Scan the literature on transcanal endoscopic ear surgery (TEES) and you’ll find a host of benefits for the procedure when it is compared with its microscope-guided counterpart, including enhanced visualization, superior training, and reduced post-operative complications, to name just a few (Am J Otolaryngol. doi:10.1016/j.amjoto.2020.102451). Coupled with recent equipment advances, such as thinner, more flexible endoscopes and ones that combine cutting and suctioning for enhanced bleeding control, it’s clearly an exciting time for TEES.
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July 2025It would be hard to find a more dedicated proponent of the technique than Justin S. Golub, MD, MS, vice chair of faculty development in the department of otolaryngology–head and neck surgery at the Columbia University Vagelos College of Physicians and Surgeons and NewYork–Presbyterian/Columbia University Irving Medical Center, in New York City. Dr. Golub is one of several leaders in ENT surgery who are part of a national, concerted effort to drive more widespread adoption of TEES.
A cornerstone of that effort is the American Endoscopic Ear Surgery Study Group (AEESSG), which held its 2024 annual meeting last Fall in Miami, during the American Academy of Otolaryngology–Head and Neck Surgery Foundation (AAO–HNSF) annual conference. Dr. Golub is a board member and past president of AEESSG and part of a panel that presented best practices for TEES treatment of cholesteatomas at the group’s annual meeting. But before offering some highlights from his presentation, he first made a pitch for ENT surgeons with an interest in TEES to join AEESSG.
“This is your chance to be a leader in this field, because it’s still relatively small—fewer than maybe 15% or so of ENT surgeons are performing TEES nationwide,” he said. “It’s an opportunity to help us spread the word and have more champions on board who can speak to and disseminate the advantages of this technique for both the surgeon and the patient.”
Key Benefits of TEES
As for what those key benefits are, Dr. Golub highlighted three he feels make the strongest case for why an ENT surgeon might want to consider TEES. The number one benefit is that the use of minimally invasive surgery avoids having to make a postauricular incision, which is often needed during microscopic-guided tympanoplasty. “That means less pain for the patient, less numbness, and less downtime,” he said.
Those benefits are supported by published data. In a head-to-head comparison of endoscope- and microscope-guided tympanoplasty conducted by Choi et al, pain scores one day after surgery using an 11-item, patient-reported numeric rating scale were significantly less in endoscopically treated patients than in those treated with a microscope-guided approach (Clin Exp Otorhinolaryngol doi:10.21053/ceo.2016.00080). Similarly, a study done by Kakehata et al found that NSAID use was lower for patients treated with TEES (1.3 pills/week) than for those treated with microscopic ear surgery (5.5 pills/week; P<0.001, Mann-Whitney U test). And a study Dr. Golub co-authored cited favorable data for post-operative numbness and other patient-reported outcomes in patients treated via the endoscopic transcanal approach (J Pers Med doi.org/10.3390/jpm12101718).
Perhaps an even more compelling benefit of the endoscope is the superior view of the middle ear that it affords, in part due to its angled orientation, Dr. Golub noted. “You really can see hidden pathology that is often very difficult to visualize with the microscope,” he said. In the case of cholesteatomas, this better visualization is particularly advantageous because it enables the surgeon to see and remove the entire mass more reliably than with a microscope, which in his clinical experience and published data (Int J Pediatr Otolaryngol doi:10.1016/j.ijporl.2020.109872) “results in less recurrences, because you are leaving behind less residual disease,” he said.
The endoscope also reduces the need to perform a canal-wall-down mastoidectomy, “a destructive and invasive” procedure that is sometimes required when using a microscope to better visualize the surgical field, Dr. Golub noted. With the endoscope, in contrast, “you can avoid taking the canal wall down because you can literally just see around it.”
Dr. Golub cited a final key benefit: Endoscopic-guided middle ear surgery “is excellent for training and fosters a sense of camaraderie in the operating room.” With the endoscope, “everyone is looking at the same screen,” he explained. With microscopic ear surgery, in contrast, only the operating surgeon has the ideal view, while everyone else typically views a 2D image on a TV screen “that is often slightly out of focus, sometimes off-center, and may not even show the area the surgeon is working on.”
Kristen Yancey, MD, an assistant professor of otolaryngology-head and neck surgery at Weill Cornell Medicine in New York City and a co-panelist at the AEESSG meeting, echoed and amplified those training benefits. With the shared visualization cited by Dr. Golub, “you’re more able to direct and guide your trainee’s movements and more effectively demonstrate key anatomy,” she said. Moreover, “with an older microscope, the observer’s view can be a little bit darker, which impedes your ability to see certain structures as clearly.”
When working in a small microscopic area, “these subtle differences in lights, optics, and orientation can make a big difference,” Dr. Yancey said.
