Endoscope‐Assisted Second‐Stage Tympanomastoidectomy

Abstract

Intact canal wall mastoidectomy techniques for cholesteatoma are often followed by a planned second look for residual disease and possible ossicular reconstruction. Endoscopic techniques may reduce morbidity but introduce new concerns. Twenty-five consecutive second-look procedures were performed from July 1994 to July 1996 utilizing endoscopes in 19 cases and avoiding or terminating their use in the others because of known difficult anatomy, inadequate exposure, or excessive bleeding. Thirteen cases were prospectively explored first through a planned exclusively endoscopic approach and then opened for a conventional second look in comparison. In one of the 13 cases, endoscopy was abandoned. There were no cases in which endoscopy yielded a false-negative result. Endoscopes underestimated the size of recurrence in one case. Our experience, indications, and precautions for endoscope-assisted second-stage tympanomastoidectomy are presented.

Thermal effects of cold light sources used in otologic surgery

“…The microscopes used in otologic surgery had some disadvantages due to their restricted visual field. Endoscopes provide certain advantages over microscopes by presenting a wider visual field; providing better visualization of certain hidden areas like the facial recess, sinus tympani, anterior epitympanum and the Eustachian orifice; shortening operation time; providing higher image resolution; securing lesser recurrence rates, providing more efficient cholesteatoma clearance, and reducing surgical risks [1][2][3][4][5].…”

Surgical Techniques to Facilitate Endoscopic Second‐Look Mastoidectomy

“…The most important factor is proper patient selection. Youssef and Poe suggest that those patients with low‐lying dura, extensive facial nerve dehiscence, an aberrant course to the facial nerve, labyrinthine fistulae, or dehiscent sigmoid sinuses may be poor candidates for endoscopic second‐look surgery 3 . Certainly, unrepaired large dural dehiscence, or dural injury at the time of primary surgery should also be considered a relative contraindication to endoscopic second look.…”

“…We have not performed routine CT scans on patients in preparation for second‐look endoscopy. CT scanning was not routinely suggested by Rosenberg, Youssef, or McKennan prior to endoscopy 3–5 . We have performed CT scans to rule out mastoid opacification when extensive granulation was removed at the primary surgery, leaving large areas denuded of mucosa, and when dural dehiscence was noted at first surgery.…”

“…When mastoidoscopy was performed at the second stage, it was done as previously described by Youssef and Poe 3 . Whenever possible, the procedure was performed under local anesthesia with intravenous sedation as necessary.…”

“…In these cases the bony removal is usually already complete, and ideally the procedure is performed primarily to validate the adequacy of prior disease removal. Previous studies have shown that endoscopic techniques have a low rate of false‐negative findings 3,4 . It also appears to facilitate the performance of the procedure under local anesthesia, with minimal morbidity 5 …”