Endoscopy in Chronic Ear Surgery

Endoscopes may be employed in chronic ear surgery as an adjunct for the removal of cholesteatoma.8 12 Residual disease most commonly occurs in the areas most difficult to expose under the operating microscope including the epitympanum, sinus tympani, and facial recess. Endoscopes are helpful to inspect these recesses and may be used to confirm the eradication of disease after microsurgical excision or to assist in the primary dissection of cholestea-toma. Tympanic membrane retraction pockets and shallow cholesteatomas that are limited to the attic, aditus ad antrum, facial recess, or sinus tympani are amenable to removal with endoscopic assistance, eliminating the need for mastoidectomy in many cases. The improved ability to remove cholesteatoma has reduced the incidence of residual disease and the number of planned second-stage operations. When a second-look procedure is necessary, it can often be performed through a transcanal approach with endoscopic assistance. Visualization into temporal bone recesses is far superior using endoscopes as opposed to surgical mirrors (Fig. 21-6).

Endoscopic techniques are not intended to replace microsurgical resection. There are several disadvantages with the use of endoscopes. There are no currently available satisfactory endoscope holders, so it is necessary to hold the endoscopes in the surgeon's nondominant hand, leaving only one hand free for surgical dissection. Bleeding usually neces

FIGURE 21 —6 (A) Microscopic view of left ear with cholesteatoma in posterosuperior pars tensa retraction pocket. (B) Four-millimeter 0-degree Hopkins rod endoscopic view of the same ear.

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FIGURE 21 —6 (A) Microscopic view of left ear with cholesteatoma in posterosuperior pars tensa retraction pocket. (B) Four-millimeter 0-degree Hopkins rod endoscopic view of the same ear.

sitates alternating between the use of a dissecting instrument and suction aspiration of blood, which markedly reduces the operating efficiency compared to two-handed techniques. It is recommended that dissection be performed with both hands using the operating microscope for dissection until reaching the limits of visualization and then switching to endoscopic techniques beyond the overhangs or into recesses. Endoscopes are usually reserved only for the limited times when dissection occurs in these difficult areas and are most typically used after most of the microscopic removal has been accomplished or for critical points when mobilization of disease out of a recess is needed. In many cases, microsurgical resection of cholesteatoma matrix may become hindered by adhesions extending into deep recesses, especially the sinus tympani. "Blind" elevation may tear the matrix and leave residual disease but endoscopes may permit direct visualization of the adhesions, allowing for lysis, mobilization of the intact matrix, and resumption of microsurgical dissection. Alternating between the microscope and endoscope is often helpful for optimal eradication of cholesteatoma.

Cases of limited cholesteatoma or tympanic membrane atelectasis with deep retraction pockets are conventionally approached using an atticotomy or mastoidectomy for exposure. The removal of cholesteatoma matrix is frequently done in a piecemeal fashion, particularly when the disease is far anterior within the epitympanum, deep into the sinus tympani, or on the medial surface of the scutum. Second-stage operations are often recommended after microsurgical removal of cholestea-toma, as complete removal of disease is uncertain. Limited cholesteatoma cases are well suited for endoscopic resection and can often be performed through a transcanal or postauricular-transmeatal approach without requiring atticotomy or mastoidectomy. Direct endoscopic visualization, allowing for complete removal of the intact matrix can obviate the need for second-look surgery

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