**7. The holder, a two-handed technique**

Otosurgeons are often skeptic and hesitant for endoscopic ear surgery for several reasons. First, single handedness in endoscopy is a limitation, especially in bleeding fields. When it occurs, bleeding is often a disturbing event, and frequent suction is needed so that the surgeon may be prone to interrupt the procedure and convert it to a traditional bimanual microscope technique [24, 45]. Second, otosurgeons are experienced with double-handed stereoscopic vision. Their teachings and therefore their maneuvers are based on two hands, whereas with endoscopy, otosurgeons have to manage maneuvers with one hand and lose the characteristic of the depth of vision. Differently, surgeons who practice sinus surgery are acquainted with a one hand procedure and for them approaching middle ear surgery is much preferred to operative microscope. This is why it seems to be more acceptable to nondedicated otosurgeons than to dedicated ones.

One of the drawbacks of the technique is being single handed. In case of a bloody field, especially in hyperplastic mucosa of the middle ear, surgery can become demanding and time consuming. Trying to overcome this limit, since January 2016, we started using the STORZ endoscope mechanical holding system followed a few months later by the Unitrack pneumatic holding system.

Different from other endoscopic procedures where a dynamic field is required, that is, cholesteatoma removal [46], during myringoplasty, the endoscope seldom needs to be moved to adjust the field of vision, so that the application of an endoscope holder is particularly favorable. The immediate advantage noticed is the rapidity of the procedure in elevating the tympanomeatal flap and fibrous annulus without frequently stopping to aspirate blood. Washing and suctioning simultaneously always guarantees optimal vision and cleaning of the endoscope. Another advantage is evident during introduction of the flap in case of liquid in the middle ear: suction by the second hand is promptly made. Positioning the graft underneath the anterior annulus with two hands is much easier by avoiding its wrinkling, and application of gelatin sponges under the graft itself is much easier. Finally, in onehanded surgery, the scope often has blurred vision due to blood clot or liquid left by hair in the EAC during the frequent introduction and extraction of the scope. The most important advantages of the use of a holding system are control of bleeding and shorter duration of surgery.

The endoscopic procedure consists of: (1) application of the endoscope holder on the operating table in front of the surgeon (**Figure 24**), (2) positioning of the endoscope at the mid level of the posterior part of the external auditory canal, (3) refreshing the margins of the perforation using a sickle knife and grasping forceps, (4) elevating a medial tympanomeatal flap with a semilunar incision at 12 and 6 o'clock, (5) inserting the graft under the malleus and the anterior margin of the perforation, and (6) applying gelatin sponges in the middle ear and, after repositioning the flap, in the ear canal. **Figure 25** shows the different steps of the endoscopic surgery and how it is handled bimanually, offering a clear advantage over a singlehanded procedure.

The endoscopes used are 3 and 4 mm in diameter rigid 0° (Hopkins KARL STORZ GmbH & Co. Tuttlingen Germany), lengths 14 and 18 cm, respectively. The optic holder used is a mechanical articulating holding system (28,272 HC; 28,272 UGK; 28,172 HR: KARL STORZ GmbH & Co. Tuttlingen Germany) (**Figure 26**) or the Unitrack pneumatic holding system (Unitrac arm, RT040R, Aesculap AG, Tuttlingen Germany (**Figure 27**). All procedures are performed under general anesthesia.

The surgical maneuvers are managed better using a 3 mm vs. a 4 mm endoscope; according to our experience, we would recommend the 3 mm thanks to the greater space offered. The reason for using an 18 and 14 cm endoscope and not 6 or 11 cm

## **Figure 24.**

*Position of holder in front of the surgeon and screen applying the same concept of standard microscope surgery using both hands.*

#### **Figure 25.**

*(A–H) Steps of double-handed myringoplasty in an inferior perforation of the tympanic membrane.*

**129**

**8. Learning curve aspects**

*Endoscopic Ear Surgery in Children*

**Figure 27.**

**Figure 28.**

*Pneumatic holding system.*

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

long is the possibility to maneuver both hands around the scope without encountering any obstacle by the camera and handle of the holder (**Figure 28**). The surgical instruments used for the microscope technique fit well with this technique.

*Observe the working distance and instrument length by using 14 and 18 cm long endoscopes.*

There are some minor limitations of the technique: the endoscope is fixed in the canal, allowing a limited range of zooming and focusing. At the beginning of the procedure, the best view is to completely observe the ear canal, and then gradually magnify the middle ear throughout the surgery. Another limitation is that during the introduction of the graft in the EAC in some cases, the scope should be slightly pushed outward by the surgeon, which allows to see the graft lying completely on the posterior wall and therefore gliding it all the way through to the middle ear. It would be of a great help to have a camera with a foot pedal remote control in order to dynamically change the magnification and focus during the procedure and a motorized holder with fine movements to better manage the visual field.

Learning curve varies upon both the complexity of otological procedure and prior experience of the otosurgeon with endoscopic sinus surgery. Furthermore, the

profile of the learning curve is expressed through two factors.

**Figure 26.** *Mechanical holding system.*

**Figure 27.** *Pneumatic holding system.*

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

*Position of holder in front of the surgeon and screen applying the same concept of standard microscope surgery* 

*(A–H) Steps of double-handed myringoplasty in an inferior perforation of the tympanic membrane.*

**128**

**Figure 26.**

*Mechanical holding system.*

**Figure 25.**

**Figure 24.**

*using both hands.*

### **Figure 28.**

*Observe the working distance and instrument length by using 14 and 18 cm long endoscopes.*

long is the possibility to maneuver both hands around the scope without encountering any obstacle by the camera and handle of the holder (**Figure 28**). The surgical instruments used for the microscope technique fit well with this technique.

There are some minor limitations of the technique: the endoscope is fixed in the canal, allowing a limited range of zooming and focusing. At the beginning of the procedure, the best view is to completely observe the ear canal, and then gradually magnify the middle ear throughout the surgery. Another limitation is that during the introduction of the graft in the EAC in some cases, the scope should be slightly pushed outward by the surgeon, which allows to see the graft lying completely on the posterior wall and therefore gliding it all the way through to the middle ear. It would be of a great help to have a camera with a foot pedal remote control in order to dynamically change the magnification and focus during the procedure and a motorized holder with fine movements to better manage the visual field.
