This research has been conducted in accordance with ethical principles, including the World Medical Association Declaration of Helsinki (2002) and the institutional human research ethics committee&#39;s guidelines (Comitato Etico dell&#39;Area Vasta Emilia Nord). The local ethical committee does not perform a formal ethical assessment for case reports.
1. Preparation of the patient
<ol>
	<li>After oro-tracheal intubation and general anesthesia, position the patient supine with the head tilted toward the opposite side of the affected ear, and the chin slightly hyperextended. Pull down the same-side shoulder as much as possible, to create a wide angle between the head and the shoulder allowing easier access to the ear.</li>
	<li>Using a 5 mL syringe with G25 0.50 x 42 mm needle, inject around 1-2 mL of local anesthetic diluted with a vasoconstrictor agent (e.g., 2% mepivacaine and epinephrine 1:200,000) in the four main points of the EAC skin (posterior wall, superior and inferior angle, retrotragal region).</li>
</ol>
2. Preparation of the sterile surgical site
<ol>
	<li>Use an iodopovidone-soaked gauze to sterilize the whole external ear, to create an aseptic field.</li>
	<li>Ensure that iodopovidone enters the EAC and reaches the tympanic membrane.</li>
</ol>
3. Preparation of the operating room and surgical instruments
<ol>
	<li>Place the endoscopic tower or a high-resolution monitor when available, in front of the surgeon, at his/her eye level, at adequate distance to keep a comfortable position of the head and neck during the surgery.</li>
	<li>Connect a 3 mm diameter, 14&#160;cm length, 0&#176; rigid endoscope to the high-definition digital camera and xenon light source. Keep the light source at 50% intensity to prevent heat damage to the inner ear.</li>
	<li>Perform white balance by pushing the central button on the camera head and adjust the focus by turning its gray wheel before starting the surgery.</li>
	<li>Prepare a quality de-misting (anti-fog) solution to clean the endoscope tip. Dip a cotton pad in this solution and place it close to the external ear. 
	&#8203;NOTE: The standard otological instruments set for stapes surgery is prepared on the instrument table, as shown in Figure 1.</li>
</ol>
4. Surgical steps
NOTE: Hold the endoscope with the non-dominant hand, leaning it against the posterior wall of the EAC, and the surgical instruments with the dominant one. Surgical instruments, if any, should be introduced in the EAC before the endoscope and moved toward the middle ear under endoscopic vision, to prevent accidental damage to the external and middle ear structures. It is advisable to keep any working instrument above the endoscope and stabilize its movement keeping the fourth and fifth fingers on the patient&#39;s head (Figure 2).
<ol>
	<li>Under direct endoscopic vision, perform anesthesia by slowly injecting another 1-2 mL of local anesthetic diluted with a vasoconstrictor agent (e.g., 2% mepivacaine and epinephrine 1:200,000) in the subperiosteal plane of the posterior wall of the EAC.</li>
	<li>Use scissors to cut hair of the most lateral part of the EAC, to avoid contaminating the tip of the endoscope at each in and out passage of the canal.</li>
	<li>Use the monopolar (molecular resonance hook) with 15 W power to delineate the tympano-meatal flap (TMF) incision from 5 to 12 o&#39;clock, about 8 to 10 mm far from the annulus (modified Rosen incision).</li>
	<li>Use the round knife to perform the actual skin incision following the previously marked line and raise the TMF with the help of epinephrine-soaked cottonoids.</li>
	<li>Once the annulus is identified as a white thickening of the tympanic membrane, continue the dissection under it. Detach the pars flaccida from the short process of the malleus with Hartmann forceps, keeping the pars tensa adherent to the umbus. 
	NOTE: During this step, identify the chorda tympani as a whitish string emerging from the chordal eminence, and leave it untouched.</li>
	<li>Remove the posterior wall of the EAC and the scutum through the curette to achieve a good exposure of the oval window region. In some cases, even if the oval window region is fully exposed, some curettage is necessary to create a favorable working area on the stapes. Displace the chorda tympani medially with a hook to further expose the footplate. 
	NOTE: Take some time to inspect the middle ear anatomy to check the important anatomical landmarks, such as the facial nerve, which could be dehiscent and/or prolapsed onto the footplate, as in the present case.</li>
	<li>Check the ossicular chain by gently pushing the stapes and the malleus with a hook, and confirm stapes fixation.</li>
	<li>Use the microdrill with a 0.6 mm diamond burr to perform posterior crurotomy. Then, create a hole in the mid or posterior portion of the footplate.</li>
	<li>Cut the stapedial tendon with Bellucci scissors. Then, disarticulate the incus from the stapes with the help of a hook and remove the stapes superstructure. 
	NOTE: Avoid using suction on the hole to prevent perilymphatic fluid removal and minimize post-operative vertigo or inner ear damage.</li>
	<li>Use the Fisch hook to regularize the footplate hole and check its adequate calibration, as well as to remove possible small bone fragments from the vestibule.</li>
	<li>Insert the stapes prosthesis (0.6 mm x 4.75 mm - total length 5.75 mm platinum/polytetrafluoroethylene prosthesis) into the EAC using the suction tube.</li>
	<li>Gently position it into the footplate hole with the hook. Crimp the prosthesis hook after anchoring it to the long process of the incus.</li>
	<li>Check the proper movement of the prosthesis, by gently pushing on the handle of the malleus.</li>
	<li>Replace the TMF and pack the EAC with resorbable hemostatic pledgets.</li>
</ol>
5. Ear dressing
<ol>
	<li>Cover the auricle with an adhesive plaster. No compression is needed.</li>
</ol>
6. Post operative care
<ol>
	<li>Allow the patient to drink, eat, and stand up at least 8 h post-operatively, if no nausea or vomiting occurred.</li>
	<li>The following day assess the facial nerve function, using the House-Brackman scale14 and the presence of spontaneous nystagmus with Frenzel googgles. Perform bone conduction pure tone audiometry to exclude sensorineural HL15. 
	NOTE: A two week-follow up visit is planned to remove residual pledgets of hemostatic material and check the healing process. Complete audiometric evaluation and otoendoscopy are usually performed between 1 to 2 months post-operatively.</li>
</ol>

