How to Integrate Ear Endoscopy into Your Surgical & Clinical ENT Practice

[Dr. Gopi Shah]
Getting into like tips and setup and equipment. I guess the first basic question, do you always have your microscope in the room draped ready to go? Is that part of-- even though you have, when you post your case and it says endoscopic tympanoplasty, is the microscope always there or do you selectively, know when you think you'll need the microscope?

[Dr. Alejandro Rivas]
For the first years, yes, the microscope was always there and draped, but today, no, not necessarily. It depends what case you're doing. Today I would say that if I'm doing a cholesteatoma case, the microscope is always in the room, but it's not draped. Unless I know that I'm going to do a combined approach and then I'm going to use it, it's going to be ready. Then if it's a second look for cholesterol, for example, it will be in the room, but it's not draped. For staple surgery, it's not in the room anymore, it's outside of the room. It's easy to have it available. It depends where you're working. If you're working in a-- if you're in a surgery center where that you can leave your microscope outside the room and nobody's going to take it, then you can leave it outside of the room. If you're at a risk of, you're in a big general operating room with everybody else, then you might want to keep that microscope in the room because it might not be there when you need it.

Those are the main issues with the microscope. Now, in terms of setup, yes, I think that setup is-- if anything is one of the most important portions during endoscopic ear surgery. First it starts with preoperative planning and talking with your anesthesiologist. I think that it's very important that you tell them that you want, like in sinus surgery, having something that decreases bleeding, which is going to be beneficial. Sinus, a combination of, so TIVA is going to be great. Ideally, a combination of Propofol with remifentanyl would be good. Depending on the OR and depending on the anesthesiologist that you can get some pushback about it. What I've compromised and I said, okay, when I get pushback, I say, okay, give me 80% TIVA and a little bit of gas. Then that seems to-- anesthesiologist is like that.

[Dr. Gopi Shah]
Just sprinkle a little. Take your time.

[Dr. Alejandro Rivas]
That works. Ultimately, what you want to do is decrease the cardiac output. With TIVA, what you do is that, is exactly that. You get less vasodilation that you get with gas. Because you get less vasodilation, then you can bring down both your heart rate and your blood pressure. You want to aim for a MAP of 60 and a heart rate of 60 in an adult and in children's just whatever it's appropriate, according to the age. With that, you get less bleeding. That conversation starts preoperatively with the anesthesiologist. You want to make sure that the cuff, like any other surgery of the blood pressure is on the opposite side. The cuff is not going up and down and pushing your arm, but you want to be able to have a chair or a system where you can rest your elbow.

The Italians, which is the people who I learned from, my good friend, Daniel Marconi, he likes to operate standing. He doesn't use anything when he just keeps his elbow close to his, to his body. That stabilizes his arm. I am an ear surgeon, training in surgery in the United States. We all sit. We don't like to stand. I sit and so I have an arm with somewhere to put my elbow. In my case, it's a dental chair now with a back in front of me. You want to have a monitor, obviously, that is as in front of you as possible as, and at the, at the same level as your eyesight. You don't want to be looking up because then your neck is going to hurt by the end of your third case. Part of the part, one of the beauties of endoscopic ear surgery is it gives you good ergonomics. I'm hoping that I don't have to get cervical surgery like my father in his 60s. By doing this, that I can achieve that. That'd be awesome. I, and I believe endoscopic ear surgery helps with that. Then injections and control bleeding. Important safety, you need to make sure that the light is not higher. I used to say 60. Then I said 50. Brandon has gone to 20. I'm not as, I'm not as-

[Dr. Gopi Shah]
It takes vitamin A supplements.

[Dr. Alejandro Rivas]
Yes, I know. I go to 40. Now, I'm going to 40. A lot of that is, is possible because of the advancement in video technology and the ability to increase the brightness on the screen as opposed to increasing the light, the light source. That's useful because you don't want to burn the ear. Brandoon, take it on after that because there's more tips that you and I share.

[Dr. Brandon Isaacson]
Yes. As far as, light settings, I've gone down as low as 10 and sometimes that's just not enough. Now I, as Alejo said, I set the light source at 20. You also would be keeping in mind what light source you have. There are different light sources out there. I would discuss that with your local rep of whatever company you're using for your light source. I'll just echo the anesthesia tips that Alejo mentioned. When I first started, I think I did my injections with the microscope and now, I've gotten pretty facile and doing the injections with the endoscope and that does save some time. I teach our residents and fellows how to do that as well. I think that the injection is really critical and giving the injection some time to work.

The order in which I do the case is once I've cleaned the ear a little bit, if it's not inflamed, I'll go ahead and do my injection and then I'll trim the hairs with a curved iris scissor and that gives some time for more time for the local to work.

[Dr. Gopi Shah]
Brandon, are you injecting bupivacaine or marcaine?

