Endoscopic Ear Surgery

Increasingly used as an adjunctive tool in the diagnosis and management of ear disease, middle ear endoscopy has the
potential to decrease patient morbidity, prevent disease recurrence, and reduce costs. Its capacity to uncover hidden
anatomy within the small dimensions of the ear has made it essential for functional surgery, allowing surgeons to
preserve key anatomic structures such as the cochlea and facial nerve.

Now for the first time, the physicians who pioneered this groundbreaking minimally invasive technique review its
indications, advantages, disadvantages, and surgical approaches:

Written by the foremost leaders in the field, all members of the International Working Group on Endoscopic Ear Surgery
Features nearly 1,000 intraoperative endoscopic images filmed with high-definition cameras, plus outstanding line
drawings that aid in understanding all concepts Comprehensively covers the field, including chapters on endoscopic and
combined endoscopic-microscopic management of cholesteatoma, surgical restoration of middle ear ventilation,
myringoplasty, Meniere disease, tympanoplasty and stapes surgery, revision surgery, and much more Demonstrates state-of-
the-art endoscopic procedures in 19 instructive videos

From the unique anatomy and pathophysiology of the middle ear through diagnosis, surgical indications, procedures, and
instrumentation, this book is indispensable for all otolaryngologists and neurotologists. It offers a full picture of
the field today, as well as exploring the future possibilities of ear endoscopes alone or in combination with operative
microscopes for the most effective treatment of middle ear pathologies.




1 Starting off with Endoscopic Ear Surgery
Dave Pothier
1.1 Instrumentation and Equipment
1.1.1 Overview
1.1.2 Choice of Endoscope
1.2 Your First Case
1.2.1 Patient Factors
1.2.2 Disease Factors
1.2.3 Investigations
1.2.4 Issues of Consent
1.2.5 Preparing the Operating Room
1.2.6 Preparing the Patient
1.3 Pitfalls
1.3.1 Giving Up Too Early
1.3.2 Controlling Hemorrhage
1.3.3 Narrow Canal
1.3.4 Fogging of the Endoscope
2 Principles of Endoscopic Ear Surgery
Muaaz Tarabichi
2.1 Introduction
2.2 Advantages of Transcanal Access to Cholesteatoma
2.3 Transcanal Access Allows Better Understanding of Anatomy, Function, and Disease
2.4 Disadvantages of the Endoscope
2.5 Safety Concerns
2.6 Procedural Options in Cholesteatoma
2.6.1 Endoscopic Transcanal Management of Limited Cholesteatoma
2.6.2 Endoscopic Open Cavity Management of Cholesteatoma
2.6.3 Expanded Transcanal Access to the Middle Ear and Petrous Apex
2.7 Management Algorithm
References
3 Ear Embryology
Eliomaria Cunsolo, Francesco Mattioli, Matteo Alicandri-Ciufelli, Daniele Marchioni
3.1 Introduction
3.2 Outer Ear Development
3.2.1 External Auditory Canal, Tympanic Ring, and Eardrum
3.3 Middle Ear Development
3.3.1 Ossicular Chain
3.3.2 Development of the Eustachian Tube and the Tympanum-Antrum Mastoid Portion
3.3.3 Development of the Primary Tympanic Cavity
3.3.4 Development of the Tympanic Atrium
3.3.5 Formation of Middle Ear Spaces and Folds
3.4 Inner Ear Development
3.4.1 Early Development of the Membranous Labyrinth
