Endoscopic mastoid sugery with tympanoplasty

TEMS with Tympanoplasty for the management of cholesteatoma and its related lesions of mastoid antrum by Dr. Sheikh Shawkat Kamal

Transcanal endoscopic mastoid surgery with tympanoplasty for the management of cholesteatoma and its related lesions of mastoid antrum

Author

Dr. Sheikh Shawkat Kamal

MBBS, FCPS Consultant ENT Surgeon

Surgiscope Hospital Chittagong, Bangladesh Tel: 880-01711406943

E-mail- [email protected]

This article is free to share among the interested readers providing with out any change and

should not be published in any journal. Questions or suggestions regarding the article will be

highly appreciated by the author.

Abstract: Objective: To describe and to evaluate a newly designed transcanal endoscopic mastoid surgical procedure for the management of cholesteatoma in

mastoid antrum.

Study design: Cross sectional study from January 2009 to January 2011.

Setting: Private tertiary care hospital

Patients: Patients having cholesteatoma clinically with presence of soft tissue shadows in their preoperative CT scan of mastoid antrum were only

selected. Patient with cholesteatoma in and around mastoid tip or having stenosed external auditory canal were excluded from this study.

Interventions: Transcanal endoscopic mastoid surgery (TEMS) involved exclusive endoscopic exploration of mastoid antrum after removal of selected

part of posterior meatal wall. Thereafter the TEMS was ended either by reconstructing the gap of posterior meatal wall with tympanoplasty (Closed –

TEMS with tympanoplasty) or by widening of the initial passage to mastoid antrum with tympanoplasty (Open- TEMS with tympanoplasty).

Main outcomes measure: Assessment of the feasibility and efficacy of transcanal endoscopic mastoid surgical approach for visualization and removal of

cholesteatoma or related pathology from mastoid antrum.

Results: The study was done on 23 patients (19 adult cases and 4 child cases) age ranging from 9 years to 54 years with maximum 2 years follow-up. All

adult patients (19 cases) got their surgery under local anesthesia and perceived intra-operative pain sensation mostly scored grade 2 (74%) in numerical

pain scale. Initially out of 23 cases open - TEMS with tympanoplasty was done in 9 cases and closed- TEMS with tympanoplasty was done in 14 cases. In

all cases mastoid antrum was found completely visible and endoscopically accessible for effective excision of cholesteatoma. After one year of follow up

second look surgery was done through transcanal route only in 2 closed TEMS cases having soft tissue shadow in postoperative CT scan with bad aural

symptoms. Commonest cholesteatoma nesting site in residual cases was retrotympanum. No facial palsy was observed in any case. Mastoid cavity in canal

wall down cases was found small and mostly clean. Postoperative bone conduction thresholds remained static in all cases.

Conclusion: Transcanal endoscopic mastoid surgery (TEMS) has been found to be an efficient new approach for the management of cholesteatoma and its

related lesions extensive up to mastoid antrum.

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Introduction:

“The least the surgery disturbs the normal anatomy, the

best its outcome will be” - the strategy behind the better

outcomes of all kinds of minimal invasive surgery. The sole

instrument that has made the operative procedure less invasive

is the rigid rod-lens endoscope introduced to the medical field

by renowned British physicist Harold Horace Hopkins. The

complementary use of endoscope in otology in addition to

microscope has already shown its superior role in detecting the

hidden cholesteatoma 1,2,3,4,5 . Middle ear surgery purely under

endoscopic guidance is a growing concern among the

otologists. Transcanal endoscopic myringoplasty, stapedotomy

or management of attic cholesteatoma is now being practicing

as new preservative approach with significant success. In this

perspective the exploration of mastoid antrum entirely by

endoscope could be an exiting and challenging experience for

the surgeons.

The transcanal endoscopic mastoid surgery (TEMS) is a

new approach for the management of middle ear

cholesteatoma. Here the exploration of mastoid antrum was

done purely under guidance of endoscope through the external

auditory canal after removing a selected part of posterior

meatal wall. The endoscopic wide angled image increases the

visibility as well as the control over hidden pathologies of

middle ear compartments. The use of transcanal route to

mastoid antrum with minimal dissection under endoscopic

guidance makes the procedure truly less invasive. Good grip to

pathological part with less disturbance of the normality

increases the chances of the better outcome of the surgery.

With this hope the present study was planed.

