Name: techniques of endoscopic ossiculoplasty
Uploaded: 2024-01-26T14:40:00.000+00:00
Duration: 9 min 7 s
Description: Read this Scientific Article Protocol about Author Spotlight: Advancing Endoscopic Ossiculoplasty – Techniques, Innovations, and Practical Guidance for Clinical Integration at JoVE.com

None.

The study protocol conformed to the guidelines of the Human Research Ethics Committee of the Inselspital Bern and was approved by the local review board (KEK-BE 2019-00555). Informed written consent was obtained from all human subjects involved in the study. All surgical procedures were performed under general anesthesia (following institutionally approved protocols) with controlled hypotension, using standard otologic instruments and appropriate hemostasis17,18. Surgical site preparation, exclusive transcanal access, middle ear examination, and defect closure of the TM are described in previously published articles by Beckmann et al. and Anschuetz et al.19,20. Additional reconstructive measures, most frequently tympanoplasties, are often required19. Usually, the OPL is performed in the end after positioning the grafts for tympanoplasty or scutum reconstruction. However, these techniques will not be covered in this protocol. Moreover, many other OPL techniques are described in the literature21,22. This article covers the methods with which we have a strong and positive experience. Figure 1 illustrates the technique for partial ossicular replacement, and Figure 2 shows the technique for total ossicular replacement. The surgical tools and the equipment needed are listed in the Table of Materials.
1. Incus interposition
<ol>
	<li>Use a needle dissector to dissect and detach the chorda tympani from the long process of the incus and proceed to slightly resect the scutum with a bone curette. 
	NOTE: Resection of the scutum provides wide access to the posterior mesotympanum and helps to identify the incudostapedial joint between the long process of the incus and the stapes head20.</li>
	<li>Identify the incudostapedial joint and cautiously disarticulate the lenticular process from the stapes head using a microhook or a small round knife. Then, gently push the incus upward to detach it from the head of the malleus. Remove the incus by pulling the long process inferiorly and then laterally. Preserve the detached incus for its intended use in the interposition procedure.</li>
	<li>Thoroughly examine the incus for any signs of erosion, ensuring its appropriateness for the upcoming reconstruction.</li>
	<li>Grind the graft using the following steps23:
	<ol>
		<li>Hold the incus using a grasping forceps.</li>
		<li>Use a diamond burr to carefully drill both the long and short processes of the incus until the level of the incus body is reached.</li>
		<li>On the opposite side of the former long process, drill an acetabulum approximately 1 mm wide to accommodate the stapes head.</li>
		<li>Verify that the length of the interposition aligns with the range of 2-2.5 mm, depending on the anatomy of the patient.</li>
	</ol>
	</li>
	<li>Utilize a microsuction tip and/or a needle to position the remodeled incus inside the tympanic cavity and to precisely locate the acetabulum onto the stapes head and, if appropriate, the anterior surface in contact with the malleus handle.</li>
</ol>
2. Malleus head interposition
<ol>
	<li>After removal of the incus (step 1), identify the malleus and dissect the chorda tympani away from its neck.</li>
	<li>Use the malleus nipper to transect the malleus neck and remove its head for its intended use in the interposition procedure.</li>
	<li>Thoroughly examine the malleus head for any signs of erosion, ensuring its appropriateness for the upcoming reconstruction.</li>
	<li>Grind the graft using the following steps24:
	<ol>
		<li>Hold the malleus head using a grasping forceps.</li>
		<li>If the whole malleus is used, use a diamond burr to carefully drill both the manubrium, lateral, and anterior process until the level of the malleus neck is reached.</li>
		<li>On the malleus head, drill an acetabulum approximately 1 mm wide to accommodate the stapes head.</li>
		<li>Verify that the length of the graft is approximately 2-2.5 mm, depending on the anatomy of the patient.</li>
	</ol>
	</li>
	<li>After carrying the graft towards the tympanic cavity, utilize a microsuction tip and/or a microhook/needle to position the malleus head interposition precisely onto the stapes head. 
	NOTE: Appropriate treatment of the underlying middle ear pathology often requires resection of the incus and the malleus. As long as the incus body remains intact, it is suitable for an interposition graft. Use the malleus head interposition in cases where the incus is absent or eroded, and the malleus head is still intact.</li>
</ol>
3. Partial ossicular replacement prosthesis (PORP)
<ol>
	<li>Confirm the integrity of the stapes suprastructure and ensure that both malleus head and incus are missing or unsuitable for use in interposition ossiculoplasty.</li>
	<li>Assess the size of the defect and decide on the size of the implant. Many different products are commercially available; here, the use of a titanium-based implant is exemplarily shown. Choose the appropriate size of the implant or trim the titanium shaft to the desired length. No pressure should be exerted on the stapes suprastructure to avoid stretching of the annular ligament.</li>
