You are on page 1of 3

-

,",'
1Jphic

SCIENCE
I REVIEW ARTICLE I
lation
strua(
Oto-Endoscopy - An Advancement in Otology
men
lIllS.
Des Raj Bhagat, Padam Singh, Vijay Gupta
endoscopic image on the film. TI,e photography of the
tympanic membrane is at 2 cm approximately (2).
Otoendoscopy is being used for various procedures
by otologists and has an upper edge of being very
useful technology in the modern days. It has
re\olutionized the field by helping in diagnosis as well
as treatment of various conditions of the ear. This
knowledge goes a long way in planning the surgical
treatment to be employed in tackling a particular
condition. Il can be performed in the outpatient
department with little inconvenience to the patient
and with minimal risk. Exploration of the middle
ear can now bc accomplished using modern tech-
nology fibreopticlrigid telescopes. Endoscopes with
small diameters and with wide fields of view
providc extraordinary visualization of the middle ear
which was previously accessible only by the surgical
means (I).
Usually the otoview endoscopes in the size of 1.7
nun with 0 - 30 view of angle and in size of 2.4
111m with O. 30 and 70 degree view of angle are used.
The use of endoscopes for the middle ear was first
described by Mer el. at. (3) who used fibreoptic
system delivered through the existing tympanic
membrane perforations in two paticnts. Eichner (4)
popularized rigid e!,doscopes for improved resolution.
Endoscopy of the middle ear has been previously used
as an adjunct to microscopic examination in the office
(5). Alunad (6) has described thc successful use of
30 fibreoptic Hopkin's rod telescopc for the post-
operative follow-up of the mastoid cavity with
gratifying results.
Using a O-degree endoscope, the intact drum call
be examined and the movements of thc ear drum
evaluated. A fluid level due to middle ear effusioll
can also be seen much more clearly with otoendoscope
than with conventional otoscope. A 30-degree
endoscope can sometimes be passed through the
Endoscopic photography came with the advent of perforated ear drwn to detern1ine the integrity of the
the Hopkin's optical system. a wide angle endoscope tiny bones ill the middle ear and also to diagnose the
afforded an enlarged field of vision. An endoscopic disease in hidden areas of the middle ear (7). The rigid
photograph will make it much easier for the patients endoscopes have also been used for endoscopic
to understand a simple explanation for their ear transcanal myringoplasty. The endoscope is passed
problems. In surgery, photos provide clinical through the perforated ear drum to visualize the status
infonnation about lesions and may help the surgcon of ossicles, eustachian tube ori fice and the status of
to decide on the surgical approach and technique. A middle ear mucosa. Also the presence of middle ear
wide angle lens gives a great depth of field. A lens cholesteatoma and granulations can be \'isualized (8).
set at infinity provides a sharp image, starting at 2.5 The graft take-up rate of myringoplasty using
mm. This is excellent for photography of a mastoid endoscopy is 91.7% and the closing of air bone gap
ea\it)'. Thc focal length used is 140 tUm and the choice to less than 10 dB in 83.3% cases has bcen seen (9).
of the focal length determines the size of the Otoendoscopy. also gives better visualization of
---------------
e
IP.
hy
an
8.
P.
il
nof
1Iar
fromlhe Departlllent of SMGS Hospital, Government Medic:.d College, Jammu (J&K) India.
Correspondence to : Dr. Des Raj Bhagat C/o Dr. Padmn Singh, Lecturer. Deptt. of ENT, SMGS Hospital (GMC) Jammu (1&K) India.
Vol. 5No.3. july-September 2003 98
... ...; _
-
retraction pockets as compared to cOI1\cntional
OlOSCOP) (10). Indirect examination \\ ith a mirror or
direct examination with the 90 needle telescope
(middle ear endoscope) may visualize the hidden
borders of the retraction pockets (11).
The use of rigid endoscope provides a large field of
view which is of excellent revolution a,ld fidility of
colour as well as gi\'ing good size views (7). Hopkin's
rod rigid endoscopes of less than 3 111111 diameter ma)
bc passcd into the middle ear cleft via the drum or
mastoid for diagnosing \\ hethcr the cholesteatoma has
recuITed behind the drum head or posterior canal wall.
One millimetre Oexible endoscopes are available \"hich
can be passed through the eustacltian lUbe for the same
purpose (12). (mastoid telescope) is
prefelTcd instead of re-opening the post-aural wound at
the second stage of a combined approach tympanoplas!).
