OBJECTIVE: The retrolabyrinthine (presigmoid) approach has been utilized in various skull base surgeries but has not been fully utilized in the management of internal auditory canal (IAC) lesions, such as vestibular schwannoma (VS). Microsurgical retrolabyrinthine approach provides limited visualization of the IAC, while endoscopic-assisted techniques allow for further lateral exposure with labyrinthine preservation.
BACKGROUND: Traditional approaches to the IAC have the disadvantage of hearing sacrifice or retraction of brain tissue. With the introduction of endoscopic techniques and enhanced visualization, access to this region of complex anatomy is possible.
METHODS: Radiomorphometric and anatomical dissection was performed on two cadaveric temporal bones. High-resolution computed tomography was used to segment and delineate the volume of the IAC. Projected accessible IAC was compared to actual postdissection data with preservation of the posterior semicircular canal (PSCC) via the retrolabyrinthine corridor.
RESULTS: While preserving the PSCC, the 0° and 30° endoscopes visualized 57.1% and 78.6% of the IAC for cadaver 1, and 64.0% and 76.0% of the IAC for cadaver 2, respectively. Sacrificing the PSCC, the 0° and 30° endoscopes provided visualization of 78.6% 85.7% of the IAC for cadaver 1, and 88.0% and 95.1% of the IAC for cadaver 2, respectively.
CONCLUSIONS: Retrolabyrinthine approach to resection of VS is a potentially viable hearing-preserving alternative to traditional approaches. This approach provides access to the majority of the IAC, while angled endoscopes or sacrifice of the PSCC can provide additional access toward the fundus. Further studies are needed to determine the clinical feasibility of this approach.

BACKGROUND: The microscopic middle ear surgery involves a limited operating space and numerous important anatomical structures in which good visualization is crucial, as even a small amount of bleeding can greatly affect the clarity of surgical field. This study aims to investigate whether intravenous 1 g of tranexamic acid can improve surgical visualization and further shorten the operation time in microscopic middle ear surgery.
METHODS: This study is a prospective, randomized, double-blind, controlled trial conducted from December 2021 to December 2022, enrolling patients who were scheduled for microscopic modified radical mastoidectomy due to chronic otitis media. In addition to standard techniques to optimize the surgical field, participants were randomized into the TXA (tranexamic acid) group (1 g diluted to 20 ml normal saline) and the control group (20 ml normal saline). The primary outcome was assessed based on the clarity of the surgical field using the Modena Bleeding Score. Secondary outcomes included operation time, the surgeon satisfaction with the visual clarity, postoperative 24 h coagulation parameters, and the incidence of adverse events. Student\'s t -test, χ2 test, and ANOVA of repeated measures were used for statistical analyses.
RESULTS: A total of 28 patients were enrolled in each group using a 1:1 randomized allocation with similar demographic characteristics, including 24 male and 32 female individuals, and the mean age is 45.6±11.9 years. The surgical visualization in the TXA group was significantly better than that of the control group (2.29±0.46 vs. 2.89±0.31, P <0.001) as assessed by the Modena Bleeding Score. Furthermore, the TXA group demonstrated a shorter operation time compared to the control group (88.61±10.9 vs. 105.2±15.9, P <0.001) and higher surgeon satisfaction with surgical field (7.82±0.55 vs. 6.50±0.64, P <0.001). No statistically significant differences were found in postoperative coagulation parameters in the two groups. No TXA-related adverse events or complications occurred during the 12-month follow-up.
CONCLUSIONS: Intravenous 1 g of TXA can further significantly improve the visual clarity in the microscopic middle ear surgery and shorten the operation time based on other standard measures implemented.

