**3. Ventilation tube placement**

Myringotomy with placement of ventilation tubes (VT) is considered to be basic treatment for the ENT surgeon in certain pathologies of the middle ear such as otitis media with effusion (OME). The alternative to the use of a microscope in carrying out such a procedure is a rigid endoscope.

Endoscopic VT placement was started at our ENT Pediatric Department in 2008 by one colleague and was gradually followed by colleagues who shifted from a microscope to an endoscope until 2012, when all grommets were placed endoscopically. Nowadays, it is considered as standard technique, owing to the easy and straightforward nature of the procedure.

No special prior preparation is needed for endoscopic VT placement. In pediatric patients, the procedure is always performed under general anesthesia. The patient is placed in an otosurgical position, and cleansing of the surgical field is performed using an antiseptic product prior to removal of wax or debris when present. Wax is not a limitation in our hands, in contrast to what noted by other authors [2]; it is easily

**113**

**Figure 2.**

*Endoscopic Ear Surgery in Children*

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

fluoroplastic and silicone Goode T-Tubes.

handled and cleaned endoscopically. Hair trimming was not needed in any patient. Antifogging liquid is needed to avoid blurred vision noted in another study [3].

The endoscopic procedure is stepwise starting with myringotomy in the anterior quadrants (**Figure 2A**) using a sickle knife; suctioning of secretions from the middle ear; positioning the rim of the grommet by forceps on the site of the incision (**Figure 2B**); and gentle slipping of the grommet inside the myringotomy with a needle or a pick (**Figure 2C**). We usually use two types of VTs: a Shepard grommet made of

No age-related limitations were encountered in endoscopic VT placement and,

The **endoscope** to use in such procedures is 0° angled. At the beginning of our experience, surgical treatment was also performed with a 30° angled scope, but no significant benefit over the 0° endoscope was observed. Moreover, as described in other studies, different lengths of endoscopes, such as 6, 11, 14, 16, and 18 cm, can be used to carry out endoscopic management [2, 4]. In our hands, the use of 11 cm or longer scopes offers greater maneuvering space for other tools without limiting

**Endoscopes** with different **diameters** (1.9, 2.7, 3, and 4 mm) are also available. Some authors have suggested the use of a small (2.7 mm) scope in pediatric patients [2]. In our experience, 3 or a 4 mm scopes can be used interchangeably except for stenotic, bending EAC or syndromic patients (i.e., Down S., Goldenhar S., Pallister-Killian S., etc.), and in that case, a 3.0 mm endoscope is recommended. A 2.7 mm, 18 cm long endoscope is avoided because in comparison with the 3.0 endoscope, it has less luminosity should slight pressure be exerted on the shaft and a black crescent appears laterally, reducing the operating field. As we all know, in narrow or oblique EACs, positioning of VTs with an operating microscope can be a troublesome task. The ear speculum itself occupies space in the membranous ear canal, further reducing its diameter. Secondly, in a curved EAC, it is often not possible to view the inferior quadrants of the eardrum where the tube should be placed. On the contrary, the use of an adequate endoscope in a narrow and curved canal offers a larger visual field. According to our experience, it is preferable to use an endoscope with a larger diameter that is compatible with the size of the EAC. There is no need for special **tools** for endoscopic placement of grommets. The same instrument set used in a standard microscopic approach is required. In our experience, sickle knives with the smallest tips, both straight and slightly curved, are the best choice. Additionally, delicate ear forceps having a working length of 8 cm are usually well handled. Suction tubes that fit well in the pediatric age are those with diameters from 3 to 5 French. The standard **endoscopic technique** for grommet insertion has been described above, whereas T-tube placement is more articulated, especially in the presence of atelectasis. However, in these cases, the degree of difficulty is not different from conventional otomicroscopy procedures. After myringotomy, the T-tube is grasped

in fact, the age of our patients at surgery ranged from 1 month to 15 years.

the excursion of the operative hand by touching the camera.

