Overview

Endoscopic ear surgery employs very similar techniques to those of standard microscopic ear surgery, but it does so by means of a very different approach to the middle ear and to middle ear pathology. Accordingly, while in general the instruments required are very similar to those used in standard ear surgery, certain dissectors and a forceps need to be adapted so as to take advantage of the endoscope’s ability to “see around corners.” The most basic middle ear instrument sets will be sufficient to undertake simple cholesteatoma and tympanoplasty surgery, but as the surgeon becomes more confident and experienced in the technique of endoscopic ear surgery, so their requirements for more advanced tools will increase.

Although the instruments used during endoscopic middle ear surgery are very similar to those used in standard ear surgery, the way in which they are used differs considerably. The fact that the entrance to the ear canal is not confined or constrained by a speculum allows the surgeon a far wider angle of attack when using the instruments in the more inaccessible areas such as the hypotympanum or retrotympanum.

Perhaps the greatest departure in technique is the one-handed nature of endoscopic ear surgery. The endoscope is held in the nondominant hand while the opposite hand undertakes the majority of the surgery. This may seem somewhat difficult and perhaps strange at first but, when analyzed, the function of the nondominant hand during traditional surgery is usually concerned with holding a suction and removing blood from the operative field while the dominant hand still undertakes the majority of the delicate surgery. Given that an endoscopic approach is considerably less traumatic than a standard approach to the middle ear, there is usually far less bleeding and as result the need for suction is reduced considerably.

1.1.2 Choice of Endoscope

Endoscopes come in a dizzying array of lengths, diameters, and angulations. Each has its own advantages and disadvantages, but the general rule is that the larger the diameter of the endoscope, the better the field of view and the better the illumination delivered by the light bundles carried within the lens. As a result, a longer, wider endoscope is actually the preferred instrument for middle ear work. Most middle ear endoscopic surgeons will undertake the majority of the surgery using a 14- to 18-cm, 3-mm diameter, 0° Hopkins rod and scope (the same endoscope as used for sinus surgery). In fact, it is unusual to need to change to a larger angle to achieve a good view of all of the middle ear. Sometimes, particularly in the sinus tympani, it may be necessary to change to a 30° or a 45° endoscope. The 45 degree endoscope allows a better view of the retrotympanic spaces but requires adequate skills. The length is important as well, given that additional endoscopes used to augment the microscopic approach to the middle ear are normally very short. One of the advantages of using a longer endoscope is that the surgeon’s two hands will be at different distances from the ear canal and thus be less likely to interfere with one another during surgery.

Although a high-quality Hopkins rod is paramount, it is also vital to ensure that the digital camera that is attached to the endoscope is of a very high specification. One of the most important considerations is that it needs to be a high definition monitor and camera, rather than a single-chip camera. The reason for this is that analog cameras are prone to “red-out” when they are used in a very small area with a lot of bleeding. Even though there is not much bleeding during endoscopic ear surgery, the field tends to become reddened and this causes complete saturation of the camera: the entire field takes on an orange hue, which makes the identification of anatomical structures very difficult indeed. The 3-mm endoscope at present is being increasingly used and accepted by the majority of surgeons, because of the possibility to work into the tympanic cavity with the same field of view as the 4-mm endoscope.

1.2 Your First Case

When starting out with endoscopic ear surgery it is usually best to begin with surgeries that are likely to go well and lend themselves to the endoscopic approach. Once you have built up your skills, you will be better equipped to undertake more challenging surgeries using the endoscopic technique.

1.2.1 Patient Factors

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