**4. Tympanoplasty (myringoplasty)**

**Myringoplasty** (MP) in children is one of the most common otologic procedures and can offer a success rate as high as 95% [5, 6]. It is considered a challenging procedure in children compared to adults due to narrowness of the EAC and generally smaller size of the ear [7, 8]. In a pediatric age, access to the tympanic membrane and elevation of tympanomeatal flap (TMF) to perform MP generally necessitates permeatal incision by employing an endaural or postauricular approach, especially in anterior and subtotal perforations, whereas a transmeatal approach is suitable only for small and posterior perforations [9–14]. In such cases, surgeons would not operate on children until the age of 10–14 years due to technical difficulties encountered in small anatomy, inability of the child to co-operate post-operatively, and increased risk of psychological trauma [10, 15–19]. In anterior perforation, surgery is more challenging as graft placement may be inaccurate [19], and the anterior aspect of the eardrum is more difficult to visualize, especially in children where the external ear canal dimensions are constraining [20, 21]. In our department, we have adopted an endoscopic technique since 2011 [22]. The

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**Figure 7.**

*Endoscopic Ear Surgery in Children*

intervention.

*DOI: http://dx.doi.org/10.5772/intechopen.84563*

or endaural incision and applying a transcanal approach.

free part of the flap and the graft are repositioned.

of pledgets soaked with a vasoconstricting agent.

*Single-handed transcanal endoscopic myringoplasty, steps A through L.*

use of endoscopy to perform myringoplasty may obviate such limiting factors. In agreement with our experience and that of others reported in the literature [23], an endoscopic approach can offer many advantages over a microscope approach in children. It provides the possibility to decrease morbidity by avoiding postauricular

The **technique** consists of refreshing the margins of the perforation using a sickle knife or Rosen needle and grasping forceps. Two vertical incisions are performed at 12 and 6 o'clock on the skin, and at a horizontal one at about 0.2 cm from the annulus and the medial TMF is elevated. The graft is inserted under the anterior margin of the perforation, underlay fashion, and under or above the handle of the malleus depending of the extension of the perforation (**Figure 7A**–**L**); in the case that the perforation involves the anterior quadrants, it is applied over the malleolus (**Figure 8A, B**). Gelfoam is applied adequately in the middle ear, and then both the

According to literature reports**, bleeding** is considered as a limit of endoscopic ear surgery. When it does occur, the surgeon is sometimes forced to interrupt or convert to an otomicroscopic bi-manual procedure [4, 24, 25]. In our experience, bleeding was never a relevant issue: in no instance did the procedure become so demanding and troublesome that it had to be converted to a microscopic

Bleeding can be handled in several ways. Injection of the EAC with epinephrine

1:1000 solution and then waiting for a few moments before incising the skin. Another hint is that after the incision prominent bleeding will be noticed at the beginning, one may shift and start harvesting the tragal perichondrium in order to provide enough time for spontaneous hemostasis to take place. During elevation of the TMF, it could be controlled by irrigation with warm saline and local application

### *Endoscopic Ear Surgery in Children DOI: http://dx.doi.org/10.5772/intechopen.84563*

*The Human Auditory System - Basic Features and Updates on Audiological Diagnosis and Therapy*

ossiculoplasties, and stapedotomies. In fact, the learning curve for grommet insertion is very short, especially for colleagues who already perform endoscopic sinus surgery. In conclusion, otoendoscopic VT placement is a valid and secure procedure. It is applicable in all patients independent of age, type of tube, Grommet tubes and T tubes, and anatomical conformation. The surgical approach is especially advantageous for grommet placement in narrow and curved EACs. In bloody fields, surgery may become more time consuming, but never compels the surgeon to abandon the technique. The learning curve is steep, especially for surgeons who are acquainted with endoscopic sinus surgery. Both cost-wise and in terms of logistic handling, the endoscope offers clear advantages. Nevertheless, the operating microscope must always be available in the operating room for rare cases of high jugular bulb or aberrant course of the internal carotid artery in the middle ear, which raises the hypothetical risk of bleeding that would not be controllable by an endoscopic approach alone. The endoscopic approach yields results that are comparable to traditional otomicroscopic techniques, but it is clearly superior in

*Iatrogenic hematoma of the left ear anterior wall and excoriation of the right ear inferior wall for a right-*

