Endoscopic Approach Reduces the Need for ‘Second-Look’ Mastoid Surgery

The impact of the endoscope has been one of evolution, not revolution, according to Dr. Haberkamp. So far, the endoscope has not changed mastoid surgery the way it has changed sinus surgery, he said.

He agreed with Dr. Sajjadi, though, that the endoscopic approach’s key advantages are greater visualization and the reduced need for more invasive repeat surgeries. It allows us to peer around the corner and see areas we couldn’t before and remove disease, he said. We’re able to avoid more radical surgeries in some cases.

Tight Space, Less Three-Dimensional Visualization

A key disadvantage that differentiates endoscopic mastoid surgery from endoscopic sinus surgery is the small size of the middle ear in relation to that of a sinus cavity. When you’re trying to work in the middle ear, it’s difficult to work with the endoscope and the instrument scooping out disease, Dr. Haberkamp said. The instrument and endoscope take up 25 percent to 30 percent of the space. Also, when you’re looking at the space with the endoscope, you lose the three-dimensional depth of field you have with the microscope, so you can’t always tell the difference between deep and shallow areas of the sinus tympani.

Surgeons should therefore be particularly cautious, he said, noting that he had observed fractures of the ossicles and stapes in training labs, even though he could not recall seeing such fractures in actual surgeries. It takes practice, he stressed. Even though fractures are rare, we should remember the potential for their occurrence and use caution.

He again agreed with Dr. Sajjadi that surgeons should be prepared to invest additional operating time during the learning phase. It takes an extra 20 minutes initially to add the endoscope to traditional techniques, he noted. It is still cost-effective, because you get better visualization and remove more disease.

Unlike repeat mastoid surgeries, endoscopic second-look procedures can be done in the office with a local anesthetic in selected patients, he added.

Dr. Haberkamp noted that the endoscopes used in mastoid procedures are much smaller than conventional sinuscopes: they come in sizes of 1.7 mm, 2.7 mm, and 3.5 mm in diameter. One limitation, though, is that the endoscopes at 70° do not come in the smaller size.

No Separate ICD-9 Code

Both experts pointed out that there is no separate International Classification of Disease-9 (ICD-9) code for endoscopic mastoid surgery. Therefore, the accounting department will need to use the same code as when billing for a standard mastoid procedure. If you bill additionally for the endoscopic, insurance companies vary in how easy it is to get paid, Dr. Haberkamp said.