A Closer Look at Endoscopic Ear Surgery

Mary Ashmead, MD, uses an endoscope every day as a general otolaryngologist in north Texas, but almost exclusively for sinus cases. When she heard about a course on endoscopic ear surgery (EES) being offered at nearby University of Texas Southwestern, she decided it was time to learn some new skills and put her experience to wider use.

Over two days, she learned about endoscopic tympanoplasty, endoscopic ear surgery in children, endoscopic procedures for cholesteatoma, and many other EES procedures. She said it was well worth the time: She’s now performing procedures using EES that she might have previously performed with a microscope or referred to someone else.

“I feel very confident with use of endoscopes—more so than the microscope—and wanted to be able to use those skills in a different way,” she said. “While I’m not going to do something out of my scope of practice, it gives me new tools to use within my current scope of practice.”

Dr. Ashmead has performed several endoscopic ear procedures, mostly tympanoplasties and debridements, and a simple cholesteatoma case was on the schedule at the time of the interview. “Patients in general are very accepting of less invasive procedures,” she said. “I’ve had patients who would have needed a retroauricular approach to their perforation using a microscope who did not want surgery. But when they found that endoscopic tympanoplasty was an option, they were much more amenable to proceeding.”

Dr. Ashmead is part of a movement toward increased use of the endoscope for performing ear surgeries that have traditionally been performed using microscopes. With an endoscope, surgeons have wider visualization of the surgical area, are able to see around anatomical corners, and can perform procedures through the ear canal without having to create an incision behind the ear—making it an attractive option for patients.

One drawback is that EES is a one-handed surgery; the other hand has to hold the scope. Another hurdle is that suctioning away blood is more difficult, and even experienced endoscopic ear surgeons say they shy away from cases with excessive inflammation because of the potential for a lot of bleeding.

Still, interest in EES continues to grow. A 2019 paper—one of the most recent attempts to quantify interest in EES out of the United Arab Emirates—found that there were 57 articles published on the use of the endoscope in ear surgery between 2001 and 2010, rising to 351 between 2011 and 2018. From 2001 to 2010, 20 of the publications were on the diagnostic use of the endoscope related to ear surgery, and 27 were on endoscopic ear surgery specifically. That has changed: Of the 351 papers published from 2011 to 2018, 283 were on endoscopic ear surgery, and just 44 were on use of the endoscope for diagnostic purposes. The other few were on endoscope-assisted ear surgery (Laryngoscope Investig Otolaryngol. 2019;4:365-373).

I’ve had patients who would have needed a retroauricular approach to their perforation using a microscope who did not want surgery. But when they found that endoscopic tympanoplasty was an option, they were much more amenable to proceeding. —Mary Ashmead, MD

“There has been a clear shift in the area of interest away from diagnostic endoscopy, to endoscope-assisted surgery, and lately, to transcanal endoscopic ear surgery (TEES),” researchers wrote.

EES Best Practices

Brandon Isaacson, MD, associate professor of otolaryngology–head and neck surgery, and Walter Kutz, MD, professor of otolaryngology and neurological surgery, both at the University of Texas Southwestern Medical Center, were two of the earlier adopters of EES in the U.S.

Their practices focus exclusively on otology, including treatment of chronic otitis media. After their neurotology fellowship, they used traditional microscope techniques for this treatment. But in the early 2010s, they began seeing publications on TEES out of Europe, Asia, and the Middle East, and their interest was piqued. Dr. Isaacson took an EES course in Toronto and brought the technique to UT Southwestern.

“When I went in, I was a little bit skeptical—we wanted to see if it provided any additional benefit over what otology has been doing for the past 40 years,” Dr. Isaacson said. “Once I completed the course in Toronto, I felt like it was something I wanted to offer to our patients.” Dr. Isaacson helped Dr. Kutz develop his own TEES skills, and now they both offer TEES for appropriate patients, as well as teaching the technique to others. In November 2019, they hosted the second annual TEES course at UT Southwestern—the same one Dr. Ashmead attended.

Drs. Isaacson and Kutz readily agree that it takes some time and effort to learn EES but say that it is a procedure that doctors can typically become comfortable with fairly quickly.

“We hadn’t picked up an endoscope in, perhaps, 10 years—since residency,” Dr. Isaacson said. “That sounds like a big leap of faith. But honestly the steps of the surgery really don’t differ that much. There are a few nuances to it, but it wasn’t that difficult to pick up.”

Dr. Isaacson said the main focus should be positioning the endoscope to give an optimal view. “Normally you operate with two hands in ear surgery—you have to adapt to operating with one hand. There’s definitely a learning curve with it, and I think it’s harder than microscopic surgery in some ways, because you’re missing your non-dominant hand to help out.”

Dr. Kutz said that despite their limited recent experience with the endoscope, their extensive knowledge of ear surgery made EES a feasible progression in their practice. “We’re experienced ear surgeons, and the endoscope is just a different way of viewing anatomy,” he said. “It varies from person to person, but I think most otolaryngologists are going to be experienced using endoscopes. As long as you have some experience with endoscopes, I don’t think it’s that challenging to learn endoscopic ear surgery.” In addition, he said that many residents who have recently graduated tend to prefer using the endoscope.

Experienced TEES surgeons say that there should be a logical progression in the types of procedures a physician performs using an endoscope when first starting out. Dr. Isaacson suggests starting with an ear tube and then progressing to small central tympanic membrane perforations. After that, repairs of larger perforations can be performed, followed by cholesteatoma.

Dr. Isaacson also suggests having the microscope available as a backup option. “When we first started, we’d have the microscope prepped and ready to go so if we felt that anything was questionable or there were any challenges, we could always switch.” For certain procedures, such as extensive cholesteatomas or if the disease involves the mastoid, a microscope is still needed.

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

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.”

Is It Right for You?

With many otolaryngologists curious about endoscopic ear surgery, experienced EES surgeons say it’s likely worth pursuing if you already see a fair amount of ear cases and have some experience with endoscopes. But without those, it likely isn’t worth it.

Drs. Isaacson and Kutz began performing EES with the instruments they already had, but Dr. Isaacson recommended purchasing 3-millimeter-diameter endoscopes of 0 degrees and either 30 or 45 degrees, at 12 to 14 cm in length. Most centers will already have the video monitors and other equipment that’s necessary, but physicians will need to make sure they have a 3-chip camera.

Dr. Lee cautioned that EES procedures can’t be picked up instantly. “If you’ve had little to no experience using an endoscope to do any sort of otolaryngological procedure, then this wouldn’t be something you want to tackle,” he said. “Putting an endoscope in your hand doesn’t make it easier. It’s a skill set, and it can be difficult to learn how to pick it up at the beginning.”

Dr. Ashmead, just beginning to tackle EES cases after her recent training, believes the procedure is something general otolaryngologists should consider. “I think it’s always worthwhile to learn to use your current skills in a different way,” she said, “especially if it makes you feel more comfortable or more adept at procedures you’re already doing. We should be open to learning new ways of operating so we don’t get left behind.”

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Thomas Collins is a freelance medical writer based in Florida.