Patients and methods: The study was conducted on total 23 patients (19 adults

and 4 children) age ranging from 9 years to 54 years in a

private tertiary care hospital named ‘Surgiscope hospital’

situated in Chittagong, Bangladesh. The duration of the study

was from January 2009 to January 2011. Patients having

cholesteatoma clinically with soft tissue shadows in their

preoperative CT scan of mastoid antrum were only selected

where as patients with cholesteatoma in and around mastoid tip

or having stenosed external auditory canal were excluded from

this study. All the cases received surgical treatment for their

mastoid pathology by the author only.

Nasoendoscope of 0 and 30 degree of 4mm outer

diameter and otoendoscope of 0 and 30 degree of 2.7 mm outer

diameter were used. Karl Storz’s fiberoptic light source with

150 volt light and camera model Telecom 90 were used for

endoscopic video system. For cutting the posterior meatal wall

electrical drill machine (Saeshin micromotor model Strong

90/90N) with cutting drill bur of 1.5-2 mm tip diameter size

were used. Some custom made instruments such as curved

sucker nozzles, angled ring curettes were also used along with

traditional middle ear instruments. Preoperative CT scan of

temporal bones and pure tone audiogram were performed in all

cases.

Intramuscular injection of pethidine and promethazine

had been used as premedication for all cases. While performing

the surgery under local anesthesia, external auditory canal and

pinna were anesthetized through usual nerve-block technique

by using injection 0.5% bupivacaine and 2% lignocaine with

adrenaline (1: 2, 00,000). Hypotensive anesthetic procedure

was conducted for surgery under general anesthesia.

All the surgical procedures were done only through

transcanal route under endoscopic guidance.

An anterior based tympano-meatal flap involving the

tympanic membrane and few millimeter of posterior meatal

skin was elevated. Thereafter a wide inferior based posterior

meatal skin flap involving the skin over the bony meatus was

elevated. If incus was found intact then its long process was

separated from head of stapes before starting the bony works.

Figure 1: Picture is showing the design of bony dissection on posterior meatal wall. Inner black dots indicate the area that has to be dissected out during initial exploratory attico-antrostomy. Outer red dots indicate the area that has to be dissected down during open-TEMS procedure. The posterior extension of this area depends upon complete visualization of mastoid antrum or adequate endoscopic accessibility of entire antrum. Vertical thick blue colored area indicates the area of posterior bony wall of the tympanic cavity.

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A design was preplanned for bony dissection of posterior

meatal wall (figure 1). Bony dissection was done mostly by

cutting bur and occasionally by curettes (figure 2). The bur was

allowed to rotate at 30,000 RMP for not more then

approximately 20 seconds at a time. Intermittent saline water

irrigation and suction clearance was employed in between bony

works. Initially a narrow strip of bone was removed from

scutum and posterior bony meatal wall and continued until the

If cholesteatoma or only huge granulation tissues were found

entirely involving the mastoid antrum or gone beyond of it into

surrounding air cells or if the patient had poor socioeconomic

condition – then the open TEMS with tympanoplasty was

considered. All the granulation tissues along with mucosa of

mastoid antrum were stripped out by ring curate (figure 4).

Then the initial surgical passage to mastoid antrum was

widened by dissecting the over hanged bone in

Figure 2: Subsequent pictures are showing the bony dissection of posterior meatal wall by cutting drill bur.

Figure 3: Pictures show different steps of exploratory attic-antrostomy. In picture1, ‘Ad’ indicates the addidus ad antrum, ‘I’ indicates the body of incus and ‘C’ indicates the cholesteatoma matrix. Picture 2 shows the removal of incus. Picture 3 shows final scenario of attic-antrostomy with presence of huge granulation tissues in mastoid antrum (An).

visualization of distal end of cholesteatoma matrix or the part

of mastoid antrum. Removal of present incus was done. This

initial removal of bony strip was named exploratory attico-

antostomy (figure 3). After taking a thorough assessment of the

extension of cholesteatoma and of its surrounding inflamed

granulation tissues, the decision of the final destination of the

surgical procedure was then planed.

posterior lateral direction with cautious steps around posterior

wall of tympanic cavity (figure 5,6) . Head of malleus from

epitympanum was removed. Remaining part of scutum was

lowered down. Healthy looking mastoid air cells were always

tried to be kept preserved.

