|Year : 2016 | Volume
| Issue : 3 | Page : 177-182
Comparative study of microscopic-assisted and endoscopic-assisted myringoplasty
Raghvendra Singh Gaur1, Praveen Tejavath2, Swati Chandel1
1 Department of ENT, CCM Medical College, Durg, Chhattisgarh, India
2 Department of ENT, Mamata Medical College, Khammam, Telangana, India
|Date of Web Publication||8-Aug-2016|
Dr. Raghvendra Singh Gaur
Department of ENT, CCM Medical College, Durg, Chhattisgarh
Source of Support: None, Conflict of Interest: None
This study was conducted to determine the advantages and disadvantages of the endoscope as compared to microscope in myringoplasty surgery and to compare the results of both groups. The cases for this study were taken from the inpatient cases of the Department of Otorhinolaryngology, in tertiary care hospital for prospective study during the period of January 2012–August 2013. Thirty cases were taken for the study under each group. All patients in both groups were followed up for a minimum of 6 months. Final assessment of tympanic membrane and hearing was done at 6 months postoperation. Subjective and objective assessment of scar was done at 6 months postoperation. In our study, the success rate of endoscope-assisted myringoplasty was comparable to that of microscope-assisted myringoplasty. Regarding cosmosis endoscope produced superior results. The wide angle, telescopic, magnified view of the endoscope overcomes most of the disadvantages of the microscope. Loss of depth perception and one-handed technique are some of the disadvantages of the endoscope that can be easily overcome with practice.
Keywords: Endoscopic, Microscopic, Myringoplasty
|How to cite this article:|
Gaur RS, Tejavath P, Chandel S. Comparative study of microscopic-assisted and endoscopic-assisted myringoplasty. Indian J Otol 2016;22:177-82
| Introduction|| |
Aim of study
To determine the advantages and disadvantages of endoscope as compared to microscope in myringoplasty surgery and to compare the results of both groups.
Chronic suppurative otitis media (CSOM) is a long standing infection of a part or whole of the middle ear cleft. CSOM is characterized by ear discharge, a permanent perforation, and impairment of hearing. Statistics shows that in our country, there are about 5 crores of CSOM patients. Corrective surgery of CSOM provides dry ear with the improvement of hearing in the majority of patients. It is the work of two Germans, Wullstein  and Zollner, which started in 1949, lead to a new concept of the treatment of deafness secondary to chronic infection in the middle ear and mastoid and the new method was called “tympanoplasty.” Tympanoplasty is an operation to eradicate disease in the middle ear and to reconstruct the hearing mechanism, with or without tympanic membrane (TM) grafting.“ Myringoplasty is performed when there is TM perforation without any ossicular damage. This comparative study deals with anatomical and functional outcome in a series of patients who underwent endoscope-assisted myringoplasty (EAM) and microscope-assisted myringoplasty (MAM) with underlay technique using temporalis fascia graft. The introduction of endoscopy into middle ear has opened up new opportunities for minimally invasive temporal bone surgery. Endoscopy imaging provides dramatic new vistas to the otologist, and we are just in the early phase of developing the appropriate applications and supporting instrumentation.
The endoscope brings the surgeon's view into the depth of operative field and can provide a wide field of view with perspectives not possible with a surgical microscope.
Operating microscopes provide magnified images in a straight line extending from the objective lens. Many deep recesses within temporal bone cannot be directly seen without the surgeon taking measures to expand the operative procedure.
Endoscopes have an immediate advantage with an inherently wide field of view that extends from the tip of instruments lens. Additional angulation of view is accomplished by placing prisms into the tip. Endoscopes therefore offer the surgeon the capability of wide fields of view with minimal exposure, looking behind the obstructions or overhangs, and peering into recesses with much less requirement for surgical exposure than demanded by conventional techniques. Surgical morbidity and operating time can be substantially reduced.
According to the new classification “chronic otittis media” is a pathological term only, indicating chronic inflammation affecting the middle ear cleft.