*(A) Myringotomy, (B) suction of secretions, and (C) positioning of the grommet.*

### *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*

starting from ventilation tube placement, myringoplasty, cholesteatoma removal, ossiculoplasty, cochlear implantation, and, finally, the application of a holder for

Endoscopy provides an easy and comfortable means of examining the external auditory canal (EAC) and tympanic membrane in children for diagnostic purposes and follow-up as data is recorded and archived on a hard disk. Most children are uncooperative during office sessions for pre- and post-operative evaluations when they are laid on a bed under the microscope. With endoscopy, the child can sit on the lap of his/her parent, feeling safe and being more compliant, but otherwise by

Myringotomy with placement of ventilation tubes (VT) is considered to be basic treatment for the ENT surgeon in certain pathologies of the middle ear such as otitis media with effusion (OME). The alternative to the use of a microscope in carrying

Endoscopic VT placement was started at our ENT Pediatric Department in 2008 by one colleague and was gradually followed by colleagues who shifted from a microscope to an endoscope until 2012, when all grommets were placed endoscopically. Nowadays, it is considered as standard technique, owing to the easy and

*On the left, a child sitting on the lap of his father during endoscopy; on the right, a boy lying on the* 

No special prior preparation is needed for endoscopic VT placement. In pediatric patients, the procedure is always performed under general anesthesia. The patient is placed in an otosurgical position, and cleansing of the surgical field is performed using an antiseptic product prior to removal of wax or debris when present. Wax is not a limitation in our hands, in contrast to what noted by other authors [2]; it is easily

two-handed endoscopic surgery.

him/herself (**Figure 1**).

**3. Ventilation tube placement**

*examination bed by himself.*

out such a procedure is a rigid endoscope.

straightforward nature of the procedure.

**2. Endoscopy as a diagnostic tool**

**112**

**Figure 1.**

handled and cleaned endoscopically. Hair trimming was not needed in any patient. Antifogging liquid is needed to avoid blurred vision noted in another study [3].

The endoscopic procedure is stepwise starting with myringotomy in the anterior quadrants (**Figure 2A**) using a sickle knife; suctioning of secretions from the middle ear; positioning the rim of the grommet by forceps on the site of the incision (**Figure 2B**); and gentle slipping of the grommet inside the myringotomy with a needle or a pick (**Figure 2C**). We usually use two types of VTs: a Shepard grommet made of fluoroplastic and silicone Goode T-Tubes.

No age-related limitations were encountered in endoscopic VT placement and, in fact, the age of our patients at surgery ranged from 1 month to 15 years.

The **endoscope** to use in such procedures is 0° angled. At the beginning of our experience, surgical treatment was also performed with a 30° angled scope, but no significant benefit over the 0° endoscope was observed. Moreover, as described in other studies, different lengths of endoscopes, such as 6, 11, 14, 16, and 18 cm, can be used to carry out endoscopic management [2, 4]. In our hands, the use of 11 cm or longer scopes offers greater maneuvering space for other tools without limiting the excursion of the operative hand by touching the camera.

**Endoscopes** with different **diameters** (1.9, 2.7, 3, and 4 mm) are also available. Some authors have suggested the use of a small (2.7 mm) scope in pediatric patients [2]. In our experience, 3 or a 4 mm scopes can be used interchangeably except for stenotic, bending EAC or syndromic patients (i.e., Down S., Goldenhar S., Pallister-Killian S., etc.), and in that case, a 3.0 mm endoscope is recommended. A 2.7 mm, 18 cm long endoscope is avoided because in comparison with the 3.0 endoscope, it has less luminosity should slight pressure be exerted on the shaft and a black crescent appears laterally, reducing the operating field. As we all know, in narrow or oblique EACs, positioning of VTs with an operating microscope can be a troublesome task. The ear speculum itself occupies space in the membranous ear canal, further reducing its diameter. Secondly, in a curved EAC, it is often not possible to view the inferior quadrants of the eardrum where the tube should be placed. On the contrary, the use of an adequate endoscope in a narrow and curved canal offers a larger visual field. According to our experience, it is preferable to use an endoscope with a larger diameter that is compatible with the size of the EAC. There is no need for special **tools** for endoscopic placement of grommets. The same instrument set used in a standard microscopic approach is required. In our experience, sickle knives with the smallest tips, both straight and slightly curved, are the best choice. Additionally, delicate ear forceps having a working length of 8 cm are usually well handled. Suction tubes that fit well in the pediatric age are those with diameters from 3 to 5 French.

