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KTP-laser--assisted endoscopic management of glomus tympanicum tumors: A case series.

Abstract

Endoscopic technology is widely used in rhinology and anterior skull base surgery, but it has been less quickly incorporated into otologic practice. The design of the instrumentation forces surgeons to work one-handed and limits depth perception. Nevertheless, endoscopy also offers wide fields of view and access to spaces that are typically difficult to visualize. Its advantages have broadened the type and extent of operations that can be performed via the ear canal. We describe a method of endoscopic resection of glomus tympanicum tumors in 5 adults who had undergone endoscopic or endoscopyassisted resection. A successful resection was achieved in all patients--exclusively via the ear canal in 4 of them. A KTP laser was used to address the tumor's vascular supply. Attachment of a neonatal feeding tube to the endoscope for use as a suction catheter obviated the need to repeatedly switch instruments while using the laser. At a minimum of 12 months of follow-up, all patients were free of recurrence. Postoperative audiometry detected no significant adverse hearing outcomes in any patient. We conclude that the minimally invasive endoscopic transcanal approach is a feasible techniquefor addressing middle ear tumors. We have also developed a method that allows surgeons constant use of the KTP laser to resect a glomus tympanicum tumor.

Introduction

Since its introduction to otologic practice in the 1960s, (1) endoscopic instrumentation has become increasingly popular in the management of middle ear diseases. Proponents of the endoscopic technique favor the wide surgical view it provides, its minimally invasive nature, and the opportunity it provides to maneuver into spaces that are typically difficult to visualize. Furthermore, adding high-definition imaging to the procedure has transformed the applications of endoscopic surgery, making it a viable and comparable alternative to traditional microscopic techniques.

While endoscopy is ubiquitous in sinus surgery, its incorporation into clinical otologic practice has been more gradual. The design of the instrumentation forces surgeons to work one-handed and limits depth perception. The diameter of the endoscope often can preclude fine manipulations through the ear canal, and the endoscope poses a risk of thermal injury to the canal skin. Endoscopy is not routinely introduced during training, since excellent outcomes are being achieved with traditional microscopic techniques.

Endoscopic surgery has been applied to a number of otologic operations, including tympanoplasty, ossiculoplasty, stapedotomy, cholesteatoma surgery, and cochlear implantation. (2-6) However, few authors have described the application of this technique to address middle ear lesions, including glomus tympanicum tumors. (7) Glomus tympanicum tumors are the most common of the benign middle ear lesions. (8)

Middle ear paragangliomas are slowly growing, benign vascular lesions that arise from the tympanic plexus on the cochlear promontory. (8) They have historically been addressed via a microscopic approach through either the canal or a postauricular incision. (9) Transcanal endoscopic ear surgery offers a novel and often more conservative approach to the middle ear and temporal bone. It provides surgeons with a wide field of illumination and more complete visualization of the lesion.

We describe the excision of glomus tympanicum tumors via an endoscopic transcanal technique in 5 patients. Tumor excision was assisted by KTP laser treatment and a novel smoke-management system.

Case series

Patients. During 2015 and 2016, the senior author (H.S.) operated on 5 patients--3 men and 2 women, aged 38 to 77 years (table)--who had a glomus tympanicum tumor (figure 1). Preoperatively, all patients underwent either computed tomography (CT) of the temporal bone or magnetic resonance imaging (MRI) of the skull base. In 4 patients, imaging demonstrated the presence of a Fisch type A tumor that was limited to the middle ear cleft; the remaining patient had a Fisch type B tumor that diffusely involved the tympanomastoid complex. Preoperative audiometry also was obtained in all cases.

Surgical methods. All operations were performed with general anesthesia. A 3.0-m (length: 14 cm) and a 2.7-m (18 cm) Hopkins 0[degrees] telescope was used for surgical excision, followed by use of a 3.0-m 30[degrees] Hopkins endoscope for inspection and confirmation of complete removal. A high-definition camera head and monitor facilitated image projection. The light intensity was set no higher than 60% to avoid thermal injury to the canal and middle ear structures.

The ear was prepped and draped sterilely; it was not Necessary to shave the post auricular hair. Infiltration with 2% lidocaine with 1:100,000 epinephrine was performed at the vascular strip and inferior canal until blanching was seen at the tympanic membrane. The radial canal incisions were made at 12 and 4 o'clock to ensure adequate exposure of the lesion on the promontory in the anterior inferior quadrant. A tympanomeatal flap was raised, and the tumor was exposed (figure 2, A). The middle ear was inspected, and the extent of the lesion noted. A KTP laser (Iridex; Mountain View, Calif.) was used on the ultrapulse setting at 4 W to address the base of the lesion where the vascular supply was evident (figure 2, B).

It is critical to consider the location of the lesion in relation to the ossicles and tympanomeatal flap, both of which are prone to injury during this step. A 3.5-Fr neonatal feeding tube was affixed to the 2.7-mm endoscope with a Steri-Strip to allow for simultaneous visualization and suctioning (figure 3).