Pseudomonas aeruginosa is the most commonly recovered organism from the chronically draining ear. Staphylococcus aureus is the second most common organism isolated from chronically diseased middle ears. The remainder of infections is caused by a large variety of Gram-negative organisms. Klebsiella (10–21%) and Proteus (10–15%) species are slightly more common than other Gram-negative organisms.,
About 5–10% of infections are polymicrobial in etiology, often demonstrating a combination of Gram-negative organisms and S. aureus. The anaerobes (Bacteroides, Peptostreptococcus, Peptococcus) and fungi (Aspergillus, Candida) complete the spectrum of colonizing organisms in this disease.,,
| Materials and Methods|| |
The cases for this study were taken from the inpatient cases of the Department of Otorhinolaryngology, in tertiary care hospital for prospective study during January 2012 to August 2013. Thirty cases were taken for the study under each group.
Patient having small, medium, and large dry central perforation of TM. Patient not having the evidence of active infection of nose, throat, and paranasal sinuses.
Patients having hearing loss of sensorineural type or mixed type. Ossicular abnormality in preoperative or during surgery. Patient with clinical and radiological evidence of atticoantral disease. Patients with a history of the previous surgery for chronic otitis media.
All the patients who presented signs and symptoms suggesting tubotympanic type CSOM were submitted to an assessment protocol, based on a guided history taking, specific physical exam (otoscopy), and subjected to audiogram. During history taking, the patients were questioned about disease onset, and if they had undergone previous otologic surgeries.
Pure tone threshold audiometry has become the standard behavioral procedure for describing audiometry sensitivity.
The operations are performed under local anesthesia using a microscope with a lens of 250 mm. In all of the cases, postauricular approach was used. In all cases, temporalis fascia graft was harvested and underlay grafting done.
All the patients are followed after surgery as usual on the 7th and 14th days. However, the audiogram was done on between 12 and 24 weeks to assess the outcome, i.e., the improvement of hearing objectively.
Technique of endoscopic myringoplasty
Zero degree, 18 cm long, 4 mm wide Hopkin's rod endoscope was used. All surgeries were done by visualization using the monitor. All the operations were done under local anesthesia.
- Approach: All EAM were done through the permeatal route. All were purely endoscopic and at no point of time, the microscope was used. All patients had a 2 cm incision in the hairline just above the helix to harvest the temporalis facia graft.
- Freshening the margins of the perforation: The endoscope was introduced through the external auditory canal and the edges of the perforation were freshened with a sickle knife.
- Elevation of tympanomeatal flap: In all the thirty cases, we used superiorly based flap. An incision was taken 5 mm from the tympanic annulus from 10 o' clock to 2 o'clock position with a circular knife. The tympanomeatal flap was elevated and flapped superiorly with the flag knife and circular knife.
- Graft placement: Dried temporalis fascia was placed by underlay technique, and the tympanomeatal flap was replaced. Hearing was checked on the table. Gelfoam was placed to stabilize the graft.
All patients in both groups were followed up for minimum of 6 months. Final assessment of TM and hearing was done at 6 months postoperation.
An intact mobile TM with the closure of air-bone gap ≤13 dB at 6 months, postoperation was considered as a successful outcome. The presence of a defect in TM or air-bone gap >13 dB or both at 6 months was considered to be a failure. Subjective and objective assessment of scar was done at 6 months postoperation.
| Observations and Results|| |
In this study, the patients were selected from those presenting in the Department of ENT and Head and Neck Surgery at tertiary care center during the period January 2012 to August 2013.
Sixty cases were examined, dividing into two groups and each group containing thirty cases were selected for the study. A period of 18 months was taken into the study.
The age of the patients ranged from 15 to 55 years [Table 1]. The majority (70%) of our patients were in their second and third decades of life.
The observations made on sex incidence showed that male patients predominated over their female counterparts in this series, the exact number being 38 (i.e., 66%) made while female patients were only 22 (34%) in number [Table 2].
It was observed that among the sixty cases that were studied, small and medium size perforation seen in 55 cases., i.e., 90% of all the cases taken for the study [Table 3].
It was observed that EAM required an average 132 min (range of 90–180 min) and MAM required an average of 116 min (range of 80–150 min) [Table 4].