<ol>
	<li>Manna, S., Kaul, V. F., Gray, M. L., Wanna, G. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+versus+microscopic+middle+ear+surgery:+A+meta-analysis+of+outcomes+following+tympanoplasty+and+stapes+surgery.">Endoscopic versus microscopic middle ear surgery: A meta-analysis of outcomes following tympanoplasty and stapes surgery.</a> Otology &amp; Neurotology. 40 (8), 983-993 (2019).</li><li>Das, A., Mitra, S., Ghosh, D., Sengupta, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+stapedotomy:+Overcoming+limitations+of+operating+microscope.">Endoscopic stapedotomy: Overcoming limitations of operating microscope.</a> Ear, Nose &amp; Throat Journal. 100 (2), 103-109 (2021).</li><li>Marchioni, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Complications+in+endoscopic+ear+surgery.">Complications in endoscopic ear surgery.</a> Otology &amp; Neurotology. 39 (8), 1012-1017 (2018).</li><li>Lucidi, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Disease-specific+quality+of+life+and+psychological+distress+after+endoscopic+tympanoplasty.">Disease-specific quality of life and psychological distress after endoscopic tympanoplasty.</a> European Archives of Oto-Rhino-Laryngology. 279 (1), 191-198 (2021).</li><li>Lucidi, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Does+microscopic+experience+influence+learning+curve+in+endoscopic+ear+surgery?+A+multicentric+study.">Does microscopic experience influence learning curve in endoscopic ear surgery? A multicentric study.</a> Auris, Nasus, Larynx. 48 (1), 50-56 (2020).</li><li>Kozin, E. D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Systematic+review+of+outcomes+following+observational+and+operative+endoscopic+middle+ear+surgery.">Systematic review of outcomes following observational and operative endoscopic middle ear surgery.</a> The Laryngoscope. 125 (5), 1205-1214 (2015).</li><li>Lucidi, D., Molinari, G., Reale, M., Alicandri-Ciufelli, M., Presutti, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Functional+results+and+learning+curve+of+endoscopic+stapes+surgery:+A+10-year+experience.">Functional results and learning curve of endoscopic stapes surgery: A 10-year experience.</a> The Laryngoscope. 131 (4), 885-891 (2020).</li><li>Fang, L., Xu, J., Wang, W., Huang, Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Would+endoscopic+surgery+be+the+gold+standard+for+stapes+surgery+in+the+future?+A+systematic+review+and+meta-analysis.">Would endoscopic surgery be the gold standard for stapes surgery in the future? A systematic review and meta-analysis.</a> European Archives of Oto-Rhino-Laryngology. 278 (4), 925-932 (2021).</li><li>Fernandez, I. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+role+of+endoscopic+stapes+surgery+in+difficult+oval+window+niche+anatomy.">The role of endoscopic stapes surgery in difficult oval window niche anatomy.</a> European Archives of Oto-Rhino-Laryngology. 276 (7), 1897-1905 (2019).</li><li>Fernandez, I. J., Villari, D., Botti, C., Presutti, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+revision+stapes+surgery:+surgical+findings+and+outcomes.">Endoscopic revision stapes surgery: surgical findings and outcomes.</a> European Archives of Oto-Rhino-Laryngology. 276 (3), 703-710 (2019).</li><li>Molinari, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Taste+impairment+after+endoscopic+stapes+surgery:+do+anatomic+variability+of+chorda+tympani+and+surgical+technique+matter.">Taste impairment after endoscopic stapes surgery: do anatomic variability of chorda tympani and surgical technique matter.</a> European Archives of Oto-Rhino-Laryngology. , (2021).</li><li>Alicandri-Ciufelli, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Rating+surgical+field+quality+in+endoscopic+ear+surgery:+proposal+and+validation+of+the+Modena+Bleeding+Score.">Rating surgical field quality in endoscopic ear surgery: proposal and validation of the Modena Bleeding Score.</a> European Archives of Oto-Rhino-Laryngology. 276 (2), 383-388 (2019).</li><li>Anschuetz, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Management+of+bleeding+in+exclusive+endoscopic+ear+surgery:+Pilot+clinical+experience.">Management of bleeding in exclusive endoscopic ear surgery: Pilot clinical experience.</a> Otolaryngology - Head and Neck Surgery. 157 (4), 700-706 (2017).</li><li>House, J. W., Brackmann, D. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Facial+nerve+grading+system.">Facial nerve grading system.</a> Otolaryngology - Head and Neck Surgery. 93 (2), 146-147 (1985).</li><li>Marchioni, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Complications+in+endoscopic+ear+surgery.">Complications in endoscopic ear surgery.</a> Otology &amp; Neurotology. 39 (8), 1012-1017 (2018).</li><li>Campbell, K. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+basic+audiologic+assessment.">The basic audiologic assessment.</a> Essential Audiology for Physicians. , (1998).</li><li>Alicandri-Ciufelli, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Epinephrine+use+in+endoscopic+ear+surgery:+Quantitative+safety+assessment.">Epinephrine use in endoscopic ear surgery: Quantitative safety assessment.</a> ORL. 82 (1), 1-7 (2020).</li><li>Anschuetz, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Discovering+middle+ear+anatomy+by+transcanal+endoscopic+ear+surgery:+A+dissection+manual.">Discovering middle ear anatomy by transcanal endoscopic ear surgery: A dissection manual.</a> Journal of Visualized Experiments: JoVE. (131), e56390 (2018).</li><li>Altamami, N. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Is+one+of+these+two+techniques:+CO2+laser+versus+microdrill+assisted+stapedotomy+results+in+better+post-operative+hearing+outcome.">Is one of these two techniques: CO2 laser versus microdrill assisted stapedotomy results in better post-operative hearing outcome.</a> European Archives of Oto-Rhino-Laryngology. 276 (7), 1907-1913 (2019).</li><li>Alicandri-Ciufelli, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Acquisition+of+surgical+skills+for+endoscopic+ear+and+lateral+skull+base+surgery:+A+staged+training+programme.">Acquisition of surgical skills for endoscopic ear and lateral skull base surgery: A staged training programme.</a> Acta Otorhinolaryngologica Italica. 38 (2), 151-159 (2018).</li><li>Anschuetz, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=An+ovine+model+for+exclusive+endoscopic+ear+surgery.">An ovine model for exclusive endoscopic ear surgery.</a> JAMA Otolaryngology - Head &amp; Neck Surgery. 143 (3), 247-252 (2017).</li></ol>

