Endoscopic ear surgery (EES) is a safe technique to approach different diseases of the middle ear, but it has certain limitations that must be respected at the risk of complications. A case of meningeal breach induced during an exclusive endoscopic approach to epitympanic cholesteatoma is presented. The limits and safety conditions of this technique are remembered.
Endoscopic ear surgery is a recent technique used by many otologists around the world to treat a broad range of otologic disease of the middle ear and even the inner ear.
In cholesteatoma surgery, the endoscope was first used as a complement to the microscope in a “combined technique”, to access “blind” areas under the microscope and avoid residual cholesteatoma [ , ]. Then it quickly became clear that the endoscope could be used “exclusively” in certain limits of pathology’s extensions [ ]. Because a cholesteatoma begins and recurs primarily in the middle ear, it was logical to approach this pathology through the middle ear [ , ]. In addition to a better visual control of the pathology and the ventilation routes of the epitympanum, the trans canal endoscopic approach avoids mastoidectomy and preserves the gas exchanges provided by the mastoid cells that guarantee postoperative ventilation.
The feasibility of an exclusive endoscopic surgery of attic cholesteatoma depends on certain conditions: access through a sufficiently wide ear canal, a cholesteatoma limited to the anterior and/or posterior epitympanum, not extending beyond an imaginary line drawn along the axis of the lateral semicircular canal, the control of dehiscence of the tegmen tympani.
Information was collected by preoperative patient temporal bone computed tomography (TBCT). The complication rate of endoscopic ear surgery was recently analyzed through a series of 825 patients [ ], it was about 4%.
To our knowledge, there are no reported cases of injury to the dura mater during endoscopic middle ear surgery.
A 25-year-old woman was followed for several years for moderate left conductive hearing loss, the diagnosis of serous otitis media was made but over the years an early attic retraction pocket leads to the realization of a TBCT. This showed an opacity limited to the Prussak space without osteolysis. Two years later, her hearing deteriorates ( Fig. 1 ) and the otoscopy showed a lysis of the scutum suspicious of epitympanic cholesteatoma ( Fig. 2 ). TBCT control shows no evolution ( Figs. 3A and 3B ). A surgical treatment by an endoscopic approach was proposed.
After removing bone of the scutum and resection of the incus, the injury occurred while cleaning the roof of the posterior epitympanic space with a 30° endoscope and a curved needle and very soon cerebrospinal fluid (CSF) leak appeared ( Fig. 4 ). At that moment, the question of a conversion to the microscope was raised.