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What is Endoscopic Ear Surgery?

Author Megan Saltsgaver covers What is Endoscopic Ear Surgery?  on BackTable ENT

Megan Saltsgaver • Updated Aug 14, 2024 • 40 hits

Endoscopic ear surgery (EES) is a minimally invasive surgical technique used to treat conditions of the ear, particularly those affecting the middle ear. It involves the use of an endoscope, a thin, tube-like instrument equipped with a camera and light source, which is inserted through the ear canal. This allows surgeons to visualize the ear structures in great detail on a monitor, providing a wide and well-lit view of the surgical field.

Neurotologists Dr. Brandon Isaacson and Dr. Alejandro Rivas discuss the contemporary uses of endoscopic ear surgery in their practices and the benefits that it can provide patients. This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.

The BackTable ENT Brief

• EES is preferable to traditional microscopic ear surgery in cases where minor anatomical details are important, such as visualizing a stapes fracture or in a pediatric patient where anatomy can vary.

• Surgeons may have variable levels of training when it comes to endoscopic ear surgery. Proficiency with endoscopic ear surgery requires practice with navigating an endoscope and surgical instruments in small spaces.

• If there is extensive ear disease, such as a large cholesteatoma, then a combined approach of endoscopic and microscopic ear surgery may be preferred.

What is Endoscopic Ear Surgery?

Table of Contents

(1) What is Endoscopic Ear Surgery?

(2) When To Do Endoscopic Ear Surgery

(3) Benefits of Endoscopic vs Traditional Microscopic Ear Surgery

What is Endoscopic Ear Surgery?

Endoscopic ear surgery is a minimally invasive technique that uses an endoscope to visualize and operate on the structures of the middle ear. Unlike traditional ear surgery, which relies on a microscope and often requires larger incisions, endoscopic ear surgery allows surgeons to gain better access to the middle ear with smaller incisions. This method enhances visualization of the ear's complex anatomy, particularly in hard-to-reach areas like the crevices and corners of the middle ear. The endoscope provides a wide field of view and improved lighting, which can make the surgery less invasive and potentially reduce recovery time for patients. Additionally, endoscopic ear surgery may be more accessible to surgeons with varying levels of training, making it a valuable tool in modern otologic surgery.

[Dr. Ashley Agan]
Let's talk about endoscopic ear surgery. For the audience who may not know, can you tell us what endoscopic ear surgery is and how is it different than traditional ear surgery? Alejo, we'll start with you.

[Dr. Alejandro Rivas]
You can have many definitions of what endoscopic ear surgery is. Some people could call it nonsense. Some people could call it a threat. Some people would call it a great application of a tool. I think that endoscopic ear surgery, it's a different way of looking at the ear. I don't think that either Brandon or I invented anything that wasn't already existed. We just started to use it in the United States. Endoscopic ear surgery had been present. My father's a neurotologist, even since my father was practicing in his '80s now. The stories that he tells me was, he once tried to use an endoscope in the ear and it was all bloody and it was all filled with blood.

Some people were trying and some people was Dennis Poe was trying to use it in the middle ear space, but it was extremely pixelated and the technology wasn't there. When Brandon and I started to use the endoscope, we had the right technology at our fingertips. We were able to use the endoscope to do middle ear procedures and to get access to a middle ear space. I think that the biggest advantage that the endoscope has provided is the ability to see the middle ear and access the middle ear to anybody that wants to do ear surgery. Before, I think that using the microscope, doing ear surgery, you need to be highly trained, but the visualization is difficult and the understanding the ear is difficult for many people that do not do that day in and day out.

With the endoscope, you get access to that better visualization and that ability to see the middle ear structures, the crevices of the middle ear space, the corners, and just understand how it looks, how it works and how you manage its disease. I think that that's endoscopic ear surgery in my mind.

[Dr. Gopi Shah]
Brandon, when you first started doing it-- so I finished residency in 12. I did not have any exposure of putting the endoscope in the ear. I think at that time, maybe a handful of times I can think of one of my attendings at Jeff or at the Pediatric Hospital at DuPont, maybe just taking a peek, but even then that was very rare. I think it was when I was a fellow with you in 14 that we started doing cases and I was like, wow, this is like, to me, I love sinus surgery. This is like sinus surgery in the ear. How did you get exposed to it and how did you develop that into your practice?