In microscope-assisted myringoplasty group, it is observed that 12 cases (40%) had an average conductive hearing loss (CHL) of 11–20 dB and 18 cases (60%) had an average CHL of 21–30 dB. Almost 100% of group had an average CHL of range 11–30 dB [Table 5].
Postoperatively in the same group after 6 months follow-up, we noticed improvement with decrease in average CHL with 07 cases (25%) having an average between 0 and 10 dB and 19 cases (65%) having an average of 11–20 dB CHL. Almost 90% of postoperative group has an improvement in CHL with average between 0 and 20 dB CHL.
In EAM group, it is observed that 12 cases (40%) had an average CHL of 11–20 dB and 15 cases (50%) had an average CHL of 21–30 dB. Almost 90% of group had an average CHL of range 11–30 dB.
Postoperatively in the same group after 6 months follow-up, we noticed improvement with decrease in average CHL with 14 cases (46%) having an average between 0 and 10 dB and 13 cases (44%) having an average of 11–20 dB CHL. Almost 90% of postoperative group has an improvement in CHL with average between 0 and 20 dB CHL.
Subjective cosmetic result
At the end of 6 months, all (100%) patients in the endoscope group rated their cosmetic result as excellent whereas in the microscope group 06 (20%) patients rated their cosmetic result as poor, 15 (50%) rated the cosmetic result as satisfactory, and 9 (30%) patients rated their cosmetic result as excellent [Table 6].
Objective analysis revealed that in endoscope group none (0%) of the patients had a visible scar, whereas in the microscope group, 21 (70%) patients had a visible scar and in 9 (30%) patients, the scar was not visible.
At 6 months follow-up, 26 (88%) patients had a successful outcome in the endoscope group and 27 (90%) patients had a successful outcome in microscope group.
Differences between two groups were not statistically significant regarding success rate and complication rate (wet ear) [Table 7].
| Discussion|| |
This study was undertaken with the objective of determining the advantages and disadvantages of endoscope when compared to the conventional operating microscope in myringoplasty surgery.
Variations of external auditory canal such as stenosis, tortuosity, bony overhangs, etc., hamper the view of TM when visualized through microscope. Therefore, a need to manipulate the patients head or the microscope repeatedly to visualize all the parts of TM. Sometimes, in spite of manipulation, TM will not be fully visualized, and canaloplasty has to be done. This in turn may increase the operative type.
In sharp contrast, the endoscope brings the surgeons eye to the tip of the scope. The wide angle of zero degree scope visualizes the entire TM. There is no need to frequently adjust the patients head or to do canaloplasty thereby saving operative time.
Similar observations were made into separate studies by Tarabichi.
With angled endoscopes, reported that it is possible to visualize other structures such as round window niche, Eustachian tube More Details orifice, incudostapedial joint.
By avoiding postaural incision in endoscope group, there is less dissection of normal tissues, less intraoperative bleeding, less incidence of postoperative pain, and better cosmetic result. Avoiding postaural route also reduces the chance of auricular displacement and asymmetry of pinna.
Our observation has found that positioning the graft was much easier and faster with the endoscope as it gives a wide-angled view which includes the entire TM, the graft, and medial end of external auditory canal.
Unlike the microscope, the endoscope is easily transportable and hence is ideal for use in ear surgery camps conducted in remote places.
Endoscopic ear surgery is one-handed technique. Scope has to be held in one hand, and other hand is free to operate, and this becomes cumbersome when there is excessive bleeding, which can be managed easily in microscope-assisted ear surgery where one hand can be used to suction the blood and simultaneously the other hand can be used to operate. We confirm these observations which were reported in studies by Tarabichi  This problem can be solved by developing a stand for endoscope which will fix it in desired position so that both the hands will be free to operate.
Another disadvantage of endoscope is that even a small amount of blood can totally obscure the view of operative field. Meticulous hemostasis is therefore a must in endoscopic ear surgery. Arm fatigue by the weight of the scope, neck stain, and back ache can be solved by developing a stand for scope.