[Dr. Brandon Isaacson]
Yes. I tend to use marcaine. You can use lidocaine. The marcaine is 1:200,000 epinephrine, which I've sometimes concentrated up to 1:50,000 epinephrine by adding a little additional epinephrine. I think also an important safety measure is the bleeding control tip. We typically use the cottonoids, the quarter by quarter inch cottonoids. I cut the strings off. Some places won't allow you to do that, but we soak those into 1:1000. For a safety tip, I don't let anybody put the 1:1000 on the field until after I'm done injecting and all the needles are off the field. The last thing you want to do is inject epinephrine into a patient who's not coding, and make them code. Again, I make sure all the needles are off the field prior to putting the 1:1000 epinephrine on the field.

Yes, so I usually use Marcaine. Disadvantage of Marcaine is that if you infiltrate enough local and it gets in the middle airspace and you have a dehiscent facial nerve, they could wake up with a facial weakness that lasts longer than lidocaine. Then if your facial nerve is anesthetized, then your nerve monitoring is not going to be effective. Just other things to keep in mind if you're using those things.

[Dr. Alejandro Rivas]
There is a dental syringes, dental carpules. That's what I used to use at Vanderbilt, but I don't have that anymore. I use what Brandon just talked about. If you have a way to get those carpule dental syringes, they're great for all your cases. Not for all your cases, because you have, they're color-coded, they're 2%, 1 to 1:1000 and 2%, 1:50,000. You never have to worry about whether you're going to inject the wrong thing or put the wrong thing at the wrong time. That is very useful. One of the things that I've learned over time, so I used to inject the ear posteriorly, and then I would make an injection from behind, from the posterior area towards the ear canal before I went outside and scrubbed, so that I would start to get local control.

I'm not doing that anymore, and I discourage everybody to do it, especially if you're doing perforations, because by doing that, a lot of times you make the middle of your space very, very oozy, because all of that lidocaine that you put from behind starts to ooze into the middle of your space. Then when you're trying to fix a perforation, put gel foam to put your fascia graft, and it becomes very soupy and you struggle. I did that for years. Now, I don't do that anymore. I just do a very little, less than 0.5 cc posterior color injection, and then only inject a little bit through the canal when I'm already scrubbed.

I don't notice any changes in terms of the control of blood, but I do notice a huge amount of difference in how soupy the middle ear ends up being during my reconstruction or during my placement of the graft. I've just been doing that for probably for the last year. That's a little tip that I just learned.

[Dr. Gopi Shah]
In terms of scopes, do you always start out with a zero? Do you go straight to a 30? How wide are your scopes? What are the lengths?

[Dr. Brandon Isaacson]
I use the three millimeter diameter scopes. When I first started, I used the pediatric, which I think are 2.7 millimeters in diameter or 2.8. The problem with those is they're 18 centimeters long and they're much easier to bend and break. Unfortunately, I've done that a few times. The three millimeters are perfect. I think they're 14 centimeters in length and that's ideal. I don't think you want to go any shorter than maybe 10 or 12 centimeters in length, but the three millimeter diameter are really perfect for endoscopic ear surgery. I start most of my cases with the zero and then I'll use a 30 occasionally for stapes or tympanoplasty, but I'll use the 30 a fair amount with colosteal tunnel work.

I know Alejo likes the 45 degree. If you were to pick two scopes, at least in the past, he preferred the zero and the 45. I've gotten used to having the zero and the 30 and it's occasional I'll use the 45 and then very rarely I'll use the 70. The 70 can be very dangerous because it's just a completely distorted view.

Especially using instruments with the 70, I would not advise, especially if you're just starting. I would stick with the zero and either the 30 or 45 for selected circumstances. Those scopes are, again, are 14 centimeters in length. If you use something really long, then the camera ends up in your face and you end up contaminating your field. If it's too short, then if it's like a, one of those little mini ear scopes that in clinics, sometimes there's not enough room to get both hands in the operative field to do the case. Again, the three millimeter diameter, 12 to 14 centimeters in length are the ideal scope.

Other instruments, honestly, the first year I just used the standard gear instruments I had before. I didn't have anything special, but there are a few instruments I think which are really helpful for endoscopic gear. If you're first starting out the suction elevators, or even if you're not just starting out, the suction elevators are wonderful instruments. I know Alejo has one or two that he's designed and there are several others that are out there that are quite good. There are a few other instruments that I like. I like something called a plester knife, which is like a side, a septoplasty D knife, but much smaller. I use that for canal incisions. There's something called Thomason dissectors, which are like a crab tree dissector, like a hockey stick type instrument, which are quite useful for chronic ear disease.

Then the other instruments, I actually use disposable suction sometimes. You can buy the sets that have all the different angled suctions, which are really nice. If you're working with lots of different places, it's hard to get all those, everywhere to order those instruments. I'll take there's disposable suctions used in pediatrics for tubes sometimes. I'll use those in 18 and I'll bend the tip. If I'm trying to reach into the adductor sapotempinum, I'll just bend the tip on those and you can throw them away afterwards. That's what I've used for different suctions. Those are my go-to thing, instruments that I use. Then there's a couple of disposable knives that I like. There's something called a 5910 blade, which is a little arachnoid knife. Then a 7200 blade I use for canal incisions.