All the authors declare no conflicts of interest.

A protocol for totally EStS is herein proposed, to guide any otologic surgeon in performing stapes surgery endoscopically.
The first surgical step (elevation of the TMF) could be the bloodiest phase of the whole procedure, and it represents a challenge for the surgeon in relation to one-hand bleeding control13. Moreover, in otosclerosis cases, the tympanic membrane is intact; so maximal care should be paid not to damage it. As reported in our protocol, some technical hints could be followed to reduce bleeding and guarantee a smooth elevation of the flap: 1) use the monopolar to delineate the incision for the TMF; 2) use cotonoid pledgets soaked in epinephrine to help raising the TMF, both to protect the flap and at the same time absorb excess blood18; 3) use the suction tube on the cotonoid pledgets to remove blood and proceed with dissection; 4) use the monopolar to cauterize any bleeding point identified in the EAC skin. Since the monopolar could result in some retraction of TMF and no graft is used to reinforce the flap in stapes surgery, we suggest making a modified Rosen incision, keeping 8-10 mm far from the annulus.
Another relevant step is the curetting of the bony structures possibly covering the oval window region (the posterior wall of the EAC, the posterior spine, the chordal eminence, and the posterior canaliculus opening) to both achieve a good visualization of the footplate and the contiguous structures (such as the facial nerve), and to create adequate working space on the stapes. For the same reasons, the chorda tympani has usually to be displaced, most commonly on the medial side (i.e. toward the middle ear cavity). No correlation of post-operative dysgeusia with the number of curetted structures or the pattern of chorda tympani manipulation has been found11, suggesting that the surgeon should remove enough bone to gain a proper area of maneuvering for the most delicate parts of the procedure, without worrying for the chorda tympani dysfunction.
The main advantage in the use of endoscope in ear surgery is the superior visualization of the mesotympanic and retrotympanic areas19. The complete visualization of the oval window region and the modifiable angle of the view achievable by simply moving the 0&#176; endoscope is particularly useful in unfavorable anatomical conditions that could increase the technical difficulty and the risk of complications, such as facial nerve palsy when the facial nerve is dehiscent9.
The presented protocol could present some variations in the sequence of the steps. This case report shows a partial reversal surgical step technique, where the hole in the footplate is performed before disarticulation of the stapes from the incus and removal of the stapes superstructure. In the authors' experience, this sequence guarantees more stability to the footplate during the creation of the hole, reducing the risks of accidental mobilization of the footplate, and in case of footplate fracture or floating footplate, aiding the surgeon in removing the footplate (stapedectomy). For the same reason, the sectioning of the tendon is preferably performed after posterior crurotomy and footplate hole. However, other techniques, originally proposed in microscopic stapes surgery, could be followed in the endoscopic setting7, such as Fisch's stapedotomy (disarticulation of the incudo-stapedial joint, stapedial tendon sectioning, posterior crurotomy, removal of stapes superstructure and making a hole in the footplate) or Fisch's reversal steps stapedotomy (after posterior crurotomy, hole in the footplate is performed and the prosthesis is placed and fixed to the incus before removing the stapes superstructure).
Regarding the stapedotomy technique, the stapedial tendon sectioning, the posterior crurotomy and the footplate hole could be performed with CO2 laser, if available. According to the literature, hearing results and complications are similar between CO2 laser and microdrill groups, despite these techniques not having been directly compared in the endoscopic setting yet20.
The positioning of the prosthesis is another difficult step of EStS: the suction tube allows to insert it into the tympanic cavity, and then the actual placement in the footplate hole should be performed with a hook. The direct and close visualization of the endoscope helps the surgeon to follow the prosthesis from the EAC to the footplate with no need of specific instruments to properly position it (i.e., self-retaining forceps). Excessive strength during crimping should be avoided to prevent incus long process necrosis and prosthesis dislocation.
Finally, during the repositioning of the TMF, particular attention should be paid to roll it out so that the cutaneous layer of the tympanic membrane is toward the ear canal, and the bony surface is completely covered. This prevents the formation of iatrogenic cholesteatoma.
In conclusion, this protocol could guide any otologic surgeon in safely performing EStS. Being a one-handed technique, management of bleeding, positioning and crimping of the prosthesis may be challenging for novice endoscopic surgeons, so the authors suggest some training in endoscopic ear surgery (either in vivo or ex vivo) before performing endoscopic stapedotomy. Indeed, according to a previously published five-staged endoscopic ear surgery training program, stapes surgery is considered "Level III", after basic procedures as myringotomy and myringoplasty21. Moreover, the ovine model has been validated as an ex vivo animal model for endoscopic training, including stapes surgery22.

