 Hello, I am Dr. Rajiv, consultant ENT at Manipal Hospital, Malaysia, Northside. Let us understand endoscopic tympanoplasty. All of you must be familiar with this picture, which is a line diagram depicting the parts of the ear. The ear has three parts, the outer ear and the middle ear and the inner ear. The outer ear consists of the pinna and the external artery canal. The middle ear is separated from the outer ear by tympanic membrane or ear drum. And the inner ear consists of the sense organs. When we hear the sound passes through the external artery canal, strikes the ear drum, causes it to vibrate and transmits the vibrations through the middle ear. The middle ear is connected behind and in front by means of tubes to the bone behind the ear, which is a spongy matrix and to the back of the nose by the eustachian tube. There are many diseases of the ear. The commonest is called chronic suppurative otitis media or chronic otitis media, which is a chronic inflammatory disease of the middle ear. It is characterized by the perforation of the ear drum, as you can see in this picture. The traditional approach to operate on the ear has been to use an operative microscope and the operative microscope as you all know, it collects light and magnifies it and gives us a magnified three-dimensional view. And the problem with the microscope is that it only collects the light, which passes in a straight line and therefore, since the external artery canal is crooked as you remember from the first slide, we cannot directly view the middle ear through the external artery canal. Therefore, several approaches were devised such as behind the ear or which is known as the post oral approach, the end oral approach which is by making an incision between the two parts of the ear and the trans canal approach which was technically difficult and made use of certain equipment such as oral specular. Endoscopy is a relatively new technique, relatively meaning it is more than 100 years old the first probable endoscope was used in 1805, but the first commercial endoscope was available only in 1960s and commercial production started in 1967. It was used mainly for endoscopic endonazole surgery in otolaryngology since the 1970s and the same instrument was used to modify the ear surgeries since the early 90s. However, innovations may be fast, but inventions may be fast, but innovations always take time especially in medicine because we do not want to harm the patient. One of the basic principles of medicine is normal efficiency and so on, no harm. So it takes time to adapt surgical techniques to the new inventions. The endoscope has off late revolutionized ear surgery and it is it has been stated that in clear contrast to the impact of endoscope in most surgical disciplines the practice of ear surgery has changed little and it continues to be the domain for microscope till now. However, the endoscope provides several advantages over the conventional operative microscope with ear surgery. In this slide, we can see that the endoscope provides a wide endoscopic field of view compared to the microscopic view which is limited by the narrowest segment of the external audit canal. To approach the middle ear if we use a microscope, we have to work around the limitations of the normal anatomy either by making a post oral incision or using specular to dilate the external audit canal and all these approaches end up giving us limited approach or limited access to the middle ear. The advantages of the endoscope include magnification. If we go closer to the middle ear structures, the magnification is much better than the microscope. The cost of endoscopy is lower. The endoscopic systems are more portable. It is much better or easier to train students and it is much better to document surgeries because of the clear view and technical availability of recording facilities. There is reduced postoperative pain because of reduced incision and dissection which is used in microscopic approach and most probably there will be a reduced operative time which depends on the experience of the surgeon. In my experience for most of the surgeries, endoscopic ear surgery reduces the operative time. There are certain limitations if there is bleeding or if there is a very narrow external audit canal whether when there is infection of the outer ear then in such conditions there can be difficulty in endoscopic ear surgery. Suppose there are some conditions which we call as osteoma which narrows the external audit canal very significantly then the endoscopic surgery is more difficult. Endoscopic surgery needs a learning curve a person who is used to microscopic ear surgery cannot immediately adapt to endoscopic ear surgery because there is a lack of depth perception and there is some edge distortion in the image provided by the endoscope. This is partially overcome by various techniques which we use which are known as dynamic endoscopy. So the endoscopic surgeon traditionally has to use one hand for surgery and the other hand is used to hold the endoscope compared to microscopic surgery where both hands are used therefore the surgeon will need some amount of skill and patience to use the endoscope for surgery. To overcome these limitations