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BACKGROUND: Patulous Eustachian tube (PET) is a condition affecting approximately 0.3% to 6.6% of the population, with autophony being the predominant complain. The management of PET lacks a well-defined standard in the literature as no effective medical treatments have been documented but various surgical options are available. This study aims to report mid-term outcomes following surgical management of PET.
METHODS: All patients who underwent surgical intervention for PET between September 2017 and June 2022 were enrolled. Data encompassing general demographics, quality of life (GBI), and procedure-specific data were collected.
RESULTS: A total of 30 PET cases (in 19 patients) underwent surgical intervention including 9 injections of hyaluronic acid, 13 fat injections, 6 endoscopic shim insertions, 1 cartilage graft, and 1 injection of hydroxy apatite. After an average follow-up of 22 ± 14 months, 16 cases (53%) achieved complete symptom relief, while 8 cases (26.6%) reported partial relief. Additionally, 11(36%) cases required multiple surgeries. No specific surgical technique demonstrated superiority. Quality of life improved in 77% of cases based on 10 out of 13 GBI collected. Recurrence of PET symptoms occurred on average 10.6 ± 9.7 months after initial surgery, with an estimated global risk of 75% at 3 years. Transient serous otitis media was observed in only 4 cases (13.3%).
CONCLUSIONS: Surgical intervention for PET was found to be effective, achieving complete symptom relief in 53% of cases and significantly improving quality of life 2 years post-surgery. However, a substantial portion of cases necessitated one or more re-interventions. The durability of effectiveness appears to diminish over time.

OBJECTIVE: This study aimed to identify what proportion of middle-ear surgery patients utilise the internet for information and to characterise which resources and media formats are used and for what durations.
METHODS: A single-arm, retrospective cohort study was performed using an online survey of English-speaking patients who underwent middle-ear surgery over a three-year period across two otology practices.
RESULTS: Of 260 invitees, 165 responded. A total of 122 used online resources: 9.8 per cent used online resources for less than 15 minutes, 27.0 per cent used them for 15 to 29 minutes, 27.0 per cent used them for 30 to 59 minutes and 36.1 per cent used them for 60 minutes or more. Of online users with complete responses (108 of 122), the most used resources (used for 12 minutes or more) were: written information (73.1 per cent); surgeons\' websites (55.6 per cent); pictures, diagrams or photos (42.6 per cent); videos (37.0 per cent); and social media (10.2 per cent).
CONCLUSIONS: At least 46.9 per cent of patients undergoing elective ear surgery use online resources. Most time is spent using written information, pictures, diagrams, photos and videos. Therefore, it is increasingly essential that accurate and informative resources in these formats are readily available online.

Quantify the learning curve for endoscopic ear skills acquisition in otolaryngology residents using a simulator. The secondary objective was to determine if demographic factors or previous endoscopic experience influenced skill development.
Prospective, multicenter study. Resident participants each completed 10 amassed trials using a validated endoscopic ear skill trainer.
Two academic teaching hospitals.
Otolaryngology residents.
Trial completion times; rate of improvement over time.
Thirty-eight residents completed the study, 26 from program A and 12 from program B. Fifteen participants were women and 23 were men. Mean age was 30 years old (range 26 to 34 years). Previous experience with otoendoscopy (B = -16.7, p = 0.005) and sinus endoscopy (B = -23.4, p = 0.001) independently correlated with lower overall trial times. Age, gender, postgraduate year, handedness, interest in otology, and video gaming were not associated with trial times. On multivariate logistic regression, resident completion times improved with trial number, and residents without previous endoscopy experience improved at a faster rate than those with experience ( p < 0.001).
Novice surgeons may acquire basic endoscopic ear experience with self-directed simulation training. The learning curve for transcanal endoscopic ear surgery is comparable to those demonstrated for other otologic surgeries, and specific task competencies can be achieved within 10 trials, suggesting that previous experiences, or lack thereof, may not dictate the ability to acquire new skills. There may be a translational value to previous endoscopic sinus experience on learning transcanal endoscopic ear surgery.

