Endoscopic transcanal stapedotomy was performed on 52 patients with otosclerosis at a tertiary hospital in Eastern India. The mean preoperative air-bone gap was 34.84 dB, which improved significantly to a mean of 9.81 dB postoperatively. The endoscope provided excellent visualization of the middle ear anatomy without needing to remove bone or touch sensitive structures. There were no reported complications. The study concluded that endoscopic stapedotomy is a safe procedure that allows for good visualization and outcomes comparable to microscopic stapedotomy.

1. ENDOSCOPIC TRANSCANAL
STAPEDOTOMY:
EXPERIENCES AT A TERTIARY CARE
TEACHING HOSPITAL OF EASTERN INDIA

2. AUTHORS
Santosh Kumar Swain, Alok Das, Bulu Nahak, Jatindra Nath Mohanty
SOURCE
Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha
“O” Anusandhan University, Bhubaneswar, Odisha, India

3. INTRODUCTION
Otosclerosis, more aptly called otospongiosis, is a primary
disease of the bony labyrinth.
In this, one or more foci of irregularly laid spongy bone
replace part of normally dense enchondral layer of bony otic
capsule
Stapedectomy/stapedotomy is the treatment of choice
Stapes surgery is done at a very fragile anatomical area where
there is a risk of injury to the chorda tympani nerve, incus,
facial nerve, and tympanic membrane.

4. There is a chance of sensorineural hearing loss due to
incorrect surgical procedure.
Surgeon often unable to observe the anterior crus of the
stapes via transcanal approach under a microscope which
may force the surgeon to do blindly fractures of such part
The possible complications, microscopic visual field, and
complex anatomy of the middle ear are causes of concern in
stapes surgery

5. The endoscope provides a wide-angle and high-resolution
image which allows improved visualization of the middle ear
cleft in comparison to the microscope.
The endoscope helps otolaryngologists to bring angled optics
and a high-contrast light to the middle ear, avoiding a
postaural approach and extended bony dissection
After introduction of 3 charge-coupled device camera,
high-definition video monitors and recently small diameter
fiberoptic and modern endoscopes provide high-resolution
images of the middle ear cleft structures

6. In this study they assess the use of rigid endoscope by transcanal
route for stapes surgery and find out the outcome and possible pros
and cons of this technique

7. AIM AND OBJECTIVE
To analyze the experiences of endoscopic transcanal stapedotomy
performed at a tertiary care teaching hospital of Eastern India

8. METHODOLOGY
This study involved a prospective analysis of patients with conductive
hearing loss those who were diagnosed as otosclerosis and who
underwent stapedotomy by endoscopic transcanal approach.
Sample size : 52 (28 female and 24 male between 29 to 48 years)
Duration: 2 years(March 2017–April 2019)
Place : tertiary care teaching hospital

9. INCLUSION CRITERIA
Patients who were diagnosed with otosclerosis based on clinical
history, otoscopic examinations, and audiological investigations
such as pure tone audiometry and tympanometry.
EXCLUSION CRITERIA
patients with narrow external auditory canal were avoided by
transcanal endoscopic surgery and excluded from this study

10. Pure tone audiometry was done in all cases preoperatively
and postoperatively with documentations of bone conduction
thresholds and air– bone gap (ABG) at the three speech
frequencies of 500 Hz, 1000 Hz, and 2000 Hz
Postoperative pure tone audiometry was performed at 1, 3, 6,
and 12 months following surgery
ABG closure within 10 dB was called as success, whereas
closure to within 20 dB called as improvement.

11. SURGICAL STEPS
surgeries were performed by senior authors under
local anesthesia
The patients were placed in same position as in
conventional ear surgeries
video monitor was placed in front of the surgeon
anterior and posterior wall were sutured in such
manner,to widen the meatus , and to make
accessibility to the middle ear easier

12. Trimming of the ear canal hair was done before starting
endoscopic surgery to reduce smudging of endoscope
3 mm diameter and 14 cm long rigid endoscope was used and
held in left hand
external auditory canal was injected with 1% lidocaine along
with 1:100,000 epinephrine
Posterior tympanomeatal flap was elevated transcanally with
the help of 0° endoscope and transposed anteriorly
All the procedures were performed with a 0° endoscope,
whereas a 30° endoscope was needed for better visualization
of oval window niche, anterior crura of the stapes, tympanic
segment of the facial nerve, and pyramidal eminence