	<li>After carrying the prosthesis towards the tympanic cavity, utilize a microsuction tip and/or a microhook/needle to position the foot of the PORP precisely onto the stapes&#39; head.</li>
	<li>Brace the head of the PORP against the manubrium (if present). Cover the head of the prosthesis with cartilage, and ensure that the implant slightly tents the TM.</li>
</ol>
4. Double cartilage block (DCB) PORP
<ol>
	<li>Confirm the integrity of the stapes suprastructure and ensure that both malleus head and incus are missing or unsuitable for interposition OPL.</li>
	<li>Prepare the double-cartilage block (DCB) graft using the following steps25:
	<ol>
		<li>Obtain a rectangular block of tragal or conchal cartilage and remove the perichondrium on one side only.</li>
		<li>Use a scalpel to cut the cartilage in half; avoid transecting the perichondrium on the opposite side.
		<ol>
			<li>Create a shallow acetabulum approximately 1 mm wide to receive the stapes capitulum on the block free from perichondrium.</li>
			<li>Fold the cartilage block on the intact perichondrium.</li>
		</ol>
		</li>
	</ol>
	</li>
	<li>Utilize a microsuction tip and/or a microhook/needle to position the DCB precisely onto the stapes head. Establish a contact to the manubrium of the hammer if applicable.</li>
</ol>
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/66155/66155fig01.jpg" /> 
Figure 1: Techniques of partial ossicular replacement. (A) Incus interposition (ii). (B) Malleus head interposition (mai). (C) PORP (*). (D) DCB PORP (car). Abbreviations: malleus (ma), promontory (p), stapes (s), tympanic membrane (tm). <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66155/66155fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
5. Total ossicular replacement prosthesis (TORP)
<ol>
	<li>Confirm the integrity of the stapes footplate and clean it from disease, adhesions, or scars.</li>
	<li>Assess the size of the defect between the TM and the footplate and decide on the size of the implant. Many different products are commercially available; here, the use of a titanium-based implant is exemplarily shown. Choose the appropriate size of the implant or trim the titanium shaft to the desired length. Ensure the implant slightly tents the TM without exerting too much pressure on the footplate.</li>
	<li>Utilize a microsuction tip and/or a needle to position the TORP inside the tympanic cavity and to locate the foot of the TORP precisely onto the stapes footplate.</li>
	<li>Brace the head of the TORP against the manubrium (if present) and cover its head with cartilage.</li>
</ol>
6. Semi-synthetic total ossicular replacement prosthesis (ssyTORP)
<ol>
	<li>Confirm the integrity of the stapes footplate and clean it from disease, adhesions, or scars.</li>
	<li>Prepare the semi-synthetic prosthesis26:
	<ol>
		<li>Choose a platinum/polytetrafluoroethylene (PTFE) stapedotomy prosthesis according to the intended size of the reconstruction.</li>
		<li>Cut the platinum wire at the base of the hook.</li>
		<li>Obtain a cartilage block from the tragal or conchal cartilage. According to the distance between the TM and the footplate, create a 5 mm long ssyTORP.</li>
		<li>Create one square block of tragal cartilage with perichondrium left on both sides.</li>
		<li>Use an insulin needle to create a small hole in the perichondrium in the middle of the block.</li>
		<li>Insert the blunt tip of the shaft into the perichondrium hole and gently push it to penetrate the cartilage.</li>
		<li>To create a 6 mm or 7 mm ssyTORP, obtain a double or triple cartilage block, respectively, by taking a rectangle (2-5 mm), preferably from the tragal cartilage, with the perichondrium left on both sides.</li>
		<li>Cut the cartilage in half. Avoid transection of the perichondrium on the opposite side.</li>
		<li>Make a small hole in the perichondrium in the middle of the block.</li>
		<li>Insert the blunt tip of the shaft into the cartilage block. Fold the cartilage back on itself with the intact perichondrium layer doubled between the two/three cartilage blocks. 
		&#8203;NOTE: In all above-mentioned techniques, ensure the stability of the reconstruction by using resorbable gelatin sponges around the interposition graft, if deemed appropriate.</li>
	</ol>
	</li>
</ol>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/66155/66155fig02.jpg" /> 
Figure 2: Techniques of total ossicular replacement. (A) TORP (t). (B) ssyTORP (*). Abbreviations: cartilage (car), footplate (f), promontory (p), tympanic membrane (tm). <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66155/66155fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
7. Postoperative care
<ol>
	<li>Ensure adequate pain management in the postoperative period. Do not administer prophylactic antibiotics unless clinically indicated.</li>
	<li>Advise patients not to blow their nose and emphasize strict protection from water for two weeks postoperatively to avoid possible damage to the surgical site.</li>
	<li>Discharge the patients on the day of the surgery or the following day, depending on their postoperative recovery and the clinical assessment.</li>
	<li>Schedule a follow-up two weeks postoperatively for complete dressing removal and assessment of the surgical site. 
	NOTE:This is a standard postoperative care protocol. Individual patient needs and clinical scenarios may necessitate modifications.</li>
</ol>

