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Philip D. Consciousness, Awareness, and Anesthesia. George A. Local Immunosuppression of Organ Transplants. Post-EES healing time is usually painless and is shorter compared to mastoidectomy. The set-up time and costs of the endoscopic procedure are comparable with mastoidectomy and even less since there is no need in drilling, cotton material and cauterization for hemostasis, suturing of the wound, bandage and postoperative wound care.

The endoscopes and video-cameras are in routine use for endoscopic sinus surgery and thus are already available in most departments. The routine otologic micro-sets should be completed with some angled picks and forceps. Although mastoidectomy is a procedure that is familiar to all otosurgeons, it can be complicated by accidental trauma to middle cranial fossa dura, dural exposure in the tegmen and sinodural angle, and brain herniation into the mastoid cavity. Dural and tegmen defect due to dural tears and cerebrospinal fluid leakage may result in pneumocephalus, brain herniation, subdural empyema, epidural or brain abscess [ 33 - 39 ].

The TEA avoids drilling in the mastoid region, thereby obviating the risk of dural injury and postoperative intracranial complications. Endoscopic view of right ear primary retraction pocket cholesteatoma extended to the mastoid cavity. Non-EPI DW coronal images of the same patient presented in Figure 7 shows a 9-mm hyperintense lesion in the left middle ear with an extension to the mastoid it was managed with TEA. Myringoplasty can be technically difficult, especially in pediatric patients, due to the narrowness of the external auditory canal and the generally small size of the ear [ 46 ].

Moreover, temporalis fascia grafts and myringoplasties for anterior perforations are more likely to fail in children [ 40 - 43 , 47 , 48 ]. As a result, drilling of the anterior part of an external auditory canal is usually unavoidable for the repair of anterior perforations when only a microscopic approach is employed [ 47 ]. A microscope is used for removal of the sclerotic plaques and releasing adhesions surrounding the ossicles when bimanual manipulations are needed. We found that an endoscope is very effective in ensuring satisfactory approximation of graft material to the perforation margins in small, medium-sized, large and subtotal perforations as well.

This technique is especially helpful in patients with narrow external canals, anterior defects and bone overhang, when perforation's margins are barely, if at all, visible under a microscope. The choice of chondro-perichondrial graft material and the meticulous removal of myringosclerotic plaques can enhance the surgical outcome of endoscopic myringoplasty performed by an experienced otologist.

Stapedotomy can be technically difficult and challenging due to anatomic variations in size, configuration, shape or irregularity of the external ear canal. The stapes and oval window niche OWN can be obscured by the scutum. Excessive removal of the bone for better visualization of the middle ear ME structures can rarely result in subluxation of the incus [ 49 - 51 ]. The existing data indicate that the CTN should be preserved whenever possible, especially if surgery is bilateral [ 53 , 54 , 57 , 58 ].

Bilateral CTN damage can result in transient or permanent bilateral ageusia of the anterior two-thirds of the tongue, as well as a decreased resting salivary flow rate. In addition, the patients may suffer from transient or persistent, distressing xerostomia or tactile dysguesia [ 58 - 60 ].


However, damage to the CTN and subluxation of the ossicles or stapes fracture significantly decreases in the hands of an experience surgeon. Endoscopic stapedotomy was introduced in our department with the intent to avoid injury to the CTN when attempting to achieve visibility of the ME structures. The CTN was preserved in all cases, and our preliminary audiometric results were comparable with the others [ 61 - 63 ]. The position of the patients is the same as for routine otomicroscopic ear surgeries.

Angled picks and curved scissors and forceps are used in addition to the routine otologic micro-instruments. Stapes fixation is confirmed by gentle testing of ossicular chain mobility. The stapes tendon is cut with curved micro-scissors and the stapes is separated from the incus in the incudo-stapedial joint. The anterior and posterior stapedial crus are carefully fractured and the superstructure is removed. The distance between the footplate and medial surface of the long process of the incus was measured to determine the required prosthesis size.

The hole in the footplate is created with a Skeeter microdrill using a 0. The appropriate ossicular chain movement with the replaced stapes is ensured by malleus palpation.

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Endoscopic view of the right middle ear after an elevation of the tympano-meatal flap. Good access to the stapes and oval window niche was achieved without removal of the scutum and without touching the chorda tympani nerve. Endoscopic view of piston prosthesis placed in the hole that was created in the footplate and covered with a small piece of fat.

The possible benefits of ES are excellent visibility and accessibility of the stapes and the OWN, and avoiding manipulation of the CTN and blind fracture of the stapedial crurae.