[Dr. Brandon Isaacson]
I read a number of articles about endoscopic ear surgery. I remember them from a surgeon out of the Middle East named Muaaz Tarabichi and it sounded like an interesting technique. I was a bit skeptical, but ended up deciding to do a course in Toronto and did the course and was convinced that once I did the course that I thought it would be a useful tool in middle ear surgery. That was in the spring of 2014. Then I went ahead and just started doing cases. We already had all the equipment we essentially needed and I started, my first case was a globus tympanicum and my whole, that's not a good case to start with.

The whole point of the case was just to elevate a flap, but I learned how to elevate, get into the middle ear. That was my intention with that case is at least to get some practice elevating a flap because that's one of the initial barriers of the technique is getting used to using one hand and using the camera in your left hand or if you're right-handed and instruments in your right hand and getting used to one-handed surgery. I just took off from there. I was fortunate enough that, I'd been in practice for about eight years by the time I started the technique.

It'd been a long time since I used an endoscope, 10 years, but a lot of the actual surgical maneuvers that you do are very similar, within the endoscope. There's a few nuances again, because you're limited to one hand, but it wasn't that hard to adapt. I felt that, even early on when I was first starting this working with residents and fellows that they were pretty quick to pick it up because they were able to use the endoscope for doing sinus cases and airway cases and things like that. It was a little bit sometimes frustrating from my standpoint that, "Oh, they made that look easy, and I just struggled with that." Over time, like anything, with enough repetition. I became more facile at it. I noticed the training is also becoming more facile at it. That's what I've been using ever since for doing most of my middle ear work and even some, lateral skull base work as well in selected cases.

[Dr. Gopi Shah]
I remember the, a journal club from maybe like when I was at PGY2 or something, when we were reading these articles about endoscopic ear surgery and talking about, pros and cons and isn't this interesting? Then, by the time I graduated, we'd done so much endoscopic ear cases that I felt super comfortable doing that. It evolved pretty rapidly once you started doing it.

[Dr. Alejandro Rivas]
I think that's an interesting point. I think that when we started, and I think that-- I don't know if this happened to Brandon, but it certainly happened to me. When I started doing endoscopic ear surgery, I wanted to do everything endoscopic. Part of it was, I didn't know what the limitations were, or it wasn't clear, but also I wanted to get better at it. I was trying to-- and I pushed the envelope in many ways, probably too much. I took on into big cholecystoses, starting to get them through the ear, only to realize that four hours later I had not been done and it was time to finish. Over time, I would say that we move-- we push so hard and so fast. Now I've become a lot more thoughtful and meticulous and regimented on what cases I do endoscopic and which ones I don't, and which ones I even try or which ones I don't even try.

It has significantly changed. At the beginning, I would say that I was doing 70% to 80% of my cases endoscopic. Today, now those numbers have-- and I did that for three to four years. Then as we got progressively more adept and knew the limitations and what was more efficient doing it this way or that way, now those numbers have gone down. For example, sometimes I would say 40, 60, still a little bit more endoscopic than macroscopic, but it's a much balance. We know the limits much better now.

Listen to the Full Podcast

Endoscopic Ear Surgery with Dr. Rivas and Dr. Isaacson on the BackTable ENT Podcast)
Ep 17 Endoscopic Ear Surgery with Dr. Rivas and Dr. Isaacson
00:00 / 01:04

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When To Do Endoscopic Ear Surgery

Endoscopic ear surgery is particularly beneficial in cases like revision stapes surgery or when dealing with pediatric patients, where the anatomy can be more variable and challenging. It can also be beneficial for procedures involving the middle ear, such as removing cholesteatomas or repairing tympanic membrane perforations.

However, there are limitations to the endoscopic approach, especially when dealing with cases involving extensive disease, such as large cholesteatomas or extensive mastoid involvement. In such instances, a combined approach using both the endoscope and the microscope may be necessary to achieve the best surgical outcomes.

Additionally, the use of an endoscope can be more time-intensive, especially in cases requiring extensive drilling or manipulation with one hand, which may not be as efficient as traditional methods. Ultimately, the choice between endoscopic and traditional ear surgery depends on the specific case, the surgeon’s experience, and the goals of the procedure.

[Dr. Ashley Agan]
Speaking of indications and limits, do you think about it as certain surgeries are better for endoscopic or are there certain anatomy or imaging findings that you look at? What are the limitations, and what would make a good candidate for endoscopic ear surgery?