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

<ol>
	<li>Bonali, 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=The+variants+of+the+retro-+and+hypotympanum:+an+endoscopic+anatomical+study.">The variants of the retro- and hypotympanum: an endoscopic anatomical study.</a> European Archives of Oto-Rhino-Laryngology. 274 (5), 2141-2148 (2017).</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=Novel+Surgical+and+Radiologic+Classification+of+the+Subtympanic+Sinus:+Implications+for+Endoscopic+Ear+Surgery.">Novel Surgical and Radiologic Classification of the Subtympanic Sinus: Implications for Endoscopic Ear Surgery.</a> Otolaryngology-Head and Neck Surgery. 159 (6), 1945998187180 (2018).</li><li>Marchioni, D., Molteni, G., 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+anatomy+of+the+middle+ear.">Endoscopic anatomy of the middle ear.</a> Indian Journal of Otolaryngology and Head &amp; Neck Surgery. 63 (2), 101-113 (2011).</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+ossiculoplasty:+Is+there+any+edge+over+the+microscopic+technique.">Endoscopic ossiculoplasty: Is there any edge over the microscopic technique.</a> The Laryngoscope. 130 (3), 797-802 (2020).</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=Surgical+implications+of+3D+vs+2D+endoscopic+ear+surgery:+A+case-control+study.">Surgical implications of 3D vs 2D endoscopic ear surgery: A case-control study.</a> European Archives of Oto-Rhino-Laryngology. 277 (12), 3323-3330 (2020).</li><li>Kamrava, B., Roehm, P. C. <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+ossicular+chain+anatomy:+Strategic+planning+for+development+of+novel+middle+ear+prostheses.">Systematic review of ossicular chain anatomy: Strategic planning for development of novel middle ear prostheses.</a> Otolaryngology-Head and Neck Surgery. 157 (2), 190-200 (2017).</li><li>Mudhol, R. S., Naragund, A. I., Shruthi, V. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ossiculoplasty:+Revisited.">Ossiculoplasty: Revisited.</a> Indian Journal of Otolaryngology and Head and Neck Surgery. 65, 451-454 (2013).</li><li>Wullstein, H., Thieme, O. h. r. ,. N. a. s. e. u. n. d. H. a. l. s. .. 2. n. d. e. d. .. S. t. u. t. t. g. a. r. t. :. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Die+Eingriffe+zur+Geh&#246;rverbesserung+[Surgery+for+hearing+improvement].">Die Eingriffe zur Geh&#246;rverbesserung [Surgery for hearing improvement].</a> Uffenorde W. Anzeige und Ausf&#252;hrung der Eingriffe an Ohr, Nase und Hals. 2nd ed. , 227-258 (1952).</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=Selective+epitympanic+dysventilation+syndrome.">Selective epitympanic dysventilation syndrome.</a> The Laryngoscope. 120 (5), 1028-1033 (2010).</li><li>Yu, H., 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=PORP+vs.+TORP:+A+meta-analysis.">PORP vs. TORP: A meta-analysis.</a> European Archives of Oto-Rhino-Laryngology. 270 (12), 3005-3017 (2013).</li><li>McGee, M., Hough, J. V. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ossiculoplasty.">Ossiculoplasty.</a> Otolaryngologic Clinics of North America. 32 (3), 471-488 (1999).</li><li>Javia, L. R., Ruckenstein, M. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ossiculoplasty.">Ossiculoplasty.</a> Otolaryngologic Clinics of North America. 39 (6), 1177-1189 (2006).</li><li>Woods, O., Fata, F. E., Saliba, I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ossicular+reconstruction:+Incus+versus+universal+titanium+prosthesis.">Ossicular reconstruction: Incus versus universal titanium prosthesis.</a> Auris Nasus Larynx. 36 (4), 387-392 (2009).</li><li>Bartel, R., 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=Hearing+results+after+type+III+tympanoplasty:+incus+transposition+versus+PORP.+A+systematic+review.">Hearing results after type III tympanoplasty: incus transposition versus PORP. A systematic review.</a> Acta Oto-Laryngologica. 138 (7), 617-620 (2018).</li><li>Tsetsos, N., Vlachtsis, K., Stavrakas, M., Fyrmpas, G. <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+ossiculoplasty+in+chronic+otitis+media:+A+systematic+review+of+the+literature.">Endoscopic versus microscopic ossiculoplasty in chronic otitis media: A systematic review of the literature.</a> European Archives of Oto-Rhino-Laryngology. 278 (4), 917-923 (2021).</li><li>Soloperto, 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=Exclusive+endoscopic+ossiculoplasty+with+autologous+material:+step-by-step+procedure+and+functional+results.">Exclusive endoscopic ossiculoplasty with autologous material: step-by-step procedure and functional results.</a> European Archives of Oto-Rhino-Laryngology. 280 (11), 4869-4878 (2023).</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; Journal for Oto-Rhino-Laryngology and its Related Specialties. 