Once the vessels had been adequately addressed, the lesion was grasped with a cupped forceps and gently avulsed from the promontory. Cottonoid pledgets soaked in epinephrine were applied to halt any additional bleeding, which was minimal. Inspection was performed with the 30[degrees] endoscope to ensure that no other lesion or abnormal pathology was present. Several pieces of Gelfoam soaked in ofloxacin were placed in the middle ear to support the tympanic membrane. The tympanomeatal flap was unrolled from the anterior canal and replaced in its preoperative position. The canal was filled with Tisseel, and a dry cotton ball was placed in the concha.

Results

All procedures were completed on an outpatient basis with limited blood loss (<25 ml). There were no intraor postoperative complications. In 4 cases, total resection was achieved endoscopically without the need for a postauricular incision. For the patient with the Fisch type B tumor, we had to use a combined endoscopic and postauricular approach because of the extent of disease.

During a follow-up of 12 to 38 months, all patients exhibited clear middle ears with no evidence of tumor on endoscopic otoscopy. There was no significant change from preoperative baseline in pure-tone average or speech discrimination score in any patient.

Discussion

Endoscopic instrumentation has facilitated the evaluation of previously challenging spaces and expanded the types and extent of procedures that can be performed via an exclusively transcanal approach. Its surgical application has been described in a number of pathologies, most notably cholesteatoma, tympanic membrane perforation, ossicular chain disruption/ fixation, and cochlear implantation. (2,4,5,10,11) Surgical outcomes are fundamental to the comparison between endoscopic and microscopic ear surgery.

Perhaps the best-described application for endoscopic ear surgery has been cholesteatoma removal. With regard to disease eradication, a systematic review by Presutti et al found a comparable rate of residual and recurrent cholesteatoma between cases treated entirely endoscopically or with endoscopic assistance (9.3%) and cases treated with classic microscopic surgery. (12) In other studies, the incidence of residual cholesteatoma discovered on endoscopy after microscope-only tympanomastoidectomy has ranged between 17 and 31%. (13-15)

In a study directly comparing the two techniques in 59 pediatric ears, Marchioni et al found that endoscopic visualization facilitated a lower rate of residual and recurrent cholesteatoma (19.3 and 12.9%, respectively) than did microscopic canal-wall-up mastoidectomy (34.4 and 17.2%, respectively). (3) Additionally, the ossicular chain was preserved in 42% of the endoscopic cases, compared with only 10% of the microscopic cases. The mean improvement in pre- and postoperative pure-tone averages was similar in the two groups.

Marchioni et al first reported the application of endoscopic instrumentation to middle ear tumors in 2013. (16) They described the resection of paragangliomas, carcinoid tumors, and osteomas from the middle ear. In the absence of significant contraindications, surgical removal is the most effective treatment for these lesions. Stereotactic radiosurgery or just simple observation may be appropriate for patients who are not amenable to or who are at too high a risk for general anesthesia. (9,17) For smaller tumors limited to the mesotympanum, a transcanal microscopic procedure has traditionally been employed. However, larger lesions that extend into the protympanum or hypotympanum may require a postauricular approach. (18) As reported by Killeen et al, the endoscope provides superior visualization of these spaces and may, in some instances, allow surgeons to avoid an incision. (19)

One of the challenges reported with endoscopic ear surgery that is particularly pertinent to these tumors is that surgeons must operate with only one hand, which in this specific context limits their ability to suction blood and smoke during dissection. We have proposed a solution to this, which involves the attachment of a neonatal 3.5-Fr feeding tube to the endoscope with a Steri-Strip. This has obviated the need to exchange instruments frequently, it has improved visibility, and it has shortened operative time. Furthermore, although limited by a lack of depth perception, endoscopic approaches do afford a wider view that can often facilitate resection while avoiding a postauricular incision.

In our series, 3 of the 5 tumors that had extended into the protympanum were visualized entirely and removed safely. Clearly, an endoscopic approach is not appropriate for larger tumors, and discretion must be used to determine the appropriateness of technique in each case.

In conclusion, surgical resection is the preferred treatment for paragangliomas. In our study, total resection was successful in all 5 patients who underwent endoscopic or endoscopy-assisted resection of their paraganglioma. We observed no evidence of recurrence on follow-up. The treatment of paragangliomas of the middle ear is but one illustration of the expanding application of endoscopic instrumentation in otology.

From the Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, Calif.

Corresponding author: Julia E. Noel, MD, Department of Otolaryngology Head and Neck Surgery, Stanford University School of Medicine, 801 Welch Rd., Stanford, CA 94035. Email: jtomlin2@stanford.edu

Julia E. Noel, MD; Hamed Sajjadi, MD

References

(1.) Mer SB, Derbyshire AJ, Brushenko A, Pontarelli DA. Fiberoptic endotoscopes for examining the middle ear. Arch Otolaryngol 1967;85(4):387-93.

(2.) Alicandri-Ciufelli M, Marchioni D, Kakehata S, et al. Endoscopic management of attic cholesteatoma: Long-term results. Otolaryngol Clin North Am 2016;49(5):1265-70.

(3.) Marchioni D, Soloperto D, Rubini A, et al. Endoscopic exclusive transcanal approach to the tympanic cavity cholesteatoma in pediatric patients: Our experience. Int J Pediatr Otorhinolaryngol 2015;79(3):316-22.