In all cases the defect of tympanic membrane was

repaired either by tragal cartilage with perichondrium or by

temporalis fascia (Figure 7). In few cases ossiculoplasty was

done with autologous sculptured incus. The previously elevated

meatal skin flap was then repositioned.

If cholesteatoma was found partly involving the mastoid

antrum with having a very few or no granulation tissue in

surrounding mucosa then the closed- TEMS with

tympanoplasty was decided to end the up the procedure.

Removal of cholesteatoma along with granulation tissue was

then carried out keeping the healthy mucosa undisturbed.

Reconstructing the posterior meatal wall was done with

composite graft of tragal cartilage with perichondrium.

Pieces of gelfoam were placed over the graft and flap to

stabilize them. Thereafter the external auditory canal (EAC)

and newly formed mastoid cavity (in case of canal wall down)

was filled with 5% povidone iodine ointment. A piece of cotton

ball was kept outside the EAC to prevent the out pouring of


ointment. The skin wound of graft harvesting site was closed

with 3/0 chromic catgut sutures.

Figure 4: Picture is showing the removal of granulation tissues by ring curate from mastoid antrum.

Figure 5: Showing the direction of dissection to enlarge the passage to mastoid antrum. Dissection along the posterior and lateral direction (green arrow) is the ideal way to enlarge the approach to mastoid antrum. Faulty dissection in posterior direction (yellow arrow) might have the risk of injuring the semicircular canal or dura of posterior cranial fossa.

All the cases done under local anesthesia were discharged

after 6 to 8 hours of observation. Cases done under general

anesthesia were kept for 24 hours observation. Cotton ball

placed in external auditory meatus was changed with fresh dry

one whenever it got soaked and was advice for change as per

needed.

Stitches of surgical wound of graft harvesting site were

removed on 5th postoperative day. Wet debris in EAC was

cleaned. A topical antibiotic drop was then started to apply into

EAC several times a day for nest 15 to 20 days. Periodic aural

dressing was employed as needed. Pure tone audiogram was

done on 3rd month following operation. Postoperative CT scan

of temporal bone was done only in closed TEMS cases after 1

year of their operation. Temporal bones having suspected soft

tissue shadow in CT radiogram with bad aural symptoms were

only subjected to second look operation. Second look

operations were done through transcanal route after elevating

the posterior meatal composite flaps consisting of tympano-

meatal skin with cartilage graft.

Figure 6: Picture of the exposed mastoid antrum (A). Lower down of over hanged bones (black arrow) near the posterior bony wall of tympanic cavity (thick blue line) should be done cautiously since it lodges the mastoid segment of facial nerve. ‘S’ indicates the position of lateral semicircular canal.

Figure 7: Picture of the end scenario of open TEMS with tympanoplasty. Meatal skin flap (MF) and tympanomeatal flap (TMF) are repositioned. Myringoplasty is done with temporalis fascia graft (G). ‘A’ indicates the mastoid antrum.

Results:

Soft tissue shadows in preoperative CT scan of total 23

cases of mastoid antrum later intra-operatively revealed as

presence of cholesteatoma in mastoid antrum either partly or

entirely in 19 cases (83%) and only as presence of huge

infected granulation tissues in entire mastoid antrum in 4 cases

(17%). Intra-operatively cholesteatoma was also found nesting

13 cases in facial recess, 10 cases in sinus tympani, 6 cases in

supratubal recess and 8 cases in between ossicles.

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The TEMS for entire adult patients (19 out of 23 cases)

were done under local anesthesia. General anesthesia was only

considered for the children (4 out of 23 cases). The perception

of intra-operative pain sensation among the patients having

their surgery under local anesthesia was measured in numerical

pain rating scale and was found grade 2 in 14 cases (74%),

grade 3 in 4 cases (21 %) and grade 5 in 1 case (5%).

In every case the entire mastoid antrum could be

completely visualized (100%) and could be attempted for total

clearance of lesions with confidence under endoscopic

guidance. The average duration of operation was 3 hours

ranging from 2.30- 4.30 hours.

Among 23 cases, closed-TEMS with tympanoplasty was

done in 14 cases (61%) and open-TEMS with tympanoplasty

was done in 9 cases (41%) as a primary surgical procedure. In

19 cases out of 23, ears became dry and free of infection with

in 8 weeks. Rest of the 4 cases which were discharging

intermittently after initial surgery were found presence of

residual cholesteatoma in 1 of closed- TEMS and tympanic

membrane graft failure in 3 open TEMS cases. The closed-

TEMS case having residual cholesteatoma was transformed in

to open TEMS case. Ears having tympanic membrane graft

failure were successfully repaired by revision myringoplasty.