The standard **endoscopic technique** for grommet insertion has been described above, whereas T-tube placement is more articulated, especially in the presence of atelectasis. However, in these cases, the degree of difficulty is not different from conventional otomicroscopy procedures. After myringotomy, the T-tube is grasped

**Figure 2.** *(A) Myringotomy, (B) suction of secretions, and (C) positioning of the grommet.*

either by both wings together or by one only and inserted inside the incision. The advantage of otoendoscopy compared to the operating microscope is that during placement of the T-tube, one can clearly evaluate the depth of insertion of the tube wings (**Figure 3**). The endoscope itself may be used to keep the T-tube in position while releasing and extracting the forceps.

Furthermore, an endoscopic surgical technique can be influenced by the size of EAC. Whenever the EAC diameter is stenotic, the surgical maneuver differs from standard cases. As performed in our patients, the tube is laid at the meatus and is then pushed medially and inserted in the myringotomy with a pick. The scope is not introduced deeply in the ear canal, but is stopped after its entrance. The impression of the endoscope on the membranous wall of the EAC can be noticed in **Figure 4A** and stenosis of the EAC with a diameter equal to that of the grommet is observed in **Figure 4B**.

In one of our patients, stenosis was not the only difficulty: the reduced space between the ear drum and the anterior wall of the EAC, that is, the acute anterior tympanomeatal angle, limited the surgical maneuvers was also problematic. Rotating the tube inside the incision was impossible due to the hindrance of the anterior wall. In this specific case, it was decided to switch to a T-tube to complete the procedure successfully (**Figure 5**). This was possible because in a very narrow space, holding the T-tube with a Hartmann forceps under endoscopic control allowed the flanges of the T to enter the myringotomy directly.

The type of **grommet** selected is another important issue in endoscopic myringotomies with VTs. Rigid materials such as fluoroplastic have some advantages over elastic ones (such as silicone or microgel). The reason lies in the need to push the grommet with a needle or a pick in smaller size EACs. The instruments would penetrate soft materials, thus not enabling correct insertion or getting stuck in it. In a couple of cases, the VT bounced back and we had to repeat the maneuver. Elastic materials might be preferred in wide EACs, where the grommet is applied directly by the ear forceps.

The **limitations** in handling instruments differ between left-handed and righthanded surgeons. For those right handed, tube placement in the right ear canal is more demanding, owing to the higher risk of excoriation of the inferior wall of the EAC and subsequent bleeding (**Figure 6**).

In left ears, the field of vision improves but there is a higher risk of skin lesions or hematoma of the anterior wall of the EAC. The opposite applies for those who are left handed; that is, excoriation of anterior canal wall in the right ear canal and inferior wall of the left ear canal (**Figure 6**).

**115**

**Figure 5.**

*T-tube placed in stenotic EAC.*

*Endoscopic Ear Surgery in Children*

**Figure 4.**

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

According to the literature, a major limit of endoscopic ear surgery is bleeding. When it occurs, the surgeon is sometimes forced to interrupt or convert the procedure to an otomicroscopic, bi-manual technique [12, 13, 15]. Senior surgeons are accustomed to use the left hand for suction (if right-handed) and the right hand to maneuver the instruments within the EAC, due to traditional otosurgical training. This allows maintaining the tiny operative field within the ear canal clear from blood. In our series, bleeding was never a relevant issue: in no instance did the procedure become so demanding and troublesome that there was the need to convert it to the microscope. In case of bloody field due to inadvertent tearing of the canal skin, the simple application of a sponge soaked with a vasoconstricting agent such as epinephrine 1/1000 for a few minutes allowed adequate hemostasis. Following this, rinsing the ear canal with warm water or saline also helps to clear the field. It is clear that the surgical skills of the operator and his/her experience with the use of

*Positioning of the grommet in stenotic EAC. (A) Notice the impression of the 2.7 mm endoscope greater in* 

*diameter w.r.t the EAC and (B) diameter of the grommet compared to that of the EAC.*

endoscopes play an important role in minimizing surgical trauma.

respected by taking into consideration the above advice.

