As a child, I had several ventilation tubes inserted into my left ear, including a long-term tube. I remember having to move from an exam room to a procedure room, lying on a flat, cushioned examination table, and having my ear suctioned. I hated it. When the ventilation tube was eventually removed, I needed a tympanoplasty. After the surgery, my auricle felt numb, I couldn’t hear, and it hurt. I still bear a large (4 cm) horizontal scar over my left ear (temporalis fascia) with a bump where the hair doesn’t grow. Even at the time (late 1980s), it seemed like an awfully large incision. My left ear had a tendency to feel clogged, and it was always harder to equalize.
In 2015, after returning home from a trip, my left ear clogged during descent and remained so for several days. I knew something was off. At the end of the day, back at work, seeing patients, I put an endoscope in my ear, and I found a small retraction pocket of the pars flaccida, accumulating debris. For goodness’ sake, I had a cholesteatoma!
I followed it for about a year with endoscopic self-examination. I had my medical partner debride my ear under the microscope every few months. He would pull out squamous debris, and the ear would ache, then feel slightly better. I knew I was eventually going to need surgery. I wanted that surgery to be endoscopic.
Using endoscopes in ear surgery has always made sense to me. I never used them in residency or fellowship, but during residency, I attended several Academy lectures about endoscopic ear surgery by Muaaz Tarabichi, MD. He was talking about something unique and interesting, and it fascinated me. I admired Dr. Tarabichi for his commitment to developing a new skill and for advocating for it. Those presentations convinced me that endoscopic ear surgery has a place in our specialty.
After I completed an otology fellowship and began practicing, I performed ear surgeries microscopically, which was how I had been trained. However, I added a step to satiate my curiosity and to assess my outcome of the microscopic surgery. At the end of each case, and after I was convinced that I had removed all cholesteatoma, I would ask for an endoscope and tower. I wanted to confirm I wasn’t missing anything, especially in the posterior mesotympanum. I wanted to apply what already made good sense to me; I wanted to see around the corner. The OR staff would sigh (I knew they were thinking I was difficult), but they dutifully did as I asked. I would not infrequently find a small bit of cholesteatoma hidden around a corner when I was certain it had all been removed. So, I wanted to make a change in my surgical practice.
It was 2014, and I decided to develop my skills. I registered for two courses: the Vanderbilt Endoscopic Middle Ear Surgical Dissection Course, directed by Drs. Alejandro Rivas and Marc Bennett, and the Toronto Endoscopic Ear Course, directed by the late Dr. David Pothier, and Drs. John Rutka and Ian Witterick. They were both outstanding courses. (Later, in 2016, I also attended the Harvard Endoscopic Ear Surgery Dissection Course, directed by Drs. Daniel J. Lee and Michael S. Cohen.)
About a week after the second course, I performed my first endoscopic ear case— the resection of an epitympanic cholesteatoma. The surgery went wonderfully, and I enjoyed it! The patient had a great outcome and continued without recurrence.
I started with the endoscopes and the video tower used for functional endoscopic sinus surgery, Rosen needles, straight suctions, round knives, sickle knives, etc. It worked well for tympanoplasties and epitympanic cholesteatoma. Shortly thereafter, I purchased angled endoscopic ear instruments, which allowed for deeper dissection into the posterior mesotympanum and toward the mastoid antrum.
After I found the cholesteatoma in my own left ear in 2015 and had had several debridements, I realized it would be irresponsible to delay definitive treatment further. If I were going to avoid a mastoidectomy, I would have to get to the cholesteatoma before it extended too deeply within the mastoid. I had a CT of the temporal bones. To my relief, my cholesteatoma was ideal for endoscopic resection, potentially avoiding a postauricular incision. At the time, no one in my area was performing endoscopic surgery for cholesteatoma, and, of course, I wanted the best surgeon within a reasonable distance. I had attended lectures about endoscopic middle ear surgery and using endoscopes in surgery for superior semicircular canal dehiscence by Dr. Daniel Lee at Massachusetts Eye and Ear. I knew he was a good surgeon, and I liked him. I brought him my CT, and we had a brief meeting. I wanted endoscopic ear surgery, and I knew he was the surgeon to do it.
The surgery went very well. Dr. Lee gave me a video of the procedure so I could review it post-op. My chorda tympani was sacrificed, and I had a partial prosthesis (Kurz, CliP). I required no pain medications. I had no numbness. I had no hair loss, with only a small incision to obtain conchal cartilage. My surgery was on a Monday, and I was back operating on my own patients on Wednesday. Water tasted metallic on the left side of my tongue for two months after surgery, but one day, like magic, it was gone. My hearing result was very good (only a mild conductive loss).
I continue to routinely perform endoscopic ear surgery. Adopting it made sense to me; it fits in my practice and with my experience. Developing the skills took some time but did not require a significant amount of new resources. I feel fortunate. My experience as a patient has allowed me to better describe surgery and the post-operative experience to my patients. Sometimes I will describe my experience to them. I feel strongly that, in many cases, endoscopic ear surgery is in their best interest, and I am confident when I make that recommendation.
Dr. Wycherly is an otolaryngology–head and neck surgeon at the Ear, Nose & Throat Institute of Connecticut.
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