On August 26th, 2021 KARL STORZ hosted a live Otology webinar with guest speakers from the US, Italy, and Switzerland. Watch the webinar recording to get insights on the following topics:
Vitom 3d exoscopic approach in ear surgery
Pediatric endoscopic ear surgery
Endoscopic ear surgery: challenging cases
Future of exoscopic & endoscopic ear surgery
Good morning ladies and gentlemen welcome you to the first international call Stores Auth ology webinar about how new visualization technology can improve clinical outcomes. My name is Marco chara Sacco. I'm from Bern Switzerland. I welcome today three tremendous and very special guests. First is Professor Daniel Marconi. He will speak about vitamin three D. Exodus coptic approach in ear and lateral skull base surgery is from Verona. He was uh recently also uh in Modena. The second speaker will be uh Stephen Hough is professor in Chicago and he will present uh something about pediatric endoscopic ear surgery. And last but not least is Brandon Jackson, Professor in Dallas texas. And he will speak about challenging cases in endoscopic ear surgery. And after the three presentation we will have a discussion uh you have the possibility to ask a question about future of exotic opic and endoscopic ear surgery. First of all uh there will be polling question and then ask now anna to show them please. The first polling question please will be how would you evaluate your current knowledge on today's uh topic. And the possibility are for answers. First is I'm not familiar with it at all. Second I have fairly limited knowledge. 3rd, I'm not legible about the theory and fourth I'm not legible about it and offered to or perform it in my hospital clinic already. The second polling question is about what are your expectation of this webinar. First, general overview of the topic. 2nd, deep understanding of today's topic. Third received tips and tricks and fourth possibility to raise question before we start now with the presentation of Professor Daniel Marconi is a disclaimer and I will read it. The content in this presentation is provided for general educational purposes only this presentation does not constitute a representation that any products, techniques or procedures described would be necessarily be appropriate or recommended for any particular patient. The decision to utilize or implement any of the medical opinions, techniques and or procedures presented in this program is up to the sole discretion and clinical judgment of each healthcare professional. A health care professional must always refer to productive labels and instruction for us, including the instruction for cleaning and sterilization if applicable before using any product. And is now the time to start with the first presentation from a famous Professor Daniel Marconi, one of the founder of the I. W. G. E. S. And he will speak about exhaust topic approach in ear and lateral skull base surgery please Daniel Good morning, thank you very much for the invitation. It's a pleasure to speak about this topic. I can start to to share the screen um just now let me know if you are able to see my presentation. Okay are you able to see my presentation now? Okay so eggs aske opic surgery of lateral skull base. We know very well that lateral skull base is a challenging surgery just because uh the complexity of the anatomy of the latter rascal base and of course the E. N. T. Performed several approaches in lateral especially based on the microscopic approaches like super total approach transatlantic approach. Trance popular approach and middle training force. Here we are. This is a microscopic basic surgery is a trans arctic approach for a tumor of the end of lymphatic sac. And we know very well this kind of surgery. And when you're using the microscope you can have a good view on the surgical field but the assistant, it is not possible for the assistant to have the same view of the first surgeon. And other important aspect is that the surgeon have to move his body in order to get the view of the surgical field. And these are some limitation of the microscopic approaches. Nowadays we are using more and more also the endoscopic procedure to reach the lateral skull based lesion like the fungus of the internal auditory canal. And I know that other Brandon probably he will speak about this kind of approaches and this our paper regarding the endoscope truss canal corridor of the lateral. We can distinguish in three kinds of approaches. The trance Cannell transform approach is an approach using the external of victoriana in order to reach some lesions in lateral skull base. Exactly located in the funds of the the advantages of the scope is the atomic city. The of the of the tool we can use the endoscope we can go directly to the fullness of the territory canal, avoiding the management of the middle cranial fossa force. And we can move our instrument along the tumor and not along the brain or along the dura of the middle force. And these advantages of the endoscopic approach is also to be able to see around the third around the corner. So looking around the corner is one of the most important advantages of the endoscope. But there are some disadvantages like that you have are able just to use one hand. And so it's a really difficult technique and sometimes it's not so easy to manage the bleeding. And these are some disadvantages of the technique. Nowadays we describe the advantages of the endoscope in combined with the microscope in order to manage the laterals camby's lesion. But nowadays we have another tool, the three D. Eggs. A scope, three D. Eggs. A scope is a tool in combining between the endoscopic approach and the microscopic approach. And in our experience in our department we are using more and more three D eggs. A scope in order to perform surgery of the lateral base. The offers a high resolution three dimensional image with a possible modification of the zoom and the position of the camera during the surgery is a good alternative to the microscope during a microscopic approaches to the lateral skull base. But it's really important to consider the three D. X. A scope technique in between the microscopic surgery and the endoscopic surgery. It's important to underline the setting of the three D. Eggs. Aske opic surgery. You can see here we are in our O. R. The surgeon is sitting in front of the here of the patient. We are performing the lateral skull base surgery and the three D. Is in between the surgeon and the tower of the of the high definition monitor. Instead the second surgeon can hold the pilot. The pilot is a really important instruments because with the pilot you can move the three D. Eggs a scope and you can decide the focus. You can decide the picture of the image during surgery. So the second surgery become the director of the movie and the first surgeon can use just the hands in order to perform the surgeon you can see here. So the endoscope three D. Eggs aske opic surgery. Hello to perform a surgery like a microscopic surgery because the surgeon can use a like during microscopic approaches but also it's really important to see the monitor during the surgery, like the endoscopic approach. So this is the three D. Eggs aske opic technique requiring the combination of the endoscopic and microscopic backgrounds, creating the concept of the eggs aske opic surgery. Some simplification in our experience we we we saw some advantages in some limitation in 3D eggs a scope approach. We can consider this technique more ergonomic with respect the microscope because the position of the surgeon is always the same Just in order to improve the view, you should move just the camera. Instead, the surgeon can perform surgery in a comfortable way sitting without moving his arm or change his position. In order to understand the advantages of the 3D eggs a scope. We can understand that we can have a large depth of field and it's really important. Also we can shift from microscopic to from eggs assk opic to microscopic view. It's really easy rapidly and we can do without moving the scope. And again the surgeon and the system can have the same three dimensional view. And this is really important, especially if we want to perform training in in our resident or in our fellow. So it's really useful tool also for training and teaching proposal. Some disadvantages of limitation is that during high intensity like can cause a modernization of the color of the anatomical structures especially during the bleeding surgical field. And sometimes we can have a low lighting in a narrow surgical corridor. So it's really important to consider this technique during the open approach is not when we are performing an approach in a hole and also some difficult visualization of the Eden area. Like the microscope, it's just a little better with respect the microscopic view because you can move the eggs a scope and you can change your view better with respect the microscopic approach but of course it's not possible to compare the endoscopic approach when we are looking around the corner. This is the components, these are the components of the three D. Eggs a scope. You can see here the camera and the monitor and the tower and the three D. Glasses and the pilot again the pilot is really important because with this tool you can decide the picture of your movie. So you can decide the zoom, you can decide the position of the eggs, a scope and you can decide also the the condition of the light. And so it's really important in our experience that the pilot is an instrument for the second surgeon. Not for the first surgeon. The first surgeon must thinking just to perform a surgery without touch the extra scope and the second surgeon can hold the pilot and he can he can become the director of the movie, the director of the surgery. So when you are performing surgery and you are the first surgeon, it's really easy to perform surgery because you don't think about the position of the camera etcetera just to perform the dissection. Look in this case there's a typical show a normal with intracranial and extra cranial extension and in this case the eggs aske opic procedure. It's a really nice procedure in order to adopt during the surgery. You can see here the surgical field and the eggs a scope is in between the surgical field and the monitor. The surgeon can see the monitor in three D. And we can perform the surgery. And also the second surgeon can see the same view. Again the definition of the camera, it's brilliant. Now during this webinar is quite difficult to show the reel, three D. Picture and the image that we can get with this system. Anyway it's really impressive surgical field during the surgery Again we tested this exists coptic approach for different kind of approaches to that rascal base. This is for example is a patient with a tumor of the temporal bone requiring the temporal bone resection the infra temporal force A. Type A. And during the infra temporal fossa. Type A. We we noted the great advantages of the three D. Exhaust scope during surgery because you can use the three D. Eggs a scope during the neck time. So you can dissect the neck through the exact scope and after you can do the must reject to me and you can do the soup total Petros ectomy always with the same tool with the extra scope. So it's a really important tool for the next for the temporal bone and in this way you needn't to change your instrument to put for example a microscope in some time or to put for example uh three D. Glasses for another time. You can see here the dissection of the neck. It's really impressive how to have this kind of naturalistic anatomy. It's more easy to understand the structures in the neck. It's more easy to teach the resident and the fellow regarding the anatomy of the neck. And it's more easy to distinguish the different color between the vein. With respect the artery with respect the nurse. So everything becomes more easy during the three D. View with respect with the microscopic approaches. And you can see here the microscopic step. After we did the deck to me and this is the facial nerve. And after we can start with the temporal bone dissection we did a study with the under three D. Stereoscopic view and we observed the difficulty during the three D. Exhaust coptic surgery during the soft tissue dissection during a Bonnie dissection and during the tomb of the section. And we compared the results with the microscopic technique. And it was really interesting to see that as the timing of the of the surgery. Was the same between the microscopic approach and the endoscopic approach and but the respect to the microscope the resident of course they enjoy in a questioner so much the three D. Exhaust cope because everything was more clear regarding the anatomy of the patient. You can see this is the routing of the facial nerve. Everything was was done and three d. exhaust culture and the until re routing also during the until you re routing you are able to see the interior routing of the and the dissection of the with the preservation of the lower cranial nerve. Again this is the result. After after the surgery. We also used the three D. Eggs. Aske opic surgery. During the coolest atom of the temporal bone. This is a bottom of the temporal bone in a patient with official policy. And this is the M. R. I. Where it's possible to see the extension of the lesion. And also in this case using the eggs a scope. It will be a completely substitution of the microscope. In this case I didn't feel anything different with regard to the microscopic approach and the different that you are able to see in three D. And you have to see the mall toe. But look this picture it's quite similar to the microscopic approach. So and this kind of uh can become a society people of the microscope And I think just evolving the technology to have a camera smaller and to improve the light inside uh some surgical field. You can see again again this is the results after eggs aske opic approach. And we did also middle cranial fossa. Using just three D. Eggs aske opic surgery. And this is the patient with the condo sarcoma of the middle cranial fossa. And we were able to perform everything under three D. Eggs aske opic approach. And we needed to use the microscope. And we we observed the same condition with respect the microscopic approach again and this is our surgery our paper regarding three D. Eggs asse coptic surgery of lateral skull base. And our objective was the aim of the study is to assess whether the three D. Eggs asse coptic surgery technique could be useful in latin rascal bays. And if this technique could replace the microscopic approach in the future we did arrest retrospective cases serious and we can see two different groups the three D. Extras copy group versus the microscopy group 12. A procedure of lateral base with the same procedure. We did the one infra temporal approach type A. With the exact scope and one with the microscope. One large trans canal transform motor approach, one with the extra scope and one with the microscope. One an approach with the eggs a scope with the microscope. Sub total petreaus. You to neck dissection and parachuted ectomy with the eggs. A scope with a microscope. Extended medical foster with eggs a scope and with the microscope to total pay trajectory, regular Byzantine approaches and transcultural approach with the eggs A scope. And with the microscope. And we observed some really interesting results. Was really important to understand the feasibility of all the surgical step using the three D. Exhaust copan. And this feasibility was evaluated considering the super division in soft tissue work Bonnie world and pathology dissection and the compassion with the microscope talking accounted deficient function. The queuing function. The inter operative and postoperative complication and the operative time. And these are some results and you can understand that during the soft tissue. Everything was done under eggs Aske opic approach like during microscopic approach. During a Bonnie work. Everything was done during the eggs Aske opic approach like in the microscopic approach. But when we did the pathology that section just in two cases we used the microscope with which our behavior from the eggs a scope to the microscope. This was just because we were at the beginning and so our expertise was not so large and we felt that was not so comfortable. But of course more and more. Nowadays we are using the three D. And it's really difficult to change the three D. With microscope regarding the compassion of the microscope and the end of eggs. A scope of the outcome of the facial nerve. We didn't observe any any difference between the two groups and the complication. We didn't observe any complication and just one minor post operative complication emerged in each group the garden the hearing outcome was the same in the two groups. And it's really nice to see the operative time. The average of operative time with the same Approaches was with the three d. microscope less with respect with respect the microscopic book But statistically no significant difference between the two groups. Again, in conclusion, I think that the three D. Eggs Aske opic technique is really promising for the future. Especially for lateral skull base surgery for open surgical field. Probably the technology will evolve and also the eggs a scope will become more and more smaller and it will be possible to perform more and more surgery. There are no significant difference between the microscopic approach and the exits coptic approach. And probably in the future the eggs a scope can substitute the microscope and high definition of the anatomical structure are really important. And I think that the most important aspect of the eggs aske opic approach is the study of the anatomy of the patient. And for this reason is also relevant education aspect in terms of surgical training for fellow and resident who can follow the surgery in the same way as the first surgeon. And I think in conclusion that this is really important advantages because if we are able to teach our resident in a good way, probably we can have a better surgeon for the future. Thank you very much for your attention. Thank you very much Daniel for this very interesting presentation about this vital three D. Excess ka Pik approach in here in lateral skull base surgery. We will discuss that later on. We will move now to Stephen Hough from Chicago, the Lurie Children's hospital. And he will speak about pediatric endoscopic surgery please, Stephen, thank you. So I'm a pediatric oncologist in Chicago. Uh and I've been using the endoscopes for quite some time now and wanted to share some tips and techniques for using the endoscopes in kids and what some of the advantages and disadvantages are. So when we're looking at um endoscopes and talking about endoscopic surgery. Really similar to other types of endoscopic surgery such as sinus and laryngoscope. He really just using those natural kind of orifices and natural holes in the head to use minimally invasive approaches to the ear. And we can get similar or even better outcomes um using that natural transitional approach with the endoscopes for kids. So pediatric endoscopic ear surgery, some of the questions that I kind of want to address during this webinar are which advantages do we gain with the endoscopes? Are there limitations for pediatric patients, particularly with size of the ear canal and how the outcomes compare to traditional post auricular techniques? Of course, the main advantage of the endoscopes is the visualization. This is a patient with a sub total perforation um during which we can see using a trans canal endoscopic approach, the entire music temple. Um get