How do you perform your tympanoplasty, endoscopically or microscopically?

Clinical Research ENT Updates 2019;9(2): 144-149 DOI: 10.32448/entupdates.594625 How do you perform your tympanoplasty, endoscopically or microscopically? Ali Bayram1, MD - Daniele Marchioni2, MD - Kevin Peng3, MD - Il Joon Moon4, MD - Cemal Cingi5, MD 1: Department of Otolaryngology, Kayseri City Hospital, Kayseri, Turkey, ORCID: 0000-0002-0061-1755 2: Department of Otolaryngology, University Hospital of Verona, Verona, Italy, ORCID: 0000-0002-8004-7284 3: Department of Otolaryngology, House Clinic, Los Angeles, California, United States, ORCID: 0000-0002-9166-0869 4: Department of Otolaryngology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea ORCID: 0000-0002-3613-0734 5: Department of Otolaryngology, University of Osmangazi, Eskişehir, Turkey, ORCID: 0000-0003-3934-5092 Abstract Since the introduction of endoscopic ear surgery (EES) in the 1990s, endoscopic systems have been utilized in a number of ear surgeries including myringoplasty and tympanoplasty. Endoscopic tympanoplasty (ET) is described as a minimally invasive surgery for surgical repair of the tympanic membrane (TM) with comparable graft survival and hearing outcomes to conventional microscopic surgery (CMT). In the present review, we aimed to outline the surgical benefits and potential drawbacks of ET with clinical outcomes in order to determine whether ET constitutes a proper alternative to CMT. Keywords: Tympanic membrane perforation, tympanoplasty, myringoplasty, endoscopes. Introduction Tympanic membrane (TM) perforation is a common pathological condition that occurs due to various etiologies including infection, trauma or idiopathic causes.[1] Repair of TM perforation can be achieved by tympanoplasty or myringoplasty, which are differentiated according to the pathological involvement of the TM and middle ear. The tympanoplasty procedure involves closure of the TM perforation in conjunction with management of chronic otitis media, cholesteatoma and hearing restoration. Conventional microscopic tympanoplasty (CMT) has been the standard method for surgical repair of the TM worldwide Correspondence: Ali Bayram, MD, Kayseri City Hospital, Şeker Mah. Molu Village, Kayseri 38080, Turkey Received: 12.06.2019; Accepted: 10.07.2019 ©2019 Continuous Education and Scientific Research Association (CESRA) with a success rate of 80-90%.[2] CMT can be performed via transcanal, endaural or postauricular routes with a variety of graft material, for which temporalis fascia and perichondrium have been mostly used. Among these routes, the postauricular approach with a microscope offers significant advantages to the surgeon by enhancing the visibility of the operative site, particularly for large or anterior TM perforations, as well as for patients with anterior canal wall bulge.[3] However, a postauricular approach usually necessitates hair shaving, incision and soft tissue dissection, as well as general anesthesia. Also, the surgical view during microscopic surOnline available at: www.entupdates.org How do you perform your tympanoplasty, endoscopically or microscopically? gery is usually affected by the width, tortuosity and bony overhangs of the ear canal, therefore canalplasty is often performed to improve the vision. Recently, endoscopic systems have gained popularity as a single operative tool or as an assistive tool in a microscopic approach for otological surgery. In 1978, Eichner [4] introduced endoscopic systems for otologic examination with a 2.7 mm diameter rigid endoscope. Since its first utilization for ear surgery in the late 1990s, endoscopic systems have promised better vision of the deep and hidden parts of the middle ear cavity, such as anterior and posterior epitympanic spaces, eustachian tube, facial recess, sinus tympani and hypotympanum (Figure 1).[5] With accumulated experience since 1990, a number of ear surgeries can be performed via an endoscopic approach, including ventilation tube insertion, repair of TM perforation, ossicular reconstruction, otosclerosis and cholesteatoma surgery and cochlear implantation. Figure 1. Endoscopic view of adhesive tympanic membrane with an eroded long arm of the incus. As in other highly sophisticated surgical procedures, endoscopic ear surgery (EES) necessitates special instruments, as implied by the nomenclature of the procedure. The 0°, 30° and 45° angled rigid endoscopes 2.7 mm, 3 mm and 4 mm in diameter with working lengths of 6 cm, 11 cm and 18 cm are the most commonly used endoscope types during EES.[6] A high-resolution camera with a monitor located opposite to the surgeon, light source and fiber optic cable are also required. The International Working Group on Endoscopic Ear Surgery (IWGEES) has been working on the development of special equipment and instruments for EES based on more than 15 years of experience.[6] In recent years, one of the most important develop- ments in endoscopic instruments is incorporating suction into the instrument shaft, hence enabling the removal of blood and debris from the surgical field. Although these instruments provide the ability to perform dissection and aspiration maneuvers simultaneously, the main disadvantage is frequent occlusion during suctioning. During EES, a surgical microscope should still be available for switching to microscopic surgery in the surgical setting. The endoscopic tympanoplasty (ET) procedure initiates with placement of the patient in an otosurgical position. The distance between the shoulder and pinna should be increased in order to improve ergonomics. The surgical procedure is mostly performed through 0° or 30°, 3x11 to 14-cm rigid endoscopes. A 45° angled rigid endoscope is usually recommended during evaluation of the protympanum, retrotympanum and ventilation routes. Optimal hemostasis is essential during ET and is achieved by infiltration of local anesthetic and vasoconstrictor agents into the ear canal and graft donor site, placement of 1:2000 epinephrine soaked cottonoids over the TM remnant for 10 minutes and total intravenous anesthesia with a targeted mean blood pressure of 60 mm Hg and heart rate of 60 bpm. After arranging the optimal circumstances for hemostasis, a graft material such as tragal perichondrium and cartilage, temporalis muscle fascia or fat tissue is harvested. Then the edges of the TM perforations are denuded and the approach to the middle ear is performed either by endocanal (without tympanomeatal flap) or transcanal technique. During the transcanal, underlay technique, a wide front tympanomeatal flap is elevated and the posterior annulus is identified and lifted from the sulcus to provide access into the middle ear. Middle ear ossicles are examined for integrity and movement, and reconstruction of the ossicles is performed when necessary. Permeability of the anterior and posterior isthmus is checked, and graft material is positioned and supported by the placement of sponges (Figure 2-5).[1] During conventional microscop (...truncated)