13. The endoscopic picture of the middle ear was
excellent without drilling/curettage of the
scutum
Stapes fixation was assessed by gentle testing
of ossicular chain mobility.
Stapedius tendon was cut by curved microscissors
and stapes was dislocated from the incus at
incudostapedial joint

14. The anterior and posterior crus of the stapes were fractured carefully
and suprastructure was taken out.
The distance between medial surface of the long process of incus and
footplate of stapes was measured for required size of prosthesis
A hole was made in footplate with a skeeter
microdrill by 0.5 mm diameter diamond burr
Teflon piston prosthesis(0.4/0.5 mm diameter/
4.5 mm length) was placed in fenestra and fitted
along the long process of the incus

15. The ossicular chain mobility was ensured by palpating malleus
The footplate area was sealed with small pieces of dry gel-foam
placed by crocodile forceps
The tympanomeatal flap was repositioned and ear canal was filled
with gel-foam soaked with topical ear drops containing
antibiotics.

16. RESULTS
Stapedotomy was performed on the right ear in 34 patients and left
ear in 18 patients.
The mean age was 32.40 years.
The mean operation time was 38.43 min
The mean preoperative ABG was 34.84 dB, whereas the mean
postoperative ABG was 9.81 dB.
A 4.5 mm size diameter prosthesis was used in 48 cases and 4.75
size used in 4 cases

19. DISCUSSION
There are several difficulties encountered during stapes surgery and
these include exposure of the oval window niche, short chorda
tympani nerve, dehiscent facial canal with bulging toward oval
window area, and narrowing of the oval window niche by otosclerotic
focus.
Cutting of the stapedius tendon, incudostapedial joint dislocation,
and fracture of the crura of the stapes are easier with endoscope than
microscope
Excellent exposure of the stapes footplate without removing the bony
overhanging or touching the chorda tympani is usually possible with
endoscope

20. Under microscope, there is a need for partial curettage of the
medial bone segment on the posterior wall of the bony external
acoustic meatus which can damage chorda tympani
But this complication was avoided by using endoscope due to
direct visaulisation of the nerve
The main advantage of the endoscopic stapes surgery is
excellent vision

21. DEMERITS.
working with only one hand
the learning curve
Endoscope light can cause high temperature in middle and
inner ear which can easily pass to the cochlea by perilymph
and leads to sensorineural hearing loss
loss of depth perception which provide reluctance to some
otologists for adopting this technique.

22. CONCLUSION
Endoscopic stapedotomy has several benefits such as good
visualization, easy accessibility to the foot plate of stapes, oval
window niche, and facial nerve
In this study, all the stapedotomy surgeries were performed with
help of endoscope where all relevant anatomical structures were
visualized without any difficulty and minimal to no complications.

23. SIMILAR STUDIES
1)Bianconi L, Gazzini L, Laura E, De Rossi S, Conti A, Marchioni D.
Conducted a study :
Endoscopic stapedotomy: safety and audiological results in 150
patients between November 2014 and September 2018
The aim of the study was to describe the surgical steps in endoscopic
stapes surgery and to evaluate the audiologic and surgical outcomes.
There were no cases of major intraoperative complications.
They concluded that Endoscopic stapes surgery is a safe procedure
with a low risk of peri- or postoperative complications and is a
possible alternative to the traditional microscopic surgical procedure
in the treatment of otosclerosis.

24. 2) Yang Q, Zhao Y, Hou ZH, Chen SJ, Yu YJ, Wang ZY,
conducted a study :
Evaluation of the safety and effect of the endoscopic stapes
surgery: a multi-
center study
Sample size: 137
Place: Fudan University from October 2015 to October 2017
Objective:To analyze the safety of artificial stapes surgery
under endoscope and compare its effectiveness with
microscopic surgery.
They concluded that Endoscopic artificial stapes surgery is
safe, and the audiological results obtained after surgery are
similar to microscopic surgery.

25. 3) Rhona Sproat, Constantina Yiannakis, and Arunachalam Iyer
conducted a study :
Endoscopic Stapes Surgery: A Comparison With Microscopic
Surgery
Sample size: 81
Place :Department of Otolaryngology, Monklands Hospital,
Airdrie, Scotland, UK
Objective: : To investigate postoperative audiological
outcomes and complication rates for fully endoscopic and
microscopic stapes surgery carried out by a single surgeon in
one center.
Conclusion: : Air-bone gap closure and patient complications
did not vary significantly between endoscopic and
nonendoscopic groups

26. THANK YOU