None.

The study protocol conformed to the guidelines of the Human Research Ethics Committee of the Inselspital Bern and was approved by the local review board (KEK-BE 2019-00555). Informed written consent was obtained from all human subjects involved in the study. All surgical procedures were performed under general anesthesia (following institutionally approved protocols) with controlled hypotension, using standard otologic instruments and appropriate hemostasis17,18. Surgical site preparation, exclusive transcanal access, middle ear examination, and defect closure of the TM are described in previously published articles by Beckmann et al. and Anschuetz et al.19,20. Additional reconstructive measures, most frequently tympanoplasties, are often required19. Usually, the OPL is performed in the end after positioning the grafts for tympanoplasty or scutum reconstruction. However, these techniques will not be covered in this protocol. Moreover, many other OPL techniques are described in the literature21,22. This article covers the methods with which we have a strong and positive experience. Figure 1 illustrates the technique for partial ossicular replacement, and Figure 2 shows the technique for total ossicular replacement. The surgical tools and the equipment needed are listed in the Table of Materials.
1. Incus interposition
<ol>
	<li>Use a needle dissector to dissect and detach the chorda tympani from the long process of the incus and proceed to slightly resect the scutum with a bone curette. 
	NOTE: Resection of the scutum provides wide access to the posterior mesotympanum and helps to identify the incudostapedial joint between the long process of the incus and the stapes head20.</li>
	<li>Identify the incudostapedial joint and cautiously disarticulate the lenticular process from the stapes head using a microhook or a small round knife. Then, gently push the incus upward to detach it from the head of the malleus. Remove the incus by pulling the long process inferiorly and then laterally. Preserve the detached incus for its intended use in the interposition procedure.</li>
	<li>Thoroughly examine the incus for any signs of erosion, ensuring its appropriateness for the upcoming reconstruction.</li>
	<li>Grind the graft using the following steps23:
	<ol>
		<li>Hold the incus using a grasping forceps.</li>
		<li>Use a diamond burr to carefully drill both the long and short processes of the incus until the level of the incus body is reached.</li>
		<li>On the opposite side of the former long process, drill an acetabulum approximately 1 mm wide to accommodate the stapes head.</li>
		<li>Verify that the length of the interposition aligns with the range of 2-2.5 mm, depending on the anatomy of the patient.</li>
	</ol>
	</li>
	<li>Utilize a microsuction tip and/or a needle to position the remodeled incus inside the tympanic cavity and to precisely locate the acetabulum onto the stapes head and, if appropriate, the anterior surface in contact with the malleus handle.</li>
</ol>
2. Malleus head interposition
<ol>
	<li>After removal of the incus (step 1), identify the malleus and dissect the chorda tympani away from its neck.</li>
	<li>Use the malleus nipper to transect the malleus neck and remove its head for its intended use in the interposition procedure.</li>
	<li>Thoroughly examine the malleus head for any signs of erosion, ensuring its appropriateness for the upcoming reconstruction.</li>
	<li>Grind the graft using the following steps24:
	<ol>
		<li>Hold the malleus head using a grasping forceps.</li>
		<li>If the whole malleus is used, use a diamond burr to carefully drill both the manubrium, lateral, and anterior process until the level of the malleus neck is reached.</li>
		<li>On the malleus head, drill an acetabulum approximately 1 mm wide to accommodate the stapes head.</li>
		<li>Verify that the length of the graft is approximately 2-2.5 mm, depending on the anatomy of the patient.</li>
	</ol>
	</li>
	<li>After carrying the graft towards the tympanic cavity, utilize a microsuction tip and/or a microhook/needle to position the malleus head interposition precisely onto the stapes head. 
	NOTE: Appropriate treatment of the underlying middle ear pathology often requires resection of the incus and the malleus. As long as the incus body remains intact, it is suitable for an interposition graft. Use the malleus head interposition in cases where the incus is absent or eroded, and the malleus head is still intact.</li>
</ol>
3. Partial ossicular replacement prosthesis (PORP)
<ol>
	<li>Confirm the integrity of the stapes suprastructure and ensure that both malleus head and incus are missing or unsuitable for use in interposition ossiculoplasty.</li>
	<li>Assess the size of the defect and decide on the size of the implant. Many different products are commercially available; here, the use of a titanium-based implant is exemplarily shown. Choose the appropriate size of the implant or trim the titanium shaft to the desired length. No pressure should be exerted on the stapes suprastructure to avoid stretching of the annular ligament.</li>
	<li>After carrying the prosthesis towards the tympanic cavity, utilize a microsuction tip and/or a microhook/needle to position the foot of the PORP precisely onto the stapes&#39; head.</li>