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=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>Beckmann, S., 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=Endoscopic+cholesteatoma+surgery.">Endoscopic cholesteatoma surgery.</a> Journal of Visualized Experiments. (179), e63315 (2022).</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. (131), e56390 (2018).</li><li>Kim, H. H., Wiet, R. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Preferred+technique+in+ossiculoplasty.">Preferred technique in ossiculoplasty.</a> Operative Techniques in Otolaryngology-Head and Neck Surgery. 14 (4), 243-246 (2003).</li><li>Springer. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Comparative atlas of endoscopic ear surgery: training techniques based on an ovine model. , (2021).</li><li>Dornhoffer, J. 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=.">.</a> 28 autograft ossicular reconstruction. The chronic ear. , (2016).</li><li>Malafronte, G., Filosa, B., Mercone, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+new+double-cartilage+block+ossiculoplasty:+long-term+results.">A new double-cartilage block ossiculoplasty: long-term results.</a> Otology &amp; Neurotology. 29 (4), 531-533 (2008).</li><li>Malafronte, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Early+results+with+semi-synthetic+total+ossicular+replacement+prosthesis.">Early results with semi-synthetic total ossicular replacement prosthesis.</a> Otolaryngology-Head and Neck Surgery. 143 (2), 307-308 (2010).</li><li>Caloway, C. 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=Pediatric+endoscopic+ossiculoplasty+following+surgery+for+chronic+ear+disease.">Pediatric endoscopic ossiculoplasty following surgery for chronic ear disease.</a> The Laryngoscope. 130 (12), 2896-2899 (2020).</li><li>Niederhauser, L., Fink, R. D., Mast, F. W., Caversaccio, M., Anschuetz, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Video+learning+of+surgical+procedures:+A+randomized+comparison+of+microscopic,+2-+and+3-dimensional+endoscopic+ear+surgery+techniques.">Video learning of surgical procedures: A randomized comparison of microscopic, 2- and 3-dimensional endoscopic ear surgery techniques.</a> Otology &amp; Neurotology. 43 (7), e746-e752 (2022).</li><li>Coleman, H., Tikka, T., Curran, J., Iyer, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+of+endoscopic+vs+microscopic+ossiculoplasty:+A+study+of+157+consecutive+cases.">Comparison of endoscopic vs microscopic ossiculoplasty: A study of 157 consecutive cases.</a> European Archives of Oto-Rhino-Laryngology. 280 (1), 89-96 (2023).</li><li>Amith, N., Rs, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Autologous+incus+versus+titanium+partial+ossicular+replacement+prosthesis+in+reconstruction+of+Austin+type+A+ossicular+defects:+a+prospective+randomised+clinical+trial.">Autologous incus versus titanium partial ossicular replacement prosthesis in reconstruction of Austin type A ossicular defects: a prospective randomised clinical trial.</a> The Journal of Laryngology and Otology. 131 (5), 391-398 (2017).</li><li>Filosa, B., Previtero, G., Novia, G., Trusio, A., Malafronte, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Partial+Ossiculoplasty:+Malafronte's+double+cartilage+block+versus+incus.">Partial Ossiculoplasty: Malafronte's double cartilage block versus incus.</a> Otology &amp; Neurotology. 40 (3), 344-350 (2019).</li><li>Vercruysse, J. P., Offeciers, F. E., Somers, T., Schatteman, I., Govaerts, P. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+use+of+malleus+allografts+in+ossiculoplasty.">The use of malleus allografts in ossiculoplasty.</a> The Laryngoscope. 112 (10), 1782-1784 (2002).</li><li>R&#225;th, 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=Ionomer+cement+for+reconstruction+of+the+long+process+of+the+incus:+The+P&#233;cs+experience.">Ionomer cement for reconstruction of the long process of the incus: The P&#233;cs experience.</a> Clinical Otolaryngology. 33 (2), 116-120 (2008).</li><li>Katar, O., K&#305;l&#305;&#231;, S., Bajin, M. D., Sennaro&#287;lu, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Long+term+results+of+glass+ionomer+ossiculoplasty.">Long term results of glass ionomer ossiculoplasty.</a> European Archives of Oto-Rhino-Laryngology. 281 (1), 171-179 (2023).</li><li>Moneir, W., Salem, M. A., Hemdan, 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+transcanal+management+of+incus+long+process+defects:+rebridging+with+bone+cement+versus+incus+interposition.">Endoscopic transcanal management of incus long process defects: rebridging with bone cement versus incus interposition.</a> European Archives of Oto-Rhino-Laryngology. 280 (2), 557-563 (2023).</li></ol>

