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Objectives: This study investigates the possible benefits and limitations of the digital image enhancement systems provided by Storz Professional Image Enhancement System (SPIES) during endoscopic ear surgery (EES) for cholesteatoma. An increased detection of cholesteatoma residuals during the final steps of endoscopic surgery using DIE technology was hypothesized., Design: Cross-sectional study., Setting: Tertiary referral hospital., Methods: A total of 10 questionnaires of 18 intraoperative pictures with equal numbers of cholesteatoma and non-cholesteatoma images, each presented in three different image-enhancing modalities (Clara, Spectra A, Spectra B), were generated. Fifty-one experienced ear surgeons participated to the survey and were randomly assigned to a questionnaire and completed it at two time points. The experts were asked to rate for each picture whether cholesteatoma was present or not. The answers were compared with the histopathological reports., Results: Clara showed the highest accuracy in cholesteatoma detection, followed by Spectra A and lastly Spectra B. In contrast, Spectra B showed the highest sensitivity and Clara the highest specificity, while Spectra A was placed in the middle for both values. Using the Spectra B modality, most responses agreed across the two time points. Ear surgeons assessed the usefulness, as well as preference among image modalities for cholesteatoma surgery, in the following order: Clara, Spectra B, Spectra A., Conclusion: Digital enhancement technologies are applicable to EES. After complete cholesteatoma removal, Spectra B showed the highest sensitivity in the detection of cholesteatoma residuals as compared with Clara and Spectra A. Thus, Spectra B may be recommended to avoid missing any cholesteatoma residuals during EES., (© 2023 John Wiley & Sons Ltd.)

Objective: The aim of the study is to evaluate cholesteatoma's surgical outcomes in patients treated with endoscopic ear surgery (EES) or a combined endoscopic-microscopic approach (cEMA) according to STAM, STAMCO, ChOLE, and EAONO/JOS system (EJS) classifications and staging., Study Design: Retrospective study., Setting: Monocentric study in a tertiary referral center., Methods: One-hundred sixty-eight patients who underwent EES or cEMA for cholesteatoma between 2010 and 2018 were classified according to the abovementioned classification and staging. Data on cholesteatoma's recurrence and residual rates were collected. Inferential statistical analysis was performed to evaluate surgical outcomes and the prognostic value of classifications and staging., Results: The recurrence rate was significantly lower in cholesteatomas classified in EJS stage 1 (2.6%) and STAM stage 1 (0%). A comparison of the different stages of the disease showed a significantly lower recurrence only for stage 1 versus the superior stages of both classifications. Involvement of mastoid bone was associated with a higher risk of recurrence (odds ratio [OR]: 4.12; p = .031). Attical involvement was associated with a higher risk of residual cholesteatoma (OR: 1.165; p = .046)., Conclusion: EES or cEMA represents an effective treatment for middle ear cholesteatoma. The STAM classification and the EJS have shown a prognostic value, with STAM 1 and EAONO-JOS 1 stages associated with a better prognosis. Mastoid involvement represents a risk factor for recurrence. Attic localization is associated with residual disease. Localization at difficult access sites did not implicate a higher risk for recurrence or residual. ChOLE classification, Ossicular chain status, and complication status did not provide prognostic information regarding recurrence or residual cholesteatoma., (© 2023 American Academy of Otolaryngology-Head and Neck Surgery Foundation.)

Objective: To assess outcomes of transcanal endoscopic ear surgery (TEES) for congenital cholesteatoma., Study Design: Case series with chart review of children who underwent TEES for congenital cholesteatoma over a 10-year period., Setting: Three tertiary referral centers., Methods: Cholesteatoma extent was classified according to Potsic stage; cases with mastoid extension (Potsic IV) were excluded. Disease characteristics, surgical approach, and outcomes were compared among stages. Outcomes measures included residual or recurrent cholesteatoma and audiometric data., Results: Sixty-five cases of congenital cholesteatoma were included. The mean age was 6.5 years (range, 1.2-16), and the mean follow-up was 3.9 years (range, 0.75-9.1). There were 19 cases (29%) of Potsic stage I disease, 10 (15%) stage II, and 36 (55%) stage III. Overall, 24 (37%) patients underwent a second-stage procedure, including 1 with Potsic stage II disease (10%) and 21 (58%) with Potsic stage III disease. Eight cases (12%) of residual cholesteatoma occurred. One patient (2%) developed retraction-type ("recurrent") cholesteatoma. Recidivism occurred only among Potsic stage III cases. Postoperative air conduction hearing thresholds were normal (<25 dB HL) in 93% of Potsic stage I, 88% of stage II, and 36% of stage III cases., Conclusion: TEES is feasible and effective for removal of congenital cholesteatoma not extending into the mastoid. Recidivism rates were lower with the TEES approach in this large series than in previously reported studies. Advanced-stage disease was the primary risk factor for recidivism and worse hearing result. As minimally invasive TEES is possible in the youngest cases, children benefit from early identification and intervention.

