Experts in ear surgery debated the merits of the endoscope in a panel session at the Triological Society Combined Sections Meeting, a discussion that centered largely on the two-handed maneuverability available when using a microscope versus the improved visualization gained when using an endoscope, which leaves just one free hand for the procedure.
Abraham Jacob, MD, associate professor and vice chair of otolaryngology and director of the University of Arizona Ear Institute in Tuscon, Ariz., said the endoscope has led to a more intimate and detailed look at the structures of the middle ear space, such as the retrotympanum and its associated structures, like the proximal portion of the intratemporal facial nerve. This new understanding paves the way for more precise and effective surgery, he said.
Because using an endoscope allows surgeons to sit in a more upright position, as opposed to the more head-forward position required for using a microscope, there may be less strain on the neck, he added. “A lot of people worry about the learning curve, but it’s not too bad,” Dr. Jacob said. “Even my very first case, where I thought I would just be raising a [tympanomeatal] flap, I ended up doing the whole tympanoplasty with the endoscope.”
- He made these suggestions for surgeons just beginning to use the endoscope:
- Start using standard otology instruments and a 14 cm-length, 3mm-width, 0-degree endoscope.
- Perform your first set of endoscopic procedures on light OR days.
- Start by using just your standard otology instruments.
- Start with simple procedures, such as a straightforward tympanoplasty or even pressure equalizer (PE) tube insertions.
- Be sure to use adequate anti-fog so the scope doesn’t cloud up.
- At first, try using the endoscope only for portions of the surgery with which you’re most comfortable.
Anterior Tympanic Membrane Perforation
Michael Hoffer, MD, professor of otolaryngology and neurotology at the University of Miami in Florida, advocated for using the microscope. “It allows you to use a two-handed technique, and it gives you 3-D vision,” he said.
He said that the lateral graft procedure has been shown to produce the best results for anterior tympanic membrane perforations, but a case involving a lot of bleeding can be very difficult using an endoscope. “I don’t see in this particular case where you would be better off using the endoscope,” he said.
Alejandro Rivas, MD, associate professor of otolaryngology and neurological surgery at Vanderbilt University in Nashville, said that using differently angled scopes can help the endoscopic procedure match the ease of using a microscope. The mobility of the endoscope means that the patient can stay in the same position. “We don’t have to turn the head,” he said. “Ergonomically, for the patient, it’s good. And, ergonomically, for you, it’s good.”
“In children, it’s ideal,” he added. “Very rarely the size of the ear canal matters. You can repair perforations as early as 4 years old. You barely have to put any packing after surgery.”