	<li>Brace the head of the PORP against the manubrium (if present). Cover the head of the prosthesis with cartilage, and ensure that the implant slightly tents the TM.</li>
</ol>
4. Double cartilage block (DCB) PORP
<ol>
	<li>Confirm the integrity of the stapes suprastructure and ensure that both malleus head and incus are missing or unsuitable for interposition OPL.</li>
	<li>Prepare the double-cartilage block (DCB) graft using the following steps25:
	<ol>
		<li>Obtain a rectangular block of tragal or conchal cartilage and remove the perichondrium on one side only.</li>
		<li>Use a scalpel to cut the cartilage in half; avoid transecting the perichondrium on the opposite side.
		<ol>
			<li>Create a shallow acetabulum approximately 1 mm wide to receive the stapes capitulum on the block free from perichondrium.</li>
			<li>Fold the cartilage block on the intact perichondrium.</li>
		</ol>
		</li>
	</ol>
	</li>
	<li>Utilize a microsuction tip and/or a microhook/needle to position the DCB precisely onto the stapes head. Establish a contact to the manubrium of the hammer if applicable.</li>
</ol>
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/66155/66155fig01.jpg" /> 
Figure 1: Techniques of partial ossicular replacement. (A) Incus interposition (ii). (B) Malleus head interposition (mai). (C) PORP (*). (D) DCB PORP (car). Abbreviations: malleus (ma), promontory (p), stapes (s), tympanic membrane (tm). <a href="https://www.jove.com/files/ftp_upload/66155/66155fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
5. Total ossicular replacement prosthesis (TORP)
<ol>
	<li>Confirm the integrity of the stapes footplate and clean it from disease, adhesions, or scars.</li>
	<li>Assess the size of the defect between the TM and the footplate and decide on the size of the implant. Many different products are commercially available; here, the use of a titanium-based implant is exemplarily shown. Choose the appropriate size of the implant or trim the titanium shaft to the desired length. Ensure the implant slightly tents the TM without exerting too much pressure on the footplate.</li>
	<li>Utilize a microsuction tip and/or a needle to position the TORP inside the tympanic cavity and to locate the foot of the TORP precisely onto the stapes footplate.</li>
	<li>Brace the head of the TORP against the manubrium (if present) and cover its head with cartilage.</li>
</ol>
6. Semi-synthetic total ossicular replacement prosthesis (ssyTORP)
<ol>
	<li>Confirm the integrity of the stapes footplate and clean it from disease, adhesions, or scars.</li>
	<li>Prepare the semi-synthetic prosthesis26:
	<ol>
		<li>Choose a platinum/polytetrafluoroethylene (PTFE) stapedotomy prosthesis according to the intended size of the reconstruction.</li>
		<li>Cut the platinum wire at the base of the hook.</li>
		<li>Obtain a cartilage block from the tragal or conchal cartilage. According to the distance between the TM and the footplate, create a 5 mm long ssyTORP.</li>
		<li>Create one square block of tragal cartilage with perichondrium left on both sides.</li>
		<li>Use an insulin needle to create a small hole in the perichondrium in the middle of the block.</li>
		<li>Insert the blunt tip of the shaft into the perichondrium hole and gently push it to penetrate the cartilage.</li>
		<li>To create a 6 mm or 7 mm ssyTORP, obtain a double or triple cartilage block, respectively, by taking a rectangle (2-5 mm), preferably from the tragal cartilage, with the perichondrium left on both sides.</li>
		<li>Cut the cartilage in half. Avoid transection of the perichondrium on the opposite side.</li>
		<li>Make a small hole in the perichondrium in the middle of the block.</li>
		<li>Insert the blunt tip of the shaft into the cartilage block. Fold the cartilage back on itself with the intact perichondrium layer doubled between the two/three cartilage blocks. 
		&#8203;NOTE: In all above-mentioned techniques, ensure the stability of the reconstruction by using resorbable gelatin sponges around the interposition graft, if deemed appropriate.</li>
	</ol>
	</li>
</ol>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/66155/66155fig02.jpg" /> 
Figure 2: Techniques of total ossicular replacement. (A) TORP (t). (B) ssyTORP (*). Abbreviations: cartilage (car), footplate (f), promontory (p), tympanic membrane (tm). <a href="https://www.jove.com/files/ftp_upload/66155/66155fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
7. Postoperative care
<ol>
	<li>Ensure adequate pain management in the postoperative period. Do not administer prophylactic antibiotics unless clinically indicated.</li>
	<li>Advise patients not to blow their nose and emphasize strict protection from water for two weeks postoperatively to avoid possible damage to the surgical site.</li>
	<li>Discharge the patients on the day of the surgery or the following day, depending on their postoperative recovery and the clinical assessment.</li>
	<li>Schedule a follow-up two weeks postoperatively for complete dressing removal and assessment of the surgical site. 
	NOTE:This is a standard postoperative care protocol. Individual patient needs and clinical scenarios may necessitate modifications.</li>
</ol>

