endoscope wasworking area visible under endoscope. Especially it was kept a few millimeters behind the isthmus of the EAC thisobserved during instrumentation in mastoid antrum. For this would allow easy introduction and movement of the instrumentreason some personally made instruments like angled tip micro along the side of the endoscope with in the canal. This principalsuction nozzles and angled ring curates had been prepared to be of placement of endoscope along with other middle earused for working in wider visible area under endoscope (figure instrument with in the canal was strictly followed in all cases.10). In one case, canaloplasty was done absolutely under endoscope for excision of an osteoma of EAC without facing any noticeable difficulty. The current study avoided TEMS for those cases having such a narrow EAC that at least half of its depth could not allow passing 4 mm diameter endoscope. The use of cutting drill bur for bony dissection was found superior over curette in terms of efficacy and accuracy. To avoid the possible lacerated injury to the EAC by rotating drill bur a protecting metallic sheath for the bur’s shaft was developed (figure 11). The friction temperature producing between bur and sheath were found negligible while rotating the bur for not more then 20 seconds at a time.Figure 8: In this axial CT scan view the position of posterior wall oftympanic cavity is indicated by the area in between two red arrows.Anterior air containing space is the epitympanum and posterior aircontaining space is the lower portion of mastoid antrum. Red lineindicates the area of posterior meatal wall that forms the lateral limitof posterior bony wall that has to be located before starting the bonydissection. Naso-endoscopes of 4 mm outer diameter were mostlyused except in child and in narrow EAC cases where 2.7 mmdiameter endoscopes were used. Figure 10: Picture of the custom made angled ring curates and curved tip micro-sucker nozzles.22nd April, 2011 -6-
  7. 7. TEMS with Tympanoplasty for the management of cholesteatoma and its related lesions of mastoid antrum by Dr. Sheikh Shawkat KamalFigure 11: Pictures show the custom made metallic sheath for drill bur to avoid injury to soft tissues of outer part of external auditory canal. Single hand maneuver is the well recognized technical uneasiness and this could reduce the operating time durationdifficulty of endoscopic ear surgery since the surgeon has to too.hold the endoscope in one hand and has to do all Endoscopic mastoid surgery was found well tolerated byinstrumentation with the other hand. It might be a prime reason patient while performing under local anesthesia. It had beenfor its slow growing popularity among otologist habituated observed that patient did complain of some pain during the Figure 12: Preoperative picture (1) shows the attic cholesteatoma (C). Postoperative picture (2) after closed TEMS with tympanoplasty shows the area of reconstructed posterior meatal wall (RPW).with two hands maneuver. To overcome this problem it has manipulation of normal mastoid mucosa that could be subsidedbeen suggested to develop special instrument capable of doing after applying 4% Lignocaine soaked cotton piece locally. Thisdual functions such as suction and manipulation of soft tissue at finding some time helped to differentiate the normal mucosaa time. from granulation tissue in difficult situation. Surgery under The image fields produced by the endoscopic camera and local anesthesia could offer some other beneficial things tooby the microscope are different since endoscopic camera such as intra-operative clinically monitoring of facial nerve,produces wider field two-dimensional images where as ensuring his short stay in hospital finally reducing the total costmicroscope produces narrow field three-dimensional images. of the surgery.For this reason, surgeon might face uneasiness while trying to This study observed that the bony dissection according toadapt him working simultaneously in these two different kinds preplanned design could create adequate passage to mastoidof image fields. Performing the whole procedures absolutely antrum. As a result the entire compartment of mastoid antrumunder endoscopic guidance could avoid this kind of could be approachable endoscopically. Custom made angled22nd April, 2011 -7-
