UT Southwestern surgeons help pioneer minimally invasive ear surgery

UT Southwestern Medical Center surgeons are helping to pioneer a trend that extends the advantages and benefits of minimally invasive surgery to patients who need middle ear surgery.

Head and neck surgeons at UT Southwestern have now performed more than 200 minimally invasive surgeries using endoscopic techniques to replace the microscopes traditionally used for middle ear surgeries. The minimally invasive techniques can be used to correct problems such as holes in the eardrums, cholesteatoma (skin cysts that form in the ear), and rare tumors that can form in the ear. The advantages of using endoscopes over the traditional behind-the-ear approach include improved visualization for surgeons, no need for an incision behind the ear, and less pain after surgery.

"Traditionally, we have done ear surgery by making an incision behind the ear using surgical microscopes. We've been doing that since the '50s and '60s, but more recently there's been a push to do more minimally invasive surgery," said Dr. Brandon Isaacson, Associate Professor of Otolaryngology. "What we do is operate through a natural orifice, through an external auditory canal. The potential benefits include faster recovery time, typically less pain because you don't have to make a big incision behind the ear and pull the ear forward, and far superior views for the surgeon with the endoscope than anything else that we have with microscopes."

The technique, called transcanal endoscopic ear surgery or TEES, uses a camera attached to an endoscope. This surgical aid consists of a narrow, rigid metal tube filled with fiber optic cables that transmit light and images to a TV screen. TEES allows the surgeon to see around corners and only requires a small incision inside the ear canal, he said.

"You can basically use it for issues related to the eardrum, ear canal, or middle ear. You can fix holes or perforations in the eardrum. You can use it for tumors in the ear, called glomus tympanicum, and for cholesteatoma. TEES also can be used for people who have conductive hearing loss, which usually results from problems with one or more of the little ear bones (malleus, incus, and stapes) that connect the eardrum to the inner ear. All these can be addressed with the endoscope."

Minimally invasive surgery has expanded broadly across various surgical specialties, but adoption for middle ear surgery has been slower, and does require some additional training.

"There's definitely a learning curve. You can use the same endoscopes you use for sinus surgery, although there is a specialized one that's shorter than a typical-sized endoscope," said Dr. Isaacson, who trained in Toronto and is now teaching UT Southwestern residents the specialized techniques. "We try to push boundaries and like to try to stay ahead of the curve in adopting new techniques."

UT Southwestern has become one of the leading centers to use the minimally invasive techniques, along with Vanderbilt University and Harvard's Massachusetts Eye and Ear hospital, said Dr. Isaacson, a member of the International Working Group on Endoscopic Ear Surgery (IWGEES), which is helping to pioneer the technique internationally.

The 1st World Congress on Endoscopic Ear Surgery was held in April in Dubai, United Arab Emirates. The technique will be highlighted during the upcoming annual meeting of the American Academy of Otolaryngology - Head and Neck Surgery (AAO-HNS) in Dallas.

"The advantage of the surgery is the visualization you get. You can look around corners. With the microscope, you only get line of sight, and there are lots of different crevasses within the middle ear space that are really difficult to see with the microscope. But you can see pretty easily with an endoscope," said Dr. Isaacson, who is involved in several studies designed to evaluate and compare effectiveness of the endoscopic technique against traditional methods. "I'm not saying it's going to replace the microscope, but it's another tool that we have to address these types of issues for our patients."