LA is consultant for Stryker ENT.

This article provides step-by-step instructions for EEO. There are various techniques, types of grafts, and prostheses to reconstruct the ossicular chain10,11. Depending on the presence or absence of the stapes suprastructure, a PORP or TORP is required. The use of an endoscope allows for detailed visualization and assessment of the ossicular chain and its functionality. Even in difficult anatomical conditions, the endoscope provides an optimal view of the oval window and stapes suprastructure or footplate to position the graft with great precision. Postauricular incision and mastoidectomy can often be avoided27. Moreover, it is an excellent tool for educating inexperienced surgeons in both anatomical and surgical aspects28.
Recently published literature has demonstrated comparable audiologic outcomes between endoscopic and microscopic OPL27,29. Das et al. reported significantly improved closure of the ABG after one month with endoscopic PORP OPL, but long-term audiologic outcomes showed no statistically significant difference from the microscopic technique4. A systematic review published by Tsetsos et al. also showed comparable audiologic results for both microscopic and endoscopic techniques15. They also observed a trend toward shorter operative time and lower morbidity, such as postoperative pain and wound infections, with the endoscopic method. The data analysis of the pre- and postoperative audiometric evaluation showed an average ABG of 30.46 dB and 21.41 dB, respectively. There was a statistically significant improvement in ABG completion of 9.05 dB &#177; 14.72 dB between the preoperative and postoperative ABG (p &#60; 0.01). The publication by Soloperto et al. showed comparable results with a mean ABG closure of 7.85 dB HL (p &#60; 0.01) in patients undergoing autologous graft reconstruction16.
Several authors compared synthetic prostheses, particularly titanium prostheses, and autologous grafts in terms of hearing outcome and complications. Aminth et al. conducted a prospective study comparing an incus autograft to a titanium PORP and found significantly better hearing outcomes and graft uptake in the incus group30. In addition, postoperative complications such as prosthesis extrusion and residual TM perforation occurred more frequently in the titanium PORP group.
OPL performed with a DCB graft was found to offer even greater advantages in reducing the risk of prosthesis displacement or fixation compared with the use of an incus autograft31. In the field of autologous grafts, different options, such as the DCB graft and the malleus allograft, have shown comparable audiological results. Both options have restored the ABG to less than 20 dB in 81% of patients25,32. The use of a patient&#39;s own tissue minimizes the risk of implant rejection or extrusion of the prosthesis through the TM, leading to enhanced biocompatibility and reduced postoperative complications15. However, autologous materials do present certain drawbacks. These include longer surgical durations required for the remodeling process, the potential for retaining microscopic pieces of cholesteatoma, and availability limitations depending on the condition of the ossicular chain13,14. A single case of prosthesis extrusion (5%) was recorded in a cohort of 20 synthetic prostheses. No cases of extrusion occurred when autologous materials were used.
COM, with or without cholesteatoma, is the most frequent cause of ossicular chain disruption. In the total 60 cases, COM accounted for 55 (91.7%) cases, and a total of 38 patients (63.3%) showed histologically confirmed cholesteatoma. There is still a debate about the most appropriate timing for ossicular chain reconstruction. In cases of single-stage OPL, endoscopic reconstruction of the ossicular chain is performed at the same time as COM surgery. If residual disease is a potential problem, ossicular chain reconstruction may be deferred to a later procedure, usually scheduled 12 to 18 months after the initial surgery and referred to as a second OPL. In this study, a uniform approach with single-stage surgery was adopted across the cohort to achieve early hearing recovery. However, in scenarios where the disease affects the stapes footplate, it may be appropriate to consider second-stage OPL. Both single-stage and second-stage OPL seem to achieve similar hearing outcomes16.
The long process of the incus is the most vulnerable part for necrosis secondary to both trauma and infections33. In cases with exclusive erosion of the incus long process, rebridging of the ossicular gap with bone cement offers a valid alternative to the OPL procedures presented in this article. Several authors reported comparable long-term audiological outcomes associated with this technique34,35.
The limited sample size of this study and the relatively short FU period prevent robust statistical results and a comprehensive evaluation of the long-term results of the individual OPL techniques. Furthermore, parametric statistical analysis of small subgroups might lead to overestimation or misleading conclusions. The predominant focus on cases of COM limits the generalizability of the results to other middle-ear pathologies. The inclusion of multiple revision cases presents a particular challenge and may not fully represent the primary surgical outcomes.
In conclusion, EEO is a valid surgical option for ossicular chain reconstruction with autologous or synthetic material. It is a safe and minimally invasive procedure with acceptable hearing restoration.

The use of endoscopes has become prevalent in modern otology. Originally used for diagnostic purposes, the endoscopic technique has gained popularity over time, leading to exclusive endoscopic ear surgery approaches. The endoscopic technique is performed through the auditory canal and requires precise and delicate maneuvers, as the technique must be performed single-handedly. It provides a panoramic view of the middle ear and allows access to hard-to-reach areas, facilitating the elimination of disease by using angled endoscopes1,2. In ossicular chain repair, modern high-definition (HD) or 4k endoscopy, along with its illuminative capabilities directed at specific structures of interest, such as the stapes or its footplate, greatly assists in the recognition of both anatomical and pathological variances3,4,5.
Ossicular chain destruction commonly results from chronic otitis media (COM), but trauma and neoplasms can alter the normal middle ear and, therefore, reduce its sound transmission capabilities6,7. Restoration of normal tympanic membrane (TM) and ossicular chain function has its roots in the 1950s8. The surgical techniques used to treat various pathologies of the middle ear aim not only to eliminate the underlying disease process but also to restore normal auditory function9.Over the past seven decades, various ossiculoplasty (OPL) techniques and prostheses have been studied and reported in the literature7,10,11.&#160;Bioinert materials like titanium gained popularity due to their lightweight, rigidity, and good visualization of their distal end during surgery. Nevertheless, these prostheses are quite expensive, and the reported rate of extrusion (1%-5%) is not negligible12. Autologous materials have demonstrated comparable effectiveness to synthetic prostheses. However, they do present certain drawbacks, such as longer surgical durations required for the remodeling process, the potential for retaining cholesteatoma, and availability limitations depending on the condition of the ossicular chain13,14.
According to Tsetsos et al., exclusive endoscopic ossiculoplasty (EEO) is associated with similar postoperative hearing results compared to the traditional microscopic approach15. A trend towards reduced morbidity and a shorter operative time for the endoscopic approach has been observed. Therefore, EEO can be considered a valid surgical option for reestablishing a functioning ossicular chain with acceptable hearing restoration in children and adults16.
This study aims to provide a comprehensive insight into the various technical refinements and latest developments for EEO. It presents different OPL techniques along with representative outcome data.