(4.) Hunter JB, O'Connell BP, Rivas A. Endoscopic techniques in tympanoplasty and stapes surgery. Curr Opin Otolaryngol Head Neck Surg 2016;24(5):388-94.

(5.) Orhan KS, Polat B, Celik M, et al. Endoscopic-assisted cochlear implantation: A case series. J Int Adv Otol 2016;12(3):337-40.

(6.) Yong M, Mijovic T, Lea J. Endoscopic ear surgery in Canada: A cross-sectional study. J Otolaryngol Head Neck Surg 2016;45:4.

(7.) Isaacson B, Nogueira JF. Endoscopic management of middle ear and temporal bone lesions. Otolaryngol Clin North Am 2016;49(5): 1205-14.

(8.) Carlson ML, Sweeney AD, Pelosi S, et al. Glomus tympanicum: A review of 115 cases over 4 decades. Otolaryngol Neck Surg 2015;152(1):136-42.

(9.) Sweeney AD, Carlson ML, Wanna GB, Bennett ML. Glomus tympanicum tumors. Otolaryngol Clin North Am 2015; 48(2):293-304.

(10.) Kiringoda R, Kozin ED, Lee DJ. Outcomes in endoscopic ear surgery. Otolaryngol Clin North Am 2016;49(5):1271-90.

(11.) Marchioni D, Alicandri-Ciufelli M, Molteni G, et al. Endoscopic tympanoplasty in patients with attic retraction pockets. Laryngoscope 2010; 120(9): 1847-55.

(12.) Presutti L, Gioacchini FM, Alicandri-Ciufelli M, et al. Results of endoscopic middle ear surgery for cholesteatoma treatment: A systematic review. Acta Otorhinolaryngol Ital 2014;34(3):153-7.

(13.) Good GM, Isaacson G. Otoendoscopy for improved pediatric cholesteatoma removal. Ann Otol Rhinol Laryngol 1999;108(9):893-6.

(14.) Sarcu D, Isaacson G. Long-term results of endoscopically assisted pediatric cholesteatoma surgery. Otolaryngol Head Neck Surg 2016;154(3):535-9.

(15.) Farahani F, Shariatpanahi E, Jahanshahi J, Poorolajal J. Diagnostic performance of endoscopic and microscopic procedures for identifying different middle ear structures and remaining disease in patients with chronic otitis media: A prospective cohort study. PLoS One 2015;10(7):e0132890.

(16.) Marchioni D, Alicandri-Ciufelli M, Gioacchini FM, et al. Transcanal endoscopic treatment of benign middle ear neoplasms. Eur Arch Otorhinolaryngol 2013;270(12):2997-3004.

(17.) Semaan MT, Megerian CA. Current assessment and management of glomus tumors. Curr Opin Otolaryngol Head Neck Surg 2008;16(5):420-6.

(18.) Alaani A, Chavda SV, Irving RM. The crucial role of imaging in determining the approach to glomus tympanicum tumours. Eur Arch Otorhinolaryngol 2009;266(6):827-31.

(19.) Killeen DE, Wick CC, Hunter JB, et al. Endoscopic management of middle ear paragangliomas: A case series. Otol Neurotol 2017;38(3):408-15.

Caption: Figure 1. Endoscopic view shows a representative glomus tympanicum tumor behind an intact tympanic membrane.

Caption: Figure 2. A: Intraoperative endoscopic view shows a glomus tumor on the cochlear promontory after elevation of the tympanomeatal flap. B: The KTP laser is used to address the vascular base of the tumor.

Caption: Figure 3. A 3.5-Fr neonatal feeding tube is attached to the distal end of the endoscope to facilitate suctioning during KTP-laser-assisted reduction of the tumor.
Table. Patient demographics, hearing outcomes,
intraoperative blood loss, and follow-up

Pt.   Age/sex   Side    SRT (dB)

1     55/F      Right   Preop: 10
                        Postop: 10
2     67/M      Right   Preop:
                        Postop: 20
3     49/M      Right   Preop:
                        Postop: 10
4     38/M      Left    Preop: 5
                        Postop: 5
5 *   77/F      Left    Preop: 20
                        Postop: 20

Pt.   Age/sex   SDS (%)         EBL (ml)   F/U (mo)

1     55/F      Preop: 100      25         16
                Postop: 100
2     67/M      15 Preop: 100   10         12
                Postop: 100
3     49/M      20 Preop: 100   5          14
                Postop: 100
4     38/M      Preop: 100      5          38
                Postop: 100
5 *   77/F      Preop: 100      20         36
                Postop: 100

* Patient 5 was treated with a combined
endoscopic and postauricular approach.

Key: SRT = speech reception threshold;
SDS = speech discrimination score;
EBL = estimated blood loss;

F/U= follow-up.
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Title Annotation:ORIGINAL ARTICLE
Author:Noel, Julia E.; Sajjadi, Hamed
Publication:Ear, Nose and Throat Journal
Article Type:Case overview
Date:Dec 1, 2018
Words:2380
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