exclusive endoscopic malleus head interposition

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

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.

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

Techniques of Endoscopic Ossiculoplasty

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.

Exclusive Endoscopic Malleus Head Interposition

To begin, prepare all the necessary surgical tools and equipment for the procedure. Disarticulate the incus from the incudostapedial joint, and then remove the incus. Identify the malleus and dissect the chorda tympani from its neck.Using the Malleus Nipper, transect the malleus neck and remove its head for its intended use in the interposition procedure. To grind the graft, hold the malleus head using a grasping forceps, and using a burr, carefully drill until the level of the malleus neck is reached. Drill an acetabulum on the malleus head approximately one millimeter wide to accommodate the head.After carrying the graft towards the tympanic cavity, position the malleus head onto the stapes head and readjust its interposition using a microneedle. Stabilize the malleus head interposition with gelatin sponges, and close the tympanomeatal flap. The overall graft intake rate showed a success rate of 98.3%Preoperatively, the average air-bone gap was 23.05 decibels, whereas after surgery, the average air-bone gap was reduced to 21.90 decibels.

exclusive-endoscopic-malleus-head-interposition

Research

JoVE Journal

Medicine

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.

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.

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

Exclusive Endoscopic Incus Interposition

To begin, prepare all the necessary surgical tools and equipment for the procedure After elevation of the tympanomeatal flap and establishing access to the middle ear, use a needle dissector to detach the chorda tympani from the long process of the incus. Then slightly resect the scutum with the ultrasonic device or a bone curette. Identify the incudostapedial joint and cautiously disarticulate the lenticular process from the stapes head using a micro hook or a small round knife.Then gently push the incus upward to detach it from the head of the malleus. and remove the incus by pulling the long process inferiorly and then laterally. To grind the graft, hold the inus using a grasping forceps and use a diamond bur to carefully drill both the long and short processes of the incus until the level of the incus body is reached.On the opposite side of the former long process, drill an acetabulum approximately one millimeter wide to accommodate the stapes head. Next, position the remodeled incus inside the tympanic cavity. Using a microsuction tip or a needle, precisely locate the acetabulum onto the stapes head, and if appropriate, the anterior surface in contact with the malleus handle.Stabilize the incus into position using resorbable gelatin sponges, and close the tympanomeatal flap. The overall graft intake rate showed a success rate of 98.3%Preoperatively, the average air-bone gap was 25.24 decibels, whereas after surgery, the average air-bone gap significantly reduced to 17.10 decibels.

Exclusive Endoscopic Partial Ossicular Replacement Prosthesis &#40;PORP&#41;

To begin, prepare all the necessary surgical tools and equipment for the procedure. Assess the size of the defect, and choose the appropriate size of the implant. After carrying the prosthesis towards the tympanic cavity, position the foot of the PORP precisely onto the stapes head using a microneedle.Cover the head of the prosthesis with cartilage, and ensure that the implant slightly tents the tympanic membrane. The overall graft intake rate showed a success rate of 98.3%Preoperatively, the average air-bone gap was 24.30 decibels, whereas after surgery, the average air-bone gap significantly reduced to 16.80 decibels.

Exclusive Endoscopic Double Cartilage Block &#40;DCB&#41; PORP

To begin, prepare all the necessary surgical tools and equipment for the procedure. To prepare the double cartilage block or DCB graft, obtain a rectangular block of tragal or conchal cartilage and remove the perichondrium on one side only. Cut the cartilage in half using a scalpel, ensuring to refrain from cutting through the perichondrium on the opposing side.Create a shallow acetabulum approximately 1 millimeter wide to recede the stapes capitulum on the block, free from perichondrium. Fold the cartilage block on the intact perichondrium. Then position the DCB inside the tympanic cavity, and locate precisely onto the stapes head using a micro suction tip or needle.Ensure the stability of the reconstruction by using resorbable gelatin sponges, and carefully cover the DCB with the tympanomeatal flap. The overall graft intake rate showed a success rate of 98.3%Preoperatively, the average air-bone gap was 28.90 decibels, whereas after surgery, the average air-bone gap was reduced to 24.50 decibels.

Exclusive Endoscopic Total Ossicular Replacement Prosthesis &#40;TORP&#41;

To begin, prepare all the necessary surgical tools and equipment for the procedure. Assess the integrity of the stapes footplate and prepare it for the prosthesis placement. Measure the defect between the tympanic membrane and the stapes footplate to choose the appropriate implant size.Next, position the TORP inside the tympanic cavity and use a microneedle to locate the foot of the TORP precisely onto the stapes footplate. Stabilize the TORP by using resorbable gelatin sponges. Ensure that there is contact between the cartilage and the prosthesis once the tympanomeatal flap has been placed over it.The overall graft intake rate showed a success rate of 98.3%Preoperatively, the average air-bone gap was 36.80 decibels, whereas after surgery, the average air-bone gap significantly reduced to 20.30 decibels.

Exclusive Endoscopic Semi-Synthetic Total Ossicular Replacement Prosthesis &#40;ssyTORP&#41;

To begin, prepare all the necessary surgical tools and equipment for the procedure. Choose a platinum or polytetrafluoroethylene stapedotomy prosthesis according to the intended size of the reconstruction. Cut the platinum wire at the base of the hook.Next, obtain a cartilage block from the tragal or conchal cartilage and create appropriate SSY TORP. Create a square block of tragal cartilage with perichondrium left on both sides. Using an insulin needle, create a small hole in the perichondrium in the middle of the block.Insert the blunt tip of the shaft into the perichondrium hole and gently push it to penetrate the cartilage. Then position the SSY TORP inside the tympanic cavity and locate it precisely onto the stapes footplate with a microhook. Establish a contact to the manubrium of the hammer, if applicable.Carefully close the tympanomeatal flap with a microhook. The overall graft intake rate showed a success rate of 98.3%Preoperatively, the average air-bone gap was 44.44 decibels, whereas after the surgery, the average air-bone gap significantly reduced to 27.85 decibels.