[Dr. Brandon Isaacson]
Like Alejandro was saying, I think I had the same issue in that I tried to do everything endoscopically and you quickly figure out, several hours later too long, that maybe that wasn't the best idea. Certainly not from a time efficiency standpoint. I would say that indications would be really anything, any middle ear disorder is probably, the purview of the endoscope and in most cases, exceptions would be is if you have a really small ear canal and you're going to need extensive canalplasty, then probably the microscope's going to be a better option. Although you can do canalplasty with the endoscope, but just more time intensive, having to drill with one hand and not have the ability to irrigate as easily, more suction.

If there is extensive disease process in the mastoid, then that's, again, my indication that this is going to be a likely a combined case or if it's, say I have a really, extensive Cholesteatoma with lots of granulation and potential bleeding, then that's potentially going to be mainly a microscopic case. With respect to things like stapes, I think that's really surgeon preference. I love doing stapes to the endoscope because I hate using the speculum and I feel like my view is that much better. The results, in most series show that the outcomes are really not that much different between, endoscopic versus microscopic stapes surgery.

For skull-based disorders, I think I definitely pushed a little bit too far on that. I still do some trans-canal lateral skull-based work, but it's just too hard to remove otic capsule bone with the drill with one hand. It just takes too long. If I do those approaches, I'm typically using a trans-canal microscopic approach if in the rare circumstances that I'm doing it, other than maybe like a glomus tympanicum or something like that. Alejo said, I think I've definitely pulled back on some of the stuff that I used to do endoscopically or try to do exclusively. It definitely has a significant place in my practice, but the microscope is still a very eminently useful tool that I use on a routine basis.

Things like cochlear implantation or any trans-vascular approach, in my mind, it doesn't make a lot of sense to use the endoscope.

[Dr. Gopi Shah]
Brandon, what would you say your split is these days now?

[Dr. Brandon Isaacson]
Probably similar to Alejo. I'd probably say, 60% endoscope, certainly for middle ear, it's going to be mostly endoscopic. If it's like extensive chronic ear disease, then I'm usually do that as a combined case. It's rare for any tympanoplast, even a lateral graft that I have to use a microscope.

[Dr. Alejandro Rivas]
When we look, for example, at cholesteatoma surgery, there has been-- we've come up with very standardized indications and limitations. I know that Brandon published on that, but so the, I think it's important to mention specifically cholesteatoma. If you have a cholesteatoma that is, as Brandon said, limited to the middle ear space, that's, you do it with the endoscope. If you start seeing a cholesteatoma that has significant amount of erosion of the ossicle, of the incus specifically, if a completely opacified mastoid, if a hollow tympanic cholesteatoma with demineralized bone, obviously if erosion of the lateral canal, all of those are things that you have signs of extensive disease.

I would argue that I would like, at least that's what I do in my practice.

I'm not going to try to remove that cholesteatoma through the ear canal to begin with. I'm just going to go from behind. I might use the endoscope through as a combined approach and just to make sure that I'm not leaving any disease behind. I'm not going to be spending the time trying to elevate that, trying to get to the middle of your space when I know that eventually I'm going to go from behind. That comes down to that efficiency. If you start that case through the ear canal, then you're going to spend a lot of your time in the middle of your space and then you're going to have to convert and then you have to go an incision behind the ear and all that ends up in time for the patient, time on their anesthesia, time where you need to get to the next case.

Those are just start from behind. Now, there are sometimes there's, the CT scan shows that there's limited disease in the middle of your space. If there's limited disease in the middle of your space, I will try to take that out endoscopically and sometimes I'm mistaken, but I'm willing to take that chance on those cases. Those are the ones that I think that it's, that you should try endoscopic and then if need convert. That's one of the most important things that I've learned throughout the years. The other thing is stapes. For regular stapes, I agree with Brandon.

Now, when we look at congenital malformations, when we look at pediatric stapes, when we look at revision stapes surgery, I think that the endoscope provides a very good advantages. We haven't demonstrated outcomes improvement because the numbers of all of those are small. It's hard, maybe once Brandon and I combines our series in 10 more years, we might be able to show that difference. I can see that the problem much faster and that poses, I believe that it poses better outcomes. I'm not going to steal Brandon's thunder, but I think that he is soon to publish a paper that shows better outcomes in osteoplasty.

We tried that before together and it showed that there was a trend, but we were not getting there with the endoscope compared to the microscope. I just interviewed one of his medical students who was working on a project like that. I grilled her about it and she told me some very interesting results. Brandon, tell us about that, please.