A Comprehensive Step-By-Step Guide for Exclusive Endoscopic Ossiculoplasty

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A systematic review.</a> Acta Oto-Laryngologica. 138 (7), 617-620 (2018).</li><li>Tsetsos, N., Vlachtsis, K., Stavrakas, M., Fyrmpas, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+versus+microscopic+ossiculoplasty+in+chronic+otitis+media:+A+systematic+review+of+the+literature.">Endoscopic versus microscopic ossiculoplasty in chronic otitis media: A systematic review of the literature.</a> European Archives of Oto-Rhino-Laryngology. 278 (4), 917-923 (2021).</li><li>Soloperto, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Exclusive+endoscopic+ossiculoplasty+with+autologous+material:+step-by-step+procedure+and+functional+results.">Exclusive endoscopic ossiculoplasty with autologous material: step-by-step procedure and functional results.</a> European Archives of Oto-Rhino-Laryngology. 280 (11), 4869-4878 (2023).</li><li>Alicandri-Ciufelli, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Epinephrine+use+in+endoscopic+ear+surgery:+Quantitative+Safety+assessment.">Epinephrine use in endoscopic ear surgery: Quantitative Safety assessment.</a> ORL; Journal for Oto-Rhino-Laryngology and its Related Specialties. 82 (1), 1-7 (2020).</li><li>Anschuetz, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Management+of+bleeding+in+exclusive+endoscopic+ear+surgery:+Pilot+clinical+experience.">Management of bleeding in exclusive endoscopic ear surgery: Pilot clinical experience.</a> Otolaryngology-Head and Neck Surgery. 157 (4), 700-706 (2017).</li><li>Beckmann, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+cholesteatoma+surgery.">Endoscopic cholesteatoma surgery.</a> Journal of Visualized Experiments. 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The chronic ear. , (2016).</li><li>Malafronte, G., Filosa, B., Mercone, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+new+double-cartilage+block+ossiculoplasty:+long-term+results.">A new double-cartilage block ossiculoplasty: long-term results.</a> Otology &amp; Neurotology. 29 (4), 531-533 (2008).</li><li>Malafronte, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Early+results+with+semi-synthetic+total+ossicular+replacement+prosthesis.">Early results with semi-synthetic total ossicular replacement prosthesis.</a> Otolaryngology-Head and Neck Surgery. 143 (2), 307-308 (2010).</li><li>Caloway, C. 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P., Offeciers, F. E., Somers, T., Schatteman, I., Govaerts, P. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+use+of+malleus+allografts+in+ossiculoplasty.">The use of malleus allografts in ossiculoplasty.</a> The Laryngoscope. 112 (10), 1782-1784 (2002).</li><li>R&#225;th, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ionomer+cement+for+reconstruction+of+the+long+process+of+the+incus:+The+P&#233;cs+experience.">Ionomer cement for reconstruction of the long process of the incus: The P&#233;cs experience.</a> Clinical Otolaryngology. 33 (2), 116-120 (2008).</li><li>Katar, O., K&#305;l&#305;&#231;, S., Bajin, M. 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LA is consultant for Stryker ENT.

This article provides step-by-step instructions for EEO. There are various techniques, types of grafts, and prostheses to reconstruct the ossicular chain10,11. Depending on the presence or absence of the stapes suprastructure, a PORP or TORP is required. The use of an endoscope allows for detailed visualization and assessment of the ossicular chain and its functionality. Even in difficult anatomical conditions, the endoscope provides an optimal view of the oval window and stapes suprastructure or footplate to position the graft with great precision. Postauricular incision and mastoidectomy can often be avoided27. Moreover, it is an excellent tool for educating inexperienced surgeons in both anatomical and surgical aspects28.