A Lighter and Better Endoscope
For most evolving surgical techniques, new developments in equipment are key. In the case of EES, Dr. Golub cited the Colibri endoscope (3NT Medical) as an example of such an advancement. Unlike bulky traditional endoscopes, Colibri features “a lightweight ergonomic handpiece, a 2.2-mm diameter tip, and built-in suction to enable two-handed functionality in a single device,” the company noted in a news release announcing the device’s 2020 U.S Food and Drug Administration approval (3NT Medical. https://tinyurl.com/yc6enwtt).
Dr. Golub said he is a fan of the Colibri endoscope for several reasons. “Number one, it’s extremely lightweight,” he said. “It’s made out of hollow plastic, as opposed to traditional endoscopes, which frankly feel like you’re holding a stick with a heavy brick coming out at the end.” Colibri, in contrast, he said, “is light enough so that you can hold it with your non-dominant hand and control its built-in suction with your thumb, while making incisions with the other hand. It’s kind of like operating with one-and-a-half hands, which is a huge improvement over traditional endoscopes.”
Dr. Golub acknowledged that using Colibri is not as good as having two free hands, which is possible during microscope-guided middle ear surgery. “But it’s definitely a huge advancement for TEES.” Asked about Colibri, Dr. Yancey said its built-in suctioning capability “is a great idea. I’m just waiting for the resolution on the camera to get better before I push for it.”
Dr. Golub also stressed that for surgeons interested in learning how to perform TEES, “you don’t need to have the latest and greatest endoscope—you can do this with a 4-mm by 18-cm Hopkins rod-style endoscope that every otolaryngologist has in their operating room for performing sinus surgery.” He added, however, that some tools will make it easier to get started, such as a suction round knife and curved suctions, which are also widely available.
Taking the First Steps
When adding TEES to one’s surgical repertoire, the obvious place to start is education and training, Dr. Golub noted. For that, he reiterated the benefits of joining AEESSG. But as a baseline, “if you’re comfortable using an endoscope for other otolaryngology procedures,” such as the aforementioned sinus surgery, “you have most of the experience you’ll need to start doing [ear] cases.”
Choosing an appropriate first patient, however, is critical, Dr. Golub stressed. “Book a simple case, like ear tubes, and try using the endoscope,” he said. “That’s an easy place to start. Once you’re comfortable, then progress to a simple reconstructive ear surgery, such as a myringoplasty. When you master that, the next step is a tympanoplasty, and it progresses from there.”
Still, patience will be required, Dr. Golub noted. “Even if you are relatively adept at microscopic ear surgery, unless you’ve been trained from the start as an attending at a center where TEES is routinely used, you’re going to be a very slow endoscopic middle ear surgeon—at least in the beginning,” he said. “So it’s really important to give this time, because if you keep at it, you will definitely acquire this skill.”
Once that happens, one of the main payoffs will be speed, Dr. Golub noted. “Ultimately, endoscopic middle ear surgery is faster than most microscopic-guided [procedures] because you don’t have to open a big postauricular incision and then close it,” he reiterated.
That clinical observation is supported by published data. In the Choi et al comparison study, for example, mean operation time for microscopic tympanostomy (MT) was 88.9 + 28.5 minutes longer than that of endoscopic tympanostomy (ET) (68.2+ 22.1 minutes; P=0.002).
Achieving Better Visualization
Once your confidence level with endoscopes in the middle ear builds, it’s useful to start thinking about refining your technique even further, Dr. Yancey noted. During her AEESSG presentation, she focused on one important goal in such efforts—achieving better visualization.
Positioning the patient is a key first step, Dr. Yancey stressed. She recommended measured use of the reverse Trendelenburg position, which can improve visualization by enhancing venous outflow from the head (Int Forum Allergy Rhinol. doi:10.1002/alr.22734). “I was taught to also have the patient positioned towards the edge of the bed by Dr. Brandon Isaacson, an expert in endoscopic ear surgery at UT Southwestern [Medical Center in Dallas],” Dr. Yancey added. That positioning strategy decreases the “reach” needed to access the ear and therefore increases the surgeon’s stability of maneuvers, she explained.
Moreover, the surgeon’s monitor should be positioned at eye level, directly across from the operative ear, to promote good ergonomics, Dr. Yancey urged. To that end, she recommended using surgical chairs with armrests to support stability while operating. Another useful tip is to set up the operative site so that an instrument wipe and a de-fog pad are readily available. Employing those items “helps efficiently maintain a clear view throughout the case,” she said.
Even basic steps, such as taking time to adequately trim the ear hair and allowing sufficient time for the local anesthetic to take effect, will also help enhance visualization. Otherwise, “you can find yourself fighting blood in the canal and cleaning the lens of your endoscope too frequently,” she said.
