Endoscopic Trans-canal Stapes Surgery

Endoscopic Trans-canal Stapes
Surgery

João Flávio O tosclerosis is one of the most frequent causes of conductive hearing loss in
Nogueira, MD, adults. Surgical treatment is considered to be the gold-standard for this
Director – Sinus Centro, disease and stapes surgeries are currently performed with the aid of an
ENT department of operating microscope with excellent results worldwide.1,2 Although it has been more
General Hospital of than 15 years since the introduction of operative endoscopy to middle ear surgery,
Fortaleza, Fortaleza, there is still perceived to be a limited role for endoscopy in the surgical management of
Brazil. middle ear diseases and otosclerosis.2,4
There are several possible reasons for this, including a potentially long learning curve
Correspondence through the initial stages of adapting newer techniques and different instrumentation
E: for one handed work.2,3
www.sinuscentro.com.br As is well known, traditional microscopic stapedotomy requires optimal exposure of
the oval window niche in order to reduce complications or failure in stapes surgery. In
Declaration of most of the cases it requires partial removal of the posterior bony wall of the external
Competing Interests ear canal (EAC) and the manipulation of the chorda tympani. When using the micro-
None declared. scope, the surgeon, most of the time, cannot easily see the anterior crus of the stapes,
thus the removal of the suprastructure will be performed in a blind fashion. This article
describes the use of the endoscope during stapes surgery and discusses the advantages
and disadvantages of this approach.

Surgical technique and equipment: nerve to ensure that it is not prolapsed
All of our endoscopic procedures are onto the footplate. After a test of the ossic-
performed under general hypotensive ular chain, the incudo-stapedial joint is
anaesthesia. Patients are positioned in the disarticulated sharply in an anterior-poste-
same manner as traditional microscopic rior plane and the stapedial tendon is
otologic surgery. The video equipment is divided with a small pair of scissors. The
placed in front of the surgeon. We use stapes superstructure is downfractured
almost the same instruments, with the with light force after the crura have been
addition of some specially designed small divided with a small drill and removed,
suction Freer elevator and curved suction leaving the footplate intact.
tips, as well as 0º and 30º, 4mm diameter, During revision surgery we carefully
18cm endoscopes. remove the scar tissue from the oval
Adrenaline (1:2,000) soaked cottonoids are window niche, exploring the stapedotomy
placed into the EAC for five minutes. No hole and the position of the prosthesis. A
infiltration is performed. With a 4mm, 0º regular Teflon or titanium prosthesis
endoscope a tympanomeatal flap is raised (0.6mm in diameter and 6mm in length) is
at the posterior wall of the EMC (Figure sized by measuring the distance from the
1A). footplate to the medial surface of the
With a 30º endoscope, an inspection of the incus. This measurement can be
middle ear is performed (Figures 1B and performed preoperatively using 3D virtual
2A). Attention is directed to the facial otoscopy programs using the DICOM files

After a test of the ossicular chain, the incudo-stapedial joint is
disarticulated sharply in an anterior-posterior plane and the stapedial
tendon is divided with a small pair of scissors

feature

Figure 1: A: Endoscopic view (4mm diameter, 18cm length, 0º). Tympanic membrane (tm). B: Middle introduction of the classic stapedectomy
ear with structures: facial nerve (fn), pyramidal eminence (pe), long process of incus (lpi). Note the technique by Shea many different
stapes footplate with a persistent stapedial artery. C: Prosthesis in place. D: Virtual otoscopy showing the procedures have been described in the
resemblance between the real anatomy and the virtual 3D reconstruction. literature using a microscopic approach.6 In
the recent literature the introduction of
the endoscope in middle ear surgery has
permitted the development of new
anatomical and physiological concepts7-9
specially in cholesteatoma surgery. It is well
known that the operative microscope does
not permit the surgical control of the
hidden areas in the middle ear such as the
sinus tympani, the anterior epytimpanic
space, the protympanic recess and the
facial sinus recess.
At present, several works are focused on
the importance of the endoscopic
approach during cholesteatoma surgery to
have a better view of the recesses of the
middle ear, detecting residual disease.10-13
There is little in the literature regarding the
use of the endoscope during stapes surgery
(stapedotomy), given the magnification,
exposition of the oval window niche and

