Bimanual Tympanoplasty Using a Nano-Arthroscope
Overview
Visualization for tympanoplasty has evolved from the microscope to the endoscope, reflecting a trend toward minimally invasive techniques. This video introduces the application of a nano-arthroscope as a visualization modality in otologic surgery, specifically an endoscopic tympanoplasty utilizing the Arthrex Nanoscope.
Equipment and Setup
The Arthrex NanoScope™ system represents a significant miniaturization of arthroscopic technology, often referred to as “nano” or “needle-sized” operative arthroscopy. Key technological features include a “chip-on-tip” camera design, where the imaging sensor is located at the very distal end of the scope, eliminating the need for a traditional bulky camera head attached to the eyepiece. The system utilizes very small imaging sensors (1 mm) and incorporates integrated LED lighting for illumination within the surgical field.
To restore a two-handed surgical approach, the endoscope holder was attached to the side rail of the operating table opposite the ear being operated on. This setup demonstrates the specific application of a distal-chip, ultra-minimally invasive nano-arthroscope within the two-handed paradigm.
Clinical Advantages
The primary advantage of the Nanoscope is the ability to enter the ear canal with minimal tissue disruption, making it particularly crucial in anatomically complex cases such as severe stenosis or in pediatric patients. Beyond its minimal invasiveness, a key innovation lies in the system’s maneuverability and the potential for flexible, articulating tips. This property of the Nanoscope allows the surgeon to enhance visualization of anatomical areas that are not in the direct line-of-sight, avoiding limitations imposed by traditional microscopy and rigid endoscopy. Consequently, it facilitates a comprehensive visualization of anatomically concealed regions which are frequent sites of disease.
Limitations and Conclusions
While the application of the nano-arthroscope in tympanoplasty is a feasible and innovative concept, its broader utility is currently limited by challenges in image quality, ergonomics, and hemostasis. This video establishes the novelty of the technique, underscoring the need for technological refinement and further clinical investigation to define its ultimate role and value in modern middle ear surgery.
Endoscopic tympanoplasty utilizing a fixed nano-arthroscope. This technique represents a landmark shift in minimally invasive otologic surgery by utilizing a stabilized nano-endoscope to restore a two-handed surgical approach,1–3 overcoming the one-handed limitation of standard rigid endoscopy4–6 while maintaining panoramic visualization.7,8
This procedure is indicated for middle ear surgery such as tympanoplasty, and is particularly advantageous in anatomically complex cases, such as patients with severe ear canal stenosis or pediatric patients, where entering the ear canal with minimal tissue disruption is crucial.
Contraindications for this procedure are those that apply to performing any standard tympanoplasty. Absolute contraindications include severe, uncontrolled infections, uncontrolled cholesteatoma, active cancer, or high anesthetic risk. Relative contraindications include age extremes, non-functioning Eustachian tube, and hearing loss.9
Arthrex NanoScope™ System (Arthrex): A miniaturized arthroscopic system featuring a 1 mm "chip-on-tip" imaging sensor located at the distal end, integrated LED lighting, and a touchscreen tablet interface for image capture and management.10
Endoscope Holder: A stabilizing mechanical holder used to secure the scope.
The endoscope holder is attached to the side rail of the operating table on the side opposite to the ear being operated on. The 1 mm NanoScope is secured onto the holder and carefully positioned within the external auditory canal.
A complete ear examination must be documented, including a detailed description of both normal and abnormal findings within the external auditory canal and the tympanic membrane. An air and bone pure-tone audiogram, along with speech reception threshold (SRT) and speech discrimination scores, ideally within 3 months prior to the surgery. Computed tomography (CT) of the temporal bone is obtained at the provider's discretion, based on the specific middle ear pathology and suspected anatomical complexities.11
This technique accesses the middle ear via the external auditory canal. The NanoScope's maneuverability and potential for flexible, articulating tips allow the surgeon to enhance visualization of anatomically concealed middle ear regions that are frequent sites of disease and often hidden from the direct line-of-sight of a traditional microscope, including the sinus tympani, facial recess, and epitympanum.12
Achieving and maintaining hemostasis is a critical challenge as blood pooling can rapidly obscure the limited field of view provided by the 1 mm scope. This necessitates continuous suctioning or specific anesthetic techniques to maintain a dry field.13
The rigidity and positioning of the scope holder must be perfectly secured to avoid trauma. Careful setup is required to prevent inadvertent movements of the fixed scope that could endanger delicate middle ear structures. No major intraoperative or postoperative complications were reported in these videos.
Conflict of interest: All authors declare that there are no conflicts of interest, financial or otherwise, that could be perceived to bias our work.
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2. Khan MM, Parab SR. Endoscopic cartilage tympanoplasty: A two‐handed technique using an endoscope holder. The Laryngoscope. 2016;126(8):1893-1898. doi:10.1002/lary.25760
3. Müller C, Raczynski A, Lailach S, Zahnert T. Conventional one-handed compared to two-handed endoscopic ear surgery using an endoscope holder: a single center study. Eur Arch Otorhinolaryngol. 2025;282(3):1217-1230. doi:10.1007/s00405-024-09018-9
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7. Sexton GP, Keogh IJ. Endoscopic Ear Surgery: Minimally Invasive, Maximum Views. J Clin Med. 2026;15(4):1369. doi:10.3390/jcm15041369
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9. Bailey HAT. Symposium: Contraindications to tympanoplasty. I. Absolute and relative contraindications. The Laryngoscope. 1976;86(1):67-69. doi:10.1288/00005537-197601000-00014
10. Arthrex. Nano arthoscopy. 2020. Accessed April 1, 2026. https://www.arthrex.com/foot-ankle/nano-arthroscopy-cameras
11. Shetty S. Pre-Operative and Post-Operative Assessment of Hearing following Tympanoplasty. Indian J Otolaryngol Head Neck Surg. 2012;64(4):377-381. doi:10.1007/s12070-011-0331-6
12. Otsuka A, Koyama H, Kashio A, Matsumoto Y, Yamasoba T. Comparison of Endoscopic and Microscopic Surgery for the Treatment of Acquired Cholesteatoma by EAONO/JOS Staging. Healthcare. 2024;12(17):1737. doi:10.3390/healthcare12171737
13. Pairaudeau C, Mendonca C. Anaesthesia for major middle ear surgery. BJA Educ. 2019;19(5):136-143. doi:10.1016/j.bjae.2019.01.006
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