DOI No.: 10.21176/ ojolhns.0974-5262.2016.10.

INVITED EDITORIAL

ENDOSCOPIC EAR SURGERY

THE FUTURE OF OTOLOGIC SURGERY ?

Vol.-10, Issue-I, Jan-June - 2016

*Philip Rajan **Prepageran Narayanan

The use of endoscopes in the field of surgery have
significantly transformed the practice of surgery in the
last few decades, shifting from open procedures to
minimally invasive or key-hole procedures. The
advantages of these newer procedures are shorter
operating time, improved cosmesis, lower complication
rates and better surgical outcomes. Endoscopes and
typically rigid or flexible depending on the whether
the fibre optic carriers are housed in a rigid metal casing
or a flexible tube. The choice of endoscope used will
depend on the anatomical region accessed and the
indication for the procedure.
Endoscopes were first popularised in the field of
Otorhinolaryngology in the late 1960s and 1970s with
the introduction of this instrument by Professors
Walter Messerklinger and Heinz Stammberger from
the Medical University at Graz/Austria for sinus
surgery. The progress in the field of endoscopic sinus
surgery has substantially evolved over time, that today
endoscopic surgery forms the standard of care in the
management nasal and paranasal sinus disease.
Endoscope used in otology was initially limited
to diagnostic purposes. Shorter endoscopes (working
length 10cm, Karl Storz, Germany) or otoendoscopes
were designed for this purpose. The endoscope enabled
excellent visualisation and documentation of otopathology. In the 1990s there was accumulating
literature on the use of endoscopes in the surgical
management of middle ear disease. Endoscopes were
used for grommet insertion, myringoplasties and for
inspection of the middle ear in the cholesteatoma
surgery. Among the key proponents of endoscopic ear
surgery was Muaaz Tarabichi, an ORL surgeon from
the American Hospital, Dubai. Like minded ENT
surgeons, sharing a similar interest in endoscopic ear
surgery formed the International Working Group on
Endoscopic Ear Surgery (IWGEES) in the mid 2000s
with the aim of educating, promoting and developing
endoscopic ear surgery. The response towards
endoscopic ear surgery from the ENT community
has been mixed, with some enthusiastically welcoming
6

Date of receipt of article -04-04-2016

Date of acceptance -2-5-2016
DOI-10.21176/ojolhns.2016.10.1.1
it as a revolution in otologic surgery while others
remain sceptical.
There are a number of factors which need to be
considered in deciding to use the endoscope for otologic
surgery:
1.

The anatomy of the ear. The ear canal and middle

ear are far smaller and compact cavities compared
to the nose and paranasal sinuses. This sometimes
makes navigation of instruments difficult in the
confined space. In addition this anatomical region
primarily consists of bone therefore the surgical
techniques and instrumentation differs from that
of sinus surgery.

2.

The clear advantage of the endoscope is the ability

to visualise hidden areas, crevices or cavities as
the scope position can be easily manipulated and
placed close to the area of interest. With a
microscope additional tissue or bone removal may
be required to visualise the same area. In addition
the endoscope offers a wider field of view which
allows a more panoramic assessment of the surgical
field. It has been argued that the endoscope would
not offer three-dimensional optical quality or
depth of perception found with binocular optics
of the microscope. However in practice this is not
the case as constant movement of the endoscope
creates a similar effect with reliable depth
perception.

Affiliations:
*Consultant ENT Surgeon, Department of Otorhinolaryngology Hospital
Raja Permaisuri Bainun, Jalan Ashman Shah, 30450, Ipoh, Perak, Malaysia
Email: prajan333@yahoo.com, **Head of Department Department of
Otorhinolaryngology, Faculty of Medicine, University of Malaya Kuala
Lumpur, Malaysia
Address of Correspondence:
Prof. Prepageran Narayan
Faculty of Medicine, University of Malaya Kuala Lumpur,
Malaysia, Email: prepageran@yahoo.com

DOI No.: 10.21176/ ojolhns.0974-5262.2016.10.1

3.

4.

5.

Endoscopes used for sinus surgery, 4mm or 2.7mm

diameter (working length 14mm), can be used for
ear surgery as well. While the 4mm endoscope
offers an excellent view, the larger diameter makes
manipulation with an additional instrument in the
ear canal difficult. The smaller 2.7mm diameter
scope suffers from some reduction in visual quality.
Endoscope manufacturers now produce a 3mm
diameter (working length 14mm) scope which
offers a balance between the advantages of the
conventional scopes.
The endoscope is a hand held instrument, thus
endoscopic ear surgery has been described as a one
hand procedure or technique as the surgeon has
only one free area to use for tissue manipulation
while the other holds the endoscope. This creates
new challenges as well requires a change or
modification of surgical techniques. Bleeding is a
cumbersome issue with endoscopic ear surgery.
Blood can easily distort the surgical field. The
absence of two free hands makes hemostasis and
clearing the visual field more difficult.
Most microsurgical instruments used for temporal

bone and middle ear surgery can comfortably be

used with the endoscope as well. However due to
differences in the techniques, instruments modified
or developed to complement endoscope use will
provide a more comfortable surgical experience
for the surgeon and better outcomes. Newer
technologies useful in endoscopic ear surgery
include piezoelectric bone dissection, lasers and
Quantum Molecular Resonance (QMR)
electrocautery.
6. Other issues that have been raised with endoscope
use are thermal damage from the endoscope light
and tissue damage from the endoscope tip.
Published studies have reported it to be safe
provided good practice guidelines are adhered to.
The surgeon should be aware of optimal light
settings and proper endoscope use.
Most ENT surgeons today would have some
familiarity using the endoscope as a diagnostic tool or
for simple otologic procedures. However, as in
Endoscopic Sinus Surgery education and training is
mandatory so that the surgeon understands the
limitations and risks of using this instrument. The table

Vol.-10, Issue-I, Jan-June - 2016

Table 1: Classification of Competence for Endoscopic Ear Surgery Procedures According to Experience* The
table is not exhaustive but describes the more common otologic procedures. The table divides a surgeons
capability in endoscopic ear surgery into 5 levels.