**Myringoplasty** (MP) in children is one of the most common otologic procedures and can offer a success rate as high as 95% [5, 6]. It is considered a challenging procedure in children compared to adults due to narrowness of the EAC and generally smaller size of the ear [7, 8]. In a pediatric age, access to the tympanic membrane and elevation of tympanomeatal flap (TMF) to perform MP generally necessitates permeatal incision by employing an endaural or postauricular approach, especially in anterior and subtotal perforations, whereas a transmeatal approach is suitable only for small and posterior perforations [9–14]. In such cases, surgeons would not operate on children until the age of 10–14 years due to technical difficulties encountered in small anatomy, inability of the child to co-operate post-operatively, and increased risk of psychological trauma [10, 15–19]. In anterior perforation, surgery is more challenging as graft placement may be inaccurate [19], and the anterior aspect of the eardrum is more difficult to visualize, especially in children where the external ear canal dimensions are constraining [20, 21]. In our department, we have adopted an endoscopic technique since 2011 [22]. The

**116**

anatomically complex cases.

**Figure 6.**

*handed surgeon.*

**4. Tympanoplasty (myringoplasty)**

use of endoscopy to perform myringoplasty may obviate such limiting factors. In agreement with our experience and that of others reported in the literature [23], an endoscopic approach can offer many advantages over a microscope approach in children. It provides the possibility to decrease morbidity by avoiding postauricular or endaural incision and applying a transcanal approach.

The **technique** consists of refreshing the margins of the perforation using a sickle knife or Rosen needle and grasping forceps. Two vertical incisions are performed at 12 and 6 o'clock on the skin, and at a horizontal one at about 0.2 cm from the annulus and the medial TMF is elevated. The graft is inserted under the anterior margin of the perforation, underlay fashion, and under or above the handle of the malleus depending of the extension of the perforation (**Figure 7A**–**L**); in the case that the perforation involves the anterior quadrants, it is applied over the malleolus (**Figure 8A, B**). Gelfoam is applied adequately in the middle ear, and then both the free part of the flap and the graft are repositioned.

According to literature reports**, bleeding** is considered as a limit of endoscopic ear surgery. When it does occur, the surgeon is sometimes forced to interrupt or convert to an otomicroscopic bi-manual procedure [4, 24, 25]. In our experience, bleeding was never a relevant issue: in no instance did the procedure become so demanding and troublesome that it had to be converted to a microscopic intervention.

Bleeding can be handled in several ways. Injection of the EAC with epinephrine 1:1000 solution and then waiting for a few moments before incising the skin. Another hint is that after the incision prominent bleeding will be noticed at the beginning, one may shift and start harvesting the tragal perichondrium in order to provide enough time for spontaneous hemostasis to take place. During elevation of the TMF, it could be controlled by irrigation with warm saline and local application of pledgets soaked with a vasoconstricting agent.

**Figure 7.** *Single-handed transcanal endoscopic myringoplasty, steps A through L.*

#### **Figure 8.**

*(A) Tympanomeatal flap elevated and malleolus is denuded. (B) Graft positioned under the osseous annulus and over the malleolus.*

A very helpful tool recently introduced as an otological instrument to overcome the presence of blood in the surgical field is the round knife with suction duct. During the dissection and elevation of the tympanomeatal, it offers the advantage of going through the dissection until reaching the annulus without the need to interrupt and use suction to aspirate blood from the surgical field (**Figure 9**).

The choice of the **graft** depends upon the preference of the surgeon. In our department, we either use the tragus (perichondrium ± cartilage) harvested and trimmed otherwise using biologic tissue. The advantage of biologic tissue is that one can reduce the surgical time by up to 15 min (**Figure 10**).

As described in other studies, endoscopes with different lengths, such as 6, 11, 16, and 18 cm, can be used to carry out endoscopic management [2, 4, 23]. According to our experience, the optimal length is between 11 and 16 cm in order to avoid impingement of instruments such as that noted on ventilation tube placement [22]. The rigid **endoscope** to use according to our experience is 3.0 mm and 16 cm long. This diameter and length fits all; both in a stenotic canal and a normal one, it provides good luminosity and adequate distance between the scope and otologic instruments. A 2.7 mm diameter, 18 cm long endoscope is not advisable due to its small field of vision, less luminosity, and inadequate rigidity of the shaft that will bend upon exertion of pressure, determining a crescent black spot field laterally (**Figure 11**).