The use of the endoscope in ear surgery has gradually increased since its first application in the 1990s, to treat a variety of middle ear pathologies, including otosclerosis1. As compared to the microscope, the endoscope guarantees a wide field of exposure, high magnification and resolution images, reduced bone removal and a significantly improved quality of life after surgery2,3,4.
The use of one hand has been mentioned as a limitation of the endoscopic technique, especially in functional procedures such as the stapes surgery5,6. However, a growing number of papers have shown that endoscopic stapes surgery (EStS) is feasible, safe, and has favorable outcomes, similar to the traditional stapedotomy7,8. Moreover, the endoscope has unraveled its full potential especially in patients with unfavorable anatomy or in revision cases, representing a valuable tool to support the surgeon in these demanding settings9,10. Limited manipulation of the chorda tympani and low rate of post-operative dysgeusia are further benefits of this technique11.
EStS could be challenging for surgeons who do not have much experience in the use of the endoscope. The problem of sharing the surgical field between the endoscope and the operating instruments could be easily overcome if proper instruments handling is understood. One-handed bleeding control in the narrow space of the external auditory canal (EAC) and the tympanic cavity could be frustrating for a novice surgeon12,13. Moreover, it is important to properly position the patient and set up the operating room in order to guarantee a comfortable setting for the surgeon across the entire operation.
The aim of this article is to show the surgical procedure of a transcanal exclusive endoscopic stapedotomy, from operating room set up and patient positioning to post-operative care. A step-by-step description of the procedure is reported, to allow any ear surgeon to understand and possibly reproduce such intervention.
We report the case of a 56-year-old female who underwent right transcanal EStS for bilateral otosclerosis. The patient reported slowly progressing and bilateral hearing loss (HL), without vertigo or tinnitus. While the right otoscopy was normal, the audiometric test demonstrated a right moderate mixed HL, with a mean preoperative bone conduction-pure tone average (BC-PTA) of 24&#160;dB, a mean preoperative air-conduction pure tone average (AC-PTA) of 71 dB, and a mean preoperative air-bone gap (ABG) of 47&#160;dB. The tympanogram was bilateral type A and stapedial reflexes were absent. No CT scan was deemed necessary as preoperative assessment.

<table><tbody><tr><td>&lt;strong&gt;Antifog solution&lt;/strong&gt;</td><td>GOLFF</td><td></td><td></td></tr><tr><td>&lt;strong&gt;Aspirator system&lt;/strong&gt; (40L/min power)</td><td>EXTRUDAN SURGERY APS</td><td></td><td>4m long, dimeter ch25</td></tr><tr><td>&lt;strong&gt;Cold light source with cable&lt;/strong&gt;</td><td>STORZ</td><td></td><td></td></tr><tr><td>&lt;strong&gt;Consumables:&lt;br/&gt; - Iodopovidone solution&lt;br/&gt; - Epinephrine&lt;br/&gt; - Sterile water to rinse&lt;br/&gt; - Spongostan (adsorbable hemostatic sponge)&lt;/strong&gt;</td><td>ETHICON INC.</td><td></td><td></td></tr><tr><td>&lt;strong&gt;Cotton pads&lt;/strong&gt;</td><td>FARMAC ZABBAN</td><td></td><td>10x10cm</td></tr><tr><td>&lt;strong&gt;Cottonoid pledgets&lt;/strong&gt;</td><td>CODMAN</td><td></td><td>10 surgical patties</td></tr><tr><td>&lt;strong&gt;Endoscope&lt;/strong&gt;</td><td>STORZ</td><td></td><td>3mm diameter, 15cm length, 0&amp;deg;</td></tr><tr><td>&lt;strong&gt;Local anesthetic with vasoconstrictor in sterile and non-sterile syringe&lt;/strong&gt;</td><td>GALENICA SENESE</td><td></td><td>10 vials x 5ml</td></tr><tr><td>&lt;strong&gt;Otologic set instruments&lt;/strong&gt;</td><td>STORZ</td><td></td><td>round knife, hook, curette, Bellucci scissors and Hartmann forceps, suction tubes</td></tr><tr><td>&lt;strong&gt;Skeeter Drill&lt;/strong&gt;</td><td>MEDTRONIC</td><td></td><td>0.6 mm diamond burr</td></tr><tr><td>&lt;strong&gt;Stapes prosthesis&lt;/strong&gt;</td><td>SPIGGLE &amp;amp; THEIS</td><td></td><td>0.6x4.75mm</td></tr><tr><td>&lt;strong&gt;Surgical scrub set for otologic patients&lt;/strong&gt;</td><td>EURONDA</td><td></td><td></td></tr><tr><td>&lt;strong&gt;Surgical scrub set for operating surgeon&lt;/strong&gt;</td><td>EURONDA</td><td></td><td></td></tr><tr><td>&lt;strong&gt;Surgical scrub set for nurse&lt;/strong&gt;</td><td>EURONDA</td><td></td><td></td></tr><tr><td>&lt;strong&gt;Vesalius molecular resonance electrosurgical unit&lt;/strong&gt;</td><td>TELEA ELECTRONIC ENGINEERING</td><td></td><td></td></tr><tr><td>&lt;strong&gt;Video equipment: 4K Camera&lt;br/&gt; - HD screen&lt;br/&gt; - Video processor (Image 1S system)&lt;/strong&gt;</td><td>STORZ</td><td></td><td></td></tr></tbody></table>