[Dr. Brandon Isaacson]
I do think there are some distinct advantages, as Alejo was saying, particularly with revision stapes and pediatric stapes, because those oftentimes have unique anatomic variance. The other day I was doing a middle-ear exploration on a child who had a-- I'd done a previous tympanoplasty on, they still had a significant conductive loss and they had the eardrum looked fine. There was no perforations. When I looked in the ear, I really couldn't find anything obvious other than that the stapes seemed to be a little bit less mobile, which is very subjective. It takes, I don't know how many cases to figure out, and I still haven't completely figured out what is-- obviously there's completely fixed stapes is easy to figure out, but when it's like partially fixed and not moving.

In this case, the patient had a tiny little bar of bone coming from the undersurface of the pyramidal process and going to the posterior crux. I don't think there would be any way I would have seen that with a microscope. In that case, we ended up using a laser and some like a rose and needle, essentially to divide that little bridge. I don't know what the outcome is yet, but there's no way I would have seen that before.

Benefits of Endoscopic vs Traditional Microscopic Ear Surgery

The primary advantage of endoscopic ear surgery is the enhanced visualization it provides. Unlike a microscope, which loses light and clarity as it zooms in, the endoscope offers instant magnification with increased light as it gets closer to the target, making it particularly useful in identifying subtle anatomical details, such as a stapes crural fracture with scar tissue. This improved view is also a significant benefit in teaching environments, as it allows instructors and trainees to observe the same structures in real-time.

However, endoscopic surgery requires adaptation, as it limits the surgeon to one-handed operation, and managing instrument collisions with the endoscope can be challenging. Despite these hurdles, the benefits of the endoscopic approach, especially in terms of visualization and teaching, make it a valuable tool in otologic surgery.

[Dr. Brandon Isaacson]
I think the big benefit is obviously the view that you get. You get essentially instant magnification and unlike the microscope, when you zoom in or you bring your endoscope closer to the structure that you're visualizing, the light actually increases instead of decreasing. In these really, I've seen cases of like a state-piece crural fracture and there was some scar tissue, and there was just no way I would have been able to really-- I think it would have been very difficult to identify that prior to me initiating using the endoscope. The visualization's great. I think for a teaching perspective, I think it's fantastic because we're all looking at the same thing, like a sinus case or any endoscopic case.

It's very easy for me to point out anatomic variants or normal anatomy or abnormal anatomy. It's also easy for me to instruct like, "Hey, this is where you need to make your incision right here and this is where you want to go." It's much easier for me to point out on a screen than it is with a instrument in my left hand or right hand, in the field with the microscope.

From a teaching perspective, I think it's fantastic. I do think it's harder to do because again, you're limited to one hand and I think that takes a longer period of time for people to adapt to that and then getting used to not having collisions with your hands, with the endoscope and your instruments and knowing how to position yourself relative to the patient to get an ideal angle on how to make incisions and do those types of things, it takes definitely some time to learn how to do that. Again, losing one hand I think is a big obstacle barrier or a barrier that people need to overcome.

For me, that trade-off is worth it. I think the views that I get and the ability to teach certain things I think is in my mind a significant advantage. At the same time, I feel like all of our trainees need to know how to-- anybody that's training to do ear surgery needs to know how to use both techniques. You need to know how to use the microscope. There are definitely, there's a significant amount of otologic surgery where the microscope is the go-to visualization tool that you need and there are certain cases where the endoscope I think has substantial advantages over the microscope.

Podcast Contributors

Dr. Alejandro Rivas discusses Endoscopic Ear Surgery on the BackTable 17 Podcast

Dr. Alejandro Rivas

Dr. Alejandro Rivas is the Division Chief of Otology/Neurotology in the University Hospitals Department of Otolaryngology-Head and Neck Surgery in Ohio.

Dr. Brandon Isaacson discusses Endoscopic Ear Surgery on the BackTable 17 Podcast

Dr. Brandon Isaacson

Dr. Brandon Isaacson is a Professor in the Department of Otolaryngology - Head and Neck Surgery at UT Southwestern Medical Center.

Dr. Ashley Agan discusses Endoscopic Ear Surgery on the BackTable 17 Podcast

Dr. Ashley Agan

Dr. Ashley Agan is an otolaryngologist in Dallas, TX.

Dr. Gopi Shah discusses Endoscopic Ear Surgery on the BackTable 17 Podcast

Dr. Gopi Shah

Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.

Cite This Podcast

BackTable, LLC (Producer). (2021, March 2). Ep. 17 – Endoscopic Ear Surgery [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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