history of ees and iwgees. · mastoid. • it’s a function of our surgical approach not disease:...
TRANSCRIPT
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History of EES and IWGEES.
Muaaz Tarabichi
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I have nothing to disclose.No, within the last 12 months I have not had any type of financial arrangement or
affiliation with commercial interests related to the content of this continuing education activity that requires disclosure.
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What is TEES?
Endoscope in Ear Surgery
Observation
Limited add on Dissection
1992 TEES
Cohen’s Classification
Class I
Class 2A
Class 2B, Class 3
2019 WHAT DOES EES MEANS TO YOU
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Gaining Access to Hidden Areas
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1992: TEES: Cholesteatoma is not
a Mastoid Disease……..
• Most cholesteatomas are manifestation of retraction pockets: tympanic cavity
• Most recurrences occur within the tympanic cavity and its extensions.
• The ear canal is the natural access point to the cholesteatoma.
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Why the Mastoid
“Why not the canal”
• You can get there easily.
• You are using it as a conduit to other area.
• You can not use the ear canal because of
the limitation of the microscope.
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Wide
postauricular
access
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Wide endoscopic
field of view
Limited
microscopic
field of view
Narrowest
segment of
the ear canal
TEES
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TEES: Rediscovering the Ear
Canal
Wide Angle View of Endoscopes
=
Wide Ear Canal Access to the
Tympanic Cavity
THE BIRTHPLACE OF COM
AND
CHOLESTEATOMA
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2008
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Status of Endoscopic Ear Surgery 1992 to 2006
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Status of Endoscopic Ear Surgery2006
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Boston in 2019 Japan in 2021
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2019 What does EES mean to you?
Mike: See better, do more with less
Daniele: Working through anatomy and physiology.
Dan: Better ergonomic=surgeon safety=patient safety.
Brandon: Great for teaching anatomy and surgery.
Justin: Good light, good exposure.
Dave’s answer: When you see and do it, you know it.
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What does TEES mean to you?
Endoscope in Ear Surgery
Observation
Limited add on Dissection
1992 TEES
Cohen’s Classification
Class I
Class 2A
Class 2B, Class 3
2019 Aligning Access with Disease Process
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Chronic Ear Surgery as it Stands
• So far, Chronic Ear Surgery: Its all about treating the battle scars.
• We ignore underlying ventilation problems and hope they have gone away.
• Good hearing result = aerated middle ear
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Widepostauricularaccess
Mastoid
Ear Canal
Eustachian Tube
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Widepostauricularaccess
Mastoid
Ear Canal
Eustachian Tube
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Valsalva CT
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Upstream VENTILATION Downstream
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Upstream VENTILATION Downstream
MICROSCOPIC ACCESS
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Aligning Access with the Disease Process:
• In terms of Ventilation: It is definitely counterintuitive physiologically to worry about mastoid.
• It’s a function of our surgical approach not disease: We usually do not fail in the mastoid.
• The mastoid is at best a temporary–transient buffering system for gas regulation.
• The Ultimate Fallacy of all : the Mastoid is the Eustachian tube twin system for ventilation.
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Protympanic Segment of ET
• The most common Site of obstruction in chronic ears.Linstrom CJ, Carol AS, Arie R, Lawrence ZM. Eustachian tube endoscopy in patients with chronic ear disease. The Laryngoscope. 2000;110: 1884-1889.
• Contains the Isthmus of the ET, just beyond the carotid canal.
• It is the end of ET that is closer to the recurrent middle ear infection site.
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Site of Eustachian Tube Obstruction in COM
• 53 consecutive chronic ears endoscopic procedures + Preoperative Valsalva CT.
• Control group of 19 cadaver ears for endoscopic findings of protympanum.
• Valsalva CT documented patency of distal 1/3rd of Eustachian tube in 51/53.
• Clear obstruction of protympanum in 21/31 COM ears as compared to consistent patency in controls.
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Eustachian Tube Isthmus
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We absolutely need to improve outcome of chronic ear surgery
Conclusion:
• Think Ventilation.
• Think about the “Isthmus”.
• Ignore (within reason) Mastoid.
• Try a different hammer.