Recently published literature has demonstrated comparable audiologic outcomes between endoscopic and microscopic OPL27,29. Das et al. reported significantly improved closure of the ABG after one month with endoscopic PORP OPL, but long-term audiologic outcomes showed no statistically significant difference from the microscopic technique4. A systematic review published by Tsetsos et al. also showed comparable audiologic results for both microscopic and endoscopic techniques15. They also observed a trend toward shorter operative time and lower morbidity, such as postoperative pain and wound infections, with the endoscopic method. The data analysis of the pre- and postoperative audiometric evaluation showed an average ABG of 30.46 dB and 21.41 dB, respectively. There was a statistically significant improvement in ABG completion of 9.05 dB &#177; 14.72 dB between the preoperative and postoperative ABG (p &#60; 0.01). The publication by Soloperto et al. showed comparable results with a mean ABG closure of 7.85 dB HL (p &#60; 0.01) in patients undergoing autologous graft reconstruction16.
Several authors compared synthetic prostheses, particularly titanium prostheses, and autologous grafts in terms of hearing outcome and complications. Aminth et al. conducted a prospective study comparing an incus autograft to a titanium PORP and found significantly better hearing outcomes and graft uptake in the incus group30. In addition, postoperative complications such as prosthesis extrusion and residual TM perforation occurred more frequently in the titanium PORP group.
OPL performed with a DCB graft was found to offer even greater advantages in reducing the risk of prosthesis displacement or fixation compared with the use of an incus autograft31. In the field of autologous grafts, different options, such as the DCB graft and the malleus allograft, have shown comparable audiological results. Both options have restored the ABG to less than 20 dB in 81% of patients25,32. The use of a patient&#39;s own tissue minimizes the risk of implant rejection or extrusion of the prosthesis through the TM, leading to enhanced biocompatibility and reduced postoperative complications15. However, autologous materials do present certain drawbacks. These include longer surgical durations required for the remodeling process, the potential for retaining microscopic pieces of cholesteatoma, and availability limitations depending on the condition of the ossicular chain13,14. A single case of prosthesis extrusion (5%) was recorded in a cohort of 20 synthetic prostheses. No cases of extrusion occurred when autologous materials were used.
COM, with or without cholesteatoma, is the most frequent cause of ossicular chain disruption. In the total 60 cases, COM accounted for 55 (91.7%) cases, and a total of 38 patients (63.3%) showed histologically confirmed cholesteatoma. There is still a debate about the most appropriate timing for ossicular chain reconstruction. In cases of single-stage OPL, endoscopic reconstruction of the ossicular chain is performed at the same time as COM surgery. If residual disease is a potential problem, ossicular chain reconstruction may be deferred to a later procedure, usually scheduled 12 to 18 months after the initial surgery and referred to as a second OPL. In this study, a uniform approach with single-stage surgery was adopted across the cohort to achieve early hearing recovery. However, in scenarios where the disease affects the stapes footplate, it may be appropriate to consider second-stage OPL. Both single-stage and second-stage OPL seem to achieve similar hearing outcomes16.
The long process of the incus is the most vulnerable part for necrosis secondary to both trauma and infections33. In cases with exclusive erosion of the incus long process, rebridging of the ossicular gap with bone cement offers a valid alternative to the OPL procedures presented in this article. Several authors reported comparable long-term audiological outcomes associated with this technique34,35.
The limited sample size of this study and the relatively short FU period prevent robust statistical results and a comprehensive evaluation of the long-term results of the individual OPL techniques. Furthermore, parametric statistical analysis of small subgroups might lead to overestimation or misleading conclusions. The predominant focus on cases of COM limits the generalizability of the results to other middle-ear pathologies. The inclusion of multiple revision cases presents a particular challenge and may not fully represent the primary surgical outcomes.
In conclusion, EEO is a valid surgical option for ossicular chain reconstruction with autologous or synthetic material. It is a safe and minimally invasive procedure with acceptable hearing restoration.