step-by-step stapedotomy through transcanal exclusive endoscopic approach

In recent years there has been an increasing trend in the use of the endoscope to treat a variety of middle ear pathologies, including otosclerosis. Several studies comparing traditional microscopic and endoscopic stapes surgery have reported similar hearing results and an overall low rate of complications. The endoscope has unraveled its full potential in demanding settings of stapes surgery, such as unfavorable anatomy of the oval window niche or revision cases. Reduced manipulation of the chorda tympani and low rate of post-operative dysgeusia are further benefits to mention for endoscopic stapes surgery.
Being a one-handed technique, management of bleeding, positioning, and crimping of the prosthesis may be challenging for novice endoscopic surgeons, so some training in endoscopic ear surgery is recommended before performing endoscopic stapedotomy. The problem of sharing the surgical field between the endoscope and the operating instruments could be easily overcome if proper instruments positioning is understood. One-handed bleeding control in the narrow space of the ear canal may represent an issue during the elevation of the tympano-meatal flap, possibly discouraging the surgeon since the preliminary steps of surgery. Following appropriate technique to raise the flap and the collaboration with the anesthesiology team in keeping the blood pressure low guarantee an adequate bleeding control in most cases.
The aim of this article is to describe the entire surgical procedure of a transcanal exclusive endoscopic stapedotomy, from operating room set up and patient positioning to post-operative care. A step-by-step description of the surgical maneuvers with technical hints is reported, to guide the surgeon across the procedure and allow any ear surgeon to perform stapes surgery endoscopically.

The patient had a normal post-operative course, without facial palsy or vertigo. The 6-month post-operative hearing test16&#160;is shown in Figure 3. The otoendoscopy showed regular healing of the tympanic membrane. The patient denied any taste impairment.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/63061/63061fig01.jpg" /> 
Figure 1: Standard otological instruments set for endoscopic stapes surgery. Most commonly used instruments are marked with numbers. 1: monopolar (molecular resonance hook); 2: Skeeter drill with 0.6 diamond burr; 3: suction tubes; 4: round knives; 5: sickle knife; 6: resorbable hemostatic sponge; 7: Hartmann forceps; 8: curettes; 9: 5 mL syringe with needle for intraoperative local anesthesia; 10: hooks; 11: crimping forceps; 12: 0&#176; optic lens; 13: 20 mL syringe for irrigation; 14: cottonoids; 15: sterile isotonic water for irrigation; 16: adrenaline to soak cottonoids; 17: Bellucci scissors. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/63061/63061fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/63061/63061fig02.jpg" /> 
Figure 2: Position of the endoscope and of the instrument (a suction tube in this case) during the surgical procedure. Note that the fourth and fifth fingers are leaning on the patient&#39;s head to stabilize the movements of the dominant hand. The endoscope leans against the posterior wall of the external auditory canal and the suction tube is inserted above it. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/63061/63061fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/63061/63061fig03.jpg" /> 
Figure 3: Pre-operative and post-operative pure tone audiometry17. dB = decibel Hz = Hertz. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/63061/63061fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>

Watch this Scientific Journal Video about Step-by-Step Stapedotomy through Transcanal Exclusive Endoscopic Approach at JoVE.com

Step-by-Step Stapedotomy through Transcanal Exclusive Endoscopic Approach

The aim of this article is to provide a step-by-step method for endoscopic stapes surgery from operating room setting and patient positioning to post-operative care. This work would represent a guide for any otologic surgeon who is willing to treat otosclerosis with endoscopic transcanal technique.

In recent years there has been an increasing trend in the use of the endoscope to treat a variety of middle ear pathologies, including otosclerosis. ...

step-step-stapedotomy-through-transcanal-exclusive-endoscopic

Nanyang Technological University

Research

JoVE Journal

Medicine

5.2K Views.  University Hospital of Modena. Stap-voor-stap stapedotomie door transcanale exclusieve endoscopische aanpak. We gaan een geval van endoscopische stape-chirurgie laten zien van operatiekamerinstelling en patiëntpositionering tot postoperatieve zorg. Ik ga u begeleiden door een stapsgewijze beschrijving van de chirurgische procedure met technische tips om elke chirurg in staat te stellen stape-chirurgie uit te voeren met een totale endoscopische benadering.Een groeiend aantal artikelen heeft aangetoond dat endoscopis...

