Outcomes of Totally Endoscopic Versus Microscopic Techniques in Middle Ear Cholesteatoma: A Systematic Review and Meta-Analysis.

Endoscopes have revolutionized the field of otology for the past two decades due to its minimally invasive technique and improved visualization. The advantage of endoscope during surgery for middle ear cholesteatoma both for diagnosing and aiding in removal of residual disease from the hidden areas and the resulting lower recurrence rates have been proven in the past by many authors. But the feasibility of totally endoscopic ear surgery and its surgical and patient related outcomes are yet to be explored in detail. We conducted this systematic review and meta-analysis to compare the surgical and patient related outcomes between totally endoscopic and microscopic technique in cases of acquired middle ear cholesteatoma. This meta-analysis has been conducted as per Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. Search engines used to identify the eligible articles were Pubmed, Web of Science, Cochrane Library, Virtual Health Library databases. The studies that compared the outcomes of microscopic and endoscopic techniques in case of acquired middle ear cholesteatoma and with more than 10 patients were included. Outcomes like recurrence, residual disease, graft uptake rate, audiological outcome, conversion rate, pain score, surgery duration, complications and quality of life outcomes were compared.The quality of the included studies was assessed by Methodological Index for Non-randomized studies criteria in case of non-randomized studies and by means of Cochrane Risk of Bias Tool in case of randomized controlled studies. A random effects model was used to calculate pooled estimates. The ODDS ratio and 95% confidence interval were calculated. The heterogeneity among the studies was represented by the Q statistic and Higgins I statistic. The test for overall effect was calculated by Z test and a p value of < 0.05 was considered as statistically significant. 11 studies were included in this meta-analysis. Out of 11 included studies, 4 were prospectively designed and 7 were retrospective studies. The overall effect showed recurrence rate (Z:2.69, P:0.007) was lower among endoscopic technique. Post-operative pain was less among the endoscopic technique and there was no difference between the groups with respect to surgical duration. Although endoscopic technique showed lower residual rate and post-operative vertigo with better graft success rate among the individual studies, the overall analysis showed that the difference was not statistically significant. Endoscope has been an invaluable tool in the cholesteatoma surgery over the past 20 years due to its excellent optics and minimally invasive technique. Evaluation of the present data available in the literature reveals that both the techniques have similar outcomes except for a definite advantage of endoscopic technique in reducing the recurrence and post-operative discomfort.