Endoscopic versus microscopic approach in attic cholesteatoma surgery

Accepted Manuscript Endoscopic versus microscopic approach in attic cholesteatoma surgery

Giuseppe Magliulo, Giannicola Iannella PII: DOI: Reference:

S0196-0709(17)30568-9 doi:10.1016/j.amjoto.2017.10.003 YAJOT 1912

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28 July 2017

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ACCEPTED MANUSCRIPT Endoscopic versus microscopic approach in attic cholesteatoma surgery

Running title: Endoscopic cholesteatoma surgery

GIUSEPPE MAGLIULO M.D.

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Organi di Senso Department University “la Sapienza”, Rome, Italy

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GIANNICOLA IANNELLA M.D.

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Address correspondence and reprint requests to: Giuseppe Magliulo, M.D., Via Gregorio VII n.80,

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Rome 00165, Italy; E-mail: [email protected] ; telephone number: +393388622344 Fax number : +390649976817

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This research did not receive any specific grant from funding agencies in the public,

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commercial, or not-for-profit sectors.

Keywords: Cholesteatoma; Endoscopic cholesteatoma surgery; Endoscopic ear surgery; „Attic cholesteatoma; Learning curve

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ABSTRACT Porpose: Compare the outcomes of primary exclusive endoscopic ear surgery with those of the microscopic ear surgery in a group of patients affected by attic cholesteatoma. Materials and Methods: Eighty patients suffered from attic cholesteatoma. Forty patients surgical

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treated with endoscopic ear surgery and forty patients surgical treated with microscopic ear surgery.

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Results: No statistical differences were found in the parameters analysed (frequency of facial nerve

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dehiscence, age, disease duration, site of dehiscence) between the endoscopic and microscopic groups indicating a homogeneous selection thus providing a good comparison of the outcomes

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between the two groups. None of the patients in our survey developed postoperative iatrogenic facial palsy. Graft success rate was 100% in both groups.

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The overall operation time of endoscopic ear surgery presented a mean value of 87.8 min, while in the group of patients treated via microscopic ear surgery a lower mean value of 69.9 min was

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reported.

microscopic subgroup.

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The average healing time was 36.3 days for the endoscopic subgroup and 47.8 days for the

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Conclusion: The surgical outcomes of endoscopic ear surgery are comparable to those of the conventional approach in terms postoperative air-conduction, graft success rate and taste sensation.

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The analysis of postoperative pain and healing times showed better results for EES. The mean operative times of endoscopic ear surgery gradually shortened as the surgeons gained expertise in performing one-hand surgery.

1. INTRODUCTION The advent of the endoscopes has modified the therapeutic approach to middle ear and mastoid cholesteatoma. There is a general consensus regarding their intraoperative use as complementary to

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ACCEPTED MANUSCRIPT traditional microscopic ear surgery (MES) in order to evaluate some sub-regions of the middle ear and mastoid not easily accessible via microscopy and to perform endoscopic revision of an accessible cholesteatoma in the post-mastoidectomy cavity[1-3]. Other authors have tested and recommended the pioneering use of endoscopic ear surgery (EES) as an exclusive trans-canal surgical technique[4-14].

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Although the use of primary, exclusive EES is becoming progressively more popular[15,16], few

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authors compared EES with MES and data regarding comparison between these two surgical

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techniques are scarce, particularly for „attic‟ cholesteatomas[17-19].

The endoscopic approach offers excellent visualization of middle ear structures and recesses, but

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does have some possible limitations linked to single-handed work, the lack of a stereoscopic view and, last but not the least, a potentially long surgical learning curve, explaining the still marginal

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role that exclusive EES plays in comparison to conventional microscopic ear surgery (MES)[3-7]. This study was specifically designed to compare primary exclusive EES with MES in a group of

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patients affected by attic cholesteatoma. In particular, the aims were: 1) Evaluate intraoperative

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characteristics of EES and MES, 2) Analyze surgical outcomes of EES vs MES 2) Assess the

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operating times and the evolution of the EES surgeon learning curve.

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2. MATERIALS AND METHODS

2.1 Prospective patients enrollment Eighty patients (48 males, 32 females; 19-72 years of age, average age 39.5) suffering from chronic suppurative otitis media with attic cholesteatoma were enrolled in this prospective study. Patients were treated by two different surgical approaches. One group of patients were submitted to tympanoplasty via MES and a second group to exclusive trans-canal EES. All surgical procedures were performed between June 2014 and October 2016 by one of the authors (G.M.) at the Organi di Senso Department at “Sapienza” University in Rome. 3

ACCEPTED MANUSCRIPT All patients underwent a preoperative otomicroscopic evaluation and a high resolution CT scan. Images analysis was performed by one radiologist (L.L.M.) and one otoneurologist (G.M.). Only patients with CT imaging showing cholesteatoma located in the epitympanic region were enrolled in the study.