Video: Step-by-Step Stapedotomy through Transcanal Exclusive Endoscopic Approach

How to Measure Cortical Folding from MR Images: a Step-by-Step Tutorial to Compute Local Gyrification Index

Cortical folding (gyrification) is determined during the first months of life, so that adverse events occurring during this period leave traces that will be identifiable at any age. As recently reviewed by Mangin and colleagues2, several methods exist to quantify different characteristics of gyrification. For instance, sulcal morphometry can be used to measure shape descriptors such as the depth, length or indices of inter-hemispheric asymmetry3. These geometrical properties have the advantage of being easy to interpret. However, sulcal morphometry tightly relies on the accurate identification of a given set of sulci and hence provides a fragmented description of gyrification. A more fine-grained quantification of gyrification can be achieved with curvature-based measurements, where smoothed absolute mean curvature is typically computed at thousands of points over the cortical surface4. The curvature is however not straightforward to comprehend, as it remains unclear if there is any direct relationship between the curvedness and a biologically meaningful correlate such as cortical volume or surface. To address the diverse issues raised by the measurement of cortical folding, we previously developed an algorithm to quantify local gyrification with an exquisite spatial resolution and of simple interpretation. Our method is inspired of the Gyrification Index5, a method originally used in comparative neuroanatomy to evaluate the cortical folding differences across species. In our implementation, which we name local Gyrification Index (lGI1), we measure the amount of cortex buried within the sulcal folds as compared with the amount of visible cortex in circular regions of interest. Given that the cortex grows primarily through radial expansion6, our method was specifically designed to identify early defects of cortical development.
In this article, we detail the computation of local Gyrification Index, which is now freely distributed as a part of the FreeSurfer Software (<a href="http://surfer.nmr.mgh.harvard.edu/">http://surfer.nmr.mgh.harvard.edu/</a>, Martinos Center for Biomedical Imaging, Massachusetts General Hospital). FreeSurfer provides a set of automated reconstruction tools of the brain's cortical surface from structural MRI data. The cortical surface extracted in the native space of the images with sub-millimeter accuracy is then further used for the creation of an outer surface, which will serve as a basis for the lGI calculation. A circular region of interest is then delineated on the outer surface, and its corresponding region of interest on the cortical surface is identified using a matching algorithm as described in our validation study1. This process is repeatedly iterated with largely overlapping regions of interest, resulting in cortical maps of gyrification for subsequent statistical comparisons (Fig. 1). Of note, another measurement of local gyrification with a similar inspiration was proposed by Toro and colleagues7, where the folding index at each point is computed as the ratio of the cortical area contained in a sphere divided by the area of a disc with the same radius. The two implementations differ in that the one by Toro et al. is based on Euclidian distances and thus considers discontinuous patches of cortical area, whereas ours uses a strict geodesic algorithm and include only the continuous patch of cortical area opening at the brain surface in a circular region of interest.

Measuring gyrification (cortical folding) at any age represents a window into early brain development. Hence, we previously developed an algorithm to measure local gyrification at thousands of points over the hemisphere1. In this paper, we detail the computation of this local gyrification index.

Cortical folding (gyrification) is determined during the first months of life, so that adverse events occurring during this period leave traces that will ...

Discovering Middle Ear Anatomy by Transcanal Endoscopic Ear Surgery: A Dissection Manual

The middle ear is located in the center of the temporal bone and bears a highly complex anatomy. The recently introduced exclusively endoscopic transcanal approach to the middle ear is a minimally invasive technique sparing the bone and mucosa of the mastoid bone, since the middle ear is accessed through the external auditory canal. This emerging method has several advantages over the traditional (microscopic) approaches to the middle ear such as the panoramic wide-angle views of the anatomy, the possibility to approach and magnify tiny structures, and the possibility of looking around the corner using angled endoscopes.
The cadaveric dissection method presented here consists of an overview on the technical requirements and a precise description of a step-by-step protocol to discover the anatomy of the middle ear. Each step and anatomical structure is carefully described in order to provide a comprehensive guide to endoscopic ear anatomy. In our opinion, this is particularly important to any novice in endoscopic ear surgery as it provides thorough anatomical knowledge and may improve surgical skills.

The aim of this article is to describe the methodology of exclusively endoscopic cadaveric middle ear dissection. Moreover, we aim to provide a comprehensive guide to endoscopic middle ear anatomy.

The middle ear is located in the center of the temporal bone and bears a highly complex anatomy. The recently introduced exclusively endoscopic transcanal ...

An Endoscopic Transcanal Transpromontorial Approach for Vestibular Schwannomas using a Computer-Based Three-Dimensional Imaging System

A 2D monocular endoscope has been used in transcanal transpromontory vestibular schwannoma surgery instead of craniotomy. However, the absence of depth perception is the limitation of this approach. With the loss of depth perception, the surgeon will be not able to perform delicate and particularly complicated surgery. A binocular endoscope has been developed to provide stereoscopic vision with better depth perception for complicated anatomic structures and has been applied in some endoscopic surgeries. However, the diameter of the endoscope is a limitation in the performance of transcanal otologic surgeries. A small diameter endoscope facilitates easier surgery in a restricted space. A computer-based 3D imaging system can obtain 3D images in real-time using a small monocular endoscope. In this study, to evaluate the feasibility of a computer-based 3D imaging system for endoscopic lateral skull base surgery, we applied this 3D imaging system in a transcanal transpromontorial approach in two patients with vestibular schwannomas. The surgical procedure was completed without complication in these two cases. There was no mortality, perioperative complications, nor notable postoperative complications. Using this computer-based 3D imaging system, a better depth perception and stereoscopic vision was observed compared to a conventional 2D endoscope. The improvement in depth perception offers superior management of the complicated surgical anatomy.