3.4.2 Duct and Endolymphatic Sac
3.4.3 Saccus and Utricle
3.4.4 Semicircular Canals
3.4.5 Cochlear Duct
3.4.6 Development of the Otic and Perilymphatic Spaces
References
4 Endoscopic Middle Ear Anatomy
Daniele Marchioni, Matteo Alicandri-Ciufelli, Domenico Villari, Livio Presutti
4.1 Introduction
4.2 Retrotympanum
4.2.1 Sinus Tympani
4.2.2 Ponticulus
4.2.3 Subiculum
4.2.4 Pyramidal Eminence and Subpyramidal Space
4.2.5 Inferior Retrotympanum
4.3 Epitympanic Diaphragm and Prussak Space
4.4 Facial Nerve
4.5 Epitympanum
4.5.1 Posterior Epitympanic Space
4.5.2 Anterior Epitympanic Space
4.5.3 Tensor Fold 4.5.4 Transverse Crest (or "Cog")
4.6 Protympanum
4.7 Hypotympanum
References
5 Ventilation and Physiopathology of the Middle Ear
Daniele Marchioni, Matteo Alicandri-Ciufelli, Alessia Piccinini, Livio Presutti
5.1 Introduction
5.2 Eustachian Tube
5.3 Transmucosal Gas Exchange
5.4 Mastoid Buffer
5.5 Blockage of Middle Ear Ventilation Routes
References
6 Radiological Considerations for Endoscopic Middle Ear Surgery
Lela Migirov, Daniele Marchioni, Matteo Alicandri-Ciufelli, Gahl Greenberg
6.1 Introduction
6.2 Preoperative CT Evaluations and Their Influence in Surgical Planning
6.2.1 The External Ear Canal
6.2.2 Sinus Tympani
6.2.3 Antral and Mastoid Involvement
6.2.4 Dural Plane Assessment
6.2.5 Involvement of Subsites
6.2.6 Epitympanic Dimensions
6.3 Postoperative CT Results
6.4 Use of Diffusion-Weighted MRI
References
7 Surgical Armamentarium Mohamed Badr-El-Dine
7.1 Introduction
7.2 Positioning and General Equipment
7.2.1 Operating Room Setup
7.2.2 The Operating Microscope
7.2.3 The Contraves Table
7.3 Standard Instruments for Microscopic Ear Surgery
7.4 Endoscopes and Special Instruments for Endoscopic Ear Surgery
7.4.1 Ear Endoscopes
7.4.2 Rigid Endoscopes
7.4.3 Instruments
7.5 Advanced New Technologies Used in Otology Surgery
7.5.1 High-Definition Digital Cameras
7.5.2 Xenon Light Sources
7.5.3 High-Definition Digital Monitors and Data Management and Documentation
7.5.4 Digital Photodocumentation
7.5.5 Microdrill Handpieces: Attachments and Burs
7.5.6 Piezosurgery
7.5.7 Vesalius
7.5.8 Lasers
7.6 Specific Instrumentation Used for Certain Endoscopic Neurotological Skull Base Procedures
7.6.1 Neuronavigation and Intraoperative Doppler
References
8 Endoscopic Diagnosis and Follow-up of Retraction Pockets and Cholesteatomas
Seiji Kakehata
8.1 Introduction
8.2 Methods
8.2.1 Endoscopy of Retraction Pockets
References
9 Principles of Endoscopic Cadaveric Ear Dissection
Daniele Marchioni, Matteo Alicandri-Ciufelli, Livio Presutti
9.1 Introduction
References
10 Endoscopic Approaches to Middle Ear Cholesteatoma: Classification and Indications for Surgery
Daniele Marchioni, Alberto Grammatica, Elisabetta Genovese, Maria Consolazione Guarnaccia, Domenico Villari, Livio
Presutti
10.1 Introduction
10.1.1 Primary Acquired Cholesteatoma
10.1.2 Secondary Acquired Cholesteatoma
10.1.3 Congenital Cholesteatoma
10.2 General Indications
10.2.1 Indications and Contraindications
10.2.2 Attic Cholesteatoma
10.3 Goals of the Transcanal Approach to Attic Cholesteatoma Removal
10.3.1 Limits of the Exclusively Transcanal Approach