of endoscopic surgery we depend on proper case selection using appropriate instrumentation and with experience we can expand the indications of endoscopic ear surgery. I have been operating with the endoscope more than 15 years now and I audited some of the surgical cases which I operated with the endoscope in 2015 which was published in 2016 and I could find that the surgery was equal in efficiency or success compared to microscopic surgery and even in revision cases it was quite useful. I have prepared a small video you can go through the various surgical steps which are done in microscopic and endoscopic surgery and you can see the difference in the dissection which will lead to improved patient outcomes. So here is a small video I will just play the video for you and you can see in the video there are two surgeries going on simultaneously on the right side of the screen you can see the endoscopic surgery on the left side you can see the microscopic surgery the first step will be to infiltrate the external audit canal with anaesthetic and adrenaline solution this is done to reduce the bleeding during surgery. I must warn you that the surgical pictures of course will have a little bit of blood but I have edited them to make them of an appropriate length and it is much easier to understand this way. So now after infiltration in microscopic ear surgery we take a large post oral incision here you can see the incision being taken the incision is not required in endoscopic ear surgery in endoscopic ear surgery we only take a small incision either inside the canal or in the hairline for the purpose of taking the graft but this post oral incision which is being shown on the video is not required for endoscopic ear surgery. So here in the microscopic ear surgery after making the post oral incision we can take a small piece of fascia for purpose of repairing the hole in the ear drum the same incision is deepened after taking the graft you can see the graft stretched out and see all this dissection is not required in endoscopic ear surgery that is why I have shown only this for the microscopic ear surgery. So we are going to elevate the periosteum of the bone and then cut the external artery canal the number of incisions also is lesser for endoscopic ear surgery after we do that we have to remove the ingrown skin from the edges of the perforation the view as you can see in the endoscopic picture is much better a 360 degree view and we can go closer or come away from the site of surgery to get a three-dimensional feel whereas in the microscopic surgery the field of view is quite limited after taking the incision in the canal in both procedures we elevate the skin and periosteum of the canal the incisions are slightly different for endoscopic and microscopic ear surgery as you can see in the microscopic ear surgery the view is limited whereas in endoscopic ear surgery quite wide angle view after lifting away the flap of skin of the external artery canal and the tympanic membrane if there is any disease in the middle ear it is cleared up by the surgeon so in the endoscopic surgery you can see that there is thickened mucosa which is being cleared up the bones of the middle ear which are the maleus inciscent stapes are exposed the joints are checked for mobility and after that we prepare the middle ear for grafting then the graft is placed the manipulation of instruments is easier for the conventionally trained surgeon with the microscopic surgery but the endoscopic surgery is not too bad it can be done with little bit of training and experience that's one of the reasons why all surgeons don't do endoscopic ear surgery once the graft is in place we put back the remaining ear drum and skin of the external artery canal and seal the surgical site by using an absorbable surgical material you can see that the outcome is looking much better in the endoscopic ear surgery not only that you can clearly see the graft in place the surgery was over faster than the microscopic ear surgery yes you can see we have reached a similar stage now in the microscopic case since there are no incisions in the patient who underwent endoscopic ear surgery there is no need to stitch inside the canal post-operative result is shown in this slide in the picture to the right you can see the healing tympanic membrane with the graft in place in the endoscopic case on the left side in this particular patient I taken an incision within the hairline which is not visible after surgery so in conclusion we can understand that there are lot of changes going on in medicine which some of which are related to use of new technologies such as endoscopes and innovation in surgery is a continuous process it needs some amount of training and experience and we can use these new technologies to give a better result in terms of reduced post-operative pain and faster healing thank you for watching this presentation if you have any questions queries or doubts you can put up the same in the comments section and I will answer it as soon as possible if you felt that this video was of benefit to you please share it with others who may find it of good use so that everyone is benefited with these new advances thank you for your kind listening