Cameron C. Wick, MD
Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
cameron.wick@wustl.edu

Trancanal endoscopic ear surgery (TEES) is an emerging technique championed for its improved visualization within the middle ear space. Stapes surgery presents a unique endoscopic challenge in that it offers a different type of depth perception compared to the binocular microscopic view. Early reports of endoscopic stapedectomy versus stapedotomy showed outcomes on par with the well described microscopic techniques (1). Further validation has shown an air-bone gap reduced to less than 15-dB in 96.3% of cases (2). With experience, the endoscopic technique can also be performed efficiently and safely (3). This video highlights the surgical steps for an endoscopic stapedotomy using a CO2 laser and Eclipse nitinol piston.

This is a single patient case report with an accompanying video highlighting the technique of an endoscopic stapedotomy. The surgical setup is consistent with other TEES. Specifically, the patient is supine with the head slightly rotated so the operative ear is up. Facial nerve monitoring is used. The head of the bed is slightly elevated. The ear is prepped with betadine paint and a standard otologic drape containing a pouch is used.

The case begins with injecting the canal with 1% lidocaine with 1:100,000 epinephrine. The remaining steps are described in the video. The endoscope used is a 3-mm diameter, 14-cm length zero-degree scope from Storz. The CO2 laser is from OmniGuide. The stapes prosthesis is an Eclipse nitinol piston from Grace Medical. The endoscopic ear instruments are from Stroz.

This case achieved closure of the air-bone gap to less than 10-dB. Specifically, the patient’s pre-operative air-bone gap was 42 dB HL. His 2-month post-operative air-bone gap was 5 dB HL. There were no complications.

The stapes footplate and stapedotomy are well visualized through the endoscopic ear surgery approach. Depth perception can be achieved, just like it can in endoscopic sinus surgery, using muscle-memory and camera movement to define the relationship and spacing between middle ear structures. Finally, instrumentation of the piston prosthesis can be assisted with devices like the feathervac suction which enables single-handed manipulation.

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1. Hunter JB, Zuniga MG, Leite J, Killeen D, Wick C, Ramirez J, Rivas JA, Nogueira JF, Isaacson B, Rivas A. Surgical and audiologic outcomes in endoscopic stapes surgery across 4 institutions. Otolaryngol Head Neck Surg. 2016;154(6):1093-1098.
2. Nassiri AM, Yawn RJ, Dedmon MM, Tolisano AM, Hunter JB, Isaacson B, Rivas A. Primary endoscopic stapes surgery: Audiologic and surgical outcomes. Otol Neurotol. 2018;39(9):1095-1101.
3. Iannella G, Magliulo G. Endoscopic versus microscopic approach in stapes surgery: Are operative times and learning curve important for making the choice? Otol Neurotol. 2016;37(9):1350-1357.