Dr. Yancey cited a few additional strategies for controlling bleeding and maintaining a clear line of sight during surgery. In addition to using colloids or pledgets infused with epinephrine for its vasoconstrictive effects (J Otorhinolaryngol Relat Spec. doi:10.1159/000503725), Dr. Yancey recommended using a dedicated suction elevator device that is designed for TEES. “These can be particularly helpful when elevating the tympanomeatal flap, which typically is the bloodiest part of ear surgery cases,” she said. There are a couple of different models designed for this, she noted, including ones from Grace Medical. Whichever device you use, “once you get that initial flap elevated, ear canal bleeding is dramatically improved, and you can really enjoy the benefits of the expanded view that the endoscope affords.”
Predicting When TEES is the Best Option
Left: Transcanal microscopic view is limited by the size of the speculum. Right: Transcanal endoscopic view is wider than the microscope.
As strong as the case is for TEES, there are instances when surgeons begin the procedure and then, at some point, have to switch to the microscope after encountering structural anomalies or other unforeseen complications. When that happens, delays in care can result. With this possible complication in mind, a few years back, Daniel Killeen, MD, an assistant professor in the department of otolaryngology–head and neck surgery at UT Southwestern Medical Center in Dallas, decided to explore whether those surgical switches could be more reliably predicted. What he and his colleagues came up with is the antrum-malleus-tegmen (AMT) score, a novel computed tomography (CT) screening tool that can be used to determine pre-operatively whether a patient is a strong candidate for TEES versus the microscope-guided approach.
Dr. Killeen first published on the efficacy of this predictive tool in 2019 (Otol Neurol. doi:10.1097/MAO.0000000000002395), but he’s using those findings to effectively guide current cases and recently described its evolving utility at the AEESSG annual meeting. He began by summarizing the key data. The 2019 study included 59 cholesteatoma patients, 39 of whom were treated with TEES and 19 who required conversion to an open mastoidectomy. After controlling for “a host of confounders,” including patient age, gender, disease laterality, and revision surgery status, Dr. Killeen and his co-investigators identified three independent radiographic predictors for having to convert to an open mastoidectomy. Those risk factors—each of which is given numerical values used in the scoring system—were antrum opacification (P=0.023), malleus erosion (P=0.044), and tegmen erosion (P=0.023) (Figure 1). Looking at the data another way, they found that when two or more of the following conditions were met—an aerated antrum, an intact malleus, and an intact tegmen—TEES was achievable in 88% of cases.
If you’re a good surgeon with a microscope, you’ll always achieve better outcomes than would a bad surgeon with an endoscope. This is not a magic wand we all can wave at a patient with middle ear disease. —Daniel Killeen, MD
But the scoring system’s ability to warn against TEES is often the one that guides Dr. Killeen in his practice. “Just last week I had a cholesteatoma patient who had two of the three red-flag imaging findings we identified in the paper—antrum opacification and malleus erosion—and I saw that as reason to not do the procedure endoscopically,” he said. Interestingly, as he began the surgery guided by the microscope, the extent of disease looked fairly limited, “and I thought, dang it, maybe I could have done this with the endoscope. But sure enough, as I progressed, the cholesteatoma kept extending into the mastoid. So I actually was glad I had used the microscope from the beginning, because it saved me the considerable time that would have been lost converting from endoscopic to open surgery.”
Making the Right Choice
For some ENT surgeons, choosing between an endoscope and a microscope often comes down to skill and experience. “If you’re a good surgeon with a microscope, you’ll always achieve better outcomes than would a bad surgeon with an endoscope,” Dr. Killeen said. “This is not a magic wand we all can wave at a patient with middle ear disease.”
Dr. Killeen also stressed that not all studies comparing TEES versus microscope-guided surgery show clear superiority for the endoscopic route. “At best, we can say it’s non-inferior,” he said, citing, as an example, a study he co-authored showing similar rates of post-operative closure in tympanoplasty patients treated with either route (Otol Neurotol Open. doi:10.1097/ONO.0000000000000016).
He did acknowledge that TEES spares a patient a postauricular incision and the longer recovery that entails. “But I have to say that most patients are not bothered by that [recovery],” Dr. Killeen said. “So if the microscope is what you excel at as a surgeon, stick with it. Now, do I think that learning the endoscope is quite as hard as some surgeons might assume? Probably not. But I also realize that if you have four or five procedures scheduled on a given day, and the endoscope will initially be about an hour slower per procedure for folks new to it, I absolutely get why you might not want to switch.”
Dr. Golub agreed that TEES will never be an attractive option for all ENT surgeons. But he certainly wants the procedure’s adherents to grow. “That’s why my personal goal is to bolster TEES adoption nationwide, by training both younger and older physicians so they can have this valuable tool in their middle ear surgery armamentarium.”