[Dr. Alejandro Rivas]
Yes, those are beaver knives and they're great. They're great because they're always sharp. You always make the cut that you need to make. I like those as well. There are some dissectors that are useful that have double ended, not double, well, that have two bends so you can fit in the canal. I like those for removal, of course, if I'm around the footplate, you need to have good right angles. You can have the ones that have two bends that are great, but if you don't have them, that's fine too. You need to have good right angles, probably one shorter and one small to be able to remove cholesteatoma disease, which you normally do in your regular ear instrumentation.

You need a very good house curette or J curette so that you can remove bone and scute them to see either for, if you're doing a stapes surgery, you're going to need to do that. If you're going to do cholesteatoma surgery, you're going to need that. You can use a drill, but it's cumbersome. If you get used to using the curette, you'll become-- with the endoscope, there's no question about where that curette is going to end up. You become very facile at using it. You just need to be sharp.

[Dr. Gopi Shah]
Alejo, when you are doing pediatric ears, are there different considerations in children or are there any other different types of instruments or scopes that you use in your kids?

[Dr. Alejandro Rivas]
No, I use exactly the same ones. People can argue that you get, well, forming your endoscope could allow you to see get a better details or a little bit better visibility. I don't think that between four and three, there's a big difference, but I do feel that there's a big difference, especially in children, to be able to fit a forming your endoscope into the middle of your cavity. That's true in adults, to be honest. If you use a forming your endoscope, a lot of times you have to leave your endoscope much further away from the tympanic cavity because it just doesn't fit with your other hand. Then you end up with the worst of both worlds. You end up from a distance view in 2D. The microscope gives you a distance view in 3D, which is much better. The beauty of the endoscope is being able to get that lens all the way down into the middle of your cavity. That you can do with a three millimeter scope.

[Dr. Gopi Shah]
Yes, I think that makes a lot of sense. Another thing I wanted to ask you guys, when I am seeing patients in clinic, I've noticed a lot lately, particularly for patients who have any eustachian tube dysfunction, patchless eustachian tube, ear fullness complaint. I'm scoping them anyway. I'll put the scope in their nose, I'm looking at the eustachian tube, and then I'll a lot of times I'll put the scope in their ear and I'll just take a look because that way I can snap a picture. I can show them what the ear looks like. Since I started doing that, I feel like I see things I didn't see sometimes when I was just looking with the microscope in the clinic. I was just curious if you guys were using the endoscope in clinic a lot or at all and if that's been helpful.

[Dr. Brandon Isaacson]
We work in the same clinic. We have an image capture device that is like a video otoscope that I use to capture clinic visits. Certainly, endoscopes in clinic work great. I've not had access to those. Having some ability to capture intra or clinic visit patients I think is really valuable. There's definitely things on that little video scope, otoscope that I've picked up that I haven't seen with a microscope. The cool thing about it is you can, again, capture that picture, but you can also capture video on some of these devices. I've had patients like you said that I thought were going to need maybe they needed a tube or consider a balloon station tuboplasty.

Then I've had them pop their ears with the video otoscope and you can watch it with a microscope too. I was able to record and see that even though they had a retracted drum, they immediately were able to valsalva and lateralize it. Those patients are probably more patchless and do chronic sniffing and that created their retraction as opposed to someone who's got a true Eustachian tube obstructive dysfunction. I do think, I do agree with you that the ability to capture these images and with an endoscope or a flexible scope or video otoscope are very helpful.

[Dr. Alejandro Rivas]
I tell you from a perspective of the patients, it's very important, especially in pediatric population. The reason for that is the parents want to know what's happening. When I look at the-- and so now we're at university hospitals, we have a very big system. I have clinics throughout all over Cleveland. At Vanderbilt we used to be very centralized. There's one clinic. You can stack up all the equipment in one clinic and it's done. Here it's impossible. We have too many hospitals. The video capture that, for example, Brandon's mentioning is fantastic, but sometimes I cannot show the parent I'm in the microscope and showing the parent what the kid has or where's the cholesteatoma or if there's a skin pearl that I need to remove.

It's very important for a parent to see, to trust you as their child. People as adults, they make their own decisions, but parents, they have a much better understanding of what should be done if they're able to see. I think that that's of paramount importance. There are times where I've seen a post-op where I think it looks great. Then the tympanogram shows still a type B and I don't see a perforation. Sure enough, I take an endoscope and yes, there's a teeny tiny perforation very anteriorly and I say, okay, well, yes, this one didn't work and you can document that. Likewise, it's important I think for your learning curve, to video your cases. If you can video your cases, I think it's great because when you feel that things have gone perfectly and you get the results that you want, it's good to go back to those videos and review them.

I have a gazillion when I'm on a video that I would love to be able to edit, but they're there and they're available. All of those things I think that are very important in the clinic and in the operating room.