Getting started-in-endoscopic-ear-surgery

Review
Getting started in endoscopic ear surgery
Peter Ryan a
, Carolina Wuesthoff b
, Nirmal Patel a, c, d, *
a
Department of Otolaryngology and Head and Neck Surgery, Royal North Shore Hospital, St Leonards, NSW, Australia
b
Kolling Deafness Research Centre, Macquarie University and University of Sydney, NSW, Australia
c
Sydney Endoscopic Ear Surgery Research Group, Department of Otolaryngology-Head & Neck Surgery, Faculty of Medicine and Health Sciences, Macquarie University, Sydney,
Australia
d
Discipline of Surgery, Sydney Medical School, University of Sydney, Australia
a r t i c l e i n f o
Article history:
Received 22 July 2018
Received in revised form
11 October 2018
Accepted 22 October 2018
Keywords:
Cholesteatoma
Pediatric
Endoscopic
Minimally-invasive
Middle ear
Mastoid
a b s t r a c t
Endoscopic ear surgery (EES) is an exciting, rapidly developing and innovative ﬁeld of otologic surgery.
Technically and conceptually, EES is a signiﬁcant departure from traditional microscopic transcanal ap-
proaches to the middle ear and canal that has shown very positive results with respect to patient out-
comes. This review serves as a primer for the otologist and otology resident embarking on EES and
discusses the theory surrounding the learning process, the optical chain for endoscopic surgery as well as
other important underlying principles.
© 2018 PLA General Hospital Department of Otolaryngology Head and Neck Surgery. Production and
hosting by Elsevier (Singapore) Pte Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Contents
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2. Modern learning theory and its application to EES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2.1. Learning EES in residency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2.2. Learning as an established surgeon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2.3. Learning curve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2.4. Learning and instruction in endoscopic vs microscopic ear surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
3. Instrumentation in EES and suggested surgical progression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
3.1. Beginning with EES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
3.2. Dedicated instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
3.3. Endoscopes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
3.4. Cameras . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
3.5. Endoscopic light source . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
3.6. Zoom . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
3.7. Post processing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
3.8. 3D systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
3.9. High & Ultra-High definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
3.10. The monitor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
3.11. Video interface and connectors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
4. The optical chain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
5. Anaesthetic considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
6. Operating room configuration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
* Corresponding author. Suite A12, 24 Lexington Drive, Bella Vista, NSW 2153, Australia.
E-mail address: nirmal.p.patel@gmail.com (N. Patel).
Peer review under responsibility of PLA General Hospital Department of Otolaryngology Head and Neck Surgery.
Contents lists available at ScienceDirect
Journal of Otology
journal homepage: www.journals.elsevier.com/journal-of-otology/
https://doi.org/10.1016/j.joto.2018.10.002
1672-2930/© 2018 PLA General Hospital Department of Otolaryngology Head and Neck Surgery. Production and hosting by Elsevier (Singapore) Pte Ltd. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Journal of Otology xxx (xxxx) xxx
Please cite this article as: Ryan, P et al., Getting started in endoscopic ear surgery, Journal of Otology, https://doi.org/10.1016/j.joto.2018.10.002

6.1. Microscope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
6.2. Ergonomics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
6.3. Equipment configuration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
7. Considerations in endoscopic cholesteatoma management: ideal initial cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
7.1. Optimal disease & patient characteristics for EES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
7.2. Preoperative assessment for EES cholesteatoma surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
8. Pitfalls and pearls when starting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
9. Common mistakes in early EES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
1. Introduction
Endoscopic ear surgery (EES) with the wide viewing angle of
modern endoscopes (Fig. 1), overcomes many of the limitations of
the traditional microscopic approaches to middle ear and canal
disease, some of which mandated postauricular approaches in the
past. A very broad range of otologic disease can now be successfully
managed with the endoscope (Box 1). This review serves as a
primer for the otologist embarking on EES and discusses many
concepts essential to safe and successful adoption of EES such as
learning theory, the optical chain and instrumentation. A broad
understanding of endoscopic, fiberoptic, camera and screen tech-
nology is essential to optimizing the endoscopic view as well as
ensuring patient safety.
