I think over time EES will clearly find its place because the visualization is better, but I think it’s going to take longer for adoption. —David Kennedy, MD
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May 2020
A review of 825 EES procedures performed by surgeons described as “experienced” from 2008 to 2016 at Modena University Hospital in Italy found that complication rates were low. The procedures included tympanoplasties, revision tympanoplasties, myringoplasties, stapedoplasties, ossiculoplasties, and exploratory tympanotomies. Researchers found minor intraoperative complications in 4.1% of cases, early postoperative complications in 1.3% of cases, and delayed complications in less than 1% (Otol Neurotol. 2018;39:1012-1017).
According to Daniel Lee, MD, director of pediatric otology and neurotology at Massachusetts Eye and Ear Infirmary in Boston and co-chair of the latest World Congress on Endoscopic Ear Surgery held in the city in June 2019, an often-overlooked benefit of EES is the dramatically improved ergonomics. Research has found that otolaryngologic surgeons doing long periods of microscopic work are at risk of musculoskeletal pain (Int J Occup Saf Ergon. 2019;25:402-411). Using a microscope involves being hunched over the device for long periods of time. “Ergonomically, using an endoscope is absolutely superior,” said Dr. Lee. “You don’t feel as beat up after a long case.”
Limiting discomfort is not only helpful to patient outcomes; it’s also a financial plus for a hospital, Dr. Lee added. He has seen this stress on the body lead to back and neck problems, forcing some doctors he has known to go on disability or into early retirement. “If you’re uncomfortable and you can’t really get the view you need, and you’re fighting the patient’s lack of a neck or big shoulder, you’re going to have more complications. You can’t have patient safety without surgeon safety.”
A Growth in Popularity
Drs. Isaacson and Kutz say their results have been comparable between endoscopic and microscopic procedures in closure rates for tympanic perforations and for hearing. They recently began a prospective trial comparing pain levels after endoscopic and microscopic procedures.
Dr. Lee said he expects EES to catch on gradually but adds that it isn’t yet a prominent part of most residency and fellowship training programs. “There are very few residency and fellowship programs that offer meaningful exposure to a new technique like endoscopic ear surgery, and so not all trainees are being exposed to it.”
At a handful of centers, such as Vanderbilt, UT Southwestern, and Harvard, where Dr. Lee teaches, the training is rigorous. Residents at Harvard, he said, might do 50 to 80 EES before they graduate—exposure that someone who’s already in practice “will never get before they start their first one,” he said. “It’s a big difference.”
David Kennedy, MD, professor of rhinology at the University of Pennsylvania in Philadelphia, who helped pioneer EES, is no stranger to resistance to a new approach. “I certainly had a difficult time introducing endoscopic sinus surgery in the mid-1980s because a number of prominent sinus surgeons felt very strongly that this was unnecessary technology and they were doing just fine with the older techniques,” he said. In one editorial that he now remembers with humor, he was referred to as a “nasal astronomer.”
“Introducing disruptive technology is always difficult and anxiety provoking in terms of people who are currently in practice or are considered experts in the field with the older style of technology,” said Dr. Kennedy, who gave a keynote address on the topic at the June 2019 World Congress on Endoscopic Ear Surgery.
Dr. Kennedy expects EES to become more and more common but doesn’t expect quite the same revolution that occurred with endoscopic sinus surgery. With the emergence of the endoscope and the use of CT imaging, the fundamental understanding of the pathogenesis of sinus disease and the effects of surgery on mucociliary clearance changed. This made the endoscope in sinus surgery nearly indispensable in a way that he said isn’t likely to occur with EES.
“It hasn’t changed the way people think about ear disease quite in the same way that the endoscope and CT imaging did about sinus disease,” he said. “I think over time EES will clearly find its place because the visualization is better, but I think it’s going to take longer for adoption. And probably not everyone will get on board because it doesn’t change the underlying concept of the disease.”