a great view of all of the middle ear structures such as the obstacles, the facial nerve, the station tube, lateral semicircular canal tensor tympani. Coakley a can palpate the malice, check the mobility of the secular chain and we can use the endoscopes to kind of look around the corners and get that dynamic view of all the structure of the middle ear through the trans canal approach. This patient didn't have a perforation. So we raised the flap up and we can see again that um the obstacles are um intact here and get a really nice view of the middle ear music, Chippenham facial nerve all through transitional approach. Of course this is afforded to us because the endoscopes have that wide view as opposed to the microscope, which is relying on direct line of sight and the photons going through the speculum up into the microscope to the operative. I uh that endoscope really has a wider field of view and you can use angled endoscopes to look around corners and seen the recesses that are always there, but don't always um jump into view as well with the microscope such as the sinus tympani, um the facial recess, the speculum, the particulates um things that are great to see for every case, but also for teaching. Um some of the more complex um nooks and crannies of the year. Typically for all kids, I'm using the three millimeter endoscopes. The 14 centimeter scopes, usually the zero degree scope for most work, third degree um comes next and then for special cases and really to look around corners. The mor angle, the 45 70 scopes, you do want to get the 14 centimeter long scopes. Um the ones in clinic that you can use um are the visualization is great but the it's much shorter and so your hands are kind of gonna bump into each other. So the long scope, your hands are at different levels and you can really um use both hands at once uh during endoscopic surgery. So one of the big questions is how young can we go with the endoscopes And I'm not sure there's really limit. This is an 18 month old using a three millimeter endoscopes. Um for congenital case raising the flap after injection here and you can see the ear canal is narrow. This is a young kid. But you know, we can get the endoscope in, we can get the instrument in a routinely use these endoscopes for kids under five. Uh and of course older kids. But um the three millimeter endoscopes are almost always usable. There are smaller endoscopes which work great too. Um but generally the rule is use the largest one you can for better light, better visualization um and save those smaller scopes for the really cinematic years. So for pediatric transitional endoscopic ear surgery, Ortiz really the main advantages here are that wide dynamic visualization that I was just showing you that heads up operative posture similar to the X. A. Scope. You're looking at a screen. You're not kind of in a fixed position with your neck. So that may be helpful for the surgeon itself. It is a minimally invasive approach. So there's no pro circular incision. This can lead to increased um or better pain measures and better quality of life measures as shown in some studies, I'll present later. Uh and with practice some decreased operative times as well because you're not doing the opening and closure of the post regular decision, you're getting direct access to disease. So approaching a classy toma or remembering preparation or something familiar directly through the canal and into the middle ear as opposed to going post curricular, which really leads to high patient and in pediatrics parent satisfaction which does count. So I'm gonna go through a couple of different scenarios for using the endoscopes in pediatric patients. Um Starting with congenital and traumatic conductive hearing loss. Um This is conductive hearing loss with an intact and panic membrane either from a congenital secular malformation or fixation um or um you know absence that is joined to erosion there. Um Or from trauma in this video there is a congenital bony bar. The posterior ligament is ossified. Um This was transacted using Mallia snipper. You could also use a laser there. The Incas is congenitally absent. So we're able to transact that bony bar reconstruct with a partial prosthesis. Um Up to the timpani membrane from the state. These all through a trans canal approach. This patient has a um uh traumatic a secular disruption. So this patient put a Q. Tip in his ear or a cotton swab. And you can see there that there is a gap between the state and the Incas. So dislocation of the I. S. Joint, they're able to lift the flap up, get an entire view of the music tempo TEM um and see that gap which is causing that conductive hearing loss and then fix that directly. Um So this um just really afford us to get a really nice view of the secular chain through that transitional approach. Not the same kid, but kind of similar problem where there was a dislocation that I just joined, able to repair that with some bone cement and get the secular chain mobile again. Which kind of goes into the next topic, which is endoscopic plastic, which is not the easiest thing to do, or at least to start off doing with the endoscopes. Uh certainly uh this takes some practice, but with practice it can be just as easy as the microscope and get great results with the endoscopes as well. Here's an example of his and facial nerve. Um After excision. Looking at the second look, if you look closely, you can actually see some red blood cells going through the capillaries on that facial nerve with an absent safety superstructure. And some new classification on the foot plate which had to be cleared off. Um That can be cleared off with the endoscopes and some um instruments such as the rosen in the section, kind of built a nest with gel foam there and then placing a titanium, um totally secular restructuring prosthesis um on the foot plate to reconstruct, make sure it has good mobility. Make sure there's stability there, add some cartilage, make sure there's still that kind of bounce and then place a flat back down. Um all using the endoscopes for that second look procedure. Um I do find it helpful as I show to kind of make a nest with the gel foam there where you take the gel foam surround everything in the music and accept the um foot plate itself so that you can work there. And then that gel foam itself stabilizes the prosthesis as you're putting it in. I typically use a 20 micro section to hold the prosthesis as it goes in with one hand with the thumb on the hole that will just hold the prosthesis and you can place it and then you lift your thumb off the whole and it usually will just drop it right there. Um Sometimes it just is exactly in the right place. Sometimes you manipulate it a little bit with a pick um to just get the final touches. Their example of this. This is a torpor placing import this patient was referred to me after getting a classy toma. Excise somewhere else. Had a poor but wasn't working because the state peace is not actually attached to the foot plate. So I built that nest of gel foam placing the torp on the foot plate. They're using that micro suction letting over the section, adjusting it with the rosen pick. Getting that notch under the malays handle and then adjusting the foot plate shoe. Such that this patient had a really nice hearing result replacing that for with the torp um endoscopic lee. Another example to his facial nerve again, post doma placing a titanium foot plate shoe on the foot plate. In this case there was not a nest built per se. But I actually used the court of Tiffany to kind of stabilize the torp as we put that in with the cartilage cap. Um and then was able to kind of packing some gel foam and then lay the flat back down. So it's a complex, it is entirely possible with endoscopes but it does take some practice. Usually people want to start off with something a little more familiar such as a timpano. Classy which can be done with the endoscopes in any way. All the way from kind of the paper patch or Moringa Classy. Um fat graft to the underlay graft of any type. All the way to the lateral graft. Um Do the, is just like you would with a microscope post circular approach. Except you're going trans canal. So for an underlay graft you raise the flap up, slide in the draft and then place the flat back down. Here's an example of a cartilage. In Panama city. I really do like using the cartilage kind of using the shield of the island graft um to get increased stability. So, rim the perforation. Usually take a large piece of tracheal cartilage and stamp it with a seven or eight speculum and then carve the cartilage to whatever size needed. This is kind of a sub total perforation. So I use a full shield graft with a notch for the Marius. And then I leave that Farrakhan dream on to provide a tale that goes up to your canal. The graph can be placed into the um ear under the perforation, not under the malice, be tucked under the entire analyst. Uh and then um kind of secured into place and then that paragon real tail comes up the ear canal. Um and then the flat can be laid back down for this heart shaped perforation. Um and he had a total closure and restoration of his hearing. Just some still images of that technique where I took a trickle cartilage graft, I typically take a pericardium off one of the sides of that, stamp it and then carve it as needed. You can get a full shield, you can get two halves, one half, one quarter, three quarters kind of design boomerang graph. Just design it as needed. Usually leaving that paragon real tail. Uh If needed. Another technique for doing timpano plastic especially with the cartilage is the butterfly graft. So taking a triangle um piece of cartilage and locking it into place in the preparation such as an ear tube. Um to get complete closure of that perforation. This is a pretty quick and easy technique for kids, we always