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Endoscopic Ear Surgery – Incus Interposition for Traumatic Ossicular Discontinuity

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.
Bleeding, infection, tympanic membrane perforation, chorda tympani nerve injury, facial weakness, failure to improve hearing, permanent sensorineural hearing loss, perilymph fistula, ear canal stenosis.
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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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