2. Modern learning theory and its application to EES
Certain concepts from modern learning theory are relevant to
any surgeon, from junior resident to experienced consultant,
looking to introduce a new technique into their practice. The sur-
geon's emotional state and cognitive bias impact on learning at the
time new information is received. With respect to EES, cognitive
bias is best exemplified by the way traditional microscopic methods
have been used in surgical scenarios in the past. Bjork (1994) de-
scribes several “desirable difficulties” that enhance the long-term
uptake of a new operative technique:
1. Varied conditions of learning e in this instance moving from
standing to sitting and interspersing different first cases, en-
hances long term hand eye co-ordination.
2. Distributed sessions e an inter-training interval of approxi-
mately 7 days is ideal, not block learning (such as repeated 2-
day intensive courses).
3. Self-testing e regular review of the relevant anatomy is
important to establishing the long-term memory.
2.1. Learning EES in residency
With less experience, residents generally bring low cognitive
bias (as to the benefits of microscopic ear surgery) and a more
erratic emotional state to the learning environment of EES. Ideally,
residents will have been through a period of autonomous scope-
holding prior to progressing onto live surgery. Most often this can
be achieved through cadaver or 3D printed temporal bone courses.
Today's residents are frequently adept with scope handling through
their experience with Functional Endoscopic Sinus Surgery.
Knowledge of anatomy is critical, and review of anatomy in
standard texts, as well as through focussed endoscopic cadaveric
dissections online (http://www.sydneyearendoscopy.com) is of
paramount importance.
A stepwise training schedule using operant conditioning in the
form of relatively neutral click prompts has been demonstrated to
show uniform improvement in cohorts of orthopaedic surgical
residents and medical students (Levy et al., 2016). This method
could be applied to EES resident training (Box 2).
2.2. Learning as an established surgeon
In contrast to residents, established surgeons generally bring a
high cognitive bias (regarding the benefits of traditional micro-
scopic methods) and a superior ability to control their emotional
state than residents. Learning for experienced surgeons com-
mences with prereading, watching anatomy and surgical videos
online (http://www.sydneyearendoscopy.com). The established
surgeon should then attend at least one course where the endo-
scopic approach is taught and begin soon after with a step wise
progression of cases (see below). Prior to progression toward more
advanced techniques, the established surgeon should consider
visiting another surgeon familiar with EES methods or asking such
a surgeon to attend their operating sessions as a mentor. Figs. 6 and
7 compare the captured images of a left stapedectomy with mi-
croscope and endoscope.
2.3. Learning curve
There is, as with all procedural skills, a learning curve that ap-
plies to the attainment of EES competency. It is widely accepted
that the learning curve for surgical skills rises in a continuous or
step-wise manner, plateauing once competency is attained
(Hopper et al., 2007). At present, there is no universally accepted
Fig. 1. Angled scope view of attic cholesteatoma sac exemplifying the wide viewing
angle of modern endoscopes.
P. Ryan et al. / Journal of Otology xxx (xxxx) xxx2

definition of competency with most studies of procedural learning
curves using operative time and postoperative complications as a
proxy for competent performance (Khan et al., 2014). These mea-
sures are prone to bias and do not encompass every domain of
competency but they are, however, the most universally compa-
rable measures. In most centers, timetabled operating lists natu-
rally space surgeons’ exposure to techniques and therefore their
development of skills. Fortunately, such temporal spacing of
learning has been shown to improve skill retention in laparoscopic
surgery (Spruit et al., 2015) and the same effect may apply to EES.
Given its relatively recent adoption, published data relating to
the learning curve in EES is not currently available. Several otologic
procedures congenital aural atresia surgery (Patel and Shelton,
2007), stapedotomy (Yung et al., 2006) and translabyrinthine
removal of vestibular schwannomas (Moffat et al.,1996)) have been
Box 1
Indications for endoscopic ear surgery
External Ear.
External canal cholesteatoma
Biopsies of external canal, toilet of ear
Canalplasty for anterior overhang or small exostoses
Middle Ear Tympanic Membrane.
Perforations e Especially useful in anterior, subtotal and
total perforations
Cholesteatoma e acquired, congenital in the middle ear,
attic and antrum
Ossicular reconstruction
Neoplasms of the middle ear e paraganglioma,
adenoma, hamartoma
Otosclerosis
Inner Ear.