Suspected soft tissue shadows were found in postoperative CT

scan of 4 out of 8 closed- TEMS cases at the end of their one

year follow up. Only 2 of them had bad aural symptoms like

otorrhea, deep retraction and perforation of tympanic

membrane. These two cases were only subjected to second look

operation and were transformed into open TEMS cases after

removal of their residual diseases. The rest 2 cases were kept

under close observation.

The cholesteatoma revealing sites in total 3 residual cases

were sinus tympani in 3 cases (100%), facial recess in 2 cases

(67%) and mastoid antrum in one case (33%).

No facial nerve palsy was seen developed in this study.

No injury was found in the skin of EAC. In follow up visits the

mastoid cavities of open TEMS cases were found small.

Postoperative bone conduction threshold remained static in all

cases. Air-bone gap (AB gap) was found reduced in 14 cases.

Out of these 14 cases, average 10db gain was noticed in 5 cases

where ossiculoplasty was done. However in 3 out of 23cases

AB gap was found increased.

Discussion:

Incorporation of endoscope in the armamentarium of

middle ear surgery in addition to microscope has significantly

reduced the incidence of residual cholesteatoma in primary

surgery and thus has made possible to choose canal up mastoid

procedures more confidently 6,7,8. Several authors had already

experienced the efficacy of endoscopic management of attic

cholesteatoma with promising results 9,10,11,12. Although the

success stories on transcanal endoscopic management of attic

cholesteatoma were found piling up in publications but

literature on transcanal endoscopic exploration of mastoid

antrum for cholesteatoma is very rare in the publications.

Tarabichi M. did mention in his literature about his efforts to

explore the mastoid but at the end he concluded this pure

endoscopic approach unsuitable for mastoid pathology 13. Very

recently Marchioni D. et el described their transcanal

endoscopic ‘centrifugal’ technique for management of

cholesteatoma extensive to antrum and periantral cells with

favorable outcomes 14.

Transcanal endoscopic mastoid surgery involves the

exploration of mastoid after removing the selected part of outer

attic wall and posterior meatal wall entirely under guidance of

endoscope. It preserves the cortical wall of mastoid intact. For

being oriented with this new endoscopic dissection, five

cadaveric temporal bones had been dissected endoscopically

before this study. The observations from those cadavaric

dissections helped to design the dissection plan on living cases.

Some of those important observations were depicted here. The

first concern was about the prediction of the exact location of

the part of posterior meatal wall which formed the lateral limit

of the posterior bony wall of tympanic cavity. The posterior

bony wall of tympanic cavity remained as almost unsighted

area in between tympanic cavity and lower portion of mastoid

antrum before starting the dissection and prediction of its

location was felt important to avoid injury to mastoid segment

of facial nerve that it contained (figure 1, 6, 8). In endoscopic

orientation it had been observed that the most possible site of

this area could be a few millimeters wide vertical area

approximately 1-3 millimeters behind the posterior bony

annulus with an upper limit demarked by the upper level of

oval window. The second concern was the direction of

mastoid antrum in relation to external auditory canal. It had

been observed that the angle between the long axes of these

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two structures was always below 90 degree (figure 9). So the

dissection in faulty straight posterior direction has the risk of

injuring the delicate structures present there such as

semicircular canals or dura of posterior cranial fossa. The safe

dissection plane should be parallel to the posterior bony meatal

wall running posterior and outward direction. The third

concern was about the mastoid cells in and around the mastoid

tip. Endoscopic exploration of mastoid air cells in those areas

had been found difficult and incomplete. So it had been decided

that any mastoid pathology present below the level of the floor

of bony external auditory canal depicted in preoperative CT

scan should have been abandoned for endoscopic mastoid

surgery. The fourth concern was necessity of new instruments

for working in mastoid antrum. Endoscope offers wider-angle

view then the view produced by microscope. Traditional

middle ear micro instruments usually failed to cover this wider

working area visible under endoscope. Especially it was

observed during instrumentation in mastoid antrum. For this

reason some personally made instruments like angled tip micro

suction nozzles and angled ring curates had been prepared to be

used for working in wider visible area under endoscope (figure

10).

Figure 9: Picture shows that the angle in between the axis of external auditory canal and mastoid antrum is always below 90 degree.