The use of endoscopes has become prevalent in modern otology. Originally used for diagnostic purposes, the endoscopic technique has gained popularity over time, leading to exclusive endoscopic ear surgery approaches. The endoscopic technique is performed through the auditory canal and requires precise and delicate maneuvers, as the technique must be performed single-handedly. It provides a panoramic view of the middle ear and allows access to hard-to-reach areas, facilitating the elimination of disease by using angled endoscopes1,2. In ossicular chain repair, modern high-definition (HD) or 4k endoscopy, along with its illuminative capabilities directed at specific structures of interest, such as the stapes or its footplate, greatly assists in the recognition of both anatomical and pathological variances3,4,5.
Ossicular chain destruction commonly results from chronic otitis media (COM), but trauma and neoplasms can alter the normal middle ear and, therefore, reduce its sound transmission capabilities6,7. Restoration of normal tympanic membrane (TM) and ossicular chain function has its roots in the 1950s8. The surgical techniques used to treat various pathologies of the middle ear aim not only to eliminate the underlying disease process but also to restore normal auditory function9.Over the past seven decades, various ossiculoplasty (OPL) techniques and prostheses have been studied and reported in the literature7,10,11.&#160;Bioinert materials like titanium gained popularity due to their lightweight, rigidity, and good visualization of their distal end during surgery. Nevertheless, these prostheses are quite expensive, and the reported rate of extrusion (1%-5%) is not negligible12. Autologous materials have demonstrated comparable effectiveness to synthetic prostheses. However, they do present certain drawbacks, such as longer surgical durations required for the remodeling process, the potential for retaining cholesteatoma, and availability limitations depending on the condition of the ossicular chain13,14.
According to Tsetsos et al., exclusive endoscopic ossiculoplasty (EEO) is associated with similar postoperative hearing results compared to the traditional microscopic approach15. A trend towards reduced morbidity and a shorter operative time for the endoscopic approach has been observed. Therefore, EEO can be considered a valid surgical option for reestablishing a functioning ossicular chain with acceptable hearing restoration in children and adults16.
This study aims to provide a comprehensive insight into the various technical refinements and latest developments for EEO. It presents different OPL techniques along with representative outcome data.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Antifog Solution</td>
			<td>Karl Storz</td>
			<td>15006H</td>
			<td></td>
		</tr>
		<tr>
			<td>Endoscopes 3 mm diameter, 15 cm length 0&#176;, 30&#176;, 45&#176;and&#160; 70&#176;</td>
			<td>Karl Storz</td>
			<td>7220AA/ 7220BA/ 7220FA/ 7220CA</td>
			<td></td>
		</tr>
		<tr>
			<td>Epinephrine 1 mg/mL</td>
			<td>Dr. Bichsel AG</td>
			<td>2824248&#160;</td>
			<td></td>
		</tr>
		<tr>
			<td>Gelatinous sponge (Gelfoam)</td>
			<td>Pfizer</td>
			<td>GTIN 00300090315085&#160;</td>
			<td></td>
		</tr>
		<tr>
			<td>Image 1S 4K</td>
			<td>Karl Storz</td>
			<td>TH120</td>
			<td></td>
		</tr>
		<tr>
			<td>ME 102</td>
			<td>KLS Martin</td>
			<td>80-010-02-04&#160;</td>
			<td></td>
		</tr>
		<tr>
			<td>Microsuction tubes&#160;</td>
			<td>Spiggle&#38;Theis</td>
			<td>301004 - 301014</td>
			<td></td>
		</tr>
		<tr>
			<td>Monitor 32&#34; 4K/3D</td>
			<td>Monitor 32&#34; 4K/3D</td>
			<td>TM350</td>
			<td></td>
		</tr>
		<tr>
			<td>NIM-Neuro 3.0</td>
			<td>Medtronic</td>
			<td>8253402</td>
			<td></td>
		</tr>
		<tr>
			<td>OsseoDuo</td>
			<td>Bien Air</td>
			<td>1700524-001</td>
			<td></td>
		</tr>
		<tr>
			<td>Otosporin (polymyxin, neomycin, hydrocortison)</td>
			<td>GlaxoSmithKline</td>
			<td>2262911000001100.00</td>
			<td></td>
		</tr>
		<tr>
			<td>Piezosurgery device</td>
			<td>Mectron</td>
			<td>N/A</td>
			<td></td>
		</tr>
		<tr>
			<td>PM2 Line Drill</td>
			<td>Bien Air</td>
			<td>1600765-001</td>
			<td></td>
		</tr>
		<tr>
			<td>PORP mCLIP ARC Partial Prosthesis&#160;</td>
			<td>MED-EL</td>
			<td>58502 - 58520</td>
			<td></td>
		</tr>
		<tr>
			<td>Povidone-iodine (Betadine)</td>
			<td>Mundi-Pharma</td>
			<td>7680342821377&#160;&#160;&#160;</td>
			<td></td>
		</tr>
		<tr>
			<td>Ringer Solution</td>
			<td>B. Braun</td>
			<td>3570000</td>
			<td></td>
		</tr>
		<tr>
			<td>Standard otological instruments (otologic dissectors, needle dissector, round knifes, hooks, curette, microscissors (Bellucci) and microforceps (Hartmann)</td>
			<td>Karl Storz</td>
			<td>N/A</td>
			<td></td>
		</tr>
		<tr>
			<td>Stapes Prosthesis Platin/PTFE</td>
			<td>Spiggle&#38;Theis</td>
			<td>1054040600/10560600</td>
			<td></td>
		</tr>
		<tr>
			<td>Steel and diamond burrs</td>
			<td>Bien Air</td>
			<td>1100290-001 - 1100303-001/ 1100247-001 - 1100260-001</td>
			<td></td>
		</tr>
		<tr>
			<td>Syringe Injekt Solo 10 mL</td>
			<td>Syringe Injekt Solo 10 mL</td>
			<td>4606108N</td>
			<td></td>
		</tr>
		<tr>
			<td>TORP Implant for shortening</td>
			<td>Spiggle&#38;Theis</td>
			<td>11830 - 11870</td>
			<td></td>
		</tr>
	</tbody>
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techniques of endoscopic ossiculoplasty