Symptomatic cochleovestibular tumour removal
Small symptomatic internal auditory canal tumours
Perilymph Fistula
Posterior Petrous Face.
Sac Surgery for Meniere's disease
Assistance in Endolymphatic Sac Tumour resection
CSF Leak identification and closure (Arachnoid
granulations)
Middle Cranial Fossa.
Superior Semicircular Canal Dehiscence: Assistance in
closure
Identification of CSF Leaks
Meningoencephalocele Identification and closure
Anterior Petrous Apex.
Extensive cholesteatoma dissection
Cholesterol granuloma and other petrous apex cyst
drainage
Cerebellopontine Angle.
0
for inspection VII, V, and VI
30e45
for dissection lateral IAC including endoscopic ear
instruments as well as identification of exposed air cells
to close and reduce CSF leak
Service delivery.
Lower equipment cost and more portable than
microscope in areas of need
Teleheath
Box 2
Sydney Endoscopic Ear Surgery Task Specific Checklist. Modi-
fied from Lin et al. (2009)
Assessment Criteria.
Basic inventory, setup of equipment
Knowledge of endoscopes, equipment, instruments
Appropriate draping
Instrument/tissue handling
Assessment of candidacy, pathology and canal size
Endoscopic assessment of canal
Endoscopic assessment of disease location
Assessment of disease radiologically
Determination of canal widening and or mastoidectomy
Ear preparation, Injection and Hair trimming
Injection
Application of otowick or neuropatty with adrenaline
Hair removal
Flap elevation
Incision location
Management of bleeding
Demonstration of Prussak's space
Elevation off handle of malleus; observe the anterior
malleolar ligament
Middle ear exploration with 3 mm scopes 0, 30 and 45
Demonstrate safe insertion of angled scopes
Naming structures of retrotympanum
Observing ventilation routes
Naming structures of the hypotympanum and
protympanum
Curetting to show limits of Prussak's space and lateral
epitympanum; name the regions of the epitympanum
Ossicle manipulation
Division of incudostapedial joint
Removal of incus and identification of the facial nerve
and relationships
Division of the neck of the malleus and head removal
Name the regions of the epitympanum
Bone removal methods, drill, curette, sonopet,
piezoelectric
Extended middle ear - dissection with angled scopes
and instruments; extended protympanum, antrum,
hypotympanum, retrotympanum
Beyond ME e infracochlear, perigeniculate,
transpromontorial
P. Ryan et al. / Journal of Otology xxx (xxxx) xxx 3

demonstrated to require performance of 50e60 procedures before
competency is attained. A similar learning curve of 40e60 pro-
cedures has been observed in endoscopic nasal procedures such as
septoplasty (Champagne et al., 2016), transsphenoidal pituitary
surgery (Leach et al., 2010) and functional endoscopic sinus surgery
(Laeeq et al., 2013). It seems reasonable to assume, given the sim-
ilarities in techniques, equipment and anatomical regions, that a
similar learning curve applies to EES.
2.4. Learning and instruction in endoscopic vs microscopic ear
surgery
One of the primary challenges in teaching otologic procedures
using the operating microscope is in the different views offered by
the primary binocular lenses, the microscope side-port and any
digital images displayed on screens. Typically, only the operating
surgeon has a binocular view of the operative field that affords
depth perception. Supervisors and observers have a view without
depth perception and an image that is often of different clarity and
brightness.
In contrast, in EES, the learning otologist, supervisor, observers
and other operating theatre staff share the one, identical image.
This shared image has obvious benefits for the teacher and learner
of EES with supervisors able to instruct on the operating screen in
real time and appreciate the same view as the operating surgeon
during all phases of a procedure. Anecdotally, the EES method also
significantly engages the operating room staff in the procedure,
more than viewing the microscopic method.