Single **handedness** in endoscopy is considered by different otologists as a limitation in ear surgery, even for simple procedures such as VT placement [2, 3]. According to our experience, this is not the case as long as the skin of the ear canal is

Unlike other studies in the literature [3], based on our experience, no special **training** for endoscopic grommet positioning is required. Special training is definitely required for more complex procedures such as tympanoplasties,

**Figure 3.** *Positioning of T-tube grabbed by its wings.*

#### **Figure 4.**

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

either by both wings together or by one only and inserted inside the incision. The advantage of otoendoscopy compared to the operating microscope is that during placement of the T-tube, one can clearly evaluate the depth of insertion of the tube wings (**Figure 3**). The endoscope itself may be used to keep the T-tube in position

Furthermore, an endoscopic surgical technique can be influenced by the size of EAC. Whenever the EAC diameter is stenotic, the surgical maneuver differs from standard cases. As performed in our patients, the tube is laid at the meatus and is then pushed medially and inserted in the myringotomy with a pick. The scope is not introduced deeply in the ear canal, but is stopped after its entrance. The impression of the endoscope on the membranous wall of the EAC can be noticed in **Figure 4A** and stenosis of the EAC with a diameter equal to that of the grommet is

In one of our patients, stenosis was not the only difficulty: the reduced space between the ear drum and the anterior wall of the EAC, that is, the acute anterior tympanomeatal angle, limited the surgical maneuvers was also problematic. Rotating the tube inside the incision was impossible due to the hindrance of the anterior wall. In this specific case, it was decided to switch to a T-tube to complete the procedure successfully (**Figure 5**). This was possible because in a very narrow space, holding the T-tube with a Hartmann forceps under endoscopic control

The type of **grommet** selected is another important issue in endoscopic myringotomies with VTs. Rigid materials such as fluoroplastic have some advantages over elastic ones (such as silicone or microgel). The reason lies in the need to push the grommet with a needle or a pick in smaller size EACs. The instruments would penetrate soft materials, thus not enabling correct insertion or getting stuck in it. In a couple of cases, the VT bounced back and we had to repeat the maneuver. Elastic materials might be preferred in wide EACs, where the grommet is applied directly by the ear forceps. The **limitations** in handling instruments differ between left-handed and righthanded surgeons. For those right handed, tube placement in the right ear canal is more demanding, owing to the higher risk of excoriation of the inferior wall of the

In left ears, the field of vision improves but there is a higher risk of skin lesions or hematoma of the anterior wall of the EAC. The opposite applies for those who are left handed; that is, excoriation of anterior canal wall in the right ear canal and

allowed the flanges of the T to enter the myringotomy directly.

while releasing and extracting the forceps.

EAC and subsequent bleeding (**Figure 6**).

inferior wall of the left ear canal (**Figure 6**).

observed in **Figure 4B**.

**114**

**Figure 3.**

*Positioning of T-tube grabbed by its wings.*

*Positioning of the grommet in stenotic EAC. (A) Notice the impression of the 2.7 mm endoscope greater in diameter w.r.t the EAC and (B) diameter of the grommet compared to that of the EAC.*

According to the literature, a major limit of endoscopic ear surgery is bleeding. When it occurs, the surgeon is sometimes forced to interrupt or convert the procedure to an otomicroscopic, bi-manual technique [12, 13, 15]. Senior surgeons are accustomed to use the left hand for suction (if right-handed) and the right hand to maneuver the instruments within the EAC, due to traditional otosurgical training. This allows maintaining the tiny operative field within the ear canal clear from blood. In our series, bleeding was never a relevant issue: in no instance did the procedure become so demanding and troublesome that there was the need to convert it to the microscope. In case of bloody field due to inadvertent tearing of the canal skin, the simple application of a sponge soaked with a vasoconstricting agent such as epinephrine 1/1000 for a few minutes allowed adequate hemostasis. Following this, rinsing the ear canal with warm water or saline also helps to clear the field. It is clear that the surgical skills of the operator and his/her experience with the use of endoscopes play an important role in minimizing surgical trauma.

Single **handedness** in endoscopy is considered by different otologists as a limitation in ear surgery, even for simple procedures such as VT placement [2, 3]. According to our experience, this is not the case as long as the skin of the ear canal is respected by taking into consideration the above advice.

Unlike other studies in the literature [3], based on our experience, no special **training** for endoscopic grommet positioning is required. Special training is definitely required for more complex procedures such as tympanoplasties,

**Figure 5.** *T-tube placed in stenotic EAC.*

#### **Figure 6.**

*Iatrogenic hematoma of the left ear anterior wall and excoriation of the right ear inferior wall for a righthanded surgeon.*

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 anatomically complex cases.