OBJECTIVE: Facial canal dehiscence (FCD), typically found in the tympanic segment, is a risk factor for facial nerve injury. An imaging scoring method was proposed to identify FCD based on ultra-high-resolution CT.
METHODS: Forty patients (21 females and 19 males, mean age 44.3 ± 17.4 years), whose tympanic facial canal (FC) was examined during otological surgery, were divided into the FCD group (n = 29) and the control group (n = 11) based on surgical findings. Imaging appearance of tympanic FC was scored 0-3: 0 = no evident bony covering, 1 = discontinuous bony covering with linear deficiency, 2 = discontinuous bony covering with dotted deficiency, and 3 = continuous bony covering. Both lateral and inferior walls were assigned a score as LFCD and IFCD, respectively. An FCD score was calculated as LFCD + IFCD. The diagnostic value of the FCD score was tested using the ROC curve.
RESULTS: The inter-observer agreement was moderate for the lateral wall (Cohen\'s κ coefficient 0.416, 95% CI 0.193-0.639), and good for the inferior wall (Cohen\'s κ coefficient 0.702, 95% CI 0.516-0.888). In the FCD group, the most common appearance for both walls was discontinuous bony covering with linear deficiency (LFCD = 1, 22/29, 75.9%; IFCD = 1, 15/29, 51.7%). An FCD score of less than 4 was associated with high sensitivity (0.82) and specificity (0.93) for identifying FCD, with an AUC of 0.928.
CONCLUSIONS: Using the proposed scoring method, FCD score < 4 could identify FCD of the tympanic segment with high concordance with surgical findings.
CONCLUSIONS: • Imaging appearance of the tympanic facial canal (FC) is divided into four types based on ultra-high-resolution CT images. • The most common appearance of FC with facial canal dehiscence (FCD) is discontinuous bony covering with linear deficiency. • An FCD score, consisting of scores of the lateral and inferior walls, less than 4 is highly indicative of FCD.

BACKGROUND: Transcanal endoscopic ear surgery enables surgeons to operate with few blind areas, and using an angled endoscope expands its usefulness. We have previously reported the usefulness of a 70° endoscope in transcanal endoscopic ear surgery, but no quantitative study has been performed. We quantitatively clarified the difference between a microscope and various endoscopes in the bone removal region, especially a 70° endoscope, in the transcanal approach.
METHODS: A temporal bone model for ear surgery training was used to compare the use of a microscope, a 0° endoscope, a 30° endoscope, a 45°endoscope, and a 70° endoscope. The drilled mass during atticotomy or atticoantrostomy and the size of the reconstructed graft were measured when the formed pseudo-lesion was removed.
RESULTS: The amount of bone excision was 57% and the size of the reconstructed graft was 32% when using a 70° endoscope compared with the case of using a microscope, both of which were the smallest of the various endoscopes.
CONCLUSIONS: It was quantitatively shown that using a 70° endoscope in transcanal endoscopic ear surgery reduced the bone removal region. We believe that a 70° endoscope is a useful tool for performing a minimally invasive and reliable surgery.

OBJECTIVE: The relatively new technique of trans-canal endoscopic ear surgery (TEES) when compared to microsurgery for ossiculoplasty has advantages of better visualization and no external incision but also has the disadvantage of being a one-handed procedure. Our study aimed to compare audiometric outcomes following ossiculoplasty performed via TESS with results of microsurgery.
METHODS: Data from a prospective audit of 157 consecutive patients who underwent ossiculoplasty by a single otologist from 2009 to 2018 was analyzed. TEES was introduced in the department in 2014; therefore, all patients before this period underwent microsurgery. Patients were classified by surgical approach, TEES, or microsurgery. Audiological outcomes were recorded at 3 and 12 months postoperatively and compared to pre-operative levels. Other variables included were the condition of stapes and reconstruction material used.
RESULTS: Of the 157 cases, 50 were TEES and 107 were microsurgery (81 microscope only and 27 combined with endoscope). There was statistically significant improvement (p < 0.001) in AC (43.4 dB pre-operatively, 36.2 dB postoperatively), BC (20.3 dB pre-operatively, 17.6 dB postoperatively), and ABG (21.8 dB pre-operatively, 16.7 dB postoperatively) in the total cohort. Both groups achieved an ABG better than 20 dB; 72% in TEES, 73% in the microscopic group, and there was no significant difference. There was no change in hearing at 12 months when compared to 3 months. No statistically significant difference was noted based on stapes condition, type of material used for ossiculoplasty, or tympanic membrane graft.
CONCLUSIONS: TEES is safe and as effective as microsurgery in ossiculoplasty with possibly much less pain and morbidity.
METHODS: