Innovations in Endoscopic Ear Surgery

This book focuses on endoscopic ear surgery, an area that has been the focus of cutting-edge research around the globe, particularly in Italy, the United States and Japan.

Ear surgery has begun to catch up with other fields of medicine in incorporating the endoscope into surgical procedures, and endoscopic, minimally invasive ear surgery is garnering international attention.

Innovations in Endoscopic Ear Surgery presents the work of the Japanese “school” of surgeons involved in advancing endoscopic ear surgery and, in particular, transcanal endoscopic ear surgery (TEES). This book not only seeks to explain TEES in detail to allay surgeons’ concerns regarding this procedure, it also describes the recent advances such as the incorporation of powered instruments to extend the range of TEES; combining TEES with the latest techniques in regenerative medicine; taking advantage of the progress in computer technology such as 3D simulations and virtual reality and more. Innovations in Endoscopic Ear Surgery is designed to help smooth the learning curve for beginners as well as guide all readers onto the new paths which endoscopic ear surgery is embarking upon.

• Language: English
• Publisher: Springer
• Release date: Aug 1, 2019
• ISBN: 9789811379321

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© Springer Nature Singapore Pte Ltd. 2020

Seiji Kakehata, Tsukasa Ito and Daisuke Yamauchi (eds.)Innovations in Endoscopic Ear Surgeryhttps://doi.org/10.1007/978-981-13-7932-1_1

1. Innovations in Endoscopic Ear Surgery

Seiji Kakehata¹  

(1)

Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine, Yamagata University, Yamagata, Japan

Seiji Kakehata

Email: [e-mail]

1.1 A Short History of the Use of the Endoscope in Otology

While the invention of the endoscope can be traced back to Philipp Bozzini, a physician of Italian and German descent, in 1806 [1], it took more than 150 years for it to become a part of the tool set for the ear surgeon. While the endoscope has long been a standard tool in other surgical fields, otologists were late adopters to the use of the endoscope in surgery, despite the fact that the internal structures and spaces of the ear had long been among the most, if not the most, difficult areas to surgically expose and access even with a microscope. This delay in the incorporation of the endoscope into ear surgery can be attributed to the delicate and tiny anatomical structures which are often interlocking and located within a miniature maze that includes hidden recesses and dead ends. Ear surgeons when using a microscope are often required, even today, to operate blindly. Many internal ear structures only became visible during surgery just before the end of the twentieth century via the use of the endoscope.

The endoscope was first incorporated into the field of otology as a diagnostic and photographic tool. Nomura et al. described in 1982 [2] using what they referred to as a needle otoscope to take photos of the tympanic membrane as well as the challenges involved. These challenges included the size of the camera itself, limitations on the size and quality of photos, and need for sending film out for development which were all part and parcel of photography in the predigital age. The endoscope next started to play a supporting role in microscopic ear surgery (MES) as a tool which allowed surgeons to look around corners into hidden recesses with straight and angled lens as reported by Thomassin [3]. It was particularly useful in cholesteatoma surgery where surgeons struggle to ensure that no remnants are left behind which can lead to a residual cholesteatoma.

1.2 The Endoscope Goes Solo

The most dramatic breakthrough came with the papers of Dr. Muaaz Tarabichi who described ear surgery successfully performed exclusively using an endoscope. His first papers in 1997 and 1999 [4, 5] described the removal of limited cholesteatomas by TEES.

1.3 High Definition Takes It to the Next Level

While ear surgery was being performed solely with the endoscope from the 1990s as stated above, the switch from standard definition (SD) to high definition (HD) imaging resulted in crystal-clear images of the internal structures of the inner anatomy of the ear. These images allayed some of the fears associated with endoscopic ear surgery, particularly as related to worries about 2D images. This technological advance was accompanied by expanded interest in TEES spurred on by the establishment of the International Working Group on Endoscopic Ear Surgery (IWGEES) in 2008. The members of the IWGEES were instrumental in developing and promoting TEES, and a real jump was seen in the number of surgeons performing endoscopic ear surgery around the world as we entered the 2010s.