Here, we present a transcanal transpromontorial approach for vestibular schwannomas using a computer-based three-dimensional (3D) imaging system combined with a two-dimensional (2D) endoscope. This system provided stereoscopic vision, better depth perception and reduced visual fatigue. This 3D imaging system enabled the application of 3D vision technology in endoscopic lateral skull base surgery.

A 2D monocular endoscope has been used in transcanal transpromontory vestibular schwannoma surgery instead of craniotomy. However, the absence of depth ...

Endaural Endoscopic Atticoantrotomy (Retrograde Mastoidectomy) using a Constant Suction Bone-drilling Technique

Endoscopic middle ear surgery is a widely employed minimally invasive surgical technique to address middle ear and mastoid pathology. Bone drilling is the main technical challenge of endoscopic middle ear surgery. The accompanying video describes the detailed protocol of a constant-suction bone-drilling technique and the procedure of endaural exclusive endoscopic atticoantrotomy (retrograde mastoidectomy) using this technique. The main components of this bone-drilling technique include a soft and flexible suction tube, which is placed into the tympanic cavity to provide constant suction, and a soft sleeve, which is wrapped around the drill shaft to prevent the high-speed rotating shaft from damaging the lens of the endoscope. With these simple modifications, the traditional otological electrodrill can be used for drilling a tiny endaural incision in endoscopic middle ear surgery. Based on this bone-drilling technique, endaural endoscopic atticoantrotomy (retrograde mastoidectomy) can be successfully established for the removal of various amounts of bone, depending on the extent of the lesion. The short-term postoperative outcome seems promising.

Endaural Endoscopic Atticoantrotomy Retrograde Mastoidectomy using a Constant Suction Bone-drilling Technique

In this paper, we present the protocol and short-term outcomes of endaural exclusive endoscopic atticoantrotomy using a constant suction bone-drilling technique.

Endoscopic middle ear surgery is a widely employed minimally invasive surgical technique to address middle ear and mastoid pathology. Bone drilling is the ...

An Integrated (Microscopic/Endoscopic) Dissection Ear Surgery Course

Traditionally, otologic surgical training consisted of microscopic cadaveric dissections. However, during the last decades the endoscope has significantly changed the surgical perspective in the otologic field. Thus, the modern ear and lateral skull base surgeon should master the entire spectrum of endoscopic and microscopic approaches, with the aim of tailoring the procedure and guaranteeing the best possible functional outcome. This work proposes a step-by-step guided and illustrated dissection course, including indications for the setup of the cadaver lab and the integration of the microscope and endoscope to enhance the use of both instruments. The alternation of the endoscope and microscope allows the novice to train the correct handling of the instruments in the surgical field under both optical views. This aspect is of utmost importance since it is not advisable to start off a technique without practicing the other one, as both are important and complementary in the modern otologic surgery setting.

An Integrated Microscopic/Endoscopic Dissection Ear Surgery Course

Traditionally, otologic surgical training consisted of microscopic cadaveric dissections. However, during the last decades the endoscope has significantly ...

The Microscopic Transcanal Approach in Stapes Surgery Revisited

The microscopic transcanal (aka transmeatal) surgical approach was first described in the 60s, offering a minimally invasive means of reaching the external auditory canal, the middle ear, and epitympanon. Such an approach avoids a retroauricular or endaural skin incision; however, working through a narrow space needs angled microsurgical instruments and specific training in otologic surgery. The transcanal approach restricts the working space; however, it offers a binocular microscopic vision into the middle ear without extended skin incisions and thus, reducing post-operative pain and bleeding. In addition, this minimally invasive approach avoids scar tissue complications, hypoesthesia of the auricle, and potential protrusion of the pinna. Despite its numerous advantages, this method is still not routinely performed by otologic surgeons. Since this minimally invasive technique is more challenging, there is a need for extensive training in order for it to be widely adopted by otologic surgeons. This article provides step-by-step surgical instructions for stapes surgery and reports possible indications, pitfalls, and limitations using this microscopic transcanal technique.

This article describes the microscopic transcanal technique for stapes surgery, providing step-by-step surgical instructions for familiarizing surgeons with this approach.

The microscopic transcanal (aka transmeatal) surgical approach was first described in the 60s, offering a minimally invasive means of reaching the ...

Endoscopic Cholesteatoma Surgery

Implementation of endoscopes in cholesteatoma surgery resulted in considerable changes in the management of cholesteatoma in the last two decades. Compared to the microscopic approach with an excellent but straight-line view and limited illumination, the introduction of endoscopes provides a wide-angled panoramic view. Moreover, angled lenses allow the surgeon to visualize the middle ear and its hidden recesses through a transcanal, minimally-invasive approach. The endoscope enables the surgeon to remove limited cholesteatoma of the middle ear and its recesses using an exclusive endoscopic technique by taking advantage of these benefits. This reduces the rate of residual disease and sparing external incisions and excessive temporal bone drilling as in a transmastoid approach. Since transcanal endoscopic access is mainly a one-handed technique, it implies the need for specific procedures and technical refinements. This article describes a step-by-step guide as a surgical manual for endoscopic removal of epitympanic cholesteatoma. Different techniques for cholesteatoma dissection and bone removal for epitympanectomy, including curettage and powered instruments such as drills and ultrasonic devices with their outcomes, are discussed. This may offer ear surgeons insight into technical refinements and the latest technological developments and open the horizon for different techniques.