The utilization of endoscopes in modern otology has evolved from diagnostic purposes to the development of exclusive endoscopic ear surgery. This technique offers a panoramic view of the middle ear and provides an optimal magnification of the oval window region, the stapes' suprastructure, and the footplate, allowing great precision in prosthesis positioning during ossiculoplasty (OPL). Various techniques for ossicular chain reconstruction have been described in the literature. Either autologous or synthetic materials can be used for reconstruction. The use of a patient's own tissue minimizes the risk of implant rejection or extrusion of the prosthesis through the tympanic membrane. On the other hand, synthetic materials like titanium are light and rigid and do not require time-consuming prosthesis remodeling. The main objective of this article is to present a comprehensive step-by-step guide that serves as a surgical manual for exclusive endoscopic OPL. This guide will explain various forms of OPL using synthetic and autologous materials. The goal is to provide a comprehensive understanding of the various surgical techniques and support the integration into clinical practice.

This study involved a comprehensive analysis of 60 cases of EEO. For each technique presented herein, the last ten consecutive cases with a follow-up (FU) period of at least three months were included. All procedures were performed by experienced surgeons at the Otolaryngology Department of the University Hospital of Bern and Bologna between April 2019 and June 2023. The mean age (&#177; standard deviation (SD)) at the surgery date was 39.28 years (&#177;19.04). Of the total cases, 30 (50.0%) were revision surgeries. The distribution between the left and right sides operated on was almost equal, with 31 cases (51.7%) on the left and 29 cases (48.3%) on the right. In 55 (91.7%) cases, the underlying disease was COM, and 38 patients (63.3%) had cholesteatoma.
Surgical results 
The graft intake rate (GIR) showed a success rate of 98.3% by the last FU, and only one case showed a TM re-perforation. The mean FU period was 11.15 months (SD &#177; 9.38 months). Prosthesis extrusion occurred in 1 case (2.1%), 19 months postoperatively. Additionally, a subset of cases, 7 in total (11.7%), necessitated revision surgery due to persistent conductive hearing loss (3 cases) or recurrent cholesteatoma (4 cases).
Audiological results 
Each patient underwent pre- and postoperative pure tone audiometry, reported as pure tone average (PTA) represented as hearing threshold (dB HL) at frequencies 0.5 kHz, 1 kHz, 2 kHz, and 4 kHz. Preoperatively, the average air-bone gap (ABG) was 30.46 dB &#177; 13.23 dB. Following surgery, a significant improvement was observed with a reduction of the postoperative ABG to an average of 21.41 dB &#177; 10.64 dB. The improvement was statistically significant as determined by a paired t-test (p &#60; 0.01). A comprehensive overview of the surgical outcomes can be found in Table 1.
Table 1: Patients&#39; disease characteristics and surgical outcome. Abbreviations: Air bone gap (ABG), Mean (M), Range (R), Standard deviation (SD). <a href="https://www.jove.com/files/ftp_upload/66155/66155_Table 1.xlsx" target="_blank">Please click here to download this Table.</a>

Read this Scientific Article Protocol about Author Spotlight: Advancing Endoscopic Ossiculoplasty â€“ Techniques, Innovations, and Practical Guidance for Clinical Integration at JoVE.com

Author Spotlight: Advancing Endoscopic Ossiculoplasty &#8211; Techniques, Innovations, and Practical Guidance for Clinical Integration

Exclusive Endoscopic ossiculoplasty (EEO) is a promising and minimally invasive approach for the treatment of conductive hearing loss due to ossicular chain disruptions and associated middle ear pathologies. Herein, step-by-step instructions and a discussion of various endoscopic ossiculoplasty techniques are presented.

Techniques of Endoscopic Ossiculoplasty

The utilization of endoscopes in modern otology has evolved from diagnostic purposes to the development of exclusive endoscopic ear surgery. This ...

In modern ontology, the use of endoscopes has evolved from diagnostics to exclusive endoscopic ear surgery. Our goal is to offer a comprehensive understanding of the various endoscopic osteoplasty techniques and support their integration into clinical practice. The focused illumination of specific middle ear structures, such as the stay piece and its foot plate allows great precision in prosthesis placement.Furthermore, it facilitates the detection of both anatomical and pathological variances. The endoscopic technique is performed through the auditory canal and requires precise and delicate maneuvers as it's performed single-handedly. Before implementing this technique in the operating room, we strongly advise hands-on training.

Research

JoVE Journal

Medicine

870 Views.  University of Bern. In modern ontology, the use of endoscopes has evolved from diagnostics to exclusive endoscopic ear surgery. Our goal is to offer a comprehensive understanding of the various endoscopic osteoplasty techniques and support their integration into clinical practice. The focused illumination of specific middle ear structures, such as the stay piece and its foot plate allows great precision in prosthesis placement.Furthermore, it facilitates the detection of both anatomical and pathological v...

Video: Author Spotlight: Advancing Endoscopic Ossiculoplasty – Techniques, Innovations, and Practical Guidance for Clinical Integration

Endaural Endoscopic Atticoantrotomy (Retrograde Mastoidectomy) using a Constant Suction Bone-drilling Technique

Endoscopic middle ear surgery is a widely employed minimally invasive surgical technique to address middle ear and mastoid pathology. Bone drilling is the main technical challenge of endoscopic middle ear surgery. The accompanying video describes the detailed protocol of a constant-suction bone-drilling technique and the procedure of endaural exclusive endoscopic atticoantrotomy (retrograde mastoidectomy) using this technique. The main components of this bone-drilling technique include a soft and flexible suction tube, which is placed into the tympanic cavity to provide constant suction, and a soft sleeve, which is wrapped around the drill shaft to prevent the high-speed rotating shaft from damaging the lens of the endoscope. With these simple modifications, the traditional otological electrodrill can be used for drilling a tiny endaural incision in endoscopic middle ear surgery. Based on this bone-drilling technique, endaural endoscopic atticoantrotomy (retrograde mastoidectomy) can be successfully established for the removal of various amounts of bone, depending on the extent of the lesion. The short-term postoperative outcome seems promising.

Endaural Endoscopic Atticoantrotomy Retrograde Mastoidectomy using a Constant Suction Bone-drilling Technique

In this paper, we present the protocol and short-term outcomes of endaural exclusive endoscopic atticoantrotomy using a constant suction bone-drilling technique.

Endoscopic middle ear surgery is a widely employed minimally invasive surgical technique to address middle ear and mastoid pathology. Bone drilling is the ...