<table><tbody><tr><td>Antifog Solution</td><td>Karl Storz</td><td>15006H</td><td></td></tr><tr><td>Endoscopes 3 mm diameter, 15 cm length 0&amp;deg;, 30&amp;deg;, 45&amp;deg;and&amp;nbsp; 70&amp;deg;</td><td>Karl Storz</td><td>7220AA/ 7220BA/ 7220FA/ 7220CA</td><td></td></tr><tr><td>Epinephrine 1 mg/mL</td><td>Dr. Bichsel AG</td><td>2824248&amp;nbsp;</td><td></td></tr><tr><td>Gelatinous sponge (Gelfoam)</td><td>Pfizer</td><td>GTIN 00300090315085&amp;nbsp;</td><td></td></tr><tr><td>Image 1S 4K</td><td>Karl Storz</td><td>TH120</td><td></td></tr><tr><td>ME 102</td><td>KLS Martin</td><td>80-010-02-04&amp;nbsp;</td><td></td></tr><tr><td>Microsuction tubes&amp;nbsp;</td><td>Spiggle&amp;amp;Theis</td><td>301004 - 301014</td><td></td></tr><tr><td>Monitor 32&quot; 4K/3D</td><td>Monitor 32&quot; 4K/3D</td><td>TM350</td><td></td></tr><tr><td>NIM-Neuro 3.0</td><td>Medtronic</td><td>8253402</td><td></td></tr><tr><td>OsseoDuo</td><td>Bien Air</td><td>1700524-001</td><td></td></tr><tr><td>Otosporin (polymyxin, neomycin, hydrocortison)</td><td>GlaxoSmithKline</td><td>2262911000001100.00</td><td></td></tr><tr><td>Piezosurgery device</td><td>Mectron</td><td>N/A</td><td></td></tr><tr><td>PM2 Line Drill</td><td>Bien Air</td><td>1600765-001</td><td></td></tr><tr><td>PORP mCLIP ARC Partial Prosthesis&amp;nbsp;</td><td>MED-EL</td><td>58502 - 58520</td><td></td></tr><tr><td>Povidone-iodine (Betadine)</td><td>Mundi-Pharma</td><td>7680342821377&amp;nbsp;&amp;nbsp;&amp;nbsp;</td><td></td></tr><tr><td>Ringer Solution</td><td>B. Braun</td><td>3570000</td><td></td></tr><tr><td>Standard otological instruments (otologic dissectors, needle dissector, round knifes, hooks, curette, microscissors (Bellucci) and microforceps (Hartmann)</td><td>Karl Storz</td><td>N/A</td><td></td></tr><tr><td>Stapes Prosthesis Platin/PTFE</td><td>Spiggle&amp;amp;Theis</td><td>1054040600/10560600</td><td></td></tr><tr><td>Steel and diamond burrs</td><td>Bien Air</td><td>1100290-001 - 1100303-001/ 1100247-001 - 1100260-001</td><td></td></tr><tr><td>Syringe Injekt Solo 10 mL</td><td>Syringe Injekt Solo 10 mL</td><td>4606108N</td><td></td></tr><tr><td>TORP Implant for shortening</td><td>Spiggle&amp;amp;Theis</td><td>11830 - 11870</td><td></td></tr></tbody></table>

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.

This study involved a comprehensive analysis of 60 cases of EEO. For each technique presented herein, the last ten consecutive cases with a follow-up (FU) period of at least three months were included. All procedures were performed by experienced surgeons at the Otolaryngology Department of the University Hospital of Bern and Bologna between April 2019 and June 2023. The mean age (&#177; standard deviation (SD)) at the surgery date was 39.28 years (&#177;19.04). Of the total cases, 30 (50.0%) were revision surgeries. The distribution between the left and right sides operated on was almost equal, with 31 cases (51.7%) on the left and 29 cases (48.3%) on the right. In 55 (91.7%) cases, the underlying disease was COM, and 38 patients (63.3%) had cholesteatoma.
Surgical results 
The graft intake rate (GIR) showed a success rate of 98.3% by the last FU, and only one case showed a TM re-perforation. The mean FU period was 11.15 months (SD &#177; 9.38 months). Prosthesis extrusion occurred in 1 case (2.1%), 19 months postoperatively. Additionally, a subset of cases, 7 in total (11.7%), necessitated revision surgery due to persistent conductive hearing loss (3 cases) or recurrent cholesteatoma (4 cases).
Audiological results 
Each patient underwent pre- and postoperative pure tone audiometry, reported as pure tone average (PTA) represented as hearing threshold (dB HL) at frequencies 0.5 kHz, 1 kHz, 2 kHz, and 4 kHz. Preoperatively, the average air-bone gap (ABG) was 30.46 dB &#177; 13.23 dB. Following surgery, a significant improvement was observed with a reduction of the postoperative ABG to an average of 21.41 dB &#177; 10.64 dB. The improvement was statistically significant as determined by a paired t-test (p &#60; 0.01). A comprehensive overview of the surgical outcomes can be found in Table 1.
Table 1: Patients&#39; disease characteristics and surgical outcome. Abbreviations: Air bone gap (ABG), Mean (M), Range (R), Standard deviation (SD). <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66155/66155_Table 1.xlsx" target="_blank">Please click here to download this Table.</a>

Read this Scientific Article Protocol about Author Spotlight: Advancing Endoscopic Ossiculoplasty – Techniques, Innovations, and Practical Guidance for Clinical Integration at JoVE.com

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.