AEESSG Eyes More Widespread Endoscopic Ear Surgery Adoption
New surgical techniques often need a champion, and transcanal endoscopic ear surgery (TEES) is no exception. Fortunately, the American Endoscopic Ear Surgery Study Group (AEESSG) is doing its part by seeking new funding that it hopes will enable it to provide more training and education, attract new members, and spread the word that this minimally invasive technique deserves more widespread adoption among U.S. practitioners.
“We’re working on getting incorporated, which will really help with funding and strengthen our ability to develop free webinars, video tutorials, social media platforms, and other methods for spreading the word about TEES,” said Daniela Carvalho, MD, MMM, the group’s current president. The key message? “That TEES is amazingly beneficial not just for our patients but also for ENT physicians and the healthcare system as a whole,” given the many benefits of TEES when compared with microscope-guided techniques, she noted.
ENT physicians who become AEESSG members “will be joining a group of about 100 practitioners who share a passion for TEES,” said Dr. Carvalho, medical director of surgical services, director of the hearing and cochlear implant program, and director of the CHARGE Center at Rady Children’s Hospital–San Diego. Given the heterogeneity of the group—it includes otologists, neuro-otologists, pediatric otolaryngologists, general ENTs, and trainees—“there’s a great opportunity for some really powerful knowledge sharing.”
TEES is amazingly beneficial not just for our patients but also for ENT physicians and the healthcare system as a whole,” given the many benefits of TEES when compared with microscope-guided techniques. —Daniela Carvalho, MD, MMM
In fact, that theme of sharing is one of Dr. Carvalho’s major AEESSG goals for 2025, with members urged to develop videos that depict particularly challenging EES cases and other valuable lessons learned. “It’s always great to have colleagues, either in person or via videos, to lean on when you have a patient with a more complicated presentation,” she said.
With the group’s impending incorporation and improved funding, “we should be able to offer those videos to AEESSG members for free,” as opposed to the majority of videos and webinars offered by other groups that charge for such content. “We also plan on keeping AEESSG membership free or just charging a nominal fee.”
Dr. Carvalho is well suited to shepherding AEESSG through all of these initiatives, having served as president of the Society for Ear, Nose and Throat Advancement in Children (SENTAC), where she spearheaded, alongside “a fantastic interdisciplinary leadership team,” significant membership growth. During her stint at SENTAC, Dr. Carvalho also promoted the dissemination of several new treatment modalities for children with ENT disorders, including TEES.
She was also the first woman to join the International Working Group on Endoscopic Ear Surgery in 2010, when the technique was still in its beginning phase. With the AEESSG created in 2015, “I was thrilled, because I saw an opportunity to help practitioners in the U.S. catch up to our colleagues in Europe and other countries around the world so that we could offer this amazing technique to our own patients.”
Several factors caused the U.S. lag, such as how the U.S. Food and Drug Administration approves medical devices, “and the way a lot of our teaching hospitals favor more traditional microscope-guided middle ear surgery,” Dr. Carvalho said. “Don’t get me wrong, the microscope can be a great modality and still plays an important role” in these cases, she stressed. “But U.S. practitioners tend to be more conservative when it comes to adopting new surgeries.” As president of AEESSG, Dr. Carvalho hopes that she can help surgeons overcome some of that reticence through training, education, and advocacy. “If I can accomplish that, then I will have done my bit to advance this great technique,” she said.
Justin S. Golub, MD, MS, vice chair of faculty development in the department of otolaryngology–head and neck surgery at the Columbia University Vagelos College of Physicians and Surgeons and New York–Presbyterian/Columbia University Irving Medical Center, in New York City, is a current board member and past president of AEESSG. His advice for those interested in joining AEESSG is to visit the group’s website (endoear.org), which includes information on how to become a member, along with directions on subscribing to a mailing list that will keep you up to date on the latest advancements in TEES.
Dr. Golub also recommended attending the next AEESSG event, which is scheduled to take place during the AAO–HNSF Annual Meeting in October 2025, in Indianapolis. And he also helps run the Columbia Endoscopic Course, “where we have been teaching endoscopic ear, sinus, and skull base surgery for seven years,” he said. “We’re skipping spring 2025 for a reset, but we will be bringing it back, and it will be better than ever next Spring,” so mark your calendars for that event, Dr. Golub stressed.
David Bronstein is a freelance medical writer based in New Jersey. Disclosure: Dr. Golub co-runs an annual endoscopic ear surgery training course that is supported by industry (https://www.columbia.edu/~jg3629/endo/sponsors/index.html) but reported no financial relationships with any company.
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