The otology specialists at the Ear Institute at New York Eye and Ear Infirmary of Mount Sinai offer the latest minimally invasive endoscopic ear surgery to children and adults with routine and complex middle ear disease. Introduced in the 1990s, the use of endoscopes for ear and otologic surgery has steadily increased and it is now a preferred tool for middle ear surgery. A minimally invasive procedure, endoscopic ear surgery allows the surgeon access to the middle ear through the ear canal (a natural ear opening) without the need for an incision behind the ear. At the Ear Institute, this unique method of otologic surgery is used for procedures such as tympanoplasty, cholesteatoma resection and ossicular reconstruction.
Benefits of Endoscopic Ear Surgery for Tympanoplasty
The surgical repair of the eardrum, called tympanoplasty, can be performed microsurgically (using an operating microscope) or endoscopically. Because microscopic and endoscopic ear surgery are complimentary approaches, each have their own advantages and disadvantages, and they can be used alone or together.
Microscopes have been used in otologic surgery for many years to visualize internal ear structures using three dimensional images. In contrast, the endoscope produces two dimensional images. However, the surgeon get a sense of 3D (pseudo 3D) while using an endoscope because it can be easily moved around.
In exclusively endoscopic transcanal tympanoplasty, the endoscope replaces the microscope as a tool for visualization during the surgery. The advantage of the endoscope was first recognized as a means to visualize the sinus tympani, a region of the retrotympanum common for harboring residual cholesteatoma. While the microscopic view is limited by the narrowest portion of the ear canal, the endoscope can bypass this, allowing for a:
- a wider operative view,
- superior magnification, and
- ability to seamlessly change the operative view while dissecting.
Overall, general principles of tympanoplasty as well as procedural choice (such as underlay, lateral graft, use of cartilage, etc) are similar and equally applicable to both methods. The primary difference between procedures lies not in patient selection or method of repair, but in details of the surgical technique. Notably, otoendoscopy requires modification of the traditional 2-handed technique of microscopic tympanoplasty as the non-dominant hand is occupied holding the endoscope. Since the endoscope must also be held in the surgeon’s hand, leaving only one hand left to operate, endoscopic ear surgeons need specialized experience to perform this minimally invasive technique.
Evidence suggests that endoscopic and microscopic tympanoplasty have comparable rates of TM closure and similar hearing outcomes. Need for a canalplasty is more common in microscopic tympanoplasty, likely related to the ability to the endoscope to bypass the narrowest portion of the ear canal during a transcanal procedure. Research is ongoing, but suggests that the outcomes are similar to traditional ear surgery and are able to avoid the need for a separate skin incision.