Abstract
To study the Impact of Otoendoscopy at the end of apparent microscopic clearance of disease during primary Cholesteatoma surgery in detecting the residual cholesteatoma. A prospective, interventional, non randomized and non comparative study was conducted at the ESIC Medical College and PGIMSR. All patients of chronic otitis media of squamosal type undergoing modified radical mastoidectomy were included in the study. Otoendoscopy was performed after apparent clearance of cholesteatoma under microscope. If any residual cholesteatoma detected during otoendocsopy was recorded. Total of 63 cases were included in the study. Residual cholesteatoma was seen in 14% of the cases. Commonest site of residual cholesteatoma was sinus tympani. Otoendoscopy helps in visualizing the deep recesses of the middle ear cleft for residual cholesteatoma after apparent clearance under the operating microscope. It also helps in clearing the cholesteatoma from these deep recesses there by it helps in reducing the recurrence rate of cholesteatoma.
Keywords: Otoendoscopy, Cholesteatoma, Middle ear cleft, Mastoidectomy
Introduction
Aims of the middle ear surgery are to eradicate the disease from middle ear cleft, restore the auditory mechanics and if possible maintain the anatomy of temporal bone. For cholesteatoma, primarly two surgical procedures are practiced. Either Canal wall up or Canal wall down mastoidectomy with hearing restoration by tympanoplasty are done. Each procedure has its own merits and demerits [1]. Concern in both procedures is the residual disease because of failure to clear the cholesteatoma from middle ear cleft recesses. Incidence of residual cholsteatoma is in the range of 10 to 42% [2, 3].
Operating microscope in otology has revolutionized the ear surgery. It gives bright illumination, magnification and binocular vision for depth perception. Microscope has the advantage of leaving both hands of the surgeon free to operate, thereby it allows for fine surgery to be done with ease. However microscope has the disadvantage, its illumination traverses in straight line, so it won’t be able to visualize the deep recesses in the temporal bone [2, 3].
To overcome this linear axis of illumination of the otologic operating microscope various procedures were tried, like Buckingham mirror, flexible and rigid endoscopes. Endoscopes were introduced two centuries ago by German physician philippi bozzini. From then endoscopes were primarily used in urologic surgeries. Mer et al. in 1967 was the first to advocate endoscope for middle ear surgery. They used fibre-optic endoscopes to visualize the recesses. Since then significant improvements in technology has resulted in availability of smaller diameter and angled endoscopes with high resolution camera systems. This has enabled them to be used in small spaces to visualize the deep recesses in the complex middle ear cleft. They give magnified panoramic view of the deeper structures [4, 5].
Though endoscopes were introduced in ear surgery 2–3 decades ago, they are not commonly used.
Hence this study was undertaken to assess the usefulness of complimentary endoscope in visualizing the residual cholesteatoma after apparent clearance under microscope.
Materials and methods
A prospective, interventional, non randomized and non comparative study was conducted at the ESIC Medical College and PGIMSR, Bengaluru from January 2018 to March 2023 after obtaining the approval from institutional ethics committee. Patients diagnosed with chronic otitis media, squamosal type in active stage who were undergoing modified radical mastoidectomy were included in the study. Informed consent was obtained from each patient for inclusion in the study. Patients undergoing revision surgery or those with intracranial complications were excluded from the study.
Detailed history, clinical examination, otomicroscopy findings and relevant investigations including pure tone audiometry, were recorded in the customized case recording from for each patient.
All patients underwent modified radical mastoidectomy under general anaesthesia using Carl zeiss Movena operating microscope and Bien Air drill system. Post auricular approach was used in all cases with standard microsurgical instruments. The surgical procedure consisted of harvesting temporalis fascia graft, elevating the tympanomeatal flap, performing cortical mastoidectomy, removing the facial bridge, reducing the facial ridge and removal of anterior and posterior buttresses. Different sites in the middle ear cleft harboring cholesteatoma noted, followed by complete removal of the cholesteatoma under microscope.
After the primary surgeon is satisfied that all cholesteatoma is cleared from middle ear cleft under microscope, second surgeon performs the otoendoscopic examination (Karl Storz endoscopes 0’ and 45’ angled, 4 mm diameter, 18 cm long) of the middle ear cleft to look for the residual cholesteatoma in all the deep recesses of the middle ear cleft. If any residual cholesteatoma was seen, it was noted and removed with help of same endoscopes and microsurigical instruments.
Then reconstruction of the ossicular chain and tympanic membrane was performed using refashioned ossicles or total or partial ossicular replacement prostheses and temporalis fascia graft. Canaloplasty and meatoplasty done and wound closed in layers. Mastoid cavity was packed with mupirocin antibiotic ointment soaked ribbon gauze for 48 h. Standard post operative care was given.
Results
A total of 63 patients were included in the study. 37 patients were males and 26 were females. Majority {(48 cases) 76%} of the patients were in the age group of 11 to 40 years. Youngest patient was 6 years old and oldest was 66 years with mean age being 29.4 years. 36 patients had right side CSOM, 26 patients had left CSOM. Only one patient had bilateral disease. Ear discharge and decreased hearing were the commonest symptoms. All patients had moderate conductive hearing loss. Incus was the most common ossicle found to be eroded. All three ossicles (except stapes foot plate) were eroded in 08 patinets.
All patients underwent modified radical mastoidectomy under general anaesthesia using the opearating microscope. Table 1 show the sites of the middle ear cleft found to be harboring the cholesteatoma.
Table 1.
