A five year old with conductive hearing loss due to traumatic ossicular discontinuity presents for surgical management. Ossicular discontinuity with a fibrous union of the incudostapedial joint is identified. Transcanal Endoscopic middle ear exploration with incus interposition is performed.
DOI: http://dx.doi.org/10.17797/t0il7famg9
Editor Recruited By: Sanjay Parikh, MD, FACS
Transcanal Endoscopic Middle Ear Exploration with Ossiculoplasty using Incus Interposition Graft
Conductive hearing loss
Active otitis, recent temporal bone trauma
All equipment for the endoscopic approach should be in position and in the OR suite prior to the case. This should include endoscopic video tower, to be placed directly opposite the surgeon, rigid endoscopes, and endoscopic middle ear instrumentation. See the following reference for a detailed description of EES OR setup: Cohen et al. Laryngoscope. 2016 Mar;126(3):732-8. doi: 10.1002/lary.25410
Otologic examination, behavioral audiometry, computed tomography of the temporal bones
Rigid endoscopes offer a broader view of the middle ear anatomy, allowing for more landmarks to be present in the visible surgical field at any given time. Critical landmarks in this case include chorda tympani nerve, malleus, incus and stapes, stapedius tendon and pyramidal eminence, cochleariform process, oval window, facial nerve, and round window niche
Endoscopic ossiculoplasty in this case offered a transcanal approach when a postauricular approach would have likely been necessary for a traditional microscopic case. The increased depth of field of the endoscope allows for the graft and the target site to both be in focus during introduction of the graft through the ear canal and up to the stapes capitulum.
Disadvantages of the endoscopic approach include the increased difficulty of one-handed surgery, particularly for positioning the graft. Extreme caution must be used when manipulating the ossicles, particularly the stapes, with an endoscopic approach, as a second stabilizing instrument is not available. Practice with endoscopic techniques on less technically challenging cases such as tympanoplasty or myringotomy with tube insertion is recommended prior to attempting ossiculoplasty.
Cohen, M. S., Landegger, L. D., Kozin, E. D. and Lee, D. J. (2016), Pediatric endoscopic ear surgery in clinical practice: Lessons learned and early outcomes. The Laryngoscope, 126: 732â738. doi: 10.1002/lary.25410
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Here, we have a 39 yrs old female with complaints of noisy breathing for last two years post thyroidectomy. Flexible laryngoscopy confirmed bilateral vocal cord paralysis. She was planned for coblation assisted cordectomy.
Patient was taken up for procedure under general anaesthesia. She also started having stridor after induction. Nasopharyngeal intubation with spontaneous breathing technique was used. Entropy leads were placed over forehead to monitor the depth of anaesthesia. Tube position was confirmed with endoscopic view and Benjamin lindohlm laryngoscope was suspended. As the patient was spontaneously breathing, the stridor became more prominent, with stable vitals and the procedure was continued. The vocal cord retractor was fixed and coblation wand was then used with 7:3 settings for ablation and coagulation respectively. The surgical limits were-anteriorly the junction between ant 2/3 and post 1/3 of the vocal cord, posteriorly just anterior to the vocal process of arytenoid to prevent cartilage exposure and post operative granulations. Superely till the ventricle and inferioly till the medial most surface of the subglottis. Laterally approx. 5 mm depth was defined to prevent injury to the superior laryngeal artery branch and further bleeding. Once the final airway was achieved , the topical lignocaine was used to prevent laryngeal spasm post extubation.
The patient was shifted to the ward without oxygen, the voice was assessed on post op day 2.
Patient was called for follow up on post op day 14th and good voice outcomes were achieved.
So lets have a look on some tips & tricks for the safe procedure—–
Nasopharyngeal insufflation technique with entropy monitor will give adequate and safe surgical field
2. Appropriate exposure will help you to delineate the surgical margins
3. Topical anaesthesia before and after the procedure will prevent sudden laryngeal spasm
4. Firm holding of coblation device will help to prevent injury to surrounding structures like anterior 2/3 vocal cord, opposite side vocal cord, medial surface of vocal cord or aryteroid posteriorly
5. Do not ablate more laterally to prevent bleeding, if at all it happens, use patties or coagulation switch for hemostasis.
6. And at the end of the procedure ,use catheter suction to suck out blood clots or saline from the airway if any….
To Conclude-Coblation Assisted Cordectomy( CAC) can be performed safely with good outcomes in case of bilateral vocal cord paralysis using tubeless anesthesia technique without tracheostomy !
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