Patients with CT evidence of mesotympanum cholesteatomas, wide mastoid

involvement and revision surgery were excluded in order to keep the study groups homogenous.

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Imaging and otomicroscopic data were used to obtain patients with same diagnosis of „attic‟

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cholesteatoma and similar findings. The eighty patients were casually assigned to one of the two

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groups (40 patients surgical treated by EES and 40 patients surgical treated by MES) of the study.

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2.2 Surgical Instruments

For EES, rigid endoscopes with an angulation of 0, 30 and 45 degree, a length of 14-cm and an

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outer diameter of 3 mm and 4 mm (Storz, Germany) were used: they were connected to a camera head (Stroz, Germany) and a high definition monitor positioned in front of the surgeon.

2.3 Surgical procedures

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All surgical procedures were performed under general anesthesia.

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The steps of EES consisted of:

a) creation of the tympanomeatal flap in the posterosuperior and posteroinferior portions of the

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external auditory canal;

b) access to the middle ear and preservation of the chorda tympani; c) removal of the bony wall in the attic part of the external auditory canal to identify the ossicles, the oval and round windows, the tympanic segment of the Fallopian canal, the cocleariform process and horizontal semicircular canal (Fig. 1); d) removal of any eroded ossicles (incus and the head of malleus); e) complete removal of the cholesteatoma matrix (Fig. 2); f) positioning of a silastic sheet on the promontorium; 4

ACCEPTED MANUSCRIPT g) Graft with temporalis fascia or cartilage tympanoplasty using an underlay technique; h) reconstruction of the attic defect with sheets of tragus or conchal cartilage (Fig. 3); i) repositioning of the tympanomeatal flap in its original position (Fig. 4). Gelfoam was also used as packing for the external auditory canal. Patients undergoing tympanoplasty through MES performed a canal wall-up technique in all cases.

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Each surgical procedure was performed using standard tympanoplasty surgery instruments and was

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recorded so that it could subsequently be reviewed.

2.4 Parameters Investigated

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The clinical records of patients were reviewed to collect data regarding preoperative and postoperative clinical symptoms (otorrhoea, facial palsy, vertigo/dizziness, hypo/anacusis). The

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presence of facial nerve dehiscence was investigated on CT images (absence of the osseous wall of the facial nerve canal), and subsequently compared to the corresponding intraoperative findings.

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The facial nerve dehiscence and the eventual presence of labyrinthine fistula, the type of surgery

eventual complications.

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performed, operating times, postoperative hearing and postoperative pain were evaluated as well as

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Any intraoperative observations of Fallopian canal erosion made with an operating microscope or with an endoscope and confirmed by palpation during the removal of the cholesteatoma matrix was

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considered as dehiscence[20-23]. The six-site classification of Moody and Lambert[21] was adopted to define the site of dehiscence. Hearing was assessed preoperatively and at 1 month, 3 months and 6 months after surgery in both groups. Final hearing recovery at six months follow-up was evaluated and classified according to the draft AAO-HNS hearing classification system[24]. All patients of the study were asked to evaluate the severity of postoperative pain. This was classified using three grades: almost no pain, mild pain requiring no analgesics drugs and pain requiring analgesics drugs[19,25,26]. In case of pain requiring analgesics, drugs were prescribed by 5

ACCEPTED MANUSCRIPT us and were in each case the same non-steroidal anti-inflammatory drug. To each patients were asked to not spontaneously take analgesics drugs without asking with us. No other medications, such as steroids, diazepam, or other drugs with possible impact on the postoperative pain or healing outcomes were taken to the patients of the study. Taste abnormalities were investigated as: presence or non-presence of a subjective abnormal taste

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sensation[4,7,22].

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Healing time was investigated by a physical examination and otomicroscopic investigation. It was

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considered as the days between the surgery and the tympanic graft success with complete eardrum repair and patient return to normal activities. Otomicroscopic follow- up was performed

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approximately every 15 days for the first 3-months after surgery and then 1 time each 3 months. The postoperative follow-up period ranged from 6 to 20 months (mean: 12.3 months).