Introduction: The Modena bleeding score is a categorical rating scale that allows the assessment of the surgical field in relation to bleeding during endoscopic surgery. It has recently been presented and validated in the field of endoscopic ear surgery by the present authors. The Modena bleeding score provides five grades for rating the surgical field during endoscopic procedures (from grade 1 - no bleeding to grade 5 - bleeding that prevents every surgical procedure except those dedicated to bleeding control)., Objective: The aim of this study was to validate the Modena bleeding score in the setting of endoscopic sinus surgery., Methods: Fifteen three-minute videos of endoscopic sinus surgery procedures (each containing three bleeding situations) were evaluated by 15 specialists, using the Modena bleeding score. Intra and inter-rater reliability were assessed, and the clinical validity of the Modena bleeding score was calculated using a referent standard., Results: The data analysis showed an intra-rater reliability ranging from 0.6336 to 0.861. The inter-rater reliability ranged from 0.676 to 0.844. The clinical validity was α = 0.70; confidence limits: 0.64 - 0.75, corresponding to substantial agreement., Conclusion: The Modena bleeding score is an effective method to score bleeding during endoscopic sinus surgery. Its application in future research could facilitate the performance and efficacy assessment of surgical techniques, materials or devices aimed to bleeding control during endoscopic sinus surgery., (Copyright © 2020 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published by Elsevier Editora Ltda. All rights reserved.)

Traditionally, otologic surgical training consisted of microscopic cadaveric dissections. However, during the last decades the endoscope has significantly changed the surgical perspective in the otologic field. Thus, the modern ear and lateral skull base surgeon should master the entire spectrum of endoscopic and microscopic approaches, with the aim of tailoring the procedure and guaranteeing the best possible functional outcome. This work proposes a step-by-step guided and illustrated dissection course, including indications for the setup of the cadaver lab and the integration of the microscope and endoscope to enhance the use of both instruments. The alternation of the endoscope and microscope allows the novice to train the correct handling of the instruments in the surgical field under both optical views. This aspect is of utmost importance since it is not advisable to start off a technique without practicing the other one, as both are important and complementary in the modern otologic surgery setting.

Background: In recent decades, endoscopic ear surgery (EES) has been rapidly evolving, expanding its boundaries from the middle ear to the lateral skull base. Nonetheless, the advantages of the endoscopic technique are associated with a number of intrinsic limitations., Methods and Objective: A narrative review was conducted to investigate the current limits of EES, analyzing the different otologic and skull base surgery procedures., Results: Limitations of EES can be divided into general and procedure-related. General limitations have been extensively described in the literature and are related to the bidimensional image provided by the endoscope, as well as the one-handed surgical technique and its implications in the management of bleeding. Procedure-related limits are continuously evolving and are also discussed in the present review., Conclusion: Although endoscope use is intrinsically associated with general limitations, these have been systematically overcome by the refinement of the surgical technique as a consequence of the increasing surgical experience gained over the last 20 years. The main limits of EES are currently associated with specific procedure- and disease-related situations. This review describes the general limitations and their management, as well as the current limits in the endoscopic management of various otologic diseases, from the external ear to the lateral skull base., (© 2021. Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Variable internal jugular vein anatomy is not rare. A high jugular bulb (JB) is reported in 6 to 34% of cases and, it can be jeopardized during middle ear surgery, especially if dehiscent. Its injury represents a threatening complication of ear surgery. In recent years there has been an increasing trend in the use of endoscopic ear surgery for a wide range of otologic procedures, but being a one-hand technique, the management of bleeding still represents a challenge. The aim of this video, http://links.lww.com/MAO/B280 is to report the endoscopic surgical management of internal jugular vein hemorrhage during endoscopic type I tympanoplasty., Competing Interests: The authors disclose no conflicts of interest., (Copyright © 2021, Otology & Neurotology, Inc.)