To overcome the difficulty of instrumentation in presence

of narrow isthmus of EAC some new techniques had been

invited. It was observed that if the tip of the endoscope was

kept a few millimeters behind the isthmus of the EAC this

would allow easy introduction and movement of the instrument

along the side of the endoscope with in the canal. This principal

of placement of endoscope along with other middle ear

instrument with in the canal was strictly followed in all cases.

In one case, canaloplasty was done absolutely under endoscope

for excision of an osteoma of EAC without facing any

noticeable difficulty. The current study avoided TEMS for

those cases having such a narrow EAC that at least half of its

depth could not allow passing 4 mm diameter endoscope. The

use of cutting drill bur for bony dissection was found superior

over curette in terms of efficacy and accuracy. To avoid the

possible lacerated injury to the EAC by rotating drill bur a

protecting metallic sheath for the bur’s shaft was developed

(figure 11). The friction temperature producing between bur

and sheath were found negligible while rotating the bur for not

more then 20 seconds at a time.

Figure 8: In this axial CT scan view the position of posterior wall of tympanic cavity is indicated by the area in between two red arrows. Anterior air containing space is the epitympanum and posterior air containing space is the lower portion of mastoid antrum. Red line indicates the area of posterior meatal wall that forms the lateral limit of posterior bony wall that has to be located before starting the bony dissection.

Naso-endoscopes of 4 mm outer diameter were mostly

used except in child and in narrow EAC cases where 2.7 mm

diameter endoscopes were used.

Figure 10: Picture of the custom made angled ring curates and curved tip micro-sucker nozzles.


Figure 11: Pictures show the custom made metallic sheath for drill bur to avoid injury to soft tissues of outer part of external auditory canal.

Single hand maneuver is the well recognized technical

difficulty of endoscopic ear surgery since the surgeon has to

hold the endoscope in one hand and has to do all

instrumentation with the other hand. It might be a prime reason

for its slow growing popularity among otologist habituated

uneasiness and this could reduce the operating time duration

too.

Endoscopic mastoid surgery was found well tolerated by

patient while performing under local anesthesia. It had been

observed that patient did complain of some pain during the

Figure 12: Preoperative picture (1) shows the attic cholesteatoma (C). Postoperative picture (2) after closed TEMS with tympanoplasty shows the area of reconstructed posterior meatal wall (RPW).

with two hands maneuver. To overcome this problem it has

been suggested to develop special instrument capable of doing

dual functions such as suction and manipulation of soft tissue at

a time.

The image fields produced by the endoscopic camera and

by the microscope are different since endoscopic camera

produces wider field two-dimensional images where as

microscope produces narrow field three-dimensional images.

For this reason, surgeon might face uneasiness while trying to

adapt him working simultaneously in these two different kinds

of image fields. Performing the whole procedures absolutely

under endoscopic guidance could avoid this kind of

manipulation of normal mastoid mucosa that could be subsided

after applying 4% Lignocaine soaked cotton piece locally. This

finding some time helped to differentiate the normal mucosa

from granulation tissue in difficult situation. Surgery under

local anesthesia could offer some other beneficial things too

such as intra-operative clinically monitoring of facial nerve,

ensuring his short stay in hospital finally reducing the total cost

of the surgery.

This study observed that the bony dissection according to

preplanned design could create adequate passage to mastoid

antrum. As a result the entire compartment of mastoid antrum

could be approachable endoscopically. Custom made angled

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ring curates were found efficient in removing of cholesteatoma

and granulation tissues from mastoid antrum. The initial small

attico-antrostomy could easily be reconstructed with cartilage

graft (figure 12). The preservative character of this new

endoscopic approach also encouraged early healing of surgical

wounds. The mastoid cavity produced after endoscopic open

TEMS procedure was found relatively small, clean and having

no or least wax (figure 13). This trouble free nature of mastoid

cavity was probably due to not involving the skin of

cartilaginous part of EAC.

Figure 13: Post operative picture of open TEMS with tympanoplasty shows small and clean mastoid cavity (MC) and well taken tragal cartilage graft (G).

This study might not reflect the actual numbers of

patients having residual cholesteatoma in canal wall up cases

since patients having bad aural symptoms with suspected

shadows in follow up CT scan were only subjected to second

look operation.