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The Student‟s T test and the χ2 test were calculated to evaluate the significance of multiple factors. A p value of <0.05 was taken as the threshold of statistical significance. If no statistical significance

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between the two groups was estimated, the definition p> 0.05 was adopted in the text.

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This research study was performed in accordance with the principles of the Declaration of Helsinki and approved by the local Ethics Committee of the University „„Sapienza‟‟ of Rome. Informed

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consent was obtained from all patients included in the study.

3. RESULTS

Forty patients (26 males and 14 females) underwent EES. The other forty patients (22 females and 18 females) underwent traditional microscopic surgery (Tab.1). Intraoperative data confirmed the preoperative CT data with a diagnosis of attic cholesteatoma in all patients of both groups. No case of intraoperative mastoid involvement appeared in patients who underwent MES (Tab. 1).

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ACCEPTED MANUSCRIPT 3.1 Preoperative and intraoperative findings Preoperative CT images showed a suspected facial nerve dehiscence in 10 cases (12.5%), 6 belonging to the EES group and 4 to the MES group. Intraoperatively, in the whole group of patients, the incidence of facial nerve dehiscence (16 cases) was 20%. In the group treated with EES, ten (25%) patients showed facial nerve dehiscence, whereas in the MES group six (15%)

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patients reported facial nerve dehiscence. This difference did not prove to be statistically significant

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(p=0.4).

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All cases of suspected facial nerve dehiscence to the CT were confirmed during surgery. Besides intraoperatively emerged that Fallopian canal bone erosion were due to the cholesteatoma matrix in

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all cases.

Both groups studied had a dehiscent tympanic segment of the facial nerve. The distribution of

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facial nerve dehiscence along the course of the tympanic segment is showed in table 2. In two patients, one from the endoscopic group and one from the microscopic group, the geniculate

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ganglion was involved too.

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None of the patients in our survey developed postoperative iatrogenic facial palsy. In all of the studied patients the cholesteatoma matrix was judged to have been totally removed. No

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horizontal semicircular canal fistulas were detected in any cases The other preoperative, intraoperative and postoperative findings of both endoscopic and

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microscopic approach are summarized in Table 1. No difference in the parameters analysed (CT findings, patient age, disease duration, intraoperative cholesteatoma characteristics, site of dehiscence) was observed between the endoscopic and microscopic groups, indicating a homogeneous selection of patients that provided a good comparison of the outcomes between the two groups.

3.2 Postoperative findings 7

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A transient abnormal taste sensation occurred in 30% and 40% of the endoscopic and microscopic groups respectively, without significant statistical difference between the two groups (p=0.5). The average postoperative air-conduction thresholds of microscopic and endoscopic approaches are depicted in Table 3 showing no statistical difference between the two groups (p>0.05). Similar data

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emerged by analysing the presence of postoperative dizziness that was reported in 15% of MES

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group and 5% of EES group.

Regarding postoperative pain: 100% of the patients from the endoscopic group rated it as “almost

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no pain” or as “mild pain requiring no analgesics drugs”. However, 25% of patients who underwent

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microscopic surgery described pain requiring analgesic drugs for 2 to 3 days after microscopic surgery. A statistical difference regarding postoperative pain between EES and MES was calculated

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(p=0.001).

Graft success rate was 100% in both groups.

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Finally, no recurrence of the disease at the mean follow-up of 12.3 months were evident in both

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group of patients.

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3.3 Average healing time and overall operation time (Tab. 4) The average healing time was 36.3 days (Hi = 58.0 Low = 20.0 ; Standard Deviation = 9.03,

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Median = 36) for the endoscopic subgroup and 47.8 days (Hi = 68.0 Low = 30; Standard Deviation = 8.4; Median = 47.5) for the microscopic subgroup. The difference in the healing times between the two approaches was statistically significant with p=0.0002. The overall operation time for EES presented a mean value of 87.8 min (Hi = 120.0 Low = 68.0 ; Standard Deviation = 11.9, Median = 88.0). In the group of patients treated via MES a lower mean value of 69.7 min was reported (Hi = 83.0 Low = 50.0; Standard Deviation = 8.49; Median = 69.0). Statistical differences were evident (p value=0.0001) with microscopic surgery being quicker.

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ACCEPTED MANUSCRIPT 3.4 Learning curve The learning curve progression for endoscopic surgery is shown in Fig 5. In the first 10 cases from the beginning of EES, the average surgical time was 92.3 min (95% confidence interval for Mean: 85.24; S.D. = 12.3; Hi = 110; Low = 70.0; Median = 91.0). In the last 10 patients surgical treated, the mean surgical time decreased to 83.9 min (Mean = 83.9; 95% confidence interval for Mean:

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76.84; S.D.= 8.58; Hi = 96.0; Low = 70.0; Median = 84.0). Despite the different average surgical

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times between these two endoscopic subgroups from the start of EES, this difference it appears to

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be trending the statistical significance, even if it does not quite reach it (p=0.09; t= 1.77; sdev= 10.6 degrees of freedom = 18). There were no differences in median time of microscopic surgery over

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time (p>0.05).

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4. DISCUSSION

Nowadays, increasingly authors propose an exclusive use of the endoscopy in different middle ear

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pathologies as patients with „attic‟ cholesteatomas[15,16]. However, definite information regarding

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surgical advances, postoperative results and information about how, and in which patients this surgical technique should be exclusively used, are a source of continuous discussions [4-14,27,29].

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Most relevant studies that reported the advantages of endoscopy in cholesteatoma surgery have been retrospective cohort studies without a comparative study design [4-9,18]. Only Panetti et

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al.[17] retrospectively comparing microscopic and endoscopic approach in cholesteatoma surgery, claimed that EES is a safe approach giving results comparable to those of a conventional microscopic approach despite the well-known endoscopic disadvantages, namely the need to work with only one hand and the lack of stereoscopic vision[12-14,30]. As claimed by Tseng et al [18] in a recent retrospective review due to the limited number of papers that have compared surgical outcomes of EES vs MES[17-19], and the absence of prospective study about this topic, several aspects are still controversial. In an effort to evaluate surgical outcomes of EES in the „attic‟ cholesteatoma surgery and compare 9

ACCEPTED MANUSCRIPT its results with the classic microscopic surgery we designed this prospective studying. In comparing the endoscopic and microscopic subgroups, there was no difference in the following outcomes: age, preoperative hearing, disease duration and presence of intraoperative facial nerve dehiscence. This indicate homogeneous study groups, ideal for analyzing the clinical impact of exclusive endoscopy.

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According to the systemic review by Tseng et al[18], tympanic graft success rates and hearing

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results for EES and MES are comparable. Our study confirms these results because the endoscopic

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and microscopic groups did not differ in terms of postoperative hearing loss, postoperative abnormal taste sensation, postoperative dizziness and graft success rates. However, the analysis of

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postoperative pain and healing times showed that postoperative results were better in the endoscopic group.

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Little is known of postoperative pain after endoscopic ear surgery because only few studies compared postoperative pain levels between EES and MES[19]. In the study of Choi et al[19], the

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endoscopic group had significantly lower level of pain than the microscopic groups, 1 day after

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surgery.

In our opinion and as claimed by Choi et al.[19] the reduced pain may reflect the lack of external

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incision and the absence of mastoid bone drilling in the EES. The average healing time considered as the days between the surgery and the complete eardrum

days for MES.

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repair and patient return to normal activities was 36.3 days for the endoscopic subgroup and 47.8

This is probably due to the fact that in cases with the same extension of the disease MES requires greater surgical manipulation of the ear and mastoid and this leads to more time for tympanic graft success and eardrum repair. Obviously, no definitive conclusions can be drawn in consideration of the limited number of patients studied, but EES seems to show favorable healing times. Our study showed a more rapid execution of microscopic surgery compared with MES. However, analyzing the operative times of the ten EES last cases surgical treated from the introduction of 10

ACCEPTED MANUSCRIPT EES, there is an improvement in the average operative times in comparison to the first ten cases although this does not reach statistical significance. The above findings suggest that it is reasonable to speculate a progressive, future improvement of operating times with the evolution of the learning curve in single-handed work similar to the one experienced in otosclerosis surgery[25,29]. A potentially long operative time and learning curve

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required for using the endoscope are the major factors underlying the reluctancy to use EES. The

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learning curve is influenced by the ear surgeon‟s experience, by his/her acquired skills in the

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procedure, by the respect and adaptation of the microscosurgical steps to the requirements and onehand surgery of EES and, finally, a more intense surgical activity with larger series of operated

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patients.