Film) adhesions in older children and bon) overgrO\\1h
in young ones. make a poor view in the majority of
the Cases m,d furthermore this techniquc is less practical
than it secms ( \ 3). Otoendoscopy also enables viewing
of different angles of tympanomastoid area and approach
to them for beller prognosis. A comparative study of
post-operative mastoid cavities lIsing Hopkin's telescope,
otoscope and microscope has shown bener results with
telescopic endoscope. Visualization of the sinodural
angle and tip cells. sinus t) mpani. facial recess and
ossicles is far superior by rod telcscopes. The degTee
of epithelization and condition of the graft margins can
be accurately assessed b) the telescope. The sinodural
angle and the tip cells arc evaluated with 70 telescope.
sinus tympani. racial recess and eustachian tube are
visuali7.ed with 30 telescope. Rest all structures can
be seen with an end on telescope (I).
Rigid otoendoseopy is also useful intra-operatively
in detecting completely removed cholesteatomas. and
to learn whether "second look" procedures are still
needed in children. For this purpose. 30, 2.7 111m
endoscope is used to evaluate the middle ears. When
used imra-operalivcl). if the residual cholesteatoma is
seen. the removal continues until all visualized with
the endoscope is removed and if the cholesteatoma is
99
not ren10ved intact. a planned surgl.:r: i.
performed (1<1). McKellnall (15) has c1is<:ussed the
role of otoendoscopk "second look" to
rule out residual epit) mpanie/mastoid cholcsteotoma.
The postaural route is used \\ ith a small I cm stail
incision made in or just anterior to the Ist stage
postCturicular incision. The mastoid air !JOC"-d is
rcpe-atcdly checked by passing a 22 gauze necJh.:: \\ ith
a feeling of "give" when the Ill:cdlc passes through
the mllcosal ellvelope of the mastoid air pocket.
resiuual cholesteatoma pearls can be rCIlH)\'ed
cndoscopicall) \\ hcreas large requires
postaliriclilar II1cislon as is usuall) performed in
"second look" procedures.
Otoendoscopy ol"fers some 01" the additional
ad\'m1tages (8) :-
Visualizes the whole tympanic <lnd the
canal \\ithou( ha\ ing 10 [he
or the microscope (3).
Extends the in Iransc3t1,.11
procedures into usually hidden unclt:r the
microscope (anterior [)mpanic pCl'furalion. posterior
pocket. facial recess nnd hypotympanum).
Visualizes structures from Illultiple as opposed
to the microscope's single axis along the can.ll.
Provides extremely sharp image \\ith high n:sollllioll.
Attains high percenlage of dr} CJ\ilics (I J.
Anatomical \'[Iriations (IortUOliS or stenotic car callal.
anterior meatal o\'crhang ClC.) that hamper the.: \'ie\\
of entire tympanic membrane during. t:ar are
overcome by otoendoscop).
Operative lime and posl-opel'.:uivc pain as Hell as
morbidity are less.
No auricular displacemellt or numbness. a COlllmon
and annoying tcmporary sidc effect of <I POS(-
auricular incision (15).
Silverstein (16) discussed the usefulness of laser
assisted otoendoseopy at Ear Research Foundation
(ERF). llere the otoendoseopy uses the laser to make
a bloodless opening in the ear drum. A tin) endoscope
can then be inserted through the opening which allo\\s
the surgeon to have a thorough look 01" the lillie bones
of the hearing anatomy in a bloodless flcld. B) this
Vol. 5 NO.3. .JulySeplcmhcr 2003
one
can
dan
me
fen
inr
tel
.JK SCIENCE
---------------o?',
one can also evaluate ccrlaill types or hearing loss.
can look through a chronic perforation to determine
dmnage to the hearing bones and ear drum, or whether
membranes (weI' the round window Ileed to be
removed before medication into the middle ear and
1l1Jlcr car.
In general. variolls procedures performed under
telescopic control include (I)
RcmnV<.ll or granulations by crocodile forceps and
suction.
Rellloval ur epithelial debris.
Removal of otomycotic flakes.
Rcmoval of residual cholesteatoma.
Removal of foreign bodies e.g. colton ball, thread
pieces. maggols ele.
Removal of aura] polyps e.g. small mastoid polyps.
Lowering of high facial ridge under local anaesthesia.
Removal or nccl'Osed meatal flaps.