  8. 8. TEMS with Tympanoplasty for the management of cholesteatoma and its related lesions of mastoid antrum by Dr. Sheikh Shawkat Kamalring curates were found efficient in removing of cholesteatoma limitations. The table below summarizes the advantages andand granulation tissues from mastoid antrum. The initial small disadvantages of TEMS that has been observed through thisattico-antrostomy could easily be reconstructed with cartilage study.graft (figure 12). The preservative character of this new Table-1: Advantages and disadvantages of transcanal endoscopic mastoid surgery (TEMS):-endoscopic approach also encouraged early healing of surgical Advantagewounds. The mastoid cavity produced after endoscopic open 1. Minimal invasive procedure.TEMS procedure was found relatively small, clean and having 2. Well tolerated under local anesthesia.no or least wax (figure 13). This trouble free nature of mastoid 3. Ensuring short hospital stay.cavity was probably due to not involving the skin of 4. Offering early recovery.cartilaginous part of EAC. 5. Ensuring good outcome. 6. Cost effective. Disadvantage 1. Not applicable for extensive stenosed EAC. 2. Not suitable for exploration of mastoid tip cells. 3. Demanding more time to develop adequate surgical skills. 4. Lack of necessary instruments. Conclusion: Cholesteatoma of mastoid antrum and its surrounding mastoid cells can be effectively managed by transcanal endoscopic mastoid surgery with appreciable surgical outcomes although due to some technical difficulties this endoscopicFigure 13: Post operative picture of open TEMS with approach cannot be advocated for cholesteatoma extended totympanoplasty shows small and clean mastoid cavity (MC) and welltaken tragal cartilage graft (G). mastoid tip. This truly minimal invasive approach has the potentiality to reduce the surgical cost specially while This study might not reflect the actual numbers of performing under local anesthesia.patients having residual cholesteatoma in canal wall up casessince patients having bad aural symptoms with suspectedshadows in follow up CT scan were only subjected to second References: 1. Good GM, Isaacson G.Otoendoscopy for improved pediatric cholesteatoma removal. Ann Otol Rhinol Laryngol. 1999 Sep;108(9):893-6.look operation. 2. Ghaffar S, Ikram M, Zia S, Raza A.Incorporating the endoscope into middle ear surgery. Ear Nose Throat J. 2006 Sep;85(9):593-6. The present study has recognized that longer time is 3. Presutti L, Marchioni D, Mattioli F, Villari D, Alicandri-Ciufelli M.Endoscopic management of acquired cholesteatoma: our experience. J Otolaryngol Head Neck Surg. 2008 Aug; 37(4):481-7.required to develop adequate surgical skill for endoscopic ear 4. Ayache S, Tramier B, Strunski V.Otoendoscopy in cholesteatoma surgery of the middle ear: what benefitssurgery then time required for obtaining skill for surgery under can be expected? Otol Neurotol. 2008 Dec; 29(8):1085-90. 5. Liu Y, Sun JJ, Lin YS, Zhao DH, Zhao J, Lei F.Otoendoscopic treatment of hidden lesions in otomastoiditis.microscope. However surgeons already involved with other Chin Med J (Engl). 2010 Feb 5;123(3):291-5. 6. Yung MW.The use of middle ear endoscopy: has residual cholesteatoma been eliminated? J Laryngol Otol.endoscopic procedures like endoscopic sinus surgery could 2001 Dec;115(12):958-61.easily pick up the necessary skills for endoscopic mastoid 7. Badr-el-Dine M.Value of ear endoscopy in cholesteatoma surgery. Otol Neurotol. 2002 Sep;23(5):631-5. 8. El-Meselaty K, Badr-El-Dine M, Mandour M, Mourad M, Darweesh R Endoscope affects decision making insurgery. As soon as the surgeon became more accustomed with cholesteatoma surgery. Otolaryngol Head Neck Surg. 2003 Nov;129(5):490-6.the procedure the total time required for whole surgical 9. Aoki K. Advantages of endoscopically assisted surgery for attic cholesteatoma. Diagn Ther Endosc. 2001;7(3-4):99-107.procedure became shorter. 10. Tarabichi M. Endoscopic management of limited attic cholesteatoma. Laryngoscope. 2004 Jul;114(7):1157- 62 Despite having some limitations transcanal endoscopic 11. Marchioni D, Mattioli F, Alicandri-Ciufelli M, Presutti L.Endoscopic approach to tensor fold in patients with attic cholesteatoma. Acta Otolaryngol. 2008 Oct 25:1-9.mastoid surgery was proved having the ability of total excision 12.Migirov L, Shapira Y, Horowitz Z, Wolf M. Exclusive Endoscopic Ear Surgery for Acquired Cholesteatoma: Priliminary Results. Oto Neurotol. 2011 Jan 3.of cholesteatoma of mastoid antrum. It was expected that when 13. Tarabichi M.Transcanal endoscopic management of cholesteatoma. Otol Neurotol. 2010 Jun;31(4):580-8.this novel surgical procedure would be practice in broader scale 14. Marchioni D, Villari D, Alicandri-Ciufelli M, Piccinini A, Presutti L Endoscopic open technique in patients with middle ear cholesteatoma. Eur Arch Otorhinolaryngol. 2011 Feb 19new techniques would definitely come out to overcome its22nd April, 2011 -8-