By comparing MES and ESS, it should be also considered that some selected middle ear

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cholestatomas can be treated by a trans-canal approach under microscopic view pointing out that the use of the microscope allows to have a 3D vision and two-hands procedure avoiding post-auricular

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incision analogously to EES surgery. Our study did not compare trans-canal EES and microscopic

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trans-canal approach. Undoubtendly, future studies will clarify this particular topic. Based on our experience, the choice between exclusive microscopic or endoscopic approaches

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should depend on a meticolous balance between their advantages and disavantages. The microscope has been the traditional instrument employed in otologic surgery, providing

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excellent vision, depth perception with possibility of magnification and the benefit of using both hands by the surgeon [27]. The advance of EES are the optimal visualization due to the proximity of the surgical filed, around the corner exploration, absence of external incisions and tissue preservation, [1,18,19]. In contrast, the disadvantage of endoscopic surgery is represented by onehand surgery. Moreover it should be remembered that, as claimed by Prasad et al, the presence of blood and bone dust in the field, requiring frequent cleaning of the endoscope, should determine a less efficacious management of surgical complications ( trauma to vital structures, etc)

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microscopic surgery[27]. 11

ACCEPTED MANUSCRIPT In our opinion, considering similar surgical results but longer operating times and a relatively long learning curve, in case of epitympanic cholesteatomas, the type of surgical approach should be chosen by the surgeon in accordance with the advantages and disadvantages of each single technique, surgeon‟s personal preference and experience [11,13,25-29], taking in mind that both options should be available in the armamentarium of the otologists.

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Finally, there were no cholesteatoma recurrences in no patients of both groups. However, we know

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that the follow-up time of this study (12.3 months) is too short to draw definite conclusions

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regarding disease recurrence in primary EES for attic cholesteatomas.

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5. CONCLUSIONS

 Audiological outcomes and tympanic graft success rates achieved by EES are similar to the

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results obtained via a microscopic approach.

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 The analysis of postoperative pain and healing times showed better results for EES.  The mean operative times of EES gradually changed as the surgeons gained expertise in

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performing one-hand surgery.

 Longer initial operative times and a learning curve are the two main factors to work on to

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make EES the first surgical choice in the treatment of attic cholesteatoma.  These aspects regarding endoscopic vs microscopic approach in

attic cholesteatoma

surgery, as this is the only entity included in the study.

Compliance with Ethical Standards: No grant or other Source of Funding Authors declares that they have not conflict of interest. 12

ACCEPTED MANUSCRIPT All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Informed consent was obtained from all individual participants included in the study.

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ACCEPTED MANUSCRIPT [6] James AL.Endoscopic middle ear surgery in children. Otolaryngol Clin North Am. 2013;46:233-44. [7] Lima Tde O, Araújo TF, Soares LC, Testa JR. The impact of endoscopy on the treatment of cholesteatomas. Braz J Otorhinolaryngol. 2013;79:505-11. [8] Hanna BM, Kivekäs I, Wu YH, Guo LJ, Lin H, Guidi J, Poe D. Minimally invasive functional approach for cholesteatoma surgery. Laryngoscope. 2014;124:2386-92. 24. [9] Presutti L, Gioacchini FM, Alicandri-Ciufelli M, Villari D, Marchioni D.Results of endoscopic middle ear

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[13] Cohen MS, Landegger LD, Kozin ED, Lee DJ. Pediatric endoscopic ear surgery in clinical practice: Lessons

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[16] Tarabichi M. Endoscopic management of limited attic cholesteatoma. Laryngoscope. 2004;114:1157-62. [17] Panetti G, Cavaliere M, Panetti M, Marino A, Iemma M. Endoscopic tympanoplasty in the treatment of chronic otitis media: our experience. Acta Otolaryngol. 2017;137:225-228. [18] Tseng CC, Lai MT, Wu CC, Yuan SP, Ding YF. Comparison of the efficacy of endoscopic tympanoplasty and microscopic tympanoplasty: A systematic review and meta-analysis. Laryngoscope. 2017;127:1890-1896. [19] Choi N, Noh Y, Park W, et al. Comparison of Endoscopic Tympanoplasty to Microscopic Tympanoplasty. Clin Exp Otorhinolaryngol. 2017;10:44-49. [20] Di Martino E, Sellhaus B, Haensel j, Schlegel JG, Westhofen AS. Fallopian canal dehiscences: a survey of clinical and anatomical findings. Eur Arch Otorhinolaryngol 2005;262:120-126.

