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Two-handed Endoscopic Tympanoplasty Using a
Pneumatic Endoscope Holder
Anuraag Parikh, MD1,2, Daniel J. Lee, MD1,2, Michael S. Cohen, MD1,2
1Dept.
of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA;
2Dept. of Otology and Laryngology, Harvard Medical School, Boston, MA, USA;
INTRODUCTION
SURGICAL TECHNIQUE
Endoscopic ear surgery (EES) continues to gain in
popularity due to improved visualization in
comparison to the binocular microscope and the
ability to perform transcanal procedures that would
otherwise require a postauricular incision. A major
challenge in EES is the increased technical difficulty
of one handed surgery, as the non-dominant hand is
occupied by the endoscope.
The patient underwent endoscopic type I
tympanoplasty with underlay fascia graft and split
thickness skin graft.
• The tympanic membrane perforation was
freshened using a Rosen needle and a 20 gauge
suction
• An anteriorly based tympanomeatal flap was
elevated using a Rosen knife and a 20 gauge
suction
• Once the annulus was elevated out of its groove,
the tympanic membrane was reflected anteriorly
and the malleus was skeletonized from umbo to
short process
• Gelfoam was placed in the middle ear, and the
fascia graft was placed with a slit for the malleus
long process
• The tympanomeatal flap was replaced and the
split thickness skin graft was placed lateral to the
reconstructed tympanic membrane
Advantages of Endoscopic Ear Surgery:
Endoscopes provide a wider field of view and more
magnified images than microscopes, as the light
source and camera are located at the distal tip of the
instrument. Microscopes require an adequate
amount of light to reach the surgical field, often
challenging in the setting of bony overhangs.
Endoscopes provide an improved ability to
visualize deep recesses without the need for
additional procedures. Angled endoscopes have
been shown to significantly improve visualization of
the sinus tympani, Prussak’s space, and the stapes
footplate. Endoscopes identified residual
cholesteatoma following microscopic resection in 1676% of primary procedures, most notably in the
sinus tympani, epitympanum, attic, facial recess,
and mastoid cavity. Curettage of the chordal crest
and canaloplasty are required significantly more
often with microscopic techniques than with
endoscopy.
Challenges of Endoscopic Ear Surgery:
Microscopy affords binocular vision and therefore
better depth perception than endoscopy. This was
initially thought to lead to increased operative times,
which would be overcome with surgeon experience.
The endoscope occupies the surgeon’s nondominant hand, thus necessitating one-handed
operation. This limitation places a premium on
minimizing bleeding during the surgery. In one study,
conversion from endoscopic to traditional
microscopic techniques was required in 14% of
cases secondary to bleeding unable to be controlled
with a one handed approach.
ENDOSCOPE HOLDER
Storz Point Setter (Mitaka
Arm) Pneumatic Endoscope
Holder
 This device is typically
used for endoscopic
neurosurgery
 It has an operating release
button for single hand
control, five joints for
coarse adjustment, and
one manual ball joint for
fine adjustment.
 It is mounted directly to
the operating room table.
 The arm must be draped,
while the endoscope
holder is autoclavable and
does not need to be
draped.
TWO-HANDED ENDOSCOPIC EAR SURGERY
Figure 1
demonstrates the
Point Setter attached
to the right side of the
operating room table
in preparation for leftsided tympanoplasty.
 Precision of the Point Setter was found to be
adequate for endoscopic ear surgery, with very
limited movement at the working end.
 Use of the Point Setter enabled two-handed
surgery, which particularly facilitated raising the
tympanomeatal flap, skeletonizing the manubrium
of the malleus, and precisely positioning the
grafts. It was also noted to decrease strain on the
surgeon’s non-dominant hand.
 Disadvantages included decreased ability to
visualize instruments as they passed through the
ear canal and crowding of the working space,
given the size of the endoscope relative to the
external auditory canal and the simultaneous
presence of two instruments in the canal.
 Questions about the safety of stationary
endoscopes in the middle ear have been raised
due to the heat generated by these instruments.
A rapid rise of 8-10o C from a baseline of
approximately 36o C has been reported, with
elevated temperatures found up to 8mm from the
tip of the endoscope. The functional
consequences of this temperature rise are
unclear, but hyperthermia has been shown to
exacerbate the effects of noise-induced hearing
loss and aminoglycoside ototoxicity in animal
models and inhibit transient evoked otoacoustic
emissions in humans. A rapid decline in
temperatures has been observed with the use of
suction; therefore, although static use of the
endoscope may risk elevated middle and inner
ear temperatures for long periods of time, the
ability to perform two-handed surgery may allow
for more constant use of suction, thereby
minimizing risks.
CONCLUSIONS
Figure 1
Figure 2
Figures 2-4
demonstrate the ability
to perform two-handed
endoscopic surgery
with the use of the
Point Setter
endoscope holder.
CASE
• 6 year old male with a history of recurrent acute
otitis media who underwent bilateral myringotomy
with tubes at age 2
• Now with persistent left-sided 30% anteroinferior
tympanic membrane perforation abutting the
manubrium of the malleus posterosuperiorly
• Presents for routine type I tympanoplasty for
repair of perforation
DISCUSSION
Figure 3
Figure 4
Correspondence: Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, 243 Charles St, Boston, MA 02115; [email protected]
Use of the Point Setter facilitated critical steps in
endoscopic tympanoplasty by allowing the surgeon
to operate two-handed. Further experience with
more complex procedures is needed to determine
the full range of benefits of this tool.
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