This video illustrates an endoscopic ossiculoplasty using a total ossicular replacement prosthesis (TORP) in a patient with a mixed hearing loss and a large conductive component. The video highlights the middle ear anatomy including a dehiscent and prolapsed facial nerve partially obstructing the oval window. Technical pearls for the ossiculoplasty are also highlighted.
Cameron C. Wick, MD
Department of Otolaryngology – Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO, USA
cameron.wick@wustl.edu
J. Walter Kutz Jr., MD
Department of Otolaryngology – Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
walter.kutz@utsouthwestern.edu
Procedure: Endoscopic ossiculoplasty (total ossicular replacement prosthesis - TORP) with a prolapsed facial nerve.
Introduction: Endoscopic ossiculoplasties, particularly TORP, are challenging secondary to the surgeon having only one-hand to manipulate the prosthesis.
Indications/Contraindications: TORP is indicated for conductive hearing loss with no useful stapes superstructure. Contraindications include stapes footplate fixation or persistent disease in the middle ear cleft.
Materials and Methods: This is a single case report using intraoperative video to highlight middle ear anatomy and technical pearls of endoscopic ossiculoplasty.
Result: 3-month postoperative audiogram shows correction of the conductive component of the patient's hearing loss. Technical pearls include use of gel foam and capillary action to assist with prosthesis placement and stability.
Conclusion: Endoscopic ossiculoplasty, even TORP, is feasible.
Transcanal endoscopic ear surgery (TEES) is gaining popularity for its improved visualization of the middle ear space and wide-angle view. Chronic ear disease, including tympanic membrane perforations and cholesteatoma, are frequently being addressed in an exclusively endoscopic fashion. Chronic ear disease often alters the ossicular chain making an ossiculoplasty necessary. This delicate surgical procedure has additional challenges when attempted using the one-handed endoscopic technique. The accompanying video shows an illustrative case where the endoscope was useful to visualize unusual middle ear anatomy and it highlights some of the technical pearls for successful total ossicular replacement prosthesis (TORP) placement.
The standard TEES setup was utilized. This entails supine position, head rotated slightly with the operative ear up, and the head of bed slightly elevated. Facial nerve monitoring was setup and is routinely used for chronic ear surgery, particularly revision cases. After prepping the ear with betadine paint, an otologic drape containing a pouch was used. Standard middle ear instrumentation can be used or specially designed endoscopic ear trays are available. In this video, standard ear instrumentation are used as well as a disposable 7200 Beaver blade. The endoscope is a 3-mm diameter, 14-cm length zero-degree scope from Storz. The prosthesis is a titanium offset ALTO TORP from Grace Medical.
Preoperative work-up included a detailed microscopic ear exam, tuning fork exam, and audiogram. Radiographic studies were not obtained.
The previously placed TORP had fallen over and was no longer in the oval window niche. The old prosthesis was removed. The facial nerve was noted to be dehiscent and prolapsed over a portion of the oval window. Careful lysis of adhesions allowed a small area of the stapes footplate to be visualized. Because this area was small, a footplate shoe was not used for this ossiculoplasty.
The ossiculoplasty size is first measured with a plastic sizing prosthesis. Once the correct size is established the titanium offset ALTO TORP is cut to size on the back table. Prior to placement, the oval window niche is prepared by placing gel foam around the anticipated landing area. The gel foam helps the endoscopic surgeon so that the prosthesis does not fall over, but rather can be supported by the gel foam. Additionally, capillary action from the undersurface of the tympanic membrane helps support the prosthesis.
Three-months after successful placement the patient's air-bone gap had been dramatically reduced, essentially eliminating the conductive component of his hearing loss. His speech discrimination score also increased.
Endoscopes are now being used to manage a myriad of otologic conditions, including cholesteatoma, tympanic membrane perforation, otosclerosis, and skull base pathology. The challenge of endoscopic ossiculoplasty is the one-handed prosthesis placement, particularly for a TORP which is top-heavy with a narrow base. A recent comparison of endoscopic versus microscopic ossiculoplasty results showed no difference in the audiologic outcomes (1). Therefore, with some technical modifications endoscopic ossiculoplasty, including TORP, is feasible.
None
None
1. Yawn RJ, Hunter JB, O'Connell BP, Wanna GB, Killeen DE, Wick CC, Isaacson B, Rivas A. Audiometric outcomes following endoscopic ossicular chain reconstruction. Otol Neurotol. 2017;38(9):1296-1300.
Review Endoscopic Ossiculoplasty (TORP) with Prolapsed Facial Nerve. Cancel reply
Related Videos
This video shows a transotic approach for a cochlear schwannoma in a 59-year-old female who presented with sudden sensorineural hearing loss in her left three years prior. She was found to have subsequent growth of her tumor on imaging and elected to undergo surgery. The transotic approach is a valuable approach within the armamentarium of a skull base team and differs from the transcochlear approach in the handling of the facial nerve. Techniques for ear canal overclosure, eustachian tube packing and mastoid obliteration are also highlighted.
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 !
We present the harvest of a osteocutaneous fibula free flap for head and neck reconstruction performed at the University of Cincinnati. This reconstructive technique has a wide variety of implications but has found greatest utility in the reconstruction of mandibular defects.
Review Endoscopic Ossiculoplasty (TORP) with Prolapsed Facial Nerve.