3. Instrumentation in EES and suggested surgical progression
3.1. Beginning with EES
Once the surgeon has familiarised themselves with the anatomy,
indications and procedures by attending an appropriate course
then it suggested that the method is commenced immediately in a
step-wise manner to reinforce previous learning. Currently avail-
able equipment in most hospitals can be used before any speci-
alised endoscopic ear equipment is required. Suggested available
equipment to start with includes:
4 mm sinuscopes 0 and 30
HD Camera
LED or Xenon Light source and shielded fiberoptic light lead e
set at 50%
Basic otology tray
Initially, simple procedures will serve as ideal training for the
hand-eye coordination required to progress to more advanced
endoscopic procedures. Suggestions for initial EES experience
includes:
Middle ear ventilation tube (grommet) insertion
Raising a tympanomeatal flap
Myringoplasty for small central or posterior perforations
Using the scope for inspection during conventional microscopic
surgery
Once the surgeon has gained some familiarity with the princi-
ples of EES, specialised EES instruments are useful for more
advanced indications such as extensive tympanoplasty, choles-
teatoma surgery and surgery beyond the middle ear (Fig. 2). These
instruments include:
Ultra-High definition cameras and high definition/4K screens
3 mm rigid 0, 30, 45
endoscopes
Short and long angled Thomassin dissectors
Angled EES curettes
Angled suckers
Angled microscissors
Angled cup forceps
Bone removal tools such as guarded drill burrs, osteotomes,
piezoelectric device or ultrasonic aspirator
Once the surgeon gains confidence with basic as well as more
advanced equipment, then progression can occur toward:
Subtotal or total perforations using angled scopes
Cholesteatoma using angled scopes
Ossicular reconstruction
Stapes surgery
Beyond the middle ear: Eustachian Tube Lateral Skull Base
Surgery
3.2. Dedicated instruments
There are two primary manufacturers of dedicated and specific
endoscopic ear instruments: Karl Storz GmbH (Fig. 3) and Spiggle
Theis Medizintechnik GmbH. The instruments they make are var-
ied, unique and some aspects complement each other well. Karl
Storz have a number of tapered curved suction instruments of
varying lengths and diameters, and specific dissection instruments.
Spiggle Theis, on the other hand, have suction capability built
into all of their instruments which have varying dissection tips
(Fig. 4). Newer and improved instruments will no doubt be made in
coming years.
3.3. Endoscopes
There are a number of manufacturers of rigid Hopkins rod-lens
endoscopes. They come in a variety of diameters, but for EES, the
most useful of these are 2.7, 3 and 4 mm. Better picture quality and
size is obtained with a larger diameter scope, so the best one to use
is the largest one that can fit into an ear canal. The 3 mm diameter
appears to offer the best balance between image quality and ability
to fit in most ear canals.
Endoscopes also come in a variety of lengths, with 11e14 cm
Fig. 2. Basic EES instruments: Curette (left) and short and long Thomassin dissectors.

being the standard for most EES scopes. The size range was chosen
as it is a good compromise between a longer scope which is too
unwieldy and a shorter scope which may clash with the operating
instrument in the dominant hand. For more lateral work, such as
simple tympanoplasty and ossiculoplasty, a shorter scope may
prove feasible.
3.4. Cameras
There are two main types of camera sensors: charged-coupled
device (CCD) and complementary metal-oxide semiconductor
(CMOS). Traditionally, CCD was the better of these technologies in
terms of picture quality, color reproduction and performance in low
light. The technology behind CMOS is now dramatically and quickly
improving, with many professional digital still and movie cameras
now utilising this technology.
Nevertheless, medical technology still predominantly employs
CCD, which can either be 1-chip or 3-chip. 1-chip uses a Bayer filter,
which means that a dominant color in the red-green-blue spectrum
can wash-out the others e leading to a phenomenon called “red-
out” if bleeding is present. 3-chip devices have prisms which split
the red-green-blue inputs into 3 separate chips, preventing this
phenomenon from occurring e and so is preferred in EES where
small amounts of bleeding in a confined space can make a big
difference.
Weight is also a factor to consider, with some camera manu-
facturers targeting the endoscopic markets of other surgical disci-
plines where weight of the camera is of less importance than in EES.
The smaller the camera, the less fatigue the surgeon is likely to
experience.
3.5. Endoscopic light source
Although there are no reported cases, consideration should be
given to the potential for thermal injury to canal skin and inner ear
and medial wall structures from endoscopic light sources. In a
recent non-sytematic review, Mitchell and Coulson (2017) reported
significant variability in the temperatures recorded at the
endoscope tip during endoscopic ear surgery. In a human temporal
bone model, Kozin et al. (2014) demonstrated a rise in temperature
at the endoscope tip from 36 C to 46 C within 30e124 s of turning
on a Xenon light source at 100% power. The rise in temperature was
similar for an LED light source. The authors demonstrated a rapid
drop in temperature to within 25% of baseline temperature within
20e88 s of removal of the light source. Of relevance to EES, Kozin
et al. (2014) demonstrated a precipitous drop in temperature to
below baseline within 20 s of applying suction at the level of the
endoscope tip.