Purpose: Otolaryngologists have had to postpone the majority of surgical procedures in the current COVID-19 pandemic. Airborne transmission, beyond the projection of droplets from upper airways, expose healthcare workers to a risk of viral infection. Aerosol generating procedures (AGP) increase the risk of viral transmission to staff within the operating room., Methods: Surgery of middle ear and mastoid is also considered an AGP, particularly mastoidectomy performed using a high-speed drill. The authors report their experience in endoscopic ear surgery as an alternative technique to reduce AGP in otologic procedures., Results: Transcanal endoscopic ear surgery is a reliable technique used to manage many otologic conditions., Conclusion: The endoscopic approach may reduce the risk of viral transmission to operating room staff by reducing the need for mastoidectomy.

Objective: The aim of the present study was to illustrate the learning curve of endoscopic type-1 tympanoplasty comparing experts in microscopic otology versus neophyte surgeons., Methods: Eight ear surgeons, from tertiary referral centers, who had performed at least 30 endoscopic type 1 tympanoplasties were included in the study. Demographic data and medical records regarding the first 30 endoscopic type-1 tympanoplasties were retrospectively collected by each surgeon. A 14-questions survey focused on subjective aspects of the learning curve was administered. Surgeons were divided in two groups: one with previous experience in microscopic ear surgery (group 1) and one with no previous experience in ear surgery (group 2). The learning curve of endoscopic type 1 tympanoplasty was compared between the groups., Results: Mean surgical time was 89.2 min in group 1 vs. 79.5 min in group 2 (p < 0.01). When divided in 5 surgeries-steps, the only significant difference was appreciated in the first 5 surgeries with a longer mean time in group 1 vs. group 2 (+28.4 min; p < 0.05)., Conclusions: Surgeon's previous experience may influence the EES learning curve. Our results show that the first 5 surgical procedures are more challenging for surgeons experienced in microscopic surgery, subsequently the curve progression improves sharply and appears reversing the initial trend by the end of the 30 surgeries., Competing Interests: Declaration of Competing Interest The authors have not any financial support or relationship that may pose a conflict of interest., (Copyright © 2020. Published by Elsevier B.V.)

Purpose: To compare 3D to 2D technology in endoscopic ear surgery (EES); to report surgeons' feedback on the use of 3D in EES; to describe the operative setting for 3D EES., Methods: A case-control study on EES was performed at a tertiary university center. All consecutive cases of 3D EES (case group) were matched to a control group operated with the standard 2D technique. Data on surgical approach, type of surgery, operative time, outcomes, and complications were compared between the two groups. After each surgery, the operating surgeons were asked to give a feedback on the use of 3D endoscopy, filling in a questionnaire based on 5-point Likert scales., Results: None of the 3D procedures was switched to 2D. Nor intraoperative or long-term complications were recorded. The operative time was similar in both groups. Postoperative hearing function did not show any statistically significant difference between 3 and 2D patients. Ninety-six percent of participants agreed or strongly agreed on better views of anatomy and pathology with the 3D technique. Discomfort induced by 3D vision was rarely reported., Conclusion: Surgical and functional results from EES respectively performed with 3D and 2D systems are overall similar, suggesting that both techniques are safe and effective. According to the surgeons' feedback, 3D provides better depth perception and improved view of anatomy and pathology. Several surgeons are willing to use the 3D system for future EES. To guarantee the best 3D EES experience, the setting in the operating room plays a crucial role.

Objectives: To determine the limits of visualization during transcanal endoscopic ear surgery (EES) by correlating the relationship between radiologic and endoscopic anatomy using angled optics., Methods: Radiology and endoscopic visualization of tensor fold, protympanum, facial sinus (FS), sinus tympani (ST), subtympanic sinus (STS), hypotympanum, and aditus ad antrum were analyzed using a transcanal approach in 30 human temporal bones specimens with different angled endoscopes (0 degree, 45 degrees, 70 degrees) to check for the full visualization of these regions. High-resolution computed tomography (CT) was performed prior to dissection to classify retrotympanic anatomy. According to previously published descriptions, FS, ST, and STS were classified into types A, B, and C depending on their morphology relative to the mastoid segment of the facial nerve. These radiologic findings were compared to endoscopic visualization of these same structures using a Chi-squared test., Results: Visualization of the posterior wall of three different retrotympanic areas was significantly associated (FS p < 0.01; ST p < 0.01; STS p = 0.02) with the radiologic classification and endoscopic optical angle. Angled endoscopy improved visual access to the other subsites, especially the aditus ad antrum and the tensor fold (>70% with 45 degrees and 70 degrees)., Conclusion: Complete visual access to the hidden recesses of the middle ear can be achieved using angled endoscopes (45 degrees and 70 degrees). We observed a statistically significant association of endoscopic visualization to radiologic description of the retrotympanum on CT and the optical angle used. The prediction of the endoscopic exposure of the retrotympanum from the preoperative CT is possible. Even with the use of 70 degrees lens, retrotympanum is not fully visualized on transcanal endoscopy if a type C retrotympanic recesses (posterior and medial to the facial nerve) is present. This represents a technical limit of exclusive transcanal EES.