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ACCEPTED MANUSCRIPT [21] Moody MW, Lambert PR. Incidence of dehiscence of the facial nerve in 416 cases of cholesteatoma. Otol Neurotol 2007;28:400-405. [22] Magliulo G, Colicchio MG, Appiani MC. Facial nerve dehiscence and cholesteatoma. Ann Otol Rhinol Laryngol. 2011;120:261-7. [23] Yetiser S.The dehiscent facial nerve canal.Int J Otolaryngol. 2012;2012:679708. [24] Committee on Hearing and Equilibrium guidelines for the evaluation of results of treatment of conductive

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hearing loss. American Academy of Otolaryngology-Head and Neck Surgery Foundation, Inc. Otolaryngol Head Neck Surg. 1995;113:186-7.

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[25] Iannella G, Magliulo G. Endoscopic Versus Microscopic Approach in Stapes Surgery: Are Operative Times

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and Learning Curve Important for Making the Choice? Otol Neurotol. 2016;37:1350-7. [26] Kojima H, Komori M, Chikazawa S et al. Comparison between endoscopic and microscopic stapes surgery.

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Laryngoscope. 2014;124:266-71.

[27] Prasad SC, Giannuzzi A, Nahleh EA, Donato GD, Russo A, Sanna M. Is endoscopic ear surgery an alternative

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to the modified Bondy technique for limited epitympanic cholesteatoma? Eur Arch Otorhinolaryngol. 2016 Sep;273:2533-40.

[28] Alicandri-Ciufelli M, Anschuetz L, Presutti L, Villari D, Marchioni D5. Letter to the Editor "Is endoscopic ear

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surgery an alternative to the modified Bondy technique for limited epitympanic cholesteatoma?" by Prasad et

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al. Eur Arch Otorhinolaryngol. 2016;273:2863-4. [29] Iannella G, Marcotullio D, Re M, et al. Endoscopic vs Microscopic Approach in Stapes Surgery: Advantages

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in the Middle Ear Structures Visualization and Trainee's Point of View. J Int Adv Otol. 2017;13:14-20.

Table 1; Endoscopic vs microscopic approach: Preoperative, intraoperative and postoperative findings

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Parameters

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Sex

Middle age

MES

EES

(40 pts)

(40 pts)

22 males

26 males

18 females 14 females 37.9

0

0

CT facial nerve dehiscence

4 (10%)

6 (15%)

Intraoperative facial nerve dehiscence

6 (15%)

10 (25%)

Horizontal semicircular canal fistulas

0

0

Complete removal of the cholesteatoma

40 (100%)

40 (100%)

Postoperative dizziness

6 (15%)

2 (5%)

Postoperative pain

0

10 (25%)

Abnormal taste sensation

16 (40%)

12 (30%)

Graft success rate

40 (100%)

40 (100%)

Recurrence of the disease

0

0

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41.2

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Intraoperative mastoid involvement

(For 2 to 3 days after surgery and requiring analgesics)

(Mean follow-up 12.3 months)

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Distal

-

Proximal

-

Mid-proximal

2 (12.5)

Mid-distal

4(25)

Total

4 (25)

Undesignated

-

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6 (37.5)

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Mid

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n (%)

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Site

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Table 2: Site of a dehiscent tympanic segment (n=16)

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Table 3; Hearing results, endoscopic vs microscopic approach

ENDOSCOPIC

air-conduction

SURGERY

SURGERY

- 20

- (0%)

2 (5%)

21 - 41

4 (10%)

4 (10%)

41 - 51

18 (45%)

14 (40%)

51-

18 (45%)

20 (50%)

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Average postoperative MICROSCOPIC

thresholds (dB)

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Table 4; Average healing time and overall operation time EES

AVERAGE HEALING TIME

47.8 days

36.3 days

(average value expressed in days)

S.D.= 8.4

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Median = 47.5

0.0002

S.D.=9.03 Median = 36

OVERALL OPERATIVE TIME

69.9 min

87.8 min

(average value expressed in minutes)

S.D.=8.49

S.D.=11.9

Median = 69.0

Median = 88.0

0.0001

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LEGEND

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Fig. 1: Endoscopic view; Removal of the bone wall in the attic part of the external auditory (arrow). c, matrix of the cholesteatoma t, tympanomeatal flap Fig. 2: Endoscopic view; Complete removal of the cholesteatoma matrix. Facial nerve dehiscence in the geniculate ganglion. f, facial nerve; p, promontory ; s, stapes residues. Fig. 3: Endoscopic view; Reconstruction of the attic defect with sheets of tragal cartilage. Fig. 4: Endoscopic view; Postoperative reconstruction graft of the tympanic membrane after 15 days .

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ACCEPTED MANUSCRIPT Fig. 5: Learning curves in according to the total operative time. Line A endoscopic ear surgery

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