Most current cameras with automatically adapt gain to lower
light settings, so it is prudent to use the lowest light source power
setting that gives adequate illumination of the operative field.
Lower settings have been shown not to affect static image inter-
pretation (McCallum et al., 2018). In most cases, a power of 50% will
achieve these goals. Where the endoscope must remain in the canal
for periods exceeding 2 min, applying suction or irrigation will help
minimize the risk of thermal injury.
Fig. 3. Karl Storz GmbH specialised EES instrument tray. ©
Karl Storz GmbH, 2018.
Fig. 4. Panetti EES instrument tray. ©
Spiggle Theis Medizintechnik GmbH, 2018.

3.6. Zoom
Some cameras have a manual focusing ring, whilst others rely on
digital zoom. As with all digital photography, manual zoom pro-
vides a crisper/clearer image.
3.7. Post processing
Some manufacturers are now starting to offer post-processing
options which make darker areas stand out more, or blood ves-
sels more vibrantly displayed. These are certainly helpful options to
have available but not essential.
3.8. 3D systems
3D image enhancement: Another development in the pursuit of
enhancing reality in surgical vision is the development of 3D vision
and flexible endoscope tips. 3D vision is possible by incorporating
video feeds from 2 different cameras. Some systems incorporate
two chip-on-tip HD sensors to obtain 3D vision (Karl Storz GmbH,
2018). Others use multiple lenses to map the surgical field
through a single optical channel, likened to the 3D vision attained
by an insect's eye (VisionSense, 2018). Recent studies have
compared a task-specific use of 2D and 3D endoscopy for the pur-
poses of endonasal skull base and neurosurgery in both experi-
enced and novice surgeons. Overall, the enhancement of depth
perception in a 3D system was perceived as superior and demon-
strated an advantage in specific tasks such as vascular and neural
dissection. The 3D system was disliked by more senior surgeons,
but preferred by less experienced surgeons, with authors suggest-
ing that it could shorten the learning curve (Inoue et al., 2013;
Marcus et al., 2014). At present 3D systems are only available in
4 mm or greater sizes, which limits their application in the ear
canal.
3.9. High Ultra-High definition
Standard definition in medical equipment is being phased out
and replaced with high definition. High definition means at least
720 pixels in height per frame; 720p, 1080p and 1440p are each
considered high definition. Ultra-high definition or 4k technology
displays at 2160p, while 8k technology displays a 4320p mode. The
video mode relates to the amount of pixels that fit in each image
frame because it is linked to the size of the screen's frame (width x
height). A 720p screen will have a frame size of 1280 Â 720pixels, a
1080i or p will have a 1920 Â 1080pixels frame size. Ultra HD will
have a 3840 Â 2160 size.
Another characteristic of a monitor is the aspect ratio. It refers to
the ratio between width and height, or the dimensions of video
screens and video picture elements. The screen aspect ratio of a
traditional television screen is 4:3. High definition monitors use an
aspect ratio of 16:9. Pixel shapes correspond to the shape of the
aspect ratio. Simplistically, pixels for the 4:3 format are thin and for
the 16:9 format are wide.
3.10. The monitor
The monitor is composed of the display device, the circuitry, the
casing, the backlight and power supply. The modality of display
device is the usual way in which we differentiate and name each
type of monitor. Modern monitors typically have a thin film tran-
sistor liquid crystal display (TFT-LCD or LCD) with a LED (Light
Emitting Diode) backlight, while older monitors used a cathode ray
tube (CRT) display. The latter are bulkier, and do not have the low
heat-emitting LED lighting system. Because LCD monitors are
slimmer and lighter, they can be easily suspended from the ceiling,
which has improved the ergonomic features and space utilization
in operating rooms in recent time.
LCD is perceived as superior in terms of overall image quality.