have kids asleep. There are results of older patients and adults doing this awake in the office. Um I like to use the dermal punch when I'm doing the butterfly graft. So size of preparation, punch out a piece of cartilage that's 2-4 mm larger. Um put a rim around the circumference of the craft and then locking into place much like a neural tube. Here's a video example of that. So sizing the perforation, this anterior superior preparation after an ear tube extrusion. Taking the graft, putting it into the perforation. Getting to lock in place. I like to use a little marking pen where I think it's gonna be anterior and you can actually see and kind of feel the graph just snap in much like a youtube would kind of snap into the ear drum. Now why do we do these things trance canal? Not only is there no visible incision, but there is some evidence that there is less postoperative pain. We know that post regular decision is not particularly painful but using a transactional approach has been shown in adults, which is this study that the trans canal and ask opic approach did have less pain than the microscope. And then two studies and Children this went out of harvard that in the initial period the endoscopes did have less pain microscope. So this evened out um over the first few days and then out of toronto that the endoscopes again had less pain than the microscope. So um you know with some practice the endoscopes get um uh equivalent results to the microscope with that less pain and low no visible incision. There shifting gears a bit to the congenital, which I think is the probably one of the most fun or at least best uses of the endoscope. Um These of course ranged anywhere from that nice pearl and the superior quadrant to a larger Purl. Two things that take up the entire music tempo TEM all of which can be approached. Endoscopic li an example here of and stage one in general with a nice pearl. The flap has been pulled down to reveal the pearl and then that suctioned out show that again where the pearl just is just released from the malice there and then using a suction after using a micro pick to just completely remove that. This is a probably a badly drawn picture, a representation of the flap incision starting at three o'clock and generally wrapping that down all the way down to six o'clock um to create that flap which is then raised and then can be reflected down and then the malaise kind of de gloved all the way down to the elbow um ideally leaving the flap attached but it can be detached for a larger class action if need be. But then the middle ear can be addressed and then the flap just replaced right back into place a similar example. But this patient actually had two pearls. That's the only time I've seen that where the flap is raised and still attached to elbow completely talked anterior inferior early. Um The pearls can be kind of mobilized there with the suction and this is a right angle pick getting in to mobilize that in general pearl. And then completely exciting that with the second pearl coming out as well. And the flat can be laid back down middle ear totally assessed. Um checking the mobility mobility of the secular chain, making sure there's no little tale from the to the reform process or elsewhere. And then replacing the flat. This also works for larger, larger congenital uh This is a congenital entirely. Feeling the you can see why these can sometimes be mistaken for otitis media. It's exactly what it looks like and that's why it can grow so large. Um In this case we also raise the flap down. This was taken out kind of in separate chunks but entirely um removed. And only involved the message in Panama and kind of a little bit of the attic but not into the mass voter Antrim uh inter positional pork was placed and you can see in clinic there's a clinic bottom right is uh clinic still shot and I'm going to show a clinic video to where you can get a good view of that intact membrane. You can see the prosthesis through the membrane and there's no recurrence. And he had a great hearing results as well. So the stage three with a secular reconstruction. Currently doing a multi center study international study in which we looked at 60 pediatric patients with congenital toma taken out entirely with the endoscopes and had some pretty good results. So in stage one and two. So the ones that are usually encapsulated pearls and not really involved in the particular chain. There were no case of residual disease and great hearing result. The stage three of the ones that involved the secular chain in which more much more extensive like the one I just showed did have some instances of residual disease but much less than previously reported. Typically these were closer to 40% um with the microscopes down to 20% um with some um with the endoscopes as well. So this is using the transcanada approach. Then we get into acquired which in kids can be really challenging. You know you not just getting that nice pearl from Congenital toma. You get some of these ears that just look like an absolute mess. Kind of like a bomb went off very granulated lot of carrot and kind of built in. These are probably the most challenging cases with the endoscopes. But I always start with the endoscopes because you're gonna be getting directly down to disease through the canal. You can address the entire museum temple um with the endoscopes and up into the attic and you station tube and Antrim and then later um decide whether you need to do a mastectomy which sometimes you do sometimes you don't but at least you've kind of get a really nice view of that middle ear with the endoscopes. Again the congenital tend to be a little more fun, so to speak with that well encapsulated pearl. Whereas the general the acquired thomas have the inflammation degranulation depleting poorly delineated margins the classy toma as you're working. But this can be cleaned up. This is entirely possible to do with the endoscopes um And leaving structures attacks such as the court of tympani and nostrils as um as possible. Um And again uh accessing the disease where it starts I think is important. This is a patient with a bad uh posterior superior retraction pocket. With obvious classy toma obviously needs surgery. Had a cat scan that showed a pacification of the mastery but you don't really know what's in there. You don't know if it's classy toma a fusion. Um And you can certainly argue for a post auricular approach but what I do is I approach a trans canal. This is the same patient. Get a good view of that retraction pocket. You can clearly see Karen going up and affecting the secular chain sitting on the facial nerve. This is during the resection Incas was already eroded. This is peeling between the facial nerve and the stay peas and just slowly picking that out and then just gonna just kind of grab it and pull it out and it turns out that all that disease in the Master Lloyd was really just a fusion that was trapped from the classic toma obstructing the to panic isthmus there. So did an economy completely excised disease was able to access to that that disease right where it started, which is the panic membrane and then close it up without a mastectomy. What really helps for this is some of those curved instruments on the endoscopic ear tray um that includes the thomas into sectors and the thing in the angled curates that really have a nice angle to get around those corners. I still use the standard microscopic um ear picks like the rosen and alligators in combination with these more uh specific endoscopic ear instruments. Here's another example of that. Um it looks like there's a staples but there's actually no crew. So it looks like a trick there where you just kind of pass the rosen. You can clearly see disease in the interim affecting the secular chain still shot there of the same thing. You can use these angled instruments to really deliver this disease which is going way up past the lateral semicircular canal. You can see there deliver it from the Antrim interview uses suction to remove that and then look up into the Antrim and even the Master Lloyd and there's no further disease up there in the master void. So that was the extent which was accessible with the endoscopes. So when we look at acquired. Classy toma really we're talking about what's essentially functional endoscopic ear surgery. So the main aims of classic toma surgery to remove it, create a safe dry ear and restore hearing. But you could also add opening those natural ventilation pathways between the middle ear and master. You station to middle ear um asteroid and then preserving that mucosa of the masquerade to help with that gas exchange. How can the endoscopes help? Well in removing classy toma, there is better visualization and lower rates of recidivism as well established in the literature that using the endoscopes, even if you've used the microscopes to entirely resect, you should always use the endoscopes to kind of look around corners. Make sure there's nothing left there when comparing directly endoscopic excision for the entire surgery or the majority of the surgery versus microscopic. The results are pretty equivalent. Which is to say the endoscopes do as well as a job as the microscopes. Not particularly better. Certainly not worse. But you do gain those kind of minimally invasive advantages of postoperative pain and decisions. Uh and then further down you can um do better at opening the natural ventilation pathways which uh allow that middle ear to ventilate and preserve example of this would be the tensor fold going between the the cog and the cochlear form process which can be visualized easily with the endoscopes and then list in order to hopefully prevent secondary um retraction and recidivism during surgery and looking down the station tube there. So just to reiterate advantages for kids for trans canal endoscopic