Step-by-Step Stapedotomy through Transcanal Exclusive Endoscopic Approach

Summary

The aim of this article is to provide a step-by-step method for endoscopic stapes surgery from operating room setting and patient positioning to post-operative care. This work would represent a guide for any otologic surgeon who is willing to treat otosclerosis with endoscopic transcanal technique.

Abstract

In recent years there has been an increasing trend in the use of the endoscope to treat a variety of middle ear pathologies, including otosclerosis. Several studies comparing traditional microscopic and endoscopic stapes surgery have reported similar hearing results and an overall low rate of complications. The endoscope has unraveled its full potential in demanding settings of stapes surgery, such as unfavorable anatomy of the oval window niche or revision cases. Reduced manipulation of the chorda tympani and low rate of post-operative dysgeusia are further benefits to mention for endoscopic stapes surgery.

Being a one-handed technique, management of bleeding, positioning, and crimping of the prosthesis may be challenging for novice endoscopic surgeons, so some training in endoscopic ear surgery is recommended before performing endoscopic stapedotomy. The problem of sharing the surgical field between the endoscope and the operating instruments could be easily overcome if proper instruments positioning is understood. One-handed bleeding control in the narrow space of the ear canal may represent an issue during the elevation of the tympano-meatal flap, possibly discouraging the surgeon since the preliminary steps of surgery. Following appropriate technique to raise the flap and the collaboration with the anesthesiology team in keeping the blood pressure low guarantee an adequate bleeding control in most cases.

The aim of this article is to describe the entire surgical procedure of a transcanal exclusive endoscopic stapedotomy, from operating room set up and patient positioning to post-operative care. A step-by-step description of the surgical maneuvers with technical hints is reported, to guide the surgeon across the procedure and allow any ear surgeon to perform stapes surgery endoscopically.

Introduction

The use of the endoscope in ear surgery has gradually increased since its first application in the 1990s, to treat a variety of middle ear pathologies, including otosclerosis¹. As compared to the microscope, the endoscope guarantees a wide field of exposure, high magnification and resolution images, reduced bone removal and a significantly improved quality of life after surgery^2,3,4.

The use of one hand has been mentioned as a limitation of the endoscopic technique, especially in functional procedures such as the stapes surg....

Protocol

This research has been conducted in accordance with ethical principles, including the World Medical Association Declaration of Helsinki (2002) and the institutional human research ethics committee's guidelines (Comitato Etico dell'Area Vasta Emilia Nord). The local ethical committee does not perform a formal ethical assessment for case reports.

1. Preparation of the patient

1. After oro-tracheal intubation and general anesthesia, position the patient supine wi.......

Discussion

A protocol for totally EStS is herein proposed, to guide any otologic surgeon in performing stapes surgery endoscopically.

The first surgical step (elevation of the TMF) could be the bloodiest phase of the whole procedure, and it represents a challenge for the surgeon in relation to one-hand bleeding control¹³. Moreover, in otosclerosis cases, the tympanic membrane is intact; so maximal care should be paid not to damage it. As reported in our protocol, some technical hi.......

Materials

Name	Company	Catalog Number	Comments
Antifog solution	GOLFF
Aspirator system (40L/min power)	EXTRUDAN SURGERY APS		4m long, dimeter ch25
Cold light source with cable	STORZ
Consumables: - Iodopovidone solution - Epinephrine - Sterile water to rinse - Spongostan (adsorbable hemostatic sponge)	ETHICON INC.
Cotton pads	FARMAC ZABBAN		10x10cm
Cottonoid pledgets	CODMAN		10 surgical patties
Endoscope	STORZ		3mm diameter, 15cm length, 0°
Local anesthetic with vasoconstrictor in sterile and non-sterile syringe	GALENICA SENESE		10 vials x 5ml
Otologic set instruments	STORZ		round knife, hook, curette, Bellucci scissors and Hartmann forceps, suction tubes
Skeeter Drill	MEDTRONIC		0.6 mm diamond burr
Stapes prosthesis	SPIGGLE & THEIS		0.6x4.75mm
Surgical scrub set for otologic patients	EURONDA
Surgical scrub set for operating surgeon	EURONDA
Surgical scrub set for nurse	EURONDA
Vesalius molecular resonance electrosurgical unit	TELEA ELECTRONIC ENGINEERING
Video equipment: 4K Camera - HD screen - Video processor (Image 1S system)	STORZ