Although CRT was preferred at off-axis viewing angles (Brown
et al., 2004), the introduction of in-place switching (IPS) to LCD
has improved the strong viewing angle dependence and low
quality color reproduction that had plagued early iterations.
Monitor adjustments in brightness, contrast and sharpness, may
improve visualization and reduce visual strain when the option for
an increment in resolution is not available. The enhancement of
these features will translate into more detail (Berber and Siperstein,
2001; Berci et al., 1995; Seagull et al., 2011).
3.11. Video interface and connectors
The video source must be connected by an interface to a video
display device in order for the signal to be transmitted. In the case
of analog signals, the method of transmission includes Y/C
(Y¼Luminance, C¼Chrominance) or S-Video (Super-Video). RGB
(Red, Green and Blue) is another method of analog transmission
that may be superior to the previously mentioned in that it trans-
mits colors via separate channels, thus providing a more vivid
image. Another analog interface connection worth mentioning is
the VGA or Video Graphics Array. Developed by IBM®
in the late
80's, it was the standard interface between computers and for
example, projectors.
Newer LCD monitors, the DVI or Digital Visual Interface is now
standard. It is used in many operating room monitors as well as in
laptops and projectors since it is compatible with both digital and
analog signals. High-Definition Multimedia Interface (HDMI) is a
new audio/video digital interface. It is not compatible with analog
signals therefore it will only work with newer video system models,
and some argue that its audio component serves little purpose in
endoscopic surgery (Milad et al., 2014). The caveat is that all
components on the optical chain must be compatible with an HDMI
cable or interface, and this may not be available at all times.
4. The optical chain
The optical chain consists of all the elements of the endoscopic
system that create and deliver the image to the surgeon's eye. This
consists of the light source, light lead, endoscope, camera, camera
processing system and video display. Optimizing the optical chain
is essential for the best surgical image. It is clearly important for the
surgeon to understand how to trouble shoot the system. Defects in
image quality can be attributed to “downstream” equipment issues
(Fig. 5), occurring from the lens at its interface with the camera unit
or to “upstream” issues from the camera unit to the monitor the
images are ultimately displayed on. Simple first steps to improve
the optical chain include:
Lowering the ambient operating room light to improve contrast.
Check the glass e look at your light lead and scope to see they
are not damaged.
Tweak the digital e experiment with settings in the camera and
screen to refine the picture.
5. Anaesthetic considerations
A relatively bloodless operating field is desirable for EES.
Excessive bleeding requires the otologist to more frequently switch
between microsuction and dissection instruments, frustrating at-
tempts at adopting the method. As discussed above, excessive

bleeding can cause “red out” in 1-chip CCD video systems, reducing
the quality of images.
Wormald et al. (2005) demonstrated that the use of TIVA
(remifentanil and propofol) compared with volatile inhalational
anaesthetics (sevoflurane) and fentanyl was associated with lower
surgical grade (less bleeding requiring less frequent suctioning) in
endoscopic sinus surgery. TIVA gives the anesthesiologist tighter
control over hemodynamic variables (pulse rate and mean arterial
pressure), aiming for a MAP of 50 mmHg and pulse rate of 50.
Infiltration of local anaesthetic should be performed, either
preoperatively or after sterile preparation of the skin, with 1%
Ropivicaine and 1:50000 adrenaline. Caution is required in children
under 3 years as the mastoid tip is not formed yet. When injecting
near the mastoid tip a finger is placed in the tympanomastoid
groove to disperse local anaesthesia away from the facial nerve.
A single canal injection (25G e 30G) very slowly in the vascular
strip is often all that is required, as well as tragal and conchal in-
jections. Overinjection should be avoided as this may greatly
reduce vision in the canal. Neuro Patties or an Otowick (Medtronic,
2018) with 1:1000 adrenaline should be placed in the bony medial
canal whilst hair is then cut from the lateral meatus. Great care (and
time) should be taken to cut the hair from the lateral meatus to
avoid remaining hairs dirtying the endoscope on entry to the canal
each time.
Fig. 6. Microscopic view of left stapedectomy.
Fig. 7. Endoscopic view of left stapedectomy.Fig. 5. Downstream equipment issues causing poor image quality. A demonstration of
the effect progressive scope damage on the endoscopic image. (Credit Dr Nicholas
Jufas).