Endoscope provides monocular vision which leads to loss of depth perception compared to the binocular vision provided by microscope, and this will be noticed more by a beginner. Extra care to be taken to ascertain that the graft had been lifted enough to make contact with edges of perforation.
Endoscopic ear surgery requires investment in endoscope, camera, and monitor. However, for a surgeon doing endoscopic sinus surgeries, there will be no added cost as same scope can be used for ear surgeries as well.
| Conclusion|| |
The wide angle, telescopic, magnified view of the endoscope overcomes most of the disadvantages of the microscope. In our study, the success rate of EAM was comparable to that of MAM. Regarding cosmosis endoscope produced superior results.
Loss of depth perception and one-handed technique are some of the disadvantages of the endoscope that can be easily overcome with practice. Endoscope is ideal for ear surgery camps held in remote places. We feel that endoscope has a definite place in myringoplasty.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Wullstein H. Technic and early results of tympanoplasty. Monatsschr Ohrenheilkd Laryngorhinol 1953;87:308-11.
Zollner F. Surgical technics for the improvement of sound conduction after radical operation. Arch Ital Otol Rinol Laringol 1953;64:455-68.
Committee on Conservation of Hearing, American Academy of Ophthalmology and Otolaryngology. Standard classification for sugery of chronic ear disease. Arch Otolaryngol 1965;81:204.
Hamilton J. Chronic otitis media in childhood. In: Gleeson M, editor. Scott-Brown's Otorhinolaryngology and Head and Neck Surgery. London: Hodder Arnold; 2008. p. 929.
Fliss DM, Dagan R, Meidan N, Leiberman A. Aerobic bacteriology of chronic suppurative otitis media without cholesteatoma in children. Ann Otol Rhinol Laryngol 1992;101:866-9.
Sweeny G, Picozzi GL, Browning GG. A quantitative study of aerobic and anaerobic bacteria in chronic suppurative otitis media. J Infect 1982;5:47-55.
Maji PK, Chatterjee TK, Chatterjee S, Chakrabarty J, Mukhopadhyay BB. The investigation of bacteriology of chronic suppurative otitis media in patients attending a tertiary care hospital with special emphasis on seasonal variation. Indian J Otolaryngol Head Neck Surg 2007;59:128-31.
Saini S, Gupta N, Aparna, Seema, Sachdeva OP. Bacteriological study of paediatric and adult chronic suppurative otitis media. Indian J Pathol Microbiol 2005;48:413-6.
Nikakhlagh S, Khosravi AF, Fazlipour A, Safarzadeh M, Rashidi N. Microbiologic findings in patients with chronic suppurative otitis media. J Med Sci 2008;8:503-6.
Tarabichi M. Endoscopic middle ear surgery. Ann Otol Rhinol Laryngol 1999;108:39-46.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]
|This article has been cited by|
||Endoscopic Versus Microscopic Middle Ear Surgery
| ||Sayan Manna,Vivian F. Kaul,Mingyang L. Gray,George B. Wanna |
| ||Otology & Neurotology. 2019; 40(8): 983 |
|[Pubmed] | [DOI]|
||Safety and Effectiveness of Endoscopic Ear Surgery: Systematic Review
| ||Mi Hye Jeon,Seokang Chung,Seok Hyun Kim,Seung-ha Oh,Gi Jung Im,Jang-Rak Kim,Jinwook Choi,Byung Don Lee |
| ||Korean Journal of Otorhinolaryngology-Head and Neck Surgery. 2019; 62(7): 367 |
|[Pubmed] | [DOI]|
||Endoscopic type I tympanoplasty is as effective as microscopic type I tympanoplasty but less invasive—A meta-analysis
| ||István Pap,István Tóth,Noémi Gede,Péter Hegyi,Zsolt Szakács,Alexandros Koukkoullis,Péter Révész,Kinga Harmat,Adrienne Németh,László Lujber,Imre Gerlinger,Tímea Bocskai,Gábor Varga,István Szanyi |
| ||Clinical Otolaryngology. 2019; |
|[Pubmed] | [DOI]|