Promotion of epithelizJtion by application of gentian
violel 10 the cavily. in case of delayed onset of
cpithclil.3tion (usually I month POsl-(;peratively).
rhe Iwo I1H1.I01' safety concerns with the
otoclldoscopes arc - onc is exccssi,c heat dissipation.
c\icknt only when xenon light is Llsed. To prc\'cnt this,
a regular light source can be used because of the size
or the cavity and with this also the illumination can
be belter. Also the lip of the endoscope needs
continuous cleaning with antifog solution. which
probably helps in ",'oling the endoscope, The other
salet) concern is accidental patient movement with
secondary direct trauma by the tip of the endoscope,
1101lcI'er. one handcd surgical technique. loss of depth
perception. limited magnification, need for training and
costly instrumentation are some of its pitfalls.
Otocndoscopic procedures need some expertise on
the part of the surgeon. Some patients may not allow
endoscopy as they are more sensitive. Assurance to
the patient and local anaesthesia will help in sllch type
of patients. In case of a discharging ear, the cleaning
of the car with suction or a course of antibiotics is
nccded prior to procedure in order to have a thorough
vo15 No.3. July-September 2003
look of the Slructures, The procedures can be done
both in sitting and lying dO\\'ll position, on an outdoor
basis and local or general anesthesia can be used.
References
I. B. P<lrkash M. Bapna AS. Telescopic examination
of cavilY. II/d .I O/u!m:1'I1go! IImd .V<.:cA S/II;Q
1998,50 Il) : 189-92,
2. Deguine C. Otoscopic photography. In David A
(ed) Recent Adv<lnces in Otolaryngology. 1st Ind. Edition.
Churchill Livingstone. New Delhi 1996 : 19-26.
3. Mer SB. Derbyshrinc AJ. Brushcnko A <Ind Pontarelli DA.
fibreoptic endoscopes for examining the middle ear.
Arch O/o!mYlIgo! 1967: 85 387-93.
4. Eichncr I-l. Eline mothcr and baby scope optic rutmclfell
andmittclohr Endoscopic. rW:I'lIgo! Rhino (Stuttg.) 1978:
57 872-76,
S. Balknn)' T. Tradius M. Flexible fibreoptic endosc0PY of
cochlea. 1Tuman tcmporal bone studies. ..1111 .I Oro! 1991;
-18 16-22.
6. Ahmad Rf. Endoscopy of mastoid cavity. Ilid .I
Oto!m:l'IIgo! Head Neck S'ur}!, t994: 3 (2) : 101-03.
7. Singhal M. Endoscopy in ENT. EN1" l 'l)({,,'e 2002: 2: (1): 1-2.
8. Anoop Rand Meher R. Endoscopic transcanal
myringoplasty-A study. {lId.l ()/o!m:l'Il,l!,rJ!!leod 'veck SIII'X
200\; 53 (I) : -17-49,
9. Ahmed EL-Guilldy. Endoscopic transcanal myringoplnsty.
.J l.m:l'IIj{o! (}Io/ 1992: 106 :
10. Sculerati N. Charles DB. Pathogensis of choleste<t1011l<1.
Oto!m:1'IIgo! ('!ill N....l1II 1939: 22 (5) : 359-63.
II. TU1l1arkin A. A contribution to the study of middle car
suppuration with speci<ll reference !O the pathogenisis and
trcatmcnt of cholesteatoma. .I 1.1IIYII}/,o! 1938: 53 : 685-90.
12. Gray RF. Acute and chronic suppurative otitis media in
children. [n : David AA, Michael JC (cds) Scott Brown's
Paediatric Otolmyngology. BUlIcrworths. o."ford. 6th edn.
1997: 6 (8), 18,
13. Dubrcuil C. l3ou[ud B. Dumarest D. Value of
otocndoscopy in the followup treatmcnt of cholesteatoma
of the middle ear. Nevel/lie de-!lII:l'lIgo!ogie vto!o;!.ie el
Rhil/ologie 1991; 112: 409-11.
14. Garth.M Good. Gellll [s<lascoll. Otoendoscop) for
improved paediatric cholesteatoma rcmoval. AIIII Owl
Rhillo Lmyngo! 1999: 86 : 893-96.
15. McKennan KX. Endoscopic "second look" mastoirloscopy
to rule alit residual epitympanic/mastoid cholestemoma.
{,lIIyl1t!.oscope 1993; 103 810-14.
16. Silverstein H. Minimally invasive otologic course. Ear
Research Foundation Saxosota (Florida) 2001.
100