Comparing Transcanal Endoscopic Ear Surgery to Post-Auricular Microscope-Guided Surgery in Pediatric Ossiculoplasty: Hearing Outcomes and Post-Operative Pain

Abstract

Objective: This study compares post-operative hearing outcomes and morbidity after pediatric total ossicular replacement prosthesis (TORP) ossiculoplasty with transcanal totally endoscopic ear surgery (TEES) versus a post-auricular microscope-guided (PAM) approach. Patients: Forty-four children who underwent ossiculoplasty with titanium TORP after previous cholesteatoma surgery Intervention: Ossiculoplasty using TEES or PAM approach. Main outcome measures: Hearing outcome after ossiculoplasty was determined by post-operative air-bone gap (ABG) on audiogram nearest to 1 year after surgery. Post-operative morbidity was measured by total number of opiate doses the child received during hospital stay, along with the highest documented post-operative pain score. Comparisons were made with Mann-Whitney U test. Results: Hearing data were available for 41 patients: 21 had undergone TEES (median preoperative ABG 39 dB) and 20 had PAM surgery (median preoperative ABG 39 dB). Postoperatively at 1 year, ABG closed significantly in each group (TEES 21 dB, p ¼ 0.003; PAM 23 dB, p ¼ 0.01), and there was no difference between groups ( p ¼ 0.6). 57% who underwent TEES and 50% who underwent PAM surgery experienced serviceable hearing post-operatively, defined as air conduction pure-tone average (PTA) 30 dB HL. Visual analogue pain scores from 0 (no pain) to 10 (worst pain imaginable) were available for 13 who underwent TEES and 18 who underwent PAM surgery. In children undergoing TEES, only two reported pain above 0, with the highest pain score being 4. Children undergoing PAM surgery had a median pain score of 3 (median difference ¼ 3, p < 0.001). Children undergoing TEES required fewer weight appropriate doses of opiate analgesic (median ¼ 0) than children who u n d e r w e n t P A M s u r g e r y ( m e d i a n ¼ 1 ) ( m e d i a n difference ¼ 1, p ¼ 0.003). Children undergoing TEES had a significantly shorter surgical time (median 135 min) than those who underwent PAM surgery (median 168 min) (median difference ¼ 33 min, p ¼ <0.006). Conclusion: Hearing outcomes in TORP ossiculoplasty are similar in TEES and PAM surgery, and TEES may decrease post-operative pain.

Comparison of Long-Term Microscopic and Endoscopic Audiologic Results After Total Ossicular Replacement Prosthesis Surgery

“…To our knowledge, our study is the largest to primarily investigate the results of endoscope-assisted total ossiculoplasty. In addition, our follow-up is longer than previously described in literature (1–3). Das et al (1) described significantly better hearing results 1 month after endoscope-assisted ossiculoplasty in comparison to microscope-assisted ossiculoplasty.…”

“…Yet, at 6 months after surgery both methods were shown to have comparable audiologic outcomes. Yawn et al and Kwinter et al ( 2 , 3 ) state that audiologic results of endoscope-assisted and microscope-assisted ossiculoplasty are equal. Short-term endoscopic results from our study are comparable to those in literature.…”

“…Yawn et al ( 2 ) state that audiologic results of endoscope-assisted and microscope-assisted ossiculoplasty are equal (endoscopic group: n = 8, follow-up 6 months, postoperative ABG PTA 0.5-3kHz 15.9 dB). Kwinter et al ( 3 ) found no difference between endoscope-assisted (n = 21) and microscope-assisted (n = 23) total ossiculoplasty results (postoperative air conduction PTA 0.5-4kHz of 29.0 vs 31.5 dB, respectively). One of the postulated advantages of endoscopic ear surgery is the wide field and high-resolution view that may benefit accurate placement of middle ear prostheses.…”

Updates in paediatric cholesteatoma

“…Patients who undergo endoscopic ear surgery have reduced postoperative pain, as well as improved disease-specific quality of life and improved general anxiety [13]. Pain scores are significantly higher in children undergoing postauricular surgery than in children undergoing totally endoscopic surgery, with children undergoing endoscopic surgery often reporting pain scores of 0 on the visual analogue scale [12]. These results are supported by a recent systematic review and meta-analysis of 11 studies, which confirmed that endoscopic ear surgery is associated with significantly less postoperative pain than microscopic ear surgery [14].…”

“…Endoscopic ear surgery has also been associated with reduced healthcare expenditures [9] and reduced operative time [12]. In a prospective case series of patients undergoing cholesteatoma surgery, ears were checked with an endoscope, intraoperatively, at the completion of microscopic dissection.…”