surgery, you get that wide dynamic visualization, it's more comfortable for the surgeon, It's minimally invasive for these kids which the patients and the parents really um really like and as a surgeon can be really satisfying. I'm gonna leave it there. Thanks very much for tuning in and I'm gonna turn it back to the discussion. Thank you very much. Stephen for this expensive presentation of the pediatric endoscopic ear surgery. Thank you very much. We will discuss in after the last talk and this will be now Brendan is Jackson is also chair of otolaryngology resident selection committee at in texas at Ut Southwestern Comprehensive School based Surgery Program. And let you know please uh Brandon to speak about challenging cases in endoscopic ear surgery please. Brandon. Thank you. Mark. It was great seeing you guys see here. So um it's hard to uh follow both Dr Hart and Dr Hough and Dr Marconi but I'll do my best. I just wanted to kind of illustrate uh several situations where I felt the endoscope was quite helpful for dealing with temporal bone pathology. And so these are just some illustrative cases and there's a few tips and uh here that that hopefully will be helpful in your practice part of my voice. Um These are my disclosures. Um So what I'm gonna go through are just a few things like indications and contraindications tips and then some illustrative cases. Um This is just a brief kind of list of things that can be addressed with endoscopic ear surgery. Um And I got all these have been alluded to in the previous talks. Things that I usually really don't use an endoscope for. And this is relative contraindications. There are some people who address mastoi pathology with an endoscope. I I've just I'm still a little bit more old school on that and still usually use the microscope for those types of pathologies. And certainly an exa scope also works quite well for the situations but I don't have as much experience for that vascular lesions. Also relative contraindications. If I have a glow mist and panic. Um or a small area I've been able to remove some of those or many of those with a trans canal, minimally invasive approach. And same thing with C. P. A. Lesion. So if if there's you know significant extension in the cerebellum pons, an angle like this tumor. That's probably not one it's definitely not one that I would try to tackle with a trans canal approach. But that being said um a few other things so tips, you know if you're just starting your endoscopic your practice, you want to start with something relatively simple. Um So you know a good case would be like a post your perforation or even just a pressure equalization tube. Um Or you know if you're gonna do a butterfly graft. Those are both. All all all three of those cases are very straightforward to start uh using the endoscope for your surgery. I think it's very important that you discuss with the patient, um both the need both. If there's a there's a possibility, there's always a possibility that you would need to convert to an open approach. I think it's very important to discuss that with the patient prior to surgery. I mean at least in my practice I have many patients now who seek me out because I I do a lot of endoscopic surgery and I'm always up front with them and telling them that, you know, we can a lot of times we while we can do things with a minimally invasive approach, it's not always possible and sometimes we have to open and so it's important to set expectations. I think for certain pathologies, imaging is critical, certainly for for tumors, um for cholesterol toma other than very limited cholesterol toma disease, like a congenital cholesterol toma. That's limited uh that you can see entirely on the skin, on the exam. I think preoperative cT imaging is critical. I was always a proponent of getting imaging prior to chronic ear surgery, priorities in the endoscope. But now I find it's quite helpful to help me make a determination on whether I'm going to have to convert or use a combined approach. Post regular mastoi approach plus the endoscope for the middle ear or just a purely endoscopic middle ear approach have the microscope available. Make sure you have the correct instruments that you need. Honestly, most of the instruments I used for the first few years using this technique where the same instruments that I had um prior to me and using the endoscope, I think some helpful additions were uh suction instruments like suction round knives. There are several of those available that are quite helpful. Um There's also some The sectors that Thomas and the sectors I find quite helpful. There are some kind of pre curved sections that are available. I have not usually use those just because I felt like it would be a little bit onerous for our scrub text to have to sort through which suction which bend I would want. And so if I need a pen suction I typically use a disposable 18 suction and bend that to how I need it for the key. Uh And then um hey more stasis and that's always a challenge. It's probably one of the initial significant barriers of using the endoscope other than just getting used to the the two dimensional view. But having a plan for dealing with bleeding is always important on these cases. And again, some of this has already been alluded to in the talks by dr hart from marconi. So starting with a kind of middle ear pathology, I'm going to go through a few of these things here um and then I'll kind of delve into more uh more medial temporal bone pathology at the end of the talk. So this is a good example. And again I think dr Hough also showed a uh an illustration of this type of case. This patient had um had a bilateral conductive hearing loss which closed kind of at the mid frequencies. And on preoperative imaging which I didn't show. It looked like they had Malley's fixation to the tag mint. And so this is just I'm gonna kind of rifle through this a little bit just to make sure we catch things. But I think actually before I even elevate the flap for any just pure conductive hearing loss of the normal timpani membrane, I will palpate them alleys to see if that's fixed. Because sometimes if say you have a congenital foot plate fixation or a state or a notice sclerosis case, you can have concurrent Marius fixation and you can mobilize that in the process of of elevating your temperamental flap and address maybe staples pathology but not realize that the malaise is fixed and it can re fix. So I always palpate the Marius before I um elevated temperamental flaps. So this is just showing this again, is a case of madness fixation. I'm just providing wider exposure of the scrotum here to address the point of fixation. And again, this is just using a little drill, this is a two millimeter drill. One of the problems with endoscopic surgery is that you cannot irrigate with the drill easily. So what I will do is I'll fill the middle ear space with a little bit of saline and then I'll drill with that again. Um if you just have the bone a little bit wet, it actually significantly facilitates bone removal with the drill. If it's your drilling dry the bone dust gets caught between the diamonds and it's just not as effective. So you can thin this out and then use the Keret. Um I think dr a number of our doctor uh Takahata out of Japan, they are experts at using chisels and mallets. I have not been brave enough to try that. Um, and you need an assistant to do that. And so I have just used traditional drilling techniques. So this is just showing that point of fixation. So here's pincus Marius. This is that point of fixation to kind of the anterior pitting panic wall. So now, just using a diode laser, we're just vaporizing this bone and we're gonna kind of carefully picked through that drilling on the canal, not the obstacles itself, and we're going to separate that bony bridge. Um 11 thing you can also do to help reduce the risk of having a high frequency loss is separate the I. S joint if you feel that you need to and something like this, I certainly would be a probably a good idea, but the key thing is you need to create a space between that anti epidemic panic wall in the malice. If you don't create a decent 1 to 2 millimeters space, you can get re fixation. So this is just illustrating that. Um I, you know, again, it's a pretty decent sized skin defect. But we were able to accomplish our goal just using a trans canal approach. I'm just removing a little bit more bone here and again, just for time's sake, I'm gonna move this along a little bit more bone removal here, we're gonna put our flat back up. I did not reconstruct the skin in this patient doesn't have you stationed to dysfunction. So I was not worried about them. Uh retracting essentially. So this is their postoperative appearance. You can see the large scale um defect, no retraction. You can see a little bit of laser marks kind of on the drum and then their post op of hearing result was quite good in that right here. I operate on the left here a few months later and had an equally good result. Next case, this was a real challenging case. It was a patient with, hold on, turn my voice off with bilateral significant conductive hearing loss and they had significant tempo. No score. Just like I'm gonna skip through the flap elevation here, just because you guys have seen that a fair amount. Here's your quarter tympani nerve. Uh This is me, de gloving. The malley is here to provide further exposure. Um and again, you can even see a little bit of temporal sclerosis here, I've stretched the court a little bit that Marius and Incas are all, all the obstacles are completely fixed here. So I'm gonna further open. Uh this skewed. Um and again, you'll see here nothing moves. It's I could have stood on top of these obstacles and they were not going to budge. So I ended up removing the Incas and then I um took the Incas out. Then there