Endoscopic Ultrasound-Guided Biliary Drainage: Endoscopic Ultrasound-Guided Hepaticogastrostomy in Malignant Biliary Obstruction

Patients with unresectable malignant biliary obstruction often require biliary drainage to decompress the biliary system. Endoscopic Retrograde Cholangiopancreatography (ERCP) is the primary biliary drainage method whenever possible. Percutaneous Transhepatic Biliary Drainage (PTBD) is used as a salvage method if ERCP fails. Endoscopic Ultrasound-Guided Biliary Drainage (EUS-BD) provides a feasible alternative biliary drainage method where one of the methods is EUS guided Hepaticogastrostomy (EUS-HGS). Here we describe the EUS-HGS technique in a case of unresectable malignant hilar biliary obstruction to achieve biliary drainage.
Presented here is the case of a 71-year-old female with painless jaundice and weight loss for 2 weeks. Computed Tomography (CT) imaging showed a 4 x 5 cm hilar tumor with lymphadenopathy and liver metastasis. EUS fine needle biopsy (FNB) of the lesion was consistent with cholangiocarcinoma. Her bilirubin levels were 212 &#181;mol/L (&lt;15) during presentation.
A linear echoendoscope was used to locate the left dilated intrahepatic ducts (IHD) of the liver. The segment 3 dilated IHD was identified and punctured using a 19 G needle. Contrast was used to opacify the IHDs under fluoroscopic guidance. The IHD was cannulated using a 0.025-inch guidewire. This was followed by the dilation of the fistula tract using a 6 Fr electrocautery dilator along with a 4 mm biliary balloon dilator. A partially covered metallic stent of 10 cm in length was deployed under fluoroscopic guidance. The distal part opens in the IHD and the proximal part was deployed within the working channel of the echoendoscope that subsequently released into the stomach. The patient was discharged three days after the procedure. Follow up performed in the second and fourth weeks showed that the bilirubin levels were 30 &#181;mol/L and 14 &#181;mol/L, respectively. This indicates that EUS-HGS is a safe method for biliary drainage in unresectable malignant biliary obstruction.

Endoscopic Ultrasound-Guided Biliary Drainage (EUS-BD) is an alternative method of biliary decompression in malignant biliary obstruction. Here we describe the technique of EUS guided-Hepaticogastrostomy (EUS-HGS) in a case of unresectable malignant hilar biliary obstruction.

Patients with unresectable malignant biliary obstruction often require biliary drainage to decompress the biliary system. Endoscopic Retrograde ...

Endoscopic Cholesteatoma Surgery

Implementation of endoscopes in cholesteatoma surgery resulted in considerable changes in the management of cholesteatoma in the last two decades. Compared to the microscopic approach with an excellent but straight-line view and limited illumination, the introduction of endoscopes provides a wide-angled panoramic view. Moreover, angled lenses allow the surgeon to visualize the middle ear and its hidden recesses through a transcanal, minimally-invasive approach. The endoscope enables the surgeon to remove limited cholesteatoma of the middle ear and its recesses using an exclusive endoscopic technique by taking advantage of these benefits. This reduces the rate of residual disease and sparing external incisions and excessive temporal bone drilling as in a transmastoid approach. Since transcanal endoscopic access is mainly a one-handed technique, it implies the need for specific procedures and technical refinements. This article describes a step-by-step guide as a surgical manual for endoscopic removal of epitympanic cholesteatoma. Different techniques for cholesteatoma dissection and bone removal for epitympanectomy, including curettage and powered instruments such as drills and ultrasonic devices with their outcomes, are discussed. This may offer ear surgeons insight into technical refinements and the latest technological developments and open the horizon for different techniques.

The present protocol describes a step-by-step guide for the complete endoscopic removal of epitympanic cholesteatoma with different techniques for cholesteatoma dissection and bone removal for epitympanectomy.

Implementation of endoscopes in cholesteatoma surgery resulted in considerable changes in the management of cholesteatoma in the last two decades. ...

Transoral Endoscopic Thyroidectomy Vestibular Approach for Thyroid Lobectomy

The manuscript describes the transoral endoscopic thyroidectomy vestibular approach (TOETVA) for thyroid lobectomy. The patient is placed in the supine position with extension and fixation of the neck. One 20 mm transverse incision and two 5 mm incisions are made through the mucosa of the oral vestibule for camera and instrument placement after disinfection of the skin and oral cavity. The workspace is established and maintained by the skin suspension device, which is made of unabsorbable string (3-0) and rubber bands, and the CO2 insufflation pressure. Lobectomy using a medial-to-lateral technique and prophylactic ipsilateral central neck dissection is performed simultaneously on patients with papillary thyroid cancer (PTC). The specimen is extracted through the 20 mm incision. The parathyroid gland is immediately searched for in the specimen and auto-transplanted to the left brachioradialis. A drainage tube is inserted through the retractor hole into the bed of the thyroid gland, and absorbable sutures are used to close the mucosal incisions in the oral vestibule and the linea alba cervicalis. Prophylactics administered intravenously are recommended for the first 24 h after surgery, and oral antibiotics are used for 7 days postoperatively.

Here, we present a protocol to describe the methodology for the transoral endoscopic thyroidectomy vestibular approach in detail.

The manuscript describes the transoral endoscopic thyroidectomy vestibular approach (TOETVA) for thyroid lobectomy. The patient is placed in the supine ...

