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.”
Explore this issue:March 2017
“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.”
He said he doesn’t use lateral grafts, but the underlay-overlay technique works well; the hardest part is raising the flap, for which he uses suction. “A lot of time that you spend doing these cases at the beginning, pays off at the end,” he said.
Lawrence Lustig, MD, Howard W. Smith Professor and chair of otolaryngology-head and neck surgery at Columbia University in New York City, said he can generally perform the typical otosclerosis procedure in 30 to 45 minutes.
“Is the endoscope the next step in our evolution? I really don’t think so,” he said. “I don’t think anybody in this room can argue that you get better visualization with an endoscope than you do with a microscope. The real crux of the matter is what’s better: one-handed surgery or two-handed surgery? … I personally would rather be a two-handed surgeon when I’m manipulating my ossicular prosthesis.”
He added that he thinks the visual quality of today’s microscopes shouldn’t be downplayed. If tools were developed to allow two-handed endoscopic surgery, he might be more interested, he added.
Dr. Jacob said that the one-handedness is outweighed by a “dramatic difference in the view that you get.… The chorda tympani is essentially untouched.”
He added: “Once you get the visualization it’s tough to go back to the microscope. Early on, there’s a lot of nervousness related to the technique and not being familiar with things. But then as time goes on, you get familiar and get used to that view.”
Attic Cholesteatoma Procedures
Dr. Rivas said that he would tend to do anterior, posterior, and lateral epitympanic cholesteatoma with an endoscope. But he added that lateral procedures are those for which the endoscope offers the least advantage.
The need for a mastoidectomy, for which a microscope is more likely to be required, has to be assessed in each case, and, at Vanderbilt, they’ve been able to avoid unnecessary mastoidectomy in about 40% of cases, he said. Using an endoscope can also help preserve the ossicular chain, which means better hearing. Controlling heart rate and mean arterial pressure so that there is less blood output, and controlling the intensity of the light for heat reduction, are important, too, he said.