Vol.-10, Issue-I, Jan-June - 2016

DOI No.: 10.21176/ ojolhns.0974-5262.2016.10.1

below (Table 1) suggests the training and experience an

ENT surgeon should have before embarking on
endoscopic ear surgery.
Most ENT surgeons should comfortably be able
to perform Level I and II procedures, which are
confined to the external auditory canal and tympanic
membrane. The endoscope is an excellent instrument
to visualise the middle ear cavity. Level III and IV
procedures require the surgeon to be flexible with the
use of both the endoscope and microscope to operate
in the middle ear. Unexpected complications such as
haemorrhage or extensive disease may require
conversion to the microscope. As such surgeons
performing these procedures should familiar with
conventional microscopic techniques. Level V
procedures to the inner ear and skull base require
familiarity with the anatomy and skull base procedures.
Often, endoscope use in Level IV or V procedures is
an adjunct or used in combination with a microscope.
Exclusive endoscopic use in Level V procedures are a
rarity and surgeons should always prioritise disease
clearance and patient safety.
One of the misconceptions trainees/junior ENT
doctors have is that endoscopic ear surgery is easier
than a conventional microscopic approach to the same
procedure. This comes from the notion that an
endoscopic procedure equates to safer, faster and
easier, terms commonly attributed to minimally
invasive surgeries. Certainly, the view offered is far
superior to conventional otoscopes or even microsopes
when directly viewing the ear canal or middle ear. In
reality, there is a learning curve and the one-handed
technique is a skill which needs to be acquired.
The use of endoscopes is a significant evolution in
ENT practice. There has been considerable progress
with high definition endoscope systems, new
instruments and better understanding of the anatomy.
The concept of Functional Endoscopic Ear Surgery
is gaining traction. Clinicians are revisiting concepts of
middle ear ventilation. While it is true that a lot of
these concepts and information have been described
before by surgeons in the past, the endoscope provides
the means to view this with a fresh insight and
understanding. Similar to sinus surgery, the future
could see changes in the practice of otologic surgery.
In conclusion, the endoscope is an instrument that
can provide excellent imaging of the ear canal and
middle ear. It does provide the means to overcome the
limitation of the microscope when viewing certain angles
8

or spaces. There is a cost factor which has to be

considered especially if newer and more precise
equipment and instruments are used. A realistic
expectation of capabilities with the endoscope for
middle ear surgery cannot be overemphasised. Ground
with this awareness and coupled with sound knowledge
and experience will enable a surgeon to decide when
and how to make optimal use of this instrument.
DISCLOSURES
(a) Competing interests/Interests of Conflict- None
(b) Sponsorships - None ,
(c) Funding - None
(d) No financial disclosures
REFERENCES
1. http://www.sinuscentro.com.br/iwgees/
index.htm International Working Group on
Endoscopic Ear Surgery (IWGEES) website.
2. Tarabichi M, Marchioni D, Presutti L, Nogueira
JF, Pothier D. Endoscopic transcanal ear anatomy
and dissection. Otolaryngol Clin North Am. 2013
Apr;46(2):131-54. doi: 10.1016/j.otc.2013.02.001.
Review.
3. MacKeith SA, Frampton S, Pothier DD. Thermal
properties of operative endoscopes used in
otorhinolaryngology. J Laryngol Otol. 2008
Jul;122(7):711-4
4. Badr-El-Dine M, James AL, Panetti G, Marchioni
D, Presutti L, Nogueira JF. Instrumentation and
technologies in endoscopic ear surgery.
Otolaryngol Clin North Am. 2013 Apr;46(2):21125. doi: 10.1016/j.otc.2012.10.005. Review.
5. Marchioni D, Alicandri-Ciufelli M, Rubini A,
Presutti L. Endoscopic transcanal corridors to the
lateral skull base: Initial experiences.
Laryngoscope. 2015 Sep;125 Suppl 5:S1-13. doi:
10.1002/lary.25203. Epub 2015 Feb 20.
6. Proctor B. The Development Of The Middle Ear
Spaces And Their Surgical Significance. J Laryngol
Otol. 1964 Jul;78:631-48.
7. Marchioni D, Piccinini A, Alicandri-Ciufelli M,
Presutti L. Endoscopic anatomy and ventilation
of the epitympanum. Otolaryngol Clin North
Am. 2013 Apr;46(2):165-78. doi: 10.1016/
j.otc.2012.10.002. Epub 2012 Nov 27. Review.
8. Takahashi H, Sugimaru T, Honjo I, Naito Y,
Fujita A, Iwahashi S, Toda H. Assessment of the
gas exchange function of the middle ear using
nitrous oxide. A preliminary study. Acta
Otolaryngol. 1994 Nov;114(6):643-6.