Figure 2: A: Endoscopic view with 0º endoscope: optimal exposition of the oval window niche (own) Figure 3: Virtual 3D reconstruction using the DICOM
without chorda tympani manipulation. Note the facial nerve (fn), incus (i), round window niche (rwn), files from the CT scan. Note the malleus (m), incus
pyramidal eminence (pe); B: The platinotomy at the stapes footplate (p); C: Prosthesis in place; D: (i), stapes (s), lateral semi-circular canal (lsc) and
Tympanic membrane after the repositioning of the tympano-meatal flap (tmf). the virtual measurement of the space between the
incus and the footplate (red line).
from the CT exam of the patient (Figures movement of the ossicles all the way
1D and 3). This measurement is always through the prosthesis. The tympa- the view of the stapes that this allows. On
confirmed during surgery. nomeatal flap is repositioned (Figure 2D) basis of our previous work9-12 we started to
A small fenestration is created at the mid- and sealed with antibiotic ointment or perform stapes surgery (stapedotomy)
portion of the footplate with a traditional antibiotic solution-treated Gelfoam©. using an endoscopic transcanal approach.
straight pick instrument or a small drill This endoscopic approach allowed us to
(Figure 2B). The prosthesis is placed Results and discussion have a better view and control on oval
between the oval window and the incus All 30 patients in our series showed window niche bypassing the EAC and
(Figures 1C and 2C). Perilymphatic fluid improvement of their hearing loss. The chorda tympani.
suctioning is avoided to minimise postop- mean preoperative speech recognition A disadvantage of the endoscopes is that it
erative vertigo and cochlear damage. The threshold (SRT) was 65dB; postoperatively requires a one-handed surgery. However,
malleus is carefully palpated to ensure this improved to 30dB. Since the most microscopic stapes surgeries are
performed using one hand with excellent

results worldwide. The lack of true three dimensional References
(binocular) vision during the procedure is perceived as a
drawback, but with sufficient experience, this has a very 1. Mahendran S, Hogg R, Robinson JM. To divide or manipulate the chorda tym-
limited impact on the procedure. Some advantages pani in stapedotomy. Eur Arch Otorhinolaryngol 2005;262(6):482-7.
regarding the use of the endoscopes during stapes surgery
include an excellent exposition of the oval window niche 2. Nogueira Junior JF, Martins MJ, Aguiar CV, Pinheiro AI. Totally endoscopic
without removal of healthy bone from the EAC, avoiding stapes surgery (stapedotomy): technique and preliminary results. Bras J
any manipulation of the chorda tympani, and a good view Otorhinolaringol 2011;77(6):721-7.
of the anterior crus of the stapes, allowing its removal
without blind manoeuvers. 3. Tarabichi M. Endoscopic middle ear surgery. Ann Otol Rhinol Laryngol
Although this technique is not suitable for those at the early 1999;108(1):39-46.
stages of endoscopic ear surgery, it has much to offer the
surgeon and the patient. 4. Karhuketo TS, Puhakka HJ. Endoscope-guided round window fistula repair. Otol
Neurotol 2001;22(6):869-73.
Conclusion
In our series, endoscopic stapes surgeries using endoscopes 5. Kisilevsky VE, Bailie NA, Halik JJ. Modified laser-assisted stapedotomy.
were technically feasible, safe and promising. There were Laryngoscope 2010;120(2):276-9.
both advantages and disadvantages. The main advantages of
the endoscopes were: no trauma to the chorda tympani, 6. Marchioni D, Alicandri-Ciufelli M, Molteni G, Artioli FL, Genovese E, Presutti L.
and an excellent field of view, with the visualisation of the Selective epitympanic dysventilation syndrome. Laryngoscope 2010;120(5):1028-
anterior crus of the stapes, its suprastructure and the oval 33
window niche. The disadvantages were lack of stereoscopic
view, no capability of bi-manual work and a learning curve. 7. Marchioni D, Alicandri-Ciufelli M, Grammatica A, Mattioli F, Presutti L.
As this technique develops, many of the drawbacks will be Pyramidal eminence and subpyramidal space: an endoscopic anatomical study.
overcome and, given the advantages of access and reduced Laryngoscope 2010;120(3):557-64.
morbidity, the use of the endoscope in surgery of the middle
ear and of the stapes will be likely to expand. 8. Nogueira Júnior JF, Cruz DN. Ear endoscopic surgery: dissection of the middle
ear. Intl Arch Otorhinolaryngol 2009;13(4):421-5.

9. Marchioni D, Mattioli F, Alicandri-Ciufelli M, Presutti L. Transcanal endoscopic
approach to the sinus timpani: a clinical report. Otol Neurotol 2009;30(6):758-
65.

10. Presutti L, Marchioni D, Mattioli F, Villari D, Alicandri-Ciufelli M. Endoscopic
management of acquired cholesteatoma: our experience. J Otolaryngol Head
Neck Surg 2008;37(4):481-7.

11. Ayache S, Tramier B, Strunski V. Otoendoscopy in cholesteatoma surgery of the
middle ear: What benefits can be expected? Otol Neurotol 2008;29(8):1085-90.

12. Badr-el-Dine M. Value of ear endoscopy in cholesteatoma surgery. Otol Neurotol
2002;23(5):631-5.