10.4 Surgical Indications for Exclusively Endoscopic Approach to Acquired Primary Cholesteatoma
10.4.1 Contraindications to the Exclusively Transcanal Approach
10.4.2 Preoperative Cholesteatoma Staging
10.4.3 Preoperative Clinical Examination
10.4.4 Follow-up
References
11 Combined Endoscopic Microscopic Middle Ear Surgery for Cholesteatoma
Daniele Marchioni, Alessia Piccinini, Matteo Alicandri-Ciufelli, Livio Presutti
11.1 General Considerations
11.2 Endoscopic/Microscopic Combined Approach
11.2.1 Indications
11.2.2 Advantages
11.2.3 Endoscopic Surgical Steps
11.2.4 Microscopic Surgical Steps
11.3 Microscopic-Endoscopically Assisted Approach in Canal Wall Up Technique
11.3.1 Indications
11.3.2 Advantages
11.3.3 Endoscopic Technique in the Closed Approach
11.4 Microscopic-Endoscopically Assisted Approach in Canal Wall Down Technique
11.4.1 Indications
11.4.2 Advantages
11.5 Postoperative Care
References
12 Exclusively Endoscopic Treatment of Severe Attic Retraction and Epitympanic Cholesteatoma
Daniele Marchioni, Gabriele Molteni, Livio Presutti
12.1 Surgical Anatomy and Physiology
12.2 History
12.3 General Surgical Evaluation
12.3.1 Indications and Contraindications
12.3.2 Advantages
12.3.3 Complications
12.3.4 Preoperative Evaluations
12.4 Epitympanic Cholesteatoma Staging
Daniele Marchioni, Livio Presutti
12.5 Surgical Steps
12.5.1 Incision and Tympanomeatal Flap Elevation
12.5.2 Middle Ear Mucosa and Evaluation of Ventilation Routes
12.5.3 Selective Epitympanic Retraction Pocket
12.5.4 Cholesteatoma with Limited Attic Extension (Stage C1)
12.5.5 Endoscopic Reventilation and Tympanoplasty
12.5.6 Surgery of the Tympanic Isthmus
12.5.7 Surgery of the Tensor Fold
12.5.8 Anatomical Features of the Epitympanum
12.5.9 Second-Look Tympanoplasty
12.5.10 Postoperative Care
References
13 Exclusively Endoscopic Treatment of Retrotympanic Cholesteatoma
Daniele Marchioni, Alberto Grammatica, Matteo Alicandri-Ciufelli, Livio Presutti
13.1 Surgical Anatomy
13.2 History
13.3 Advantages
13.4 Indications and Contraindications
13.4.1 Indications
13.4.2 Contraindications
13.5 Complications
13.6 Surgical Steps
13.7 Postoperative Care
References
14 Endoscopic Treatment of Cholesteatoma with Antral Extension
Daniele Marchioni, Francesco Mattioli, Domenico Villari, Livio Presutti
14.1 Introduction
14.2 Transcanal Endoscopic "Open" Technique
14.3 Indications
14.4 Contraindications
14.5 Surgical Steps
14.6 Reconstructive Considerations
14.6.1 Endoscopic Open Cavity
14.6.2 Endoscopic Open Reconstructive Cavity
14.7 Intraoperative Complications
14.8 Postoperative Complications
14.9 Postoperative Management
References
15 Endoscopic Myringoplasty
Stephane Ayache, Davide Soloperto, Alessia Piccinini, Domenico Villari, Livio Presutti, Daniele Marchioni
15.1 Surgical Anatomy
15.2 Surgical Concepts
15.2.1 Advantages of Endoscopic Myringoplasty
15.2.2 Disadvantages of Endoscopic Myringoplasty
15.3 Indications and Contraindications
15.3.1 Pure Tone Audiometry
15.3.2 Role of Imaging
15.4 Surgical Approach
15.4.1 Setup of the Patient and Surgeon
15.5 Myringoplasty Through the Creation of a Tympanomeatal Flap
15.5.1 Sampling and Preparation of the Graft
15.5.2 Surgical Technique
15.5.3 Postoperative Care
15.6 Direct Endoscopic Myringoplasty without Creation of a Tympanomeatal Flap
15.6.1 Indications
15.6.2 Contraindications
15.6.3 Surgical Steps
15.6.4 Postoperative Care
References
16 Endoscopic Transcanal Stapes Surgery (Stapedotomy)
Joao Flavio Nogueira, Livio Presutti, Joao Paulo Saraiva Abreu, Moises Ximenes Feijao, Matteo Alicandri-Ciufelli,
Daniele Marchioni
16.1 History
16.2 Advantages
16.3 Indications and Contraindications
16.3.1 Indications
16.3.2 Contraindications
16.4 Complications
16.5 Surgical Steps
16.5.1 Stapedotomy/Stapedectomy without Preservation of the Stapedial Tendon
16.5.2 Stapedotomy with Preservation of the Stapedial Tendon
16.6 Postoperative Care
References
17 Endoscopic Removal of Middle Ear Neoplasms
Daniele Marchioni, Federico Maria Gioacchini, Matteo Alicandri-Ciufelli, Franca Laura Artioli, Livio Presutti
17.1 Introduction
17.2 Tumor Characteristics
17.2.1 Glomus Tympanicum
17.2.2 Middle Ear Adenomatous Tumors
17.2.3 Middle Ear Osteoma
17.3 Treatment
17.3.1 Indications
17.3.2 Surgical Technique
17.4 Postoperative Care
References
18 Exclusively Endoscopic Transcanal Approach to the Inner Ear and Petrous Apex
Livio Presutti, Matteo Alicandri-Ciufelli, Francesco Mattioli, Gabriele Molteni, Daniele Marchioni
18.1 Introduction
18.1.1 Anatomical Concepts
18.2 Exclusively Transcanal Endoscopic Infracochlear Approach
18.2.1 Indications
18.2.2 Surgical Steps
18.3 Exclusively Transcanal Endoscopic Transvestibular/Transcochlear Approach
18.3.1 Indications
18.3.2 Preoperative Examinations
18.3.3 Surgical Steps
References
19 Combined Approaches to Petrous Apex and Inner Ear Diseases
Livio Presutti, Alberto Grammatica, Matteo Alicandri-Ciufelli, Domenico Villari, Daniele Marchioni
19.1 Introduction and Classification of Endoscopic Approaches to the Inner Ear
19.1.1 Transmastoid Route
19.1.2 Retrosigmoid Route
19.2 Transmastoid Route: Micro-Endoscopic Combined Surgical Approaches (Endoscopically Assisted) to the Petrous Apex
and/or IACI
19.2.1 Infralabyrinthine Endoscopically Assisted Route
19.2.2 Transotic Endoscopically Assisted Route
19.2.3 Suprameatal Translabyrinthine Endoscopically Assisted Route
19.2.4 Postoperative Care of the Transmastoid Route
19.3 Retrosigmoid Route: Combined Microscopic and Endoscopically Assisted Approaches to the Posterior Cranial Fossa
19.3.1 Retrosigmoid Route
19.4 Surgery of Neurovascular Conflicts
19.4.1 Trigeminal Neuralgia
19.4.2 Hemifacial Spasm
19.4.3 Glossopharyngeal Neuralgia
19.4.4 Surgical Approach
19.4.5 Postoperative Care
19.4.6 Complications
References
20 Endoscopic Endonasal Approach to the Petrous Apex
Francesco Mattioli, Daniele Marchioni, Joao Flavio Nogueira, Livio Presutti
ni hata hau estrogueira,
20.1 Introduction
20.2 Anatomy
20.3 Lesions of the Petrous Apex
20.4 Preoperative Selection of Patients
20.5 Indications for an Endoscopic Endonasal Approach
20.6 Contraindications for an Endoscopic Endonasal Approach
20.7 Surgical Steps
20.7.1 The Transnasal Approach
20.7.2 The Transethmoid Approach
20.8 Intraoperative Devices
20.9 Advantages of the Endoscopic Approach
20.10 Risks of the Endoscopic Approach
20.11 Postoperative Care
20.12 Conclusion
References

Index