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 ...

Nanyang Technological University

Research

JoVE Journal

Medicine

2.2K Views.  University of Bern. In de moderne ontologie is het gebruik van endoscopen geëvolueerd van diagnostiek naar exclusieve endoscopische oorchirurgie. Ons doel is om een uitgebreid begrip te bieden van de verschillende endoscopische osteoplastiektechnieken en hun integratie in de klinische praktijk te ondersteunen. De gerichte verlichting van specifieke middenoorstructuren, zoals het steunstuk en de voetplaat, maakt een grote precisie mogelijk bij het plaatsen van de prothese.

Video: Auteur in de schijnwerpers: Voortschrijdende endoscopische ossiculoplastiek - technieken, innovaties en praktische richtlijnen voor klinische integratie

Analytical Techniques for Assaying Nitric Oxide Bioactivity

Nitric oxide (NO) is a diatomic free radical that is extremely short lived in biological systems (less than 1 second in circulating blood)1. NO may be considered one of the most important signaling molecules produced in our body, regulating essential functions including but not limited to regulation of blood pressure, immune response and neural communication. Therefore its accurate detection and quantification in biological matrices is critical to understanding the role of NO in health and disease. With such a short physiological half life of NO, alternative strategies for the detection of reaction products of NO biochemistry have been developed. The quantification of relevant NO metabolites in multiple biological compartments provides valuable information with regards to in vivo NO production, bioavailability and metabolism. Simply sampling a single compartment such as blood or plasma may not always provide an accurate assessment of whole body NO status, particularly in tissues. The ability to compare blood with select tissues in experimental animals will help bridge the gap between basic science and clinical medicine as far as diagnostic and prognostic utility of NO biomarkers in health and disease. Therefore, extrapolation of plasma or blood NO status to specific tissues of interest is no longer a valid approach. As a result, methods continue to be developed and validated which allow the detection and quantification of NO and NO-related products/metabolites in multiple compartments of experimental animals in vivo. The established paradigm of NO biochemistry from production by NO synthases to activation of soluble guanylyl cyclase (sGC) to eventual oxidation to nitrite (NO2-) and nitrate (NO3-) may only represent part of NO's effects in vivo. The interaction of NO and NO-derived metabolites with protein thiols, secondary amines, and metals to form S-nitrosothiols (RSNOs), N-nitrosamines (RNNOs), and nitrosyl-heme respectively represent cGMP-independent effects of NO and are likely just as important physiologically as activation of sGC by NO. A true understanding of NO in physiology is derived from in vivo experiments sampling multiple compartments simultaneously. Nitric oxide (NO) methodology is a complex and often confusing science and the focus of many debates and discussion concerning NO biochemistry. The elucidation of new mechanisms and signaling pathways involving NO hinges on our ability to specifically, selectively and sensitively detect and quantify NO and all relevant NO products and metabolites in complex biological matrices. Here, we present a method for the rapid and sensitive analysis of nitrite and nitrate by HPLC as well as detection of free NO in biological samples using in vitro ozone based chemiluminescence with chemical derivitazation to determine molecular source of NO as well as ex vivo with organ bath myography.

The endogenous production of nitric oxide (NO) regulates a wide variety of biological functions. It is becoming increasingly clear that disruption or dysregulation of NO based signaling is involved in many human diseases. Methods to quantify relevant NO metabolites may provide novel diagnostic or prognostic biomarkers for human disease.

Nitric oxide (NO) is a diatomic free radical that is extremely short lived in biological systems (less than 1 second in circulating blood)1. NO may be ...

ADSC-sheet Transplantation to Prevent Stricture after Extended Esophageal Endoscopic Submucosal Dissection

In past years, the cell-sheet construct has spurred wide interest in regenerative medicine, especially for reconstructive surgery procedures. The development of diversified technologies combining adipose tissue-derived stromal cells (ADSCs) with various biomaterials has led to the construction of numerous types of tissue-engineered substitutes, such as bone, cartilage, and adipose tissues from rodent, porcine, or human ADSCs. Extended esophageal endoscopic submucosal dissection (ESD) is responsible for esophageal stricture formation. Stricture prevention remains challenging, with no efficient treatments available. Previous studies reported the effectiveness of mucosal cell-sheet transplantation in a canine model and in humans. ADSCs are attributed anti-inflammatory properties, local immune modulating effects, neovascularization induction, and differentiation abilities into mesenchymal and non-mesenchymal lineages. This original study describes the endoscopic transplantation of an ADSC tissue-engineered construct to prevent esophageal stricture in a swine model. The ADSC construct was composed of two allogenic ADSC sheets layered upon each other on a paper support membrane. The ADSCs were labeled with the PKH67 fluorophore to allow probe-based confocal laser endomicroscopy (pCLE) monitoring. On the day of transplantation, a 5-cm and hemi-circumferential ESD known to induce esophageal stricture was performed. Animals were immediately endoscopically transplanted with 4 ADSC constructs. The complete adhesion of the ADSC constructs was obtained after 10 min of gentle application. Animals were sacrificed on day 28. All animals were successfully transplanted. Transplantation was confirmed on day 3 with a positive pCLE evaluation. Compared to transplanted animals, control animals developed severe strictures, with major fibrotic tissue development, more frequent alimentary trouble, and reduced weight gain. In our model, the transplantation of allogenic ADSCs, organized in double cell sheets, after extended ESD was successful and strongly associated with a lower esophageal stricture rate.

