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INTRODUCTIONStapedectomies and stapedotomies are currently done in most centers in the world under the microscope. The access to article's content is restricted to members of ABORL-CCF (Brazilian Association of Otolaryngology and Cervico-Facial Surgery). However, the microscope has some limitations and may cause complications such as damage to the chorda tympani nerve.
Although many have been the techniques already described in recent years, results continue to be excellent with very low risk of complications1-3.Surgical microscopes provide a good quality amplified image in a straight line. There are just a few cases and no series published on the use of sino-nasal endoscopes in stapedotomies. However, such limitation inherent to the equipment limits visual field when we make exclusively transcanal access in the narrowest segment of the external ear canal. Objectives: a) To investigate the feasibility of using sino-nasal endoscopes in stapedotomies, focusing on the visualization of important structures. In winding canals, this may represent an even greater limitation, requiring other access pathways to the middle ear, behind the ear or modified transcanal approaches3,4.Even with extended access to the middle ear, one of the important steps in performing stapes surgeries under the microscope is to partially remove the bone wall of the most medial segment of the external acoustic meatus. Due to its limited diameter, these endoscopes have a very restricted visual field, differently from the regular endoscopes used in sinonasal surgeries2-4.Sinonasal scopes with 4mm in diameter and 18cm length, with wide-angle lens and different angles, allow for an amplified image which can be quickly modified by advancing or pulling the instrument back2.
The anatomical conditions of the oval window niche and surgical steps were described and used to assess possible benefits of such procedures. Results: The surgeries were performed with endoscopes only and all relevant anatomical structures were visualized without difficulty. No complications were observed and 14 of the 15 patients reported improvement of their hearing, confirmed by postoperative audiological tests.
The audiometric tests were held between 30 and 40 days after the surgeries and the complications were listed according to reports from the patients in medical charts and in the postop visits, held 7, 15 and 45 days after surgery.Surgical techniqueAll procedures were carried out under hypotensive general anesthesia. Conclusion: Totally endoscopic stapes surgeries are technically feasible, safe and promising.
The patients were all placed in the same position for conventional ear surgeries done under the microscope. In this small series, the main advantages were: virtually no trauma to the chorda tympani nerve and excellent vision. The disadvantages were the lack of stereoscopic vision, having to work with one hand only and the learning curve.

We used basically the same techniques and instruments used in conventional ear surgeries, except for the use of the 4mm in diameter and 18cm long endoscope with 0 to 30 degrees, curved micro aspirators and curved-tip micro scissors.Figure 1. We did not inject locally.With the 0 or 30 degree angle endoscope we raised a tympanic-meatal flat in the posterior region of the external acoustic meatus. We carried out vertical (6 and 12 hours) incisions and one horizontal incision which merged them posteriorly at about 1 to 1.5 cm from the tympanic membrane.
We paid special attention to the position of the facial nerve, probing for a possible positioning or a prolapse of the nerve over the stapes footplate.Figure 2. We can see important middle ear structures, such as the long process of the incus (RLB), chorda tympani nerve (CT) and in some cases, we can also see the Jacobson nerve (NJ).A dedicated test with the ossicular chain was done in order to check for stapes fixation. The stapes tendon was cut with a micro-knife or a curved micro-scissors and the incus-stapes joint was cut.The stapes superstructure was carefully fractured in the anterior and posterior crura under direct endoscopic view (Figure 3) and removed, leaving the footplate fully exposed. A: facial nerve canal (NF), long process of the incus (RLB), pyramidal eminence (EP) with its tendon and its anterior and posterior crura (*). The prosthesis was placed in this hole and fit along the long process of the incus (Figure 4).Figure 4. Endoscopic view (30 degree instrument) of the Teflon prosthesis (P) in place.In order to properly position the prosthesis, we previously opened its fitting point in the long process of the incus with a small stylet or a micro forceps. After such opening, with the micro-forceps, we tried to place the prosthesis directly in the hole created in the stapes footplate. After positioning it in the hole, with the stylet we fit the prosthesis to the long process of the incus. Since we used a TeflonĀ® prosthesis, a material which does not have memory, it was not necessary to tighten the prosthesis in the long process of the incus.We avoided frequent suctions, especially after opening the footplate, in order to avoid post-op complications, such as vertigo and cochlear damage. The malleus was palpated in order to rule out head fixation and make sure the entire ossicular chain moves all the way to the prosthesis. In order to seal the footplate, we used small pieces of dry GelfoamĀ®, placed with the micro scissors.
No specific medication was prescribed for this patient, who reported substantial improvement in his postop visit, 15 days after the procedure.Another patient, in whom we had difficulty in placing the prosthesis, there was postop vertigo. Fax of the audiogram belonging to the patient submitted to left ear fully endoscopic stapes surgery.
However, they all use the surgical microscope6.Endoscopes are being increasingly used in middle ear surgery.

Many anatomy-based papers have been published, showing the possible advantages of using endoscopes in ear surgery, especially due to a better visualization of the structures and recesses within the tympanic cavity (Figure 6).Figure 6. Endoscopic image of the anatomical dissection after removal of the ear drum, with a 30 degree scope, showing the type of image which can be achieved by means of endoscopic approaches. However, this implies some degree of chorda tympani nerve manipulation, or even totally damaging it. In some patients, this maneuver may be more difficult for anatomical reasons, causing damage to the facial nerve when further burring is needed.In the fully endoscopic stapes surgeries from our series, we obtained excellent visualization with the 30 degrees angled endoscope in the oval window niche, the pyramidal eminence, facial nerve and long process of the incus, without the need to cut or burr this posterior wall of the external acoustic meatus. Nonetheless, three patients had their chorda tympani nerve manipulated, because when we raised the tympanic-meatus flap, this nerve was right in front of our visual field, preventing us from seeing the oval window.
We handled the nerve very carefully, but even then one patient complained of temporary taste changes.That fact that it is not in all cases that we have to burr or curette the posterior wall of the external acoustic meatus, and very little or no touching the chorda tympani nerve, seems to be one of the pros of the endoscopic technique when compared to the microscopic approach. It may be because of the fact that we do not curette and also because we make broad tympanic-meatal flaps, there were no patients with postop tympanic perforations.Another interesting point, it is a single-handed work, which is necessary during fully endoscopic stapes surgery, since the surgeon holds the endoscope with one hand and works with the other. During stapes surgeries done under the microscope, the surgeon holds the instruments with one of the hands, and the ear speculum with the other. Except for the curved micro scissors and curved micro aspirators, the other instruments were the same.
However, it is worth stressing that a new set of instruments must be developed for fully endoscopic stapes surgery, as well as for other endoscopic ear surgeries.We used the same endoscopes used in nasal surgeries, with 4mm in diameter and 18cm long. Figure showing how the endoscope is positioned inside the external auditory canal, as well as hand position - one holding the endoscope and the other holding the instruments. In the meatus, special care must be taken in order to avoid unnecessary bleeding caused by trauma in the region. In the middle ear, special care must be taken considering all potentially important structures, such as the ossicular chain, the facial nerve, and others. In one patient, despite his subjective improvement in hearing, it was not confirmed by the audiometric exam carried out between 30 and 45 days after the surgeries.
Endoscopic transtympanic tympanoplasty in the treatment of conductive hearing loss: early results.

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