Objective: The aim of this article is to study the role and advantages of combined microscopic/endoscopic procedures or exclusive endoscopic approaches in the treatment of petrous apex pathologies., Methods: The study was designed as a retrospective case series analysis. We included patients affected by pathologies of the petrous apex, who underwent microscopic/endoscopic-assisted or exclusive endoscopic procedures. Patient and pathology characteristics and surgical data (focusing on the involvement of the internal carotid artery (ICA) and facial nerve by the disease) were collected. Residual disease, detected through the endoscopic check, and the feasibility of endoscopic residual tumor removal were also evaluated. Finally, facial nerve and hearing functions were assessed pre- and postoperatively., Results: The records of 75 patients undergoing lateral skull base surgery for petrous apex lesions, from May 2009 to March 2019, were collected. In 17 out of 75 patients, an exclusive endoscopic procedure was possible. The remaining 58 patients underwent a combined microscopic/endoscopic approach. In 15 cases, residual disease was found and removed endoscopically at the end of the microscopic procedure; in eight cases, the residual disease was medial and/or inferior to the horizontal segment of the ICA, while in two cases, it was located in the fundus of the internal auditory canal. In five cases, it involved the labyrinthine segment of the facial nerve., Conclusion: Petrous apex surgery remains a traditional microscopic-based surgery, but the recent advent of endoscopic surgery has permitted an improvement in radicality minimizing the manipulation of neurovascular structures.

Introduction: The management of bleeding in exclusive endoscopic ear surgery (EES) is largely dependent on epinephrine use. However, to date its suitability and safety have not been assessed. The aim of the present study would be to assess the safety profile of topical application and/or local infiltrationof diluted epinephrine during EES regarding the intra- and postoperative periods. We hypothesize that epinephrine may be safely used during EES., Methods: Retrospective analysis of 90 EES cases performed at the University Hospital of Modena, Italy. Patient's charts and video recordings of the operations were assessed., Results: Epinephrine was used in all cases for hemostatic purposes as following: (1) diluted epinephrine (1:200,000) injection: mean 1.2 mL (range: 0-3.5) corresponding to 0.006 mg (range 0-0.018), and (2) topical application (1:1,000) directly in the surgical field: mean 7 cottonoids (range: 0-18) corresponding to mean 0.56 mg (range: 0-1.44). No major cardiovascular adverse effects were assessed. Only 2 intraoperative hypertensive events were recorded. One sensorineural hearing loss was observed in a case of cholesteatoma involving the stapes; no facial palsy occurred during the study period., Conclusion: The combined use of local injection and topical epinephrine is a safe and effective strategy to control bleeding in exclusive EES, when used within the dilutions and quantities reported in this study., (© 2019 S. Karger AG, Basel.)

Purpose: To develop and validate a bleeding score that could be applied in endoscopic ear surgery (EEarS)., Methods: A prospective validation study was performed. A new bleeding score, called "Modena Bleeding Score" (MBS), was created by the authors. It provides five grades for rating the surgical field during EEarS procedures (from grade 1-no bleeding to grade 5-bleeding that prevents every surgical procedure except those dedicated to bleeding control). A preliminary "face validity" was performed by 18 ENT specialists to assess possible misunderstandings in interpreting the scale. Then, 15 videos of endoscopic ear surgery procedures, each divided into three parts (t0, t1, and t2), were subsequently evaluated by 15 specialists, using MBS. The videos were randomly selected and assigned. Intra-rater reliability and inter-rater reliability were calculated. The clinical validity of the instrument was calculated using a referent standard (i.e., four ENT experts whose ratings were compared to those obtained by the former sample)., Results: The face validity showed a good consensus about the clarity and comprehension of the scale; both intra and inter-rater reliability demonstrated good performance (intra-rater reliability ranged from 0.741 to 0.991 and inter-rater reliability was 0.790); clinical validity also showed positive values, ranging from 0.75 to 0.93., Conclusions: MBS has proved to be an effective method to rate surgical field during EEarS, with good-to-excellent performances. Its use would possibly help comparisons of groups in clinical trials or comparisons between studies.

Objective: The aim of this study was to examine the premise that endoscopic ear surgery (EES) is associated with a low rate of complications (intraoperative and postoperative)., Study Design: Retrospective review at two institutions., Setting: Tertiary referral center., Patients: The study included 825 patients who underwent exclusive EES between 2008 and 2016 at the Otorhinolaryngology-Head and Neck Surgery Department of Modena University Hospital, and between 2014 and 2016 at the Otorhinolaryngology-Head and Neck Surgery Department of Verona University Hospital., Interventions: Exclusive endoscopic ear surgery between 2008 and 2016 (tympanoplasties, second look or revision tympanoplasties, myringoplasties, stapedoplasties, canalplasties, ossiculoplasties, and exploratory tympanotomies). All surgical procedures were performed by two experienced surgeons., Main Outcome Measure: For each procedure, intraoperative, and early and delayed postoperative complications were evaluated., Results: The most common ear pathologies for which patients were sent for EES were cholesteatoma (33.6%), chronic otitis media (36.3%) and otosclerosis (26.8%). There was no case of major intraoperative complications such as injury to the dura or vascular structures. We observed minor intraoperative complications in 4.1% of the cases. Only 1.3% of patients experienced early postoperative complications. Delayed complications affected less than 1% of the cohort., Conclusions: Data from this study confirm the safety of the endoscopic technique, with very low complication rates, indicating that EES is a reliable therapeutic option, in particular, for tympanoplasties, myringoplasties, and stapedoplasties, as well as second look procedures. We have reported our experience with EES morbidity so that it can be compared with data from other centers using the same surgical technique.

Objective: To define a new surgical option, with lower morbidity, for the treatment of intralabyrinthine schwannomas., Study Design: Retrospective case review., Setting: Tertiary referral centers., Patients: Eight patients affected by an intralabyrinthine schwannoma, with or without extension to the internal auditory canal, that underwent surgery with a transcanal transpromontorial approach, were included in the study. The average age at presentation was 47 years. Patients' characteristics, symptoms, tumor features, and surgical results were analyzed., Interventions: All patients were diagnosed and evaluated pre-operatively with high-resolution, gadolinium-enhanced MRI and CT scan of the temporal bone, and underwent surgery via either transcanal transpromontorial endoscopic approach (TTEA) or enlarged transcanal transpromontorial endoscopic approach (ETTA)., Main Outcome Measures: Hearing function was evaluated with the Hearing Classification System according to the Committee on Hearing and Equilibrium Guidelines. Facial nerve function was evaluated using the House-Brackmann grading system (HB)., Results: In six patients out of eight, a TTEA was performed, whereas, due to the extension of the pathology to the cerebellopontine angle, two patients underwent an ETTA. The mean follow-up period was 15.5 months (range 1-69). No intra-operative and post-operative major complications were observed. Post-operative facial nerve function was normal in seven out of eight patients (grade I HB). One patient presented a grade II HB., Conclusion: The endoscopic approach to cochlear schwannoma represents a good treatment option for patients and should be preferred to other more invasive surgical techniques when indicated, to reduce complications, hospitalization, and offer to patients the chance to eradicate the disease, thus avoiding the stress of a long-life radiological follow-up., Level of Evidence: 4.

Background: Recently, the transcanal approach for the removal of acoustic neuromas has been introduced. Facial nerve (FN) preservation is one of the main challenges of this kind of surgery., Objective: To describe our experience in the surgical treatment of acoustic neuromas, focusing on the functional results of FN preservation after a transcanal approach., Methods: A retrospective chart review was carried out on clinical data and videos from operations on 49 patients who underwent surgery with a totally transcanal exclusive endoscopic approach for Koos stage I-II lesions, or an enlarged transcanal transpromontorial approach for Koos stage II-III tumors, between March 2012 and February 2017. Patients and tumor characteristics, clinical manifestations, radiologic features, audiological results, FN outcomes (according to the House-Brackmann [HB] grading system) and complications were evaluated. Tumors were classified according to the Koos grading system., Results: The age of the patients (34 females and 15 males) ranged from 27 to 77 years (mean age: 54.9 yr). Preoperative diagnosis was "vestibular schwannoma" in all patients. At the last follow-up (range 1-60 mo, mean 13.9 mo), 42 of 49 showed grade I HB FN function, 5 of 49 grade II HB, and 2 of 49 grade III HB. Overall, in 95.9%, FN function was preserved (grade I-II HB) with stable results at follow-up; in 4.1% of cases, FN function was reduced, but not worse than grade III., Conclusion: The transcanal approach represents a feasible, minimally invasive, and conservative technique for the management of acoustic neuromas of the internal auditory canal.

The middle ear is located in the center of the temporal bone and bears a highly complex anatomy. The recently introduced exclusively endoscopic transcanal approach to the middle ear is a minimally invasive technique sparing the bone and mucosa of the mastoid bone, since the middle ear is accessed through the external auditory canal. This emerging method has several advantages over the traditional (microscopic) approaches to the middle ear such as the panoramic wide-angle views of the anatomy, the possibility to approach and magnify tiny structures, and the possibility of looking around the corner using angled endoscopes. The cadaveric dissection method presented here consists of an overview on the technical requirements and a precise description of a step-by-step protocol to discover the anatomy of the middle ear. Each step and anatomical structure is carefully described in order to provide a comprehensive guide to endoscopic ear anatomy. In our opinion, this is particularly important to any novice in endoscopic ear surgery as it provides thorough anatomical knowledge and may improve surgical skills.

Objective Transcanal exclusive endoscopic ear surgery requires the management of the endoscope and the surgical instruments in the external auditory canal. Bleeding in this narrow space is one of the most challenging issues, especially for novice endoscopic ear surgeons. We aim to assess the severity and occurrence of bleeding and describe strategies to control the bleeding during endoscopic ear surgery. We hypothesize that bleeding is reasonably controllable in endoscopic ear surgery. Study Design Case series with chart review. Setting Tertiary referral center. Subjects and Methods We retrospectively assessed 104 consecutive cases of exclusive endoscopic ear surgery at the University Hospital of Modena, Italy. The surgical videos and the patient charts were carefully investigated and analyzed. Results Hemostatic agents included injection of diluted epinephrine (1:200,000, 2% mepivacaine), cottonoids soaked with epinephrine (1:1000), mono- or bipolar cautery, washing with hydrogen peroxide, and self-suctioning instruments. The localization of bleeding in the external auditory canal was most frequently the posterior superior part, and inside of the middle ear, it was the pathology itself. Statistical analysis revealed significant differences comparing the mean arterial pressure and the type of intervention among bleeding scores. Conclusion The management of bleeding in endoscopic ear surgery is feasible through widely available hemostatic agents in reasonable frequency. This study gives an instructive overview on how to manage the bleeding in the exclusive endoscopic technique. Even the highest bleeding scores could be managed in an exclusively endoscopic technique.

Importance: With the international spread of exclusive transcanal endoscopic ear surgery, the need for a suitable and affordable surgical training model has grown during the past years., Objective: To develop and validate an ex vivo animal model for exclusive endoscopic ear surgery., Design, Setting, and Animal Models: In an experimental study, we compared ovine and human middle ear anatomy in 4 specimens and assessed the lamb as a model for endoscopic ear surgery. After confirming its suitability, we developed a surgical training program for canaloplasty, myringoplasty, and ossiculoplasty. From March 1 to May 31, 2016, the ex vivo model was tested, assessing the time needed for dissection and complications. Each experience was subjectively validated on a scale from 1 (very poor) to 10 (excellent)., Main Outcomes and Measures: Suitability of the lamb model for training in exclusive endoscopic ear surgery., Results: We assessed the suitability of our novel lamb model on 20 ovine middle ears. All interventions could be performed in a satisfactory manner. The mean (SD) time required to perform canaloplasty was 29.7 (13.2) minutes, for middle ear dissection was 7.7 (2.6) minutes, for myringoplasty was 7.7 (4.3) minutes, and for ossiculoplasty was 10.4 (2.7) minutes. The time required for canaloplasty and tympano-meatal flap elevation during dissection decreased from 46.4 minutes in the first 5 cases to 16.2 minutes in the last 5 cases, representing an absolute difference of 30.2 minutes (95% CI, 22.28-38.12). Subjective ratings revealed excellent values for tissue quality (8.9 points of 10), overall satisfaction (8.3 points), and the learning experience (8.8 points)., Conclusions and Relevance: The ovine model is suitable for endoscopic ear surgery. We describe a novel, exclusively endoscopic approach in an ex vivo animal model for middle ear surgery. The proposed surgical program leads the trainee step by step through the main otologic procedures and is able to enhance his or her surgical skills.

A detailed and comprehensive discussion of transcanal endoscopic management of cholesteatoma is presented. After a presentation of the anatomy of the area, the rationale, advantages and limitations, technique, and long-term results of each technique are presented. A case presentation follows each technique. Techniques presented are: endoscopic transcanal management of limited cholesteatoma, endoscopic open cavity management of cholesteatoma, and expanded transcanal access to middle ear and petrous apex., (Copyright © 2013 Elsevier Inc. All rights reserved.)

At present, the main application of endoscopic surgery is in the surgical treatment of middle ear cholesteatoma; however, for definitive validation and acceptance by scientific community, results are needed regarding recurrent and residual rates of the condition. This article analyzes the single-institution experience from results of surgical treatment of attic cholesteatoma., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Currently, the main application of endoscopic surgery relies on the middle ear cholesteatoma surgical treatment. However, in the natural evolution of the technique there are the steps toward of lateral skull base surgery and treatment of pathologic conditions of pertous bone. The endoscopic approaches to lateral skull base are (1) a transcanal exclusively endoscopic approach or (2) combined approaches (microscopic endoscope-assisted), including transotic, infralabyrinthine, and suprameatal translabyrinthine., (Crown Copyright © 2013. Published by Elsevier Inc. All rights reserved.)

This article covers state-of-the-art instruments and devices specially designated for endoscopic ear surgery. New technologies stimulate the creation of special endoscopic equipment and microinstruments specially designed to satisfy the exclusive requirements of endoscopic ear surgery, which contribute to the progress of the procedure. The article presents the advantages and disadvantages of working with ear endoscopes and details the advances in equipment used in ear endoscopies. New instruments specially modified for working with angled-vision endoscopes and considerations of the surgeon's use of them are discussed., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objectives: To investigate the anatomic limitations of the endoscopic transcanal approach to sinus tympani (ST), in particular, how this approach might allow a complete visualization of the ST recesses and to propose a morphologic classification of the ST using computed tomography and to examine if this could be useful for the surgeon in preoperative planning to decide the type of approach to the ST., Study Design: Case series., Patients and Methods: Forty patients affected by middle ear disease with ST involvement were included in our study. All patients underwent a preoperative computed tomographic scan of the temporal bone. All patients underwent tympanomastoid surgery with intraoperative use of the endoscope. We assessed the variation in depth of the ST area, analyzing the posterior and medial extension of the medial boundary of the ST, and performing a radiomorphologic classification of the ST., Results: Of the 40 patients, it has been possible to describe the detailed morphology of the shape of the ST in 38. We classified the depth of the ST into 3 types based on radiologic findings: Type A (a limited ST), Type B (a deep ST), and Type C (a deep ST with a posterior extension). Of 35 ST of Types A and B, there was good exposure of the medial boundary of the sinus using a transcanal endoscopic approach in 33 (94.2%), whereas in 3 (60%) of 5 patients of Type C, it was not possible to explore the complete depth of the sinus, especially the ST portion under and posterior to the facial nerve., Conclusion: The transcanal endoscopic approach to the ST is indicated in ST of Types A and B. In ST of Type C, it is not always possible to have good control of the ST; in these cases, a posterior retrofacial approach is suggested.

The transsphenoid approach to the petrous apex, a surgical procedure described for the first time by Montgomery in 1977, is a rarely performed approach for the drainage and ventilation of cholesterol granuloma. We consider this approach to be the technique of choice when the cholesterol granuloma is located in the medial section of the petrous apex abutting and/or prolapsing into the posterior wall of the sphenoid sinus. The transsphenoid approach, unlike other lateral approaches to the petrous apex, is highly conservative and spares cochlear and vestibular function; moreover, it allows simple and adequate post-operative endoscopic follow up as an out-patient, with easier treatment in the case of recurrence.