6. Operating room configuration
There are several specific considerations that must be made in
configuring the operating room for EES. Some of the changes dis-
cussed below may represent a significant change to the current
practice of the otologist, anesthesiologist and/or nursing staff in the
early stages of EES adoption.
6.1. Microscope
The microscope remains in the operating room for all EES cases.
In the early adoption phase the microscope is draped for all cases to
allow the surgeon quick access for confirming EES views with the
old microscopic view. With experience the microscope remains in
the room but can be undraped.
6.2. Ergonomics
Freedom of movement and posture is greatly reduced in mini-
mally invasive surgical procedures, increasing the risk of muscu-
loskeletal injuries (Janki et al., 2017). Complex endoscopic ear
procedures can exceed 3 h in duration, requiring otologists to
maintain fixed position of the neck, back and non-dominant hand
for extended periods.
Many of the principles that apply to other forms of endoscopic
surgery are applicable to EES. The most important ergonomic
principle, and the simplest to adhere to is the maintenance of a
neutral neck, shoulder and upper back position (Fig. 8). This is
achieved with a screen that is adjustable in height, positioned after
the otologist has assumed the position that will be maintained for
the duration of the procedure. Positioning the centre of the screen
at eye height avoids the temptation to extend the neck during the
procedure.
Both standing and sitting positions can be adopted for EES. If
microscope use is likely, a sitting position should be adopted to
reduce the likelihood the patient or table will need to be moved
intraoperatively. Many otologists comfortable with the operating
microscope for transcanal procedures will find a sitting position
more natural. Standing, however, allows the surgeon a degree of
freedom in positioning the camera and body toward the attic,
antrum and retrotympanum which is hard to achieve sitting.
For the right handed surgeon the left ear is generally easier to
operate upon for two reasons. Firstly, the scope is held in the left
hand in the inferior canal and the pathology is usually directly
accessed with the operating right hand without a risk of instrument
cross over. Secondly, the surgeon may intermittently and gently
rest their wrist on the patient's shoulder to reduce camera shake.
A stable image that is maintained throughout the procedure, is
essential in EES. Careful consideration should be given to reducing
the risk of muscle strain and fatigue while maintaining the comfort
and safety of the patient. Adjustable armrests firmly fixed to the
operating table or the surgeon's chair provide steady support for
the camera arm while operating. Mayo or hand tables with towels
or folded drapes can also be used. Alternatively, where handedness
allows, the forearm can be rested intermittently on the patient's
shoulder with folded towels used to protect the patient.
Where the surgeon holds the camera in the non-dominant hand
is a matter of personal preference, however, in the learning period
various options should be tried. Three common options include,
holding the body of the camera with the whole hand, holding the
camera with index and thumb with the light lead between index
and middle and finally holding the body with thumb and index and
having the light lead between middle and ring finger.
Endoscope holders are available but their usage is not common
and their benefits unclear. Theoretically, their use frees up a hand to
participate in dissection, useful when both suction and curette are
required for the same step of the procedure for example. Endoscope
holders, however, reduce the space available in the canal, risk
ossicular or canal injury if the patient were to move during surgery
and risk significant heat transfer from a static endoscope tip.
6.3. Equipment configuration
There are many suitable ways to configure operating theatre
equipment for EES. Factors influencing configuration include the
size of the operating theatre, likelihood of microscope use and any
Fig. 8. Ideal neck, shoulder and upper back position for EES with the centre of the screen at eye height. Consider standing, especially for right-handed surgeons operating on the left
ear.

fixed or installed theatre equipment. Configurations may change
over time to suit otologist experience, handedness and preferences.
Figs. 9 and 10 illustrate a recommended configuration for single
and dual-screen endoscopic case respectively. Specific positioning
of instrument tables should be determined by ergonomics and
surgeon handedness.
7. Considerations in endoscopic cholesteatoma management:
ideal initial cases
When commencing endoscopic cholesteatoma surgery, patient
assessment is critical to identify ideal endoscopic candidates. For
example, a patient with limited attic disease, no evidence of
infection and a wide canal (Fig. 11) is an ideal initial EES case, as are
most cases of congenital cholesteatoma (Fig. 12). Other character-
istics ideal for initial EES are included in the list below.