1.4 Embarking on the Path to TEES

We hope that our book will stir the interest of ear surgeons and prompt many readers to take the first steps to incorporating TEES into their own surgical practice. However, as with most new endeavors, it is incumbent upon the novice TEES surgeon to gather the necessary information, study the appropriate resources, observe experts in action, and obtain the required skills through careful and diligent practice. This section shall take a brief look at relevant issues related to TEES, recommend resources for individual study, and suggest ways to participate in the growing community of TEES surgeons.

1.4.1 Steep Learning Curve

A common refrain that is heard by surgeons who have not yet embarked upon TEES is that TEES has a steep learning curve. While that may have been absolutely true in the early days of TEES, any hurdles to learning TEES have become much lower over time for both the novice ear surgeon and the experienced ear surgeon who has not yet embarked upon learning TEES. While TEES is characterized by the need to perform one-handed surgery and its 2D view, any surgeon who has experience performing endoscopic sinus surgery (ESS) will have a good head start on these and other aspects of TEES which they should then supplement with an in-depth study of the internal ear anatomy. Such study should be accompanied by rigorous practice on cadavers and/or 3D printed models as well as observation of and guidance from experienced TEES surgeons. Observation of TEES procedures is actually made easier by the fact that both the surgeon and any observers can simultaneously see the same view of the surgery as it is performed which greatly facilitates the teaching of TEES.

Thus, a step-by-step approach to both the theory and practice of TEES should ensure that any competent ear surgeon can become a competent TEES surgeon.

1.4.2 Heads-up Surgery

One of the big differences between MES and TEES is the posture assumed by the surgeon. Some surgeons may find looking up at the video monitor rather than down through a microscope a bit disconcerting in the beginning and take some time to get used to this difference. However, the heads-up posture of TEES is more ergonomically sound than the posture of MES which requires a more rigid posture that is harder to maintain over the course of a long surgical procedure [6, 7]. Moreover, MES is starting to also move in the direction of heads-up surgery with the introduction of the exoscope.

1.4.3 Resources in the Literature

A wide range of resources are available for surgeons interested in TEES. Among our recommendations are Endoscopic ear surgery—principles, indications, and techniques by Livio Presutti and Daniele Marchioni [8] and TEES Surgical Atlas by Seiji Kakehata for Japanese readers [9] (which will also soon be published in Chinese). An excellent primer on getting started in TEES is an article which was written by Ryan et al. and provides a detailed step-by-step guide to learning TEES [10]. We also recommend checking the references listed for each of the sections herein.

1.4.4 Face-to-Face Resources

In addition to resources in the literature, any aspiring TEES surgeon would be well advised to take advantage of the many opportunities to meet up with the growing community of TEES surgeons. This community strives to promote TEES and warmly welcomes newcomers.

1.4.4.1 International Working Group on Endoscopic Ear Surgery (IWGEES)

The International Working Group on Endoscopic Ear Surgery (IWGEES) was, as stated above, established in 2008 with the stated goals of developing and improving endoscopic ear surgery in conjunction with the microscope. The IWGEES works year-round to promote and facilitate discussion on the latest in endoscopic ear surgery, and its home page (https://​iwgees.​org/​) is a good place to start when looking for information and gatherings on endoscopic ear surgery. We also encourage all to become a member of the IWGEES.

1.4.4.2 World Congress on Endoscopic Ear Surgery

The first World Congress on Endoscopic Ear Surgery was held in 2015 in Dubai, the second was held in Bologna in 2017, the third was held in Boston in 2019, and the fourth World Congress on Endoscopic Ear Surgery is scheduled from April 8th to the 10th of 2021 in Kyoto, Japan. This World Congress brings together experts on endoscopic ear surgery to promote its continued advancement, growth, and acceptance.

1.4.4.3 Hands-on Seminar in Yamagata

One of the best ways to get an idea of the benefits of TEES is the annual Hands-on Seminar in Yamagata, Japan. This seminar is a two-day event which offers attendees the opportunity to hear lectures from leaders in the field, get hands-on experience by practicing TEES using 3D printed models, observe several live surgeries, and last, but not least, enjoy a night at a traditional Japanese hot spring! The 9th annual seminar should be held in the late spring or early summer of 2020.

