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Endoscopic Approach Opens Up Middle Ear Anatomy

0920-EndoscopicIt has only been in the last decade that otolaryngologists have gained experience with middle ear endoscopic surgery. More recently the technique has gained popularity, especially with the dissemination of published articles, conferences, books, and encouraging surgical results on the topic.

Prior to the Sunday International Symposium session “Endoscopic Middle Ear Anatomy,” the lead instructor, Daniele Marchioni, MD, shared his thoughts on the topic. Although not a difficult learning curve, it’s crucial for those early in their training to gain expertise by participating in several endoscopic ear dissections.

“In my experience, young people have a natural preference to use endoscopes because they are able to grow as a surgeons using an endoscope and a microscope at the same time during residency. Endoscopically they are able to realize the anatomy of the middle ear much better than under microscopic view,” said Dr. Marchioni, director of the School of Ear, Nose, and Throat at the University of Verona, Italy.

He cautioned that middle ear anatomy is complex, but the use of the endoscope has opened a new world of anatomy to otolaryngologists.

“We have to consider the retrotympanum, epitympanum, and protympanum as anatomical hidden areas during traditional microscopic surgery, especially in canal wall up or transcanal procedures,” Dr. Marchioni said. “And, of course, the anatomical knowledge of these areas is crucial, especially during cholesteatoma surgery. The use of the endoscope in the middle ear has dramatically changed the anatomical knowledge of these areas, permitting good surgical access via a transcanal approach and allowing the minimally invasive management of the cholesteatoma.”

The complete eradication of cholesteatoma in the retrotympanum while preserving healthy mucosa is an additional challenge for surgeons.

“A cholesteatoma could spread under the ponticulus bone and involve a deep sinus tympani. This condition is quite challenging during a microscopic approach due to the lack of a surgical view on the surgical field,” said Dr. Marchioni, adding that the course examined how to resolve these situations using the endoscopic approach while considering the anatomy of the middle ear recesses.

“The advantages are, of course, better visualization and magnification of the anatomy, ‘look around the corner’ vision, and the possibility of a very close view. The preservation of healthy mucosa and mastoid preservation are other important advantages,” Dr. Marchioni said. “The endoscope is a crucial tool during surgery on the tympanic cavity. The lateral semicircular canal is considered the limit of the transcanal endoscopic surgery, and microscopic surgery is much better than endoscopic surgery for mastoid bone diseases requiring mastoidectomy.”

He added that the use of an endoscope in ear surgery requires the correct management of bleeding, so good infiltration with anesthesia, vasoconstriction of the external auditory canal, and collaboration with the anesthesiologist is fundamental, especially during the reconstruction.

Through the International Working Group on Endoscopic Ear Surgery, surgeons around the world aim to study endoscopic anatomy and introduce endoscopic surgery to the otology community.

“We are arranging courses all over the world in order to spread this new advancement in ear surgery,” Dr. Marchioni said.

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