Sites of cholesteatoma detected under microscope
| Sr No | Sites involved | Number of cases | Percentage |
|---|---|---|---|
| 1 | Mesotympanum | 45 | 71% |
| 2 | Epitympanum | 62 | 98% |
| 3 | Mastoid | 48 | 76 |
| 4 | Hypotympanum | 2 | 0.03% |
After the primary surgeon is satisfied that all the cholesteatoma is cleared from the middle ear cleft under microscope, second surgeon performed otoendoscopic examination of the middle ear cleft. Residual cholesteatoma, after apparent clearance of all the disease under microscope, was identified in 09 cases. That means cholesteatoma was cleared completely under microscope in 54(86%) cases. There was residual cholesteatoma in 09(14%) cases, which was detected and removed under endoscopic vision. Table 2 shows the sites of middle ear cleft harboring the residual cholesteatoma which was detected by the otoendoscopic examination of the middle ear cleft.
Table 2.
Sites of residual cholesteatoma with otoendoscopy
| Sr No | Sites involved | Number of cases | Percentage |
|---|---|---|---|
| 01 | Sinus tympani | 08 | 89% |
| 02 | Around stapes | 01 | 11% |
| 03 | Hypotympanum | 01 | 11% |
Discussion
Mastoidectomy is one of commonly done surgery in otorhinolaryngology practice. This procedure is performed under operating microscope routinely. While microscope gives excellent illumination, allows visualization of structures directly ahead and leaves both hands of the surgeon free to carry out the fine surgical movements it does not give the visualization of structure around the corner. The middle ear cleft anatomy is extremely complex with numerous deep crevices or recesses. This is the major limitation of the operating microscope as these areas can’t be visualized with its straight line tunnel vision. The primary goal of mastoidectomy in cholsteatoma is disease eradication from the middle ear cleft to make it safe and dry. And if possible try to reconstruct the hearing mechanism. If structures around the corner are not well visualized, surgeons end up doing blind probing of these hidden areas to clear the disease, which may not be successful in all cases resulting in residual cholesteatoma in some cases. Failure to visualize may also result in excess drilling and bone removal and is associated complications [6, 7].
On the other hand endoscopes can give excellent illumination and wide angled visualization of these hidden areas. This allows clearing the disease under direct vision, which would reduce the complications of blind probing. With need to drill lesser, complications of drilling are also likely lesser [6, 7].
Biswas D et al. in 2014 found residual cholesteatoma in 11.8% of the cases undergoing canal wall down mastoidectomy and 13% of the cases in patients undergoing canal wall up procedure. In all the cases where residual cholesteatoma found on otoendoscopy, they were able to clear the residual disease under endoscopic vision. Sinus tympani was the commonest of residual cholesteatoma in their study. They concluded that otoendoscopy in choleasteatoma surgery ensures disease clearance and enhances the outcome results [8]. Verma B et al. in their study published in 2017, noted residual cholesteatoma in 11.2% cases [6]. Our results are similar to their findings and we also agree that otoendoscopy during tympanomastoid surgery will enhance its success.
Sajjadi H et al. in 2013 reported a residual desease in 10% of cases of open cavity mastoidectomy and 22% of cases of closed cavity mastoidectomies, after apparent clearance under microscope [9]. Gupta N et al. noted residual cholesteatoma in around 30% of cases [7]. The higher rate of residual disease in closed cavity cases may be due to more number of hidden areas such as anterior epitympanic recess, facial recess, which would have been missed under microscope due to its straight line vision.
Good GM et all in their study conducted between 1994 and 1997 discovered residual cholesteatoma in 24% of cases after apparent disease clearance under microscope. This high rate of residual disease detected could be because they used canal wall up surgery in many patients of their study [10].
In a study conducted by Thomasin et al. in 2007, it is reported that sinus tympani is the most difficult site to address and is the common site of residual cholesteatoma. In our study also, we found sinus tympanic was the commonest site (88%) of residual desease [11]. Similar finding of sinus tympani harboring the residual disease was noticed in the studies conducted by Magnan et al. and Pratt [12, 13].
Meselaty K et al. (2003), Tarabichi M (2010) and Migirov L et al. (2011) also concluded from their studies that endoscopy during cholesteatoma surgery gives better visualization of middle ear cleft, enabling the surgeon to have better control over the disease clearance from it [14–16].
However, endoscopes do have some limitations like, one of the operating surgeons hand will be engaged in holding endoscopes all the time. So surgeon has to operate with one hand only. Some of the space will be occupied by the endoscope in the ear, limiting the movement of the surgical instruments, affecting the quality of the work. Then there is long learning curve for surgeons to get used to the endoscopic ear surgery.
Conclusion
While otoendoscopy alone may not be the surgical method of choice in cholesteatoma surgery, its use as an adjuvant to microscope helps in identification of residual cholesteatoma in deep recesses of middle ear cleft which are not visualized by operative microscope due to its straight line visual axis. Otoendoscopy can also be used to remove the disease from these recesses. This will reduce the number of patients requiring the revision surgeries. Thus we conclude that otoendoscopy should be used as adjunct to microscope in cholesteatoma surgery.
Declarations
Ethical Aprroval
This study was performed in line with the principles of the Declaration of Helsinki. The study was approved by the Institutional ethics committee of the ESIC Medical College and PGIMSR Rajajinagar, Bengaluru (No. 532/L/11/12/Ethics/ESICMC&PGIMSR/Estt.Vol III Dated 29/07/2017).
Consent to Participate
Informed consent was obtained from all individual participants included in the study.
Consent to Publication
The participants have consented to the submission of the study to the journal.
Conflict of Interest
The authors did not receive support from any organization for the submitted work. All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript.
Footnotes
Publisher’s Note
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