Fully Endoscopic Mitral Valve Repair with Percutaneous Cannulation of Groin Vessels

Endoscopic mitral valve surgery (EMS) has become a standard of care at specialized heart centers, further reducing surgical trauma compared to a traditional minimally invasive, thoracotomy-based approach. Exposure of the groin vessels for the establishment of cardiopulmonary bypass (CPB) via surgical cutdown in minimally invasive surgery (MIS) may result in wound healing disorders or seroma formation. The avoidance of surgical exposure of the groin vessels by using fully percutaneous techniques for the insertion of a CPB cannula with the implementation of vascular pre-closure devices has the potential to reduce these complications and improve clinical results. Herein, we present the utilization of a novel plug based vacsular closure device with a resobable collagen plug and the absence of suture material for closure of the arterial access for CPB in MIS. While this device was initially predominantly used in transcatheter aortic valve implantation (TAVI) procedures, with its safety and feasibility shown, we herein show that it can be used in CPB cannulation, since it is capable of closing arterial access sites up to 25 French (Fr.) in size. This device may be suitable to significantly reduce groin complications in MIS and simplify the establishment of CPB. Here, we describe the fundamental steps of EMS, including percutaneous groin cannulation and decannulation using a vascular closure device.

This protocol demonstrates in detail how to perform fully endoscopic mitral valve surgery (EMS) with percutaneous cannulation of the groin vessels, using a percutaneous plug-based vascular closure device. Fundamental steps and useful instructions are described in detail for each step.

Endoscopic mitral valve surgery (EMS) has become a standard of care at specialized heart centers, further reducing surgical trauma compared to a ...

Gasless Endoscopic Thyroidectomy via the Trans-Axillary Approach

For patients with early, low-risk papillary thyroid carcinoma, an increasing number are opting for endoscopic thyroid surgery due to its ability to achieve favorable therapeutic outcomes while maintaining excellent cosmetic results. Among the available endoscopic procedures, the Gasless Endoscopic Thyroidectomy Trans-axillary Approach (GETTA) has gained popularity among surgeons. This is attributed to its straightforward cavity construction, spacious operating area, precise visual field exposure, and manageable learning curve. However, few studies have provided detailed descriptions of the specific surgical steps involved in GETTA. Drawing from a synthesis of existing literature and our own clinical expertise, we present a comprehensive outline of the GETTA procedure. This process can be categorized into five distinct stages: positioning and incision planning; establishment of surgical cavities; identification and protection of the recurrent laryngeal nerve, inferior parathyroid gland, and central neck dissection; localization and preservation of the superior laryngeal nerve, superior parathyroid gland, and dissection of the thyroid's superior pole; transection of the thyroid isthmus followed by en bloc resection of the thyroid gland and central neck lymph nodes. The five-step approach of GETTA is easy to learn and can be adapted for resecting both benign and malignant thyroid and parathyroid diseases.

Gasless Endoscopic Thyroidectomy via the Trans-Axillary Approach

This protocol presents the procedure for conducting thyroidectomy using the gasless endoscopic thyroidectomy trans-axillary approach (GETTA).

For patients with early, low-risk papillary thyroid carcinoma, an increasing number are opting for endoscopic thyroid surgery due to its ability to ...

Endoscopy from Kocher&#39;s Point Enabling Third Ventriculostomy and Pineal Biopsy

Endoscopic Third Ventriculostomy and Pineal Biopsy from a Single Entry Point

Pineal neoplasms have a significant impact on children although they are relatively uncommon. They account for approximately 3-11% of all childhood brain tumors, which is considerably higher than the &lt;1% seen in adult brain tumors. These tumors can be divided into three main categories: germ cell tumors, parenchymal pineal tumors, and tumors arising from related anatomical structures. Obtaining an accurate and minimally invasive tissue diagnosis is crucial for selecting the most appropriate treatment regimen for patients with pineal gland tumors. This is due to the diverse treatment options available and the potential risks associated with complete resection. In cases where patients present with acute obstructive hydrocephalus caused by a pineal gland tumor, immediate treatment of the hydrocephalus is necessary. The urgency stems from the potential complications of hydrocephalus, including increased intracranial pressure and neurological deficits. To address these challenges, a minimally invasive endoscopic approach provides a valuable opportunity. This technique allows clinicians to promptly relieve hydrocephalus and obtain a histological diagnosis simultaneously. This dual benefit enables a more comprehensive understanding of the tumor and assists in determining the most effective treatment strategy for the patient.

Author Spotlight: A Single-Entry Point Endoscopic Intraventricular Approach for Third Ventriculostomy and Pineal Biopsy

Pineal neoplasms frequently cause obstructive hydrocephalus and require histopathological diagnosis to decide the treatment regimen. They might be treated by surgical resection or chemoradiotherapy according to the pathological diagnosis. As a minimally invasive initial treatment, an endoscopic approach from Kocher's point enables both third ventriculostomy and biopsy.

Pineal neoplasms have a significant impact on children although they are relatively uncommon. They account for approximately 3-11% of all childhood brain ...