The present protocol describes a step-by-step guide for the complete endoscopic removal of epitympanic cholesteatoma with different techniques for cholesteatoma dissection and bone removal for epitympanectomy.

Implementation of endoscopes in cholesteatoma surgery resulted in considerable changes in the management of cholesteatoma in the last two decades. ...

Robot-Assisted Transcanal Endoscopic Ear Surgery for Congenital Cholesteatoma

Congenital cholesteatoma accounts for 25% of cholesteatoma cases in children. Transcanal Endoscopic Ear Surgery (TEES) is ideal for these patients because it offers a wide endoscopic view of the middle ear and a minimally invasive approach. The two main limitations are the loss of one operative hand and a narrow external auditory canal in younger children. Here, we present the case of a 3-year-old patient with a Potsic stage III congenital cholesteatoma adherent to the incus and branches of the stapes. A robotic-assisted TEES procedure was performed, during which a robotic arm with 6 degrees of freedom held a 0&#176;, 2.9 mm wide endoscope, enabling the surgeon to work in a narrow environment with both hands. The procedure's duration was 2 h and 9 min, including 16 min for the installation and draping of the robotic arm. After a trans-canal approach, the cholesteatoma was dissected from the ossicles using both a needle (or sickle knife) and suction to stabilize the ossicles and limit the risk of hearing trauma. The cholesteatoma was debulked to reduce its size, allowing it to be pushed under the malleus anteriorly and then separated from other adherences before removal. A tragal cartilage graft was used to reinforce the tympanic membrane.

This protocol describes the removal of congenital cholesteatoma using minimally invasive transcanal endoscopic ear surgery with a two-handed approach and a robotic endoscope holder.

Congenital cholesteatoma accounts for 25% of cholesteatoma cases in children. Transcanal Endoscopic Ear Surgery (TEES) is ideal for these patients because ...

A Comprehensive Step-By-Step Guide for Exclusive Endoscopic Ossiculoplasty

Techniques of Endoscopic Ossiculoplasty

The utilization of endoscopes in modern otology has evolved from diagnostic purposes to the development of exclusive endoscopic ear surgery. This technique offers a panoramic view of the middle ear and provides an optimal magnification of the oval window region, the stapes' suprastructure, and the footplate, allowing great precision in prosthesis positioning during ossiculoplasty (OPL). Various techniques for ossicular chain reconstruction have been described in the literature. Either autologous or synthetic materials can be used for reconstruction. The use of a patient's own tissue minimizes the risk of implant rejection or extrusion of the prosthesis through the tympanic membrane. On the other hand, synthetic materials like titanium are light and rigid and do not require time-consuming prosthesis remodeling. The main objective of this article is to present a comprehensive step-by-step guide that serves as a surgical manual for exclusive endoscopic OPL. This guide will explain various forms of OPL using synthetic and autologous materials. The goal is to provide a comprehensive understanding of the various surgical techniques and support the integration into clinical practice.

Author Spotlight: Advancing Endoscopic Ossiculoplasty &#8211; Techniques, Innovations, and Practical Guidance for Clinical Integration

Exclusive Endoscopic ossiculoplasty (EEO) is a promising and minimally invasive approach for the treatment of conductive hearing loss due to ossicular chain disruptions and associated middle ear pathologies. Herein, step-by-step instructions and a discussion of various endoscopic ossiculoplasty techniques are presented.

The utilization of endoscopes in modern otology has evolved from diagnostic purposes to the development of exclusive endoscopic ear surgery. This ...

Hearing Preservation with Long Electrodes in Electric-Acoustic Stimulation

Enhanced Cochlear Coverage and Hearing Preservation in High-Frequency Hearing Loss via Electric Acoustic Stimulation with Longer Electrode

Electric-acoustic stimulation (EAS) is a promising treatment to improve hearing ability in patients with high-frequency hearing loss (HL). In EAS surgeries, shorter electrodes have been preferred to avoid the presence of an electrode covering the residual hearing region. However, our earlier studies showed that EAS with longer electrodes (28 mm) could preserve acoustic hearing. Additionally, we reported that the hearing preservation (HP) scores were independent of the length of the inserted electrodes, consistent with the systematic review. As most EAS patients gradually lose residual hearing over time due to the natural course of HL, in these cases, providing broader cochlear coverage using longer electrodes was beneficial toward better place-pitch matching. In addition to preparing for the deterioration in&#160;hearing in&#160;the future, EAS with longer electrodes could offer various types of map strategies. Herein, we show the pre-, intra-, and post-procedures for EAS surgery. Appropriate preoperative evaluation, less invasive surgery, flexible lateral-wall electrodes, and steroid administration resulted in good HP following EAS with longer electrodes.

Author Spotlight: Optimizing EAS with Long Electrodes for Enhanced Cochlear Coverage and Hearing Preservation

Electric acoustic stimulation (EAS) with longer electrodes can offer broader cochlear coverage and various types of maps in cases of high-frequency hearing loss. Combining less invasive surgery, flexible lateral-wall electrodes, and steroid administration permits deeper insertion with little or no surgical trauma, resulting in good preservation of hearing.

Step-by-Step Stapedotomy through Transcanal Exclusive Endoscopic Approach

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