What is Endoscopic Ear Surgery?

[Dr. Ashley Agan]
Let's talk about endoscopic ear surgery. For the audience who may not know, can you tell us what endoscopic ear surgery is and how is it different than traditional ear surgery? Alejo, we'll start with you.

[Dr. Alejandro Rivas]
You can have many definitions of what endoscopic ear surgery is. Some people could call it nonsense. Some people could call it a threat. Some people would call it a great application of a tool. I think that endoscopic ear surgery, it's a different way of looking at the ear. I don't think that either Brandon or I invented anything that wasn't already existed. We just started to use it in the United States. Endoscopic ear surgery had been present. My father's a neurotologist, even since my father was practicing in his '80s now. The stories that he tells me was, he once tried to use an endoscope in the ear and it was all bloody and it was all filled with blood.

Some people were trying and some people was Dennis Poe was trying to use it in the middle ear space, but it was extremely pixelated and the technology wasn't there. When Brandon and I started to use the endoscope, we had the right technology at our fingertips. We were able to use the endoscope to do middle ear procedures and to get access to a middle ear space. I think that the biggest advantage that the endoscope has provided is the ability to see the middle ear and access the middle ear to anybody that wants to do ear surgery. Before, I think that using the microscope, doing ear surgery, you need to be highly trained, but the visualization is difficult and the understanding the ear is difficult for many people that do not do that day in and day out.

With the endoscope, you get access to that better visualization and that ability to see the middle ear structures, the crevices of the middle ear space, the corners, and just understand how it looks, how it works and how you manage its disease. I think that that's endoscopic ear surgery in my mind.

[Dr. Gopi Shah]
Brandon, when you first started doing it-- so I finished residency in 12. I did not have any exposure of putting the endoscope in the ear. I think at that time, maybe a handful of times I can think of one of my attendings at Jeff or at the Pediatric Hospital at DuPont, maybe just taking a peek, but even then that was very rare. I think it was when I was a fellow with you in 14 that we started doing cases and I was like, wow, this is like, to me, I love sinus surgery. This is like sinus surgery in the ear. How did you get exposed to it and how did you develop that into your practice?

[Dr. Brandon Isaacson]
I read a number of articles about endoscopic ear surgery. I remember them from a surgeon out of the Middle East named Muaaz Tarabichi and it sounded like an interesting technique. I was a bit skeptical, but ended up deciding to do a course in Toronto and did the course and was convinced that once I did the course that I thought it would be a useful tool in middle ear surgery. That was in the spring of 2014. Then I went ahead and just started doing cases. We already had all the equipment we essentially needed and I started, my first case was a globus tympanicum and my whole, that's not a good case to start with.

The whole point of the case was just to elevate a flap, but I learned how to elevate, get into the middle ear. That was my intention with that case is at least to get some practice elevating a flap because that's one of the initial barriers of the technique is getting used to using one hand and using the camera in your left hand or if you're right-handed and instruments in your right hand and getting used to one-handed surgery. I just took off from there. I was fortunate enough that, I'd been in practice for about eight years by the time I started the technique.

It'd been a long time since I used an endoscope, 10 years, but a lot of the actual surgical maneuvers that you do are very similar, within the endoscope. There's a few nuances again, because you're limited to one hand, but it wasn't that hard to adapt. I felt that, even early on when I was first starting this working with residents and fellows that they were pretty quick to pick it up because they were able to use the endoscope for doing sinus cases and airway cases and things like that. It was a little bit sometimes frustrating from my standpoint that, "Oh, they made that look easy, and I just struggled with that." Over time, like anything, with enough repetition. I became more facile at it. I noticed the training is also becoming more facile at it. That's what I've been using ever since for doing most of my middle ear work and even some, lateral skull base work as well in selected cases.

[Dr. Gopi Shah]
I remember the, a journal club from maybe like when I was at PGY2 or something, when we were reading these articles about endoscopic ear surgery and talking about, pros and cons and isn't this interesting? Then, by the time I graduated, we'd done so much endoscopic ear cases that I felt super comfortable doing that. It evolved pretty rapidly once you started doing it.

[Dr. Alejandro Rivas]
I think that's an interesting point. I think that when we started, and I think that-- I don't know if this happened to Brandon, but it certainly happened to me. When I started doing endoscopic ear surgery, I wanted to do everything endoscopic. Part of it was, I didn't know what the limitations were, or it wasn't clear, but also I wanted to get better at it. I was trying to-- and I pushed the envelope in many ways, probably too much. I took on into big cholecystoses, starting to get them through the ear, only to realize that four hours later I had not been done and it was time to finish. Over time, I would say that we move-- we push so hard and so fast. Now I've become a lot more thoughtful and meticulous and regimented on what cases I do endoscopic and which ones I don't, and which ones I even try or which ones I don't even try.

It has significantly changed. At the beginning, I would say that I was doing 70% to 80% of my cases endoscopic. Today, now those numbers have-- and I did that for three to four years. Then as we got progressively more adept and knew the limitations and what was more efficient doing it this way or that way, now those numbers have gone down. For example, sometimes I would say 40, 60, still a little bit more endoscopic than macroscopic, but it's a much balance. We know the limits much better now.

[Dr. Brandon Isaacson]
I think the big benefit is obviously the view that you get. You get essentially instant magnification and unlike the microscope, when you zoom in or you bring your endoscope closer to the structure that you're visualizing, the light actually increases instead of decreasing. In these really, I've seen cases of like a state-piece crural fracture and there was some scar tissue, and there was just no way I would have been able to really-- I think it would have been very difficult to identify that prior to me initiating using the endoscope. The visualization's great. I think for a teaching perspective, I think it's fantastic because we're all looking at the same thing, like a sinus case or any endoscopic case.

It's very easy for me to point out anatomic variants or normal anatomy or abnormal anatomy. It's also easy for me to instruct like, "Hey, this is where you need to make your incision right here and this is where you want to go." It's much easier for me to point out on a screen than it is with a instrument in my left hand or right hand, in the field with the microscope.

From a teaching perspective, I think it's fantastic. I do think it's harder to do because again, you're limited to one hand and I think that takes a longer period of time for people to adapt to that and then getting used to not having collisions with your hands, with the endoscope and your instruments and knowing how to position yourself relative to the patient to get an ideal angle on how to make incisions and do those types of things, it takes definitely some time to learn how to do that. Again, losing one hand I think is a big obstacle barrier or a barrier that people need to overcome.

For me, that trade-off is worth it. I think the views that I get and the ability to teach certain things I think is in my mind a significant advantage. At the same time, I feel like all of our trainees need to know how to-- anybody that's training to do ear surgery needs to know how to use both techniques. You need to know how to use the microscope. There are definitely, there's a significant amount of otologic surgery where the microscope is the go-to visualization tool that you need and there are certain cases where the endoscope I think has substantial advantages over the microscope.