James Adrian L, Cushing Sharon, Papsin Blake C
*Department of Otolaryngology-Head and Neck Surgery, University of Toronto †Department of Otolaryngology-Head and Neck Surgery, Hospital for Sick Children, Toronto, Ontario, Canada.
Otol Neurotol. 2016 Feb;37(2):196-201. doi: 10.1097/MAO.0000000000000948.
Endoscopes can facilitate surgery within tympanomastoid recesses that are not visible with the operating microscope. This study investigates whether use of endoscopes to guide dissection of cholesteatoma leads to lower rates of residual cholesteatoma than using the endoscope only for inspection after microscope-guided dissection.
Comparative cohort study.
Tertiary pediatric center.
Two hundred thirty-five patients with acquired or congenital cholesteatoma in children <18 years having intact canal wall surgery and follow-up >12 months.
Comparison of group (A) microscope surgery followed by endoscopic inspection, with group (B) endoscope-guided dissection.
Residual cholesteatoma rates, controlling for site of initial cholesteatoma, detection by second-stage surgery, and length of follow-up.
Analysis of all patients showed endoscopic dissection was associated with less residua in the middle ear (risk difference = 0.12; p = 0.026, Kaplan-Meier log rank analysis; number needed to treat = 9) but not at other sites. When restricting analysis to ears that were evaluated with second look surgery, no significant reduction in residual disease was found after endoscopic dissection at any site (e.g., retrotympanic residua: 12% Group A versus 7% Group B (NS, Fisher exact test). Endoscopic dissection allowed more permeatal surgery. No complications were attributable to endoscope use. Wound complications occurred in 4% of open cases.
Endoscopes enhance surgical access to tympanomastoid recesses. In conjunction with the availability of the operating microscope, angled instruments, and KTP laser, endoscope-guided dissection provides a small incremental benefit for prevention of residual cholesteatoma, and facilitates a minimally invasive approach.
在内耳手术中，中耳乳突隐窝在手术显微镜下不可见，而内镜可以辅助观察。本研究旨在探讨与仅在显微镜引导下切除胆脂瘤后使用内镜进行检查相比，使用内镜引导胆脂瘤切除术是否能降低残余胆脂瘤的发生率。
比较队列研究。
三级儿科中心。
235例年龄小于18岁的后天性或先天性胆脂瘤患儿，均接受了完整外耳道壁手术且随访时间超过12个月。
比较（A）组显微镜手术加内镜检查与（B）组内镜引导下切除术。
残余胆脂瘤发生率，同时控制初始胆脂瘤的部位、二期手术的检测情况以及随访时间。
对所有患者的分析表明，内镜下切除术与中耳残余病变较少相关（风险差异=0.12；p=0.026，Kaplan-Meier对数秩检验；需治疗人数=9），但在其他部位并非如此。当将分析局限于接受二次探查手术评估的耳朵时，在内镜下切除术后，任何部位的残余疾病均未发现显著减少（例如，鼓室后残余病变：A组为12%，B组为7%（无统计学意义，Fisher精确检验）。内镜下切除术允许更多的经耳道手术。未发现与使用内镜相关的并发症。4%的开放手术病例出现伤口并发症。
内镜可增强对中耳乳突隐窝的手术入路。结合手术显微镜、角形器械和KTP激光的使用，内镜引导下切除术在预防残余胆脂瘤方面有微小的额外益处，并有助于实现微创方法。