The present study has recognized that longer time is

required to develop adequate surgical skill for endoscopic ear

surgery then time required for obtaining skill for surgery under

microscope. However surgeons already involved with other

endoscopic procedures like endoscopic sinus surgery could

easily pick up the necessary skills for endoscopic mastoid

surgery. As soon as the surgeon became more accustomed with

the procedure the total time required for whole surgical

procedure became shorter.

Despite having some limitations transcanal endoscopic

mastoid surgery was proved having the ability of total excision

of cholesteatoma of mastoid antrum. It was expected that when

this novel surgical procedure would be practice in broader scale

new techniques would definitely come out to overcome its

limitations. The table below summarizes the advantages and

disadvantages of TEMS that has been observed through this

study. Table-1: Advantages and disadvantages of transcanal endoscopic mastoid

surgery (TEMS):-

Advantage

1. Minimal invasive procedure.

2. Well tolerated under local anesthesia.

3. Ensuring short hospital stay.

4. Offering early recovery.

5. Ensuring good outcome.

6. Cost effective. Disadvantage

1. Not applicable for extensive stenosed EAC.

2. Not suitable for exploration of mastoid tip cells.

3. Demanding more time to develop adequate surgical skills.

4. Lack of necessary instruments. Conclusion:

Cholesteatoma of mastoid antrum and its surrounding

mastoid cells can be effectively managed by transcanal

endoscopic mastoid surgery with appreciable surgical outcomes

although due to some technical difficulties this endoscopic

approach cannot be advocated for cholesteatoma extended to

mastoid tip. This truly minimal invasive approach has the

potentiality to reduce the surgical cost specially while

performing under local anesthesia.

References: 1. Good GM, Isaacson G.Otoendoscopy for improved pediatric cholesteatoma removal. Ann Otol Rhinol Laryngol. 1999 Sep;108(9):893-6. 2. Ghaffar S, Ikram M, Zia S, Raza A.Incorporating the endoscope into middle ear surgery. Ear Nose Throat J. 2006 Sep;85(9):593-6. 3. Presutti L, Marchioni D, Mattioli F, Villari D, Alicandri-Ciufelli M.Endoscopic management of acquired cholesteatoma: our experience. J Otolaryngol Head Neck Surg. 2008 Aug; 37(4):481-7. 4. Ayache S, Tramier B, Strunski V.Otoendoscopy in cholesteatoma surgery of the middle ear: what benefits can be expected? Otol Neurotol. 2008 Dec; 29(8):1085-90. 5. Liu Y, Sun JJ, Lin YS, Zhao DH, Zhao J, Lei F.Otoendoscopic treatment of hidden lesions in otomastoiditis. Chin Med J (Engl). 2010 Feb 5;123(3):291-5. 6. Yung MW.The use of middle ear endoscopy: has residual cholesteatoma been eliminated? J Laryngol Otol. 2001 Dec;115(12):958-61. 7. Badr-el-Dine M.Value of ear endoscopy in cholesteatoma surgery. Otol Neurotol. 2002 Sep;23(5):631-5. 8. El-Meselaty K, Badr-El-Dine M, Mandour M, Mourad M, Darweesh R Endoscope affects decision making in cholesteatoma surgery. Otolaryngol Head Neck Surg. 2003 Nov;129(5):490-6. 9. Aoki K. Advantages of endoscopically assisted surgery for attic cholesteatoma. Diagn Ther Endosc. 2001;7(3-4):99-107. 10. Tarabichi M. Endoscopic management of limited attic cholesteatoma. Laryngoscope. 2004 Jul;114(7):1157-62 11. Marchioni D, Mattioli F, Alicandri-Ciufelli M, Presutti L.Endoscopic approach to tensor fold in patients with attic cholesteatoma. Acta Otolaryngol. 2008 Oct 25:1-9. 12.Migirov L, Shapira Y, Horowitz Z, Wolf M. Exclusive Endoscopic Ear Surgery for Acquired Cholesteatoma: Priliminary Results. Oto Neurotol. 2011 Jan 3. 13. Tarabichi M.Transcanal endoscopic management of cholesteatoma. Otol Neurotol. 2010 Jun;31(4):580-8. 14. Marchioni D, Villari D, Alicandri-Ciufelli M, Piccinini A, Presutti L Endoscopic open technique in patients with middle ear cholesteatoma. Eur Arch Otorhinolaryngol. 2011 Feb 19

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Endoscopic mastoid sugery with tympanoplasty

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