In conclusion, endoscopic-assisted transcanal myringoplasty is feasible in all cases of tympanic perforation in children of any age and can be considered as a valid, alternative approach to the microscope. It is less invasive, especially in

#### **Figure 9.**

*(A) Standard round knife and (B) round knife with suction duct. Notice the difference of the surgical field in B, which is free of blood.*

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*Endoscopic Ear Surgery in Children*

**Figure 10.**

**Figure 11.**

*DOI: http://dx.doi.org/10.5772/intechopen.84563*

*submucosa (Biodesign; Cook Medical Inc., Bloomington, IN).*

anterior perforations and in narrow and curved external canals where post-auricular or endaural approaches are otherwise required. An endoscopic approach grants better cosmetic outcomes and less psychological trauma with comparable anatomi-

*(A) Autograft tragus perichondrium with cartilage isle and (B) xenograft acellular porcine small intestinal* 

Endoscopy as a surgical tool in otosurgery is gradually evolving in daily practice when approaching middle and inner ear pathologies. Moreover, it is well known that cholesteatoma in a pediatric age, with an incidence that varies between 3 and 6 per 100,000 [26, 27], is an aggressive disease with respect to that in adults. The surgical approach is tailored according to the nature of cholesteatoma in being acquired or congenital, cystic or invasive. It often requires an extensive surgical approach, without undermining the preservation of hearing, as an attempt to eradicate the pathology due to its high rates of recidivism. The strategy to manage recidivism depends if it is residual, recurrent, or iatrogenic in nature. The standardized techniques at our disposition for such a destructive pathology, contrived upon the application of an operative microscope, are the transcanal (TC), canal wall-up (CWU), canal wall-down (CWD), and subtotal petrosectomy approaches. The surgeon should apply the indicated but least invasive and most effective approach, bearing in mind that the child will still have their entire life span ahead. Therefore, not only should

cal and functional results vs. a traditional otomicroscopic technique.

**5. Endoscopic approach to cholesteatoma**

*Different lengths of endoscopes: 14 and 18 cm are indicated for ear surgery.*

#### **Figure 10.**

*The Human Auditory System - Basic Features and Updates on Audiological Diagnosis and Therapy*

A very helpful tool recently introduced as an otological instrument to overcome

*(A) Tympanomeatal flap elevated and malleolus is denuded. (B) Graft positioned under the osseous annulus* 

As described in other studies, endoscopes with different lengths, such as 6, 11, 16, and 18 cm, can be used to carry out endoscopic management [2, 4, 23]. According to our experience, the optimal length is between 11 and 16 cm in order to avoid impingement of instruments such as that noted on ventilation tube placement [22]. The rigid **endoscope** to use according to our experience is 3.0 mm and 16 cm long. This diameter and length fits all; both in a stenotic canal and a normal one, it provides good luminosity and adequate distance between the scope and otologic instruments. A 2.7 mm diameter, 18 cm long endoscope is not advisable due to its small field of vision, less luminosity, and inadequate rigidity of the shaft that will bend upon exer-

tion of pressure, determining a crescent black spot field laterally (**Figure 11**).

In conclusion, endoscopic-assisted transcanal myringoplasty is feasible in all cases of tympanic perforation in children of any age and can be considered as a valid, alternative approach to the microscope. It is less invasive, especially in

*(A) Standard round knife and (B) round knife with suction duct. Notice the difference of the surgical field in* 

the presence of blood in the surgical field is the round knife with suction duct. During the dissection and elevation of the tympanomeatal, it offers the advantage of going through the dissection until reaching the annulus without the need to interrupt and use suction to aspirate blood from the surgical field (**Figure 9**). The choice of the **graft** depends upon the preference of the surgeon. In our department, we either use the tragus (perichondrium ± cartilage) harvested and trimmed otherwise using biologic tissue. The advantage of biologic tissue is that one

can reduce the surgical time by up to 15 min (**Figure 10**).

**118**

**Figure 9.**

*B, which is free of blood.*

**Figure 8.**

*and over the malleolus.*

*(A) Autograft tragus perichondrium with cartilage isle and (B) xenograft acellular porcine small intestinal submucosa (Biodesign; Cook Medical Inc., Bloomington, IN).*

**Figure 11.** *Different lengths of endoscopes: 14 and 18 cm are indicated for ear surgery.*

anterior perforations and in narrow and curved external canals where post-auricular or endaural approaches are otherwise required. An endoscopic approach grants better cosmetic outcomes and less psychological trauma with comparable anatomical and functional results vs. a traditional otomicroscopic technique.