7.1. Optimal disease patient characteristics for EES
Congenital cholesteatoma
Acquired cholesteatoma in mesotympanum and confluent areas
(especially retrotympanum, protympanum and anterior epi-
tympanum), with minimal mastoid extension
Minimal inflammation in the middle ear
Fig. 9. Recommended operating theatre configuration for single screen endoscopic case.
Fig. 10. Recommended operating theatre configuration for dual screen endoscopic case.

Sclerotic mastoid
7.2. Preoperative assessment for EES cholesteatoma surgery
The lateral meatus and bony canal relative to disease location
should be assessed to determine the largest endoscope size that
can be used and whether a canal widening procedure (meato-
plasty or canalplasty) is required.
The status of middle ear e whether inflamed or not will help
assist the surgeon in determining the need for preoperative
topical therapy and microscopy during some of the middle ear
work.
The status of the mastoid is assessed with imaging including:
Fine cut CT temporal bones is essential in pre-operative eval-
uation of cholesteatoma to determine the extent of disease.
With the limitations of current instrumentation, a mastoid-
ectomy will be required if disease extends into the mastoid
beyond the posterior aspect of the lateral semicircular canal or
into a deep type C Sinus tympani.
A non-echo planar diffusion weighted magnetic resonance im-
aging (non-EPI DWI MRI) is useful to determine mastoid,
intralabyrinthine and intracranial spread. Caution is required
regarding negative prediction rates in discharging ears and
with disease less than 4 mm.
8. Pitfalls and pearls when starting
Slow down and add time to the operating list when starting EES
Start in a deliberate manner with wide ear canals and simple
uninflamed pathology
Pick the ideal cases to start endoscopic cholesteatoma upon and
appropriately preoperatively assess the patient
Spend time trimming hair
Have the microscope in the OR ready for use
Avoid 45 and 70
scopes when starting
Don't give up too early. The first few cases of tympanomeatal
flap elevation may take time but they are useful for developing
hand eye coordination
Manage bleeding by:
- Anaesthetic control of mean arterial pressure and pulse
- Neuropatties or cottoinoids with 1:1000 adrenaline, ensuring
to allow it time to work before suctioning
- Haemostatic agents like surgicel or floseal
- Warm saline irrigation
- Microbipolar forceps
- Low power protected time monopolar for the vascular strip
incision
9. Common mistakes in early EES
Poor bleeding management e in early cases spending time to
control the bleeding is one of the most important factors in
getting comfortable with the endoscopic methods
Trauma to the canal with angled scope and instrument move-
ment e early on with angled scope insertion this should be
performed in a two handed manner. Slowly progressing to
single handed making sure to identify and treat any canal
trauma.
Understanding the limitations of the equipment e the endo-
scopic otologic equipment is slightly different to the usual oto-
logic tray and takes time to understand its limitations, such the
reach and angulation of Thomassin instruments.
Short tympanomeatal flap e the limited depth perception in EES
can result in the inexperienced otologist creating a tympano-
meatal flap that is too short for the intended procedure. An
adequate flap length is particularly important where, for
Fig. 11. Ideal initial EES case: limited attic disease, uninfected and in a patient with a
wide canal.
Fig. 12. Ideal initial EES case: congenital cholesteatoma.

example, an extensive atticotomy will be performed. To achieve
an adequate tympanomeatal flap length, the diameter of the
round knife (approximately 3 mm) can be used as a guide in
early EES. A tympanomeatal flap 5e6 mm is adequate for most
cases, approximately twice the diameter of the round knife.
Failing to convert earlier to a mastoidectomy e when starting
the endoscopic approach particularly with attic and antral dis-
ease, the temptation is to spend a lot of time chasing choles-
teatoma to try and avoid a mastoidectomy. Consider adopting a
“10 min by the clock rule”. Here the surgeon considers con-
verting to mastoidectomy if they are chasing the same antral
disease for more than 10 min by the clock measured by the scrub
nurse.
Overdoing the atticotomy e Usually a small atticotomy in con-
juction with angled scopes gives the endoscopic surgeon an
adequate view of disease. When chasing posterior attic and
antral disease, the temptation is to continue extending the
atticotomy. The concern is with reconstruction of large defects
which are challenging after large atticotomies. Sometimes the
patient is better off with a small atticotomy and a canal wall up
mastoidectomy.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
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