was also this kind of toothpaste, like timpano involving the step, tedious tendon as well as the oval window niche. Um I was able to free that up, I at least that part, but there's still a significant amount of temporal sclerosis in the anterior, which we'll use the laser to try to free that up and ended up taking out the superstructure. And then we'll peel out this uh tempo sclerotic plaque. Uh you know this, there's always a possibility can mobilize the foot plate here. So, probably a good id idea would be to have a piece of fashion or para condom ready to cover the window. If you were to enter the inner ear in an untimely fashion. This is a little bit of tempo sclerosis on top of the same panic facial nerve. And again, we're gonna peel this out of the oval window. This is not foot plate. This is actually a timpano sclerosis. So we'll peel that out and then uh I've made a hole and I'm gonna make a hole in the foot plate here, That's the pair of condiments ready. We're gonna remove this foot plate and then we're going to put. So that's the foot plate. So moving the post here, probably 3/4 of the foot plate that's gonna come out and then we'll seal that off with uh that that that graft. And this is a um Aaliyah vestibular pixie process that has a joint in it. I think it's key that before you try to mobilize the mounties, if it's stuck like this one, it was a little bit. Now it's a little more mobile, it's important to put this on before you completely free up the mounties. The mounties is moving all over the place. Getting this implant on is quite challenging. So you'll see here that now that I have it on, I'm gonna cut the head off so it doesn't really fix. And then I'm going to push this prosthesis into the kind of the best where my para Condra graft is covering that area. And again, just for time's sake, I'm gonna move along here and then you have to cover this part of the implant between the drum and the uh and the mouth, so it doesn't get extruded through the drum. Uh and then I'm just putting some more cartilage grafts in here and then recovering with tim tomato flap and that's what it looked like post operatively. This is awesome cartilage looks kind of funny, but it's all cartilage and had a pretty good result with the left ear. He kind of disappeared. So I don't know if he will ever come back to the right here. This is another interesting case. Uh This is a congenital foot plate fixation case. Um And you can see here that foot plate looks a little bit thick here. Like you don't see a true kind of air to fluid interface on the CT scan. So we'll mobilize the quarter here right away to skew them. And then you can see here that you can see the oval window right here. Marius is mobile in CASS's mobile but there really is no annual annular ligament here. So that's what differentiates um auto sclerosis from congenital foot plate fixation. You have a state the superstructure, but there's no really define herbal foot plate, there's no annular ligament. So here or remove the staples, superstructure as per what you would do with the standards appendectomy case. Um And again, I'm just moving through this down fracture, the superstructure, making sure it's separated from the Incas and they will remove that. And I think ST p surgery is probably one of the final frontiers of middle ear surgery for using the endoscope. It's really, I mean it's already stay piece. I mean the steps are relatively straightforward, but this is the working with not having depth perception in the foot plate is very challenging. So this should be one of the other than tumors of the middle ear or inner ear. This is the last type of case. You should do with an endoscope. You should really kind of bone up on getting everything else perfected doing some panda plastic and cluster toma cases and state vasectomy should be the last thing you try to take on just because of the depth perception issues. So we ended up using a drill here to remove the foot plate, covering that with graft. And we'll put our little prosthesis here which is I use a bucket handle prosthesis that will go on top of the para Condra graft and then we'll go underneath the Incas again. Just moving this along here, bucket handle is gonna go over the Incas were able to save the quarter and keep that out of the way and then um putting the flat back and then here's the postoperative audio left ear looks great. This was another interesting case. This kid was involved in a a T. V. Accident and had a um you can see he's got an Incas here, you can see that there's it looks like a stay piece but it definitely looks strange and so you can see the malice right here that appears to be mobile. But when you press here you can see that there's actually crew a fracture which is I don't know how you would identify this, the microscope but here's the crew a fracture right here. The foot plate is not moving at all when I'm palpitating the state peace. And so if you were to just stick a poor pawn here, it's not gonna work. And that's why you you know, it's the endoscope I think is particularly helpful for traumatic uh particular uh reconstruction because things like this are very subtle. And again, I don't know how you would see that with a microscope. So here we can see that the foot plates mobile, but the crew are not, the superstructure is not attached. Uh Another case, this was a patient who had a long standing policy toma. Um that was completely retracted down to the promontory and this is just showing this is a right left ear. This is epidemic in um facial nerve is actually right here. And you can see this matrix is just densely adherent to the tim panic facial nerve, which is right here, This is promontory and there there was disease in the oval window on each. So even though this nervous to his and I feel quite comfortable in removing this disease off the nerve. Even with a one handed technique sometimes using a dull instrument like this crap like this Thomas in the sector will work. Other times you have to use sharp dissection and um like a little 59-10 blade or writing a hook to lice that really dense adhesion that's on the facial nerve. If you really keep pulling it, you can practice the nerve if you put too much tension on it. So again, this is just kind of pulling this disease out of the oval Indonesia, we've essentially got the facial nerve dissected. And again, just for time's sake, I'm gonna move this along again. Here's the distant nerve, there's more disease in that oval window we're trying to pick out and then mobilizing it in fairly off super aspect of the promontory. And then we'll see the foot plate here in a second. There's the beginning of the staples, foot plate that you're starting to see here. So even for difficult cases like this with foot plate work again, foot plate work is kind of the last thing you should, you know, really use the endoscope with you need to get really comfortable with using the endoscope for other techniques but something like this is gonna be. Again, it's always a challenge. But I find the endoscope is quite helpful in these situations. So again, now you can see that I've got all that matrix lifted out and the foot plate is intact right here, we've peeled it off the facial nerve and we should be good to go excuse me. Um This is another middle ear pathology. This was a glioma stem panic. Um That was uh taking up most of the inferior means attempting. Um um And so I make a super early based hypno flap. So I've got an incision from the anterior to the post ear canal wall, we're gonna elevate this temperamental flap and I designed my flaps based on the pathology. So if I have um you know, inferior inferior, like hypoxic panic pathology, I'll often do these super early based in Canada flaps. If I had like a congenital toma, I'll do more of an in Philly based flap. So this is exposing that Gloria's tumor. We've got a cottonwood here with epinephrine. We're getting the Tm lifted out of the inferior and anti R analysts. And then once we've done that, you can see the quarter, I stretch a little bit here. I'm gonna pull it away from the obstacles and then we'll use um this is uh endoscopic skull base uh rhinology bipolar called the indo pin. Uh It's pretty nice for something like this. And really you just cauterize this thing and then you have to remove it in pieces essentially. Um and once you get it out it does stop bleeding. But again, this is using that bipolar and we're slowly dissecting this thing. It almost looks like a cooked piece of, you know, bacon, essentially. And you can see this disease going up into the pro temple. And this is the bony Angeles. We're gonna cauterize that piece and then all this tumor is going to, it's still piecemeal here and then all this tumor is gonna come out essentially. I'll show you right here. So that's that anti malignant tumor that comes out. There's a little bit more kind of right at the the vascular blood supply from that um tim panic artery. And then what I do with this we can control again with cotton noise. But then I'll drill this these hyper panic aerosols away just to make sure that there's no residual bits of tumor in that space. Uh Sometimes you know what appears to be a glorious too panic. Um is actually a jugular. So it's really important to look at your preoperative ct and or M. R. I. Or both to make that determination ahead of time. Otherwise your may be biting off something a lot more than what you should with the endoscope. And so we're putting the temporal flat back down again. This is a super early based temperamental flab. Again I'm gonna go through a couple other things and then end it just so we have time. This is another pediatric case. Uh This was a congenital CSF leak. A patient who had two episodes of of bacterial meningitis. You can see they have an incomplete partition defect here with a defect between the I. C. And the cochlea. Uh