This study reports a successful method of endoscopical adipose tissue-derived stromal cell (ADSC)-sheet transplantation for esophageal stricture prevention after an extended endoscopic submucosal dissection (ESD) in a swine model.

In past years, the cell-sheet construct has spurred wide interest in regenerative medicine, especially for reconstructive surgery procedures. The ...

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 ...

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 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. ...

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. ...

Application of the O-arm Intraoperative Imaging System to Assist Anterior Cervical Screw Fixation for Odontoid Fractures

Odontoid fractures account for a large proportion of cervical spine fractures in the elderly, causing pain in the occiput and the back of the neck and restricting neck movement. Anterior cervical screw fixation is a common surgical procedure to treat odontoid fractures. Due to the special location and complex anatomy of the odontoid, surgeons need to perform intraoperative fluoroscopies repeatedly to ensure correct screw position and avoid damage to the peripheral nerves and vessels of the odontoid. The traditional anterior cervical screw fixation is usually conducted with the assistance of a C-arm. However, compared to the C-arm, an O-arm intraoperative imaging system can provide 3D images during surgery, which improves the accuracy of screw placement. This study retrospectively analyzed patients with anterior cervical odontoid fractures treated in our hospital. The application of the O-arm intraoperative imaging system for assisting screw placement in the treatment of odontoid fractures can reduce intraoperative blood loss, operation time, and trauma to the patients.

This study describes the application of the O-arm intraoperative imaging system in odontoid fractures.

Odontoid fractures account for a large proportion of cervical spine fractures in the elderly, causing pain in the occiput and the back of the neck and ...

Full-Endoscopic Decompression for Thoracic Ossification of the Ligamentum Flavum Combined with Dural Ossification

Ossification of the ligamentum flavum (OLF) can result in spinal stenosis. Thoracic spinal cord compression due to spinal stenosis is a common cause of progressive thoracic myelopathy in Asian countries. The incidence of complications is high in open decompression surgeries for thoracic OLF. With dural ossification (DO), the risk of complications is even higher in thoracic OLF. We introduce a full-endoscopic decompression surgery for thoracic OLF combined with DO under local anesthesia. Hemilaminectomy is performed using a high-speed burr under the endoscopy first, and then decompression of the contralateral spinal canal is completed using an "over the top" technique. DO resection uses the eggshell technique; after the base of the DO is cut from the lamina, forceps or lamina rongeurs are typically used for removal. The dural defect left after resection does not need repair. Neurological function was improved, and no complications such as hematoma or neck pain occurred. On imaging, no pseudodural cyst, cerebrospinal fluid leakage, or wound complications were observed after the operation. Endoscopic surgery causes less damage to the posterior ligament complex, so no cases of persistent back pain complaints or secondary internal fixation requirements were found in this study. Full-endoscopic decompression can achieve good imaging and clinical effects in the treatment of thoracic OLF with DO.

We describe a minimally invasive surgery using a full-endoscopy system for the single segmental thoracic ossification of the ligamentum flavum, combined with dural ossification, at Hebei General Hospital.

Ossification of the ligamentum flavum (OLF) can result in spinal stenosis. Thoracic spinal cord compression due to spinal stenosis is a common cause of ...

Transoral Endoscopic Thyroidectomy Vestibular Approach for Thyroid Lobectomy

The manuscript describes the transoral endoscopic thyroidectomy vestibular approach (TOETVA) for thyroid lobectomy. The patient is placed in the supine position with extension and fixation of the neck. One 20 mm transverse incision and two 5 mm incisions are made through the mucosa of the oral vestibule for camera and instrument placement after disinfection of the skin and oral cavity. The workspace is established and maintained by the skin suspension device, which is made of unabsorbable string (3-0) and rubber bands, and the CO2 insufflation pressure. Lobectomy using a medial-to-lateral technique and prophylactic ipsilateral central neck dissection is performed simultaneously on patients with papillary thyroid cancer (PTC). The specimen is extracted through the 20 mm incision. The parathyroid gland is immediately searched for in the specimen and auto-transplanted to the left brachioradialis. A drainage tube is inserted through the retractor hole into the bed of the thyroid gland, and absorbable sutures are used to close the mucosal incisions in the oral vestibule and the linea alba cervicalis. Prophylactics administered intravenously are recommended for the first 24 h after surgery, and oral antibiotics are used for 7 days postoperatively.

Here, we present a protocol to describe the methodology for the transoral endoscopic thyroidectomy vestibular approach in detail.

The manuscript describes the transoral endoscopic thyroidectomy vestibular approach (TOETVA) for thyroid lobectomy. The patient is placed in the supine ...

Techniques of Endoscopic Ossiculoplasty

Samenvatting

Meer video's verkennen

Hoofdstukken in deze video