1.5 Moving Forward and into the Future

The purpose of this book, Innovations in Endoscopic Ear Surgery, is to provide a peek into the future of TEES as it continues to develop and evolve. With TEES now entering its maturation phase, innovations are appearing that not only build upon what has become standard practice, but also expand into new and exciting directions. This book is designed to provide a guide to the future of TEES.

References

1.

De Groen PC. History of the endoscope [scanning our past]. Proc IEEE. 2017;105(10):1987–95.Crossref

2.

Nomura Y. Effective photography in otolaryngology e head and neck surgery: endoscopic photography of the middle ear. Otolaryngol Head Neck Surg. 1982;90:395e398.Crossref

3.

Thomassin JM, Korchia D, Duchon Doris JM. Endoscopic-guided otosurgery in the prevention of residual cholesteatomas. Laryngoscope. 1993;103(8):939–43.Crossref

4.

Tarabichi M. Endoscopic management of acquired cholesteatoma. Am J Otol. 1997;18(5):544–9.

5.

Tarabichi M. Endoscopic management of limited attic cholesteatoma. Otolaryngol Head Neck Surg. 1999;121(2_suppl):195.Crossref

6.

Vijendren A, Devereux G, Tietjen A. The Ipswich microbreak technique to alleviate neck and shoulder discomfort during microscopic procedures. Appl Ergon. 2018. https://​doi.​org/​10.​1016/​j.​apergo.​2018.​04.​013.

7.

Vijendren A, Devereux G, Kenway B. Effects of prolonged microscopic work on neck and back strain amongst male ENT clinicians and the benefits of a prototype postural support chair. Int J Occup Saf Ergon. 2017;1:1–10. https://​doi.​org/​10.​1080/​10803548.​2017.​1386411.Crossref

8.

Presutti L, Marchioni D. Endoscopic ear surgery – principles, indications, and techniques. New York: Thieme; 2015.

9.

Kakehata S. TEES surgical atlas. Tokyo: Nakayama Shoten; 2018.

10.

Ryan P, Wuesthoff C, Patel N. Getting started in endoscopic ear surgery. J Otol. 2018. https://​doi.​org/​10.​1016/​j.​joto.​2018.​10.​002.

© Springer Nature Singapore Pte Ltd. 2020

Seiji Kakehata, Tsukasa Ito and Daisuke Yamauchi (eds.)Innovations in Endoscopic Ear Surgeryhttps://doi.org/10.1007/978-981-13-7932-1_2

2. The TEES Lineup: Non-powered TEES, Powered TEES, and the Dual MES/TEES Approach

Seiji Kakehata¹   and Tsukasa Ito¹  

(1)

Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine, Yamagata University, Yamagata, Japan

Seiji Kakehata (Corresponding author)

Email: [e-mail]

Tsukasa Ito

Email: [e-mail]

2.1 Introduction

While the endoscope plays the starring role in transcanal endoscopic ear surgery (TEES), TEES has a supporting cast of equipment that have helped guarantee its success, particularly the 3-charged-coupled device (CCD) camera and more recently the complementary metal-oxide semiconductor (CMOS) cameras connected to video monitors. These cameras and monitors, which were originally high definition (HD) and more recently ultra HD or 4K, combine to produce clear images that allow surgeons to confidently perform transcanal surgery with an endoscope within the delicate anatomical structures of the middle ear.

However, indications for removal of cholesteatomas by TEES are generally considered to be limited to the tympanic cavity and inferior portion of the attic. Those cholesteatomas located beyond the inferior portion of the attic had been considered outside the reach of TEES. Instead such cholesteatomas still continue to be removed, even by TEES surgeons, via microscopic ear surgery (MES) with its invasive retroauricular incision and extensive temporal bone removal. However, as in the past, technical advances in outside fields allowed us to expand the indications for TEES. These advances, once again, include advances in digital imaging technology in the field of MRI imaging which facilitate pinpointing the anatomical location of a cholesteatoma during the preoperative diagnosis, as well