This is uh entering the middle ear space. You can see that there's already CSF leaking out through uh the middle ear space. And again just times take on moving things along. Here's the promontory, this left ear, you can see the Incas and the stay peas and there's fluid that just keeps welling up and it's coming through here between the facial nerve and stay peas. So what you'll see here and again this patient has a dead deer. They have no hearing pre operatively. We're gonna separate the I. S. Joint because they have no hearing. I'm gonna take out the Incas and take out the staples. And you're gonna see where the defect is. That is a central defect in the superior aspect of the foot plate and that's where they're leaking from the vestibule. And I see into the middle ear space and that's every time I've seen this maybe four or five times. And every time it's been this type of defect in the state piece foot plate and all those patients have had profound hearing loss preoperative. So you can look into the vestibule and see CSF leaks CSF coming out. I'm just going to hear in this case. Um I I was gonna put a little cochlear implant electrode in in case they later on they wanted an implant. Later on. What I ended up doing is making a super small super circular incision and harvesting some fat and fascia and we're gonna stuff that in the vestibule to stop the CSF league. Once we do that. Well um once you pack that enough we'll close it off. Um That's where I'm gonna put a dummy electrode in case the patient wants a cochlear implant. Later on. Here's that dummy electrode. So moving on in for. Cochlear approach. This is the most common reason I use this which is not that common is a cholesterol granuloma. Um This is just demonstrating a picture of a left uh cholesterol granuloma. You can see the Jacobson's nerve right over here. You can use it to buy into the petrus apex or if there's extending in the petrus apex, if you have much larger reasons like that where you have an intact inner ear function and intact hearing, then sometimes this in Fukuoka approach is not gonna be adequate to deal with your pathology. You're certainly if you have a high jugular bulb that's also going to block your view and block your surgical access. Um Again, this is an inferior middle ear pathology. So we're gonna use a superior based temple. No flap will do a canal Plasticky identify our landmarks. Follow the carotid artery, widen our opening, Irrigate and inspect the apex and then close our flap. So this is just showing that I'm gonna again move along here. This is a patient who presented with a essentially a dead, he had a left and right uh cholesterol granuloma. They had presented with a dead here on this side and a sudden hearing loss on this side and we elected already had drained the left side. So we went ahead and scheduled this again, this is that super early. Based on the flap, I'm gonna just move this along because you've seen enough flap elevations and this one wasn't right up to the hype attempt. Um We actually had to drill and open up a fair amount of air cells. This is doing a canal plasticky just provide a little bit more room to drill immediately in the hip attempting. Um And now we're in the hypertension. Um Here's a round window niche. Carrot is gonna be right here, jugular bulb is gonna be right here and we're just working between that carotid. So my first step on this after I've elevated the middle the flap and done my canal plastic is I want to identify the vertical petrus carotid artery. That is the anti limit of the dissection. And you can see here it's right there, that white stuff is the vertical petrus carotid artery. That's the anti limit of my dissection. And I will stay right on that karate because that's uh that's uh that that advantage is quite thick and and and it's actually safer and it's gonna be the anti extent of your opening. So here we're just kind of drilling between that carotid and the jugular bulb. You can start seeing, it's starting to look a little blue here, that's the wall of the uh we're gonna poke through this and you'll see that motor oil, classic motor oil fluid start coming out here in a second. There it is, you can start seeing that stuff, it's not as impressive, you'll see it hopefully gush out here in a second. So we're gonna punch through and we're just making this opening a little wider. There it is. Alright, we got our cyst so we'll get that opened up, widen the opening and then I'll irrigate here, this is a view inside the petrus apex, you can see that yellowish cluster, classic cluster and granuloma appearance. Um and then I'm just wide in the open here. You want to make this opening as wide as can I do not use stents at all. I feel like they're more likely to kind of include so I've never used them for this approach. Last case uh is dr mark even alluded to. This is a patient who actually presented with drop attacks in a dead deer. They actually had ODed capsule Schwann oma. You can see here it's in the basil turn of the coakley as well as in the vestibule. You can see it on the corona images here and they already had a dead here. So we're gonna do a kind of a large temperamental flat and we're gonna take out the obstacles cause I already have a dead deer. Again, I'm gonna just skip through the flap elevation. So this is just cutting the malice at the at the neck. We're gonna remove the lateral chain and I've mobilized the drum with the handle. We're gonna take out the Incas take up stay peas and actually can see the foot plate come out here again. This patient already has a dead deer and you can see that there's tumor in the vestibule. So I'm gonna take up the mouse here and then this is using a little writing a hook to kind of dissect this question toma out of the, out of the vestibule. You'll see here a big chunk comes out here in a second. There it goes. So that's all tumor in the vestibule. And then we're gonna progressively open that vestibule up and get this stuff out, trying to save the quarter here and again. Here's that all that tumor coming out of the best of you. Okay, now, we're gonna open the basil turn of the cochlea to address that tumor and see that the tumor is right here in the inferior basil turn. And again, we're just peeling that out up, up to the a sending turn essentially, again, promontory, that's the last piece of tumor that was going up to the a sending basil turn. You can see the opening in the cochlear right there, we're just gonna cure it a little bit away here. Now you can look in the vestibule, you can see one of the openings of the semicircular canal right here. There's a little bit more tumor or that maybe some europe feel elements of the post here, semicircular canal amputated in. We're gonna peel that out just to make sure we have a complete tumor excision. And then this is a little bit of tumor kind of up where those the opening of the superior semicircular canal is we're gonna peel that or maybe latter canal. Actually, we're gonna open that up. And then that should be everything. We're just gonna. Then I put some gel foam over this area and then we'll just close our flat and she fortunately had no further drop attacks. She's been very happy since this surgery. No evidence of recurrence and that's all. Thank you. Thank you very much Brandon for this excellent challenging cases uh performed by endoscopic surgery. I thank all the panelists, Danielle and steven and you Branson. And we will start now with the discussion and I have received a different question. First of all I will start now on the list by Ranchi Peter. You have asked asked Danielle perhaps. So the other can answer this is what you recommend three D. X. A scope for regular cholesterol toma surgery. What do you think? Daniella? I repeated would you recommend? Yeah. The question is ready to recommend. The question is would you recommend three T. Exas cope for regular cholesterol toma surgery? Actually my regular cholesterol thomas surgery is endoscopic surgery. So it's different if you want to use the three D. Eggs a scope you need to perform a large surgical field like for example canal wall down procedure or total petros ectomy. So the right tool for regular college thomas surgery nowadays is the endoscope for the the timpani cavity and the microscope or eggs. Roscoe picked ready for the master died. Okay all the comments from Brandon and steven about this question. Yeah I I for toma If it's purely middle ear I use an endoscope uh if there's extension and there's a very kind of large epidemic in um then it's not uncommon that I have to convert into a microscopic approach. But that being said I've gotten I've done extensive that extend into that Master interim with an endoscope but it's required a significant amount of sputum removal that requires uh cartilage reconstruction. So you don't get recurrence. But I I use private I start with an endoscope for most of all my mamas unless there's some extenuating circumstance. And then uh we'll use the microscope in an open approach if necessary. Okay. And steven you is also an ex a scope in Chicago. I do typically, you know as the other panelists have said, I'll use the endoscope for toma. Um and start always start with the endoscope really assess what's going on. And often that's all you'll need with a large kind of a dichotomy there which was reconstructed. Um And then I'll go to a microscope for the masquerade if needed. I have used the X. A scope form asteroid. I've used it more for cochlear implants. Um mostly just to get practiced with the X. A scope and those were incredibly fun to do with an extra scope because it's kind of uh just kind of a different way to do something that you're already very familiar with and those tend to be patients without extensive inflammatory disease. And so it's kind of a good practice case. But my the most fun thing about doing the cochlear implant with the excess scope is mostly just so everyone else in the room has some clue what's happening. Uh you know, on the microscope, there's always a video on the screen, but it's not the same view that the surgeon is getting. So um I have found it more uh it's fun for me, but actually better for kind of educational purposes. Even people who have, you know, anesthesiologist been in place for hundreds of covid airplanes really finally understood what was happening. So that was definitely a fun application. Thank you very much. There is another question from Ben Pattinson about economic comfort, benefits of the X. A scope over the microscope. What do you think? Because uh let's say it's more comfortable with the extra scope. More economic. Uh what do you think? Perhaps you start with Daniela first and then uh steven and Brendan. Of course uh the ergonomic is because uh you are working the sitting in the same position and just to move your camera and in order to get the view that you want to get to dissect with you more is of course more ergonomic because you needed to move your body with the microscope or perform some surgery in a really difficult condition with your body. You are sitting in a comfortable way dissecting the tumor and the camera is moving around the surgical field. So for this reason the eggs aske opic approach is more ergonomic. Okay. All the comment on this Brandon steven. Yeah it's using that heads up approach. Um You know the microscope can be very comfortable especially if you're doing in that ideal position. But you know as you kind of get deep into cases sometimes you do that weird kind of low back position or or lean back position and with the excess scope and the endoscopes you you always have that kind of heads up position which which can help over time. Yeah. I I we got to trial the X. A. Scope but I don't I don't actually have one. So I probably I can't really comment a few times. I used it. I did like it. I the one case I remember it was I felt was very helpful was the middle fossa acoustic neuroma. Um But that again it's been a while and we don't have one on campus. Okay. Thank you. There is another question from piece white cocoa. Excuse me. My spelling. But the question is, what is the final recording output three D. Or two D. And how you store this uh on your machine? Danielle. Mhm. Honestly, for endoscopic approach to the is uh is sufficient and I think that in the future will be possible to improve the high definition for example. Now that is the four key. But in the future probably you will be able to see with the really impressive technology also in two D. For the microscopic approach. The possibility to have a three D. View is really important. Especially because also the second surgeon and the fellow can see in the same way this is the problem of the microscope. Er instead with the eggs a scope three D. Probably you are able to teach in a better way your resident and fellow. Thank you All the comments from Stephen and Brandon about three D. To two D. I. Sorry. I think if the question is about the video recording. I think the typical is to D. I remember when I was using an X. A. Scope I asked our stores uh who was with me at the time it was possible to record in three D. And the answer was yes but the file is enormous. So um I think that is possible but whether it's practical you'd have to kind of look at your own logistics. Um and I imagine that would get better over time but usually it's two D. I don't have anything to add on that. Okay thank you very much. Another question from Patrick's Gandolfi. Uh thanks for the amazing presentation first of all on regards of exodus copy which have been the most common procedures being performed. Exactly. It's a public surgery. Okay so talk to me. Okay steven. I'm not gonna add something. Not much. I'm not doing a lot of inner ear or I mean skull base for section of tumors in pediatric patients. So I just really used it for the coconut plans. Okay. And Brandon, you know, I don't don't use it just because we don't have it. Uh, there was another question, but I think Stephen has already answered this about bleeding during the city and Temple City. You will add something steven this question. Um, Sure. Yeah. And this is one of the kind of challenges of getting started with endoscopic ear surgery is all the bleeding. Um, I had a video in here of watching that your bleed, which I took out. But that's that's kind of a common thing where you make your incision, the flat bleeds. It smudges the scope. And honestly, that's I think where a lot of people just kind of give up on endoscopic ear surgery, but you can really control that. And really just some patients, you know, get a good injection helps. Um, I tend to position the patient, put them in reverse to Muhlenberg. Such that the um, the, you know, the blood is kind of flowing away from the head. Uh, keep the blood pressure low. Uh, using epinephrine soaked pledge. It's um, and just getting good homeostasis. So we'll bleed while you're raising the flap and then up to the annual sometimes raising the analyst is the hardest thing because the blood pools, writing that annular sulcus, but once you've raised the annual is and once it's given a, you know, a chance to bleed for a few minutes. Um there's almost no bleeding for the rest of the case. With the exception of an acquired with a lot of graduation and inflammatory reaction in the middle ear. But for japan it classy or secular. Classy or middle ear exploration, so to speak. Um all the bleeding tends to be up front and so you just kind of control that with the pledges and the injection and the positioning and just waiting and then after that there isn't too much and so just kind of part of that learning curve. But I would definitely encourage getting past that initial bleeding part with the endoscopes and not not giving up at that point. Okay. There was another question and that will uh remodel a little bit the question I give you $300,000 what you will buy extra scope of endoscope or a microscope. Danielle. Of course the endoscope is my first tool. So if I have this money I want the best tower for endoscopic year surgery and for the rest I can spend also for eggs. Aske opic approach just because the training, if you are able to I'm working in the university and if you are able to have a tool where it's possible to see in three D. And also teach your residents. This is the best tool but the first position is the endoscope. Okay. Okay. Stephen in Chicago. I would agree with that. Yeah. The endoscopes would be go to I for pediatric patients. I use the endoscopes every time for the majority of cases I only use the endoscopes. I'll use the microscope as needed for required um extensive toma. Um But even though I'm using the endoscope, so the answer would be endoscopes with the endoscopic instruments because some of those especially curved instruments really make a big difference. Um So that would be my go to and Brandon uh same endoscopes and again my experience with extra scopes is limited. I the times I used I did like it but I'd probably endoscopes And then microscope. Okay thank you very much. Uh time is progress but only perhaps the last question from my side. Uh you are at the university level. You have in the first year you start uh temporal plus t with the endoscope or with the microscope. Danielle training residents now. Today. Honestly, now nowadays we are trying to spread the endoscopic and microscopic approach. But honestly if we are speaking about middle year, 80% of the procedure are under the endoscope. For example. Nowadays for a marengo plastic or a simple timpano plastic, It's really difficult to use the microscope. It's 100% endoscopic procedures. So my idea is to spread the endoscopic approaches and also microscopic approaches. But the endoscope also here is at the first position. Okay thank you Chicago steven. Yeah. First training is uh and the question is uh yeah and you know I think the learning curve is a little overstated. Obviously if somebody's exclusively used microscope for a long time, there's definitely learning curve of the endoscopes. But the residents are all very facile with the endoscopes already usually from sinus surgery. And it really does help them show that middle yer anatomy which they don't they aren't that familiar with. So I would say endoscopes every time. Okay. And Brandon. Yeah, we we do a lot of endoscopic surgery with our residents I think. And it's in a lot of ways they're probably more comfortable with that than with the microscope. I do think it's important that they know how to use both instruments because there are times where you really need to use the microscope or something like an X. A. Scope. And so um again, most of the time we start with the endoscope, I think it's great for teaching purposes and learning surgical technique. I think it's more difficult uh to master than with a microscope. Um but I think it's important to know both. Okay, thank you very much the time progress. And I think I will close now this webinar. I will thank uh Daniel Marconi Stephen Hough and this axon. The question was and this is the answer is not already done is how new visualization technology can improve clinical outcomes. And you go a little bit through the midline and through the different publication. We need more publication that show us that we have an objective estimation between endoscope against microscope and I think also in the future to have this very interesting extra scope. I think we have other meetings that we can discuss this a little bit earlier on. But I think it's very interesting to have this new visualization technology and I think here again, carl start for organizing the webinar. And I wish you a nice day in in texas in Chicago as well, near from here in Verona. Thank you very much and enjoy the day by by. Thank you.
