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\begin{document}

\title{The Efficacy of Transcanal Endoscopic Ear Surgery in Children Compared
to Adults}



\author[1]{Wan-Hsuan Sun}%
\author[2]{Tzu-Chin Huang}%
\affil[1]{Tri-Service General Hospital}%
\affil[2]{Cathay General Hospital Hsinchu Branch}%


\vspace{-1em}



  
  \date{May 29, 2024}


\begingroup
\let\center\flushleft
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\selectlanguage{english}
\begin{abstract}
Objectives: Using transcanal endoscopic ear surgery to manage middle ear
disease in children remains a controversial topic. The aim of this study
was to compare the efficacy of transcanal endoscopic ear surgery between
children and adults. Methods: This study consisted of 20 children (31
ears) and 86 adults (102 ears) with chronic otitis media who underwent
transcanal endoscopic ear surgery between January 2014 and August 2016
at Taipei and Hsinchu Cathay General Hospital. Among these patients, 13
children (23 ears) and 23 adults (34 ears) had chronic otitis media with
effusion, 4 children (5 ears) and 46 adults (51 ears) had chronic otitis
media without cholesteatomas, and 3 children (3 ears) and 17 adults (17
ears) had cholesteatomas. The two groups were compared with respect to
(1) surgical outcome, which included the rates of surgical success,
hearing restoration, and postoperative complications, and (2) surgical
time. Results: We observed no significant difference between pediatric
and adult patients with regard to the rates of surgical success,
postoperative hearing gain, and postoperative complications in all
surgical procedures. As for ventilation tube insertion, the pediatric
patients had shorter surgical time compared to adult patients. With
respect to tympanoplasty, the pediatric group had a longer surgical time
than adults did. Conclusions: Our study showed that transcanal
endoscopic ear surgery can be successfully applied to manage various
middle ear diseases in children.%
\end{abstract}%



\sloppy


\textbf{The Efficacy of Transcanal Endoscopic Ear Surgery in Children
Compared to Adults}

\textbf{Running Title:} The Efficacy of TEES in Children

\textbf{Abstract}

\textbf{Objectives:}

Using transcanal endoscopic ear surgery to manage middle ear disease in
children remains a controversial topic. The aim of this study was to
prove the efficacy of transcanal endoscopic ear surgery in children.

\textbf{Design:}

Comparing the efficacy of transcanal endoscopic ear surgery between
children and adults by surgical outcome, which included the rates of
surgical success, hearing restoration, postoperative complications, and
surgical time.

\textbf{Setting:}

Among the patients recruited in this study, 13 children and 23 adults
had chronic otitis media with effusion, 4 children and 46 adults had
chronic otitis media without cholesteatomas, and 3 children and 17
adults had cholesteatomas.

\textbf{Participants:}

This study consisted of 20 children and 86 adults with chronic otitis
media who underwent transcanal endoscopic ear surgery between January
2014 and August 2016.

\textbf{Main outcome measures:}

Between children and adults, two groups were compared with respect to
surgical outcome, which included the rates of surgical success, hearing
restoration, and postoperative complications, and surgical time.

\textbf{Results:}

As for ventilation tube insertion, the pediatric patients had shorter
surgical time compared to adult patients. With respect to tympanoplasty,
the pediatric group had a longer surgical time than adults did.

\textbf{Conclusions:}

Our study showed that transcanal endoscopic ear surgery can be
successfully applied to manage various middle ear diseases in children.

\textbf{Keywords:}

Transcanal endoscopic ear surgery, Pediatric, Chronic otitis media,
Cholesteatoma, Middle ear diseases

Key Points:

\begin{enumerate}
\tightlist
\item
  Transcanal Endoscopic Ear Surgery (TEES) has become one of the most
  influential methods in dealing with adult ear disease.
\item
  The surgical time for VTI in children was shorter than in adults.
  However, for tympanoplasty was significantly longer in the pediatric
  patients than in the adult patients.
\item
  No significant difference between children and adults with regard to
  rates of surgical success, postoperative complications, and
  postoperative hearing gain when VTI, tympanoplasty, or TEES management
  of cholesteatoma was performed.
\item
  The feasibility of transcanal endoscopic ear surgery for the
  management of pediatric middle ear disease is sufficient.
\item
  TEES can be successfully and effectively used in the treatment of
  middle ear disease in both adults and children, even in complicated
  cholesteatoma cases.
\end{enumerate}

\textbf{Objectives:}

Microscopic ear surgery (MES) is a well-developed traditional surgical
procedure for treating middle ear disease. However, the microscope
provides only a straight-line view through the ear canal, and blind
spots and hidden recesses can easily be missed using this transcanal
approach. This problem is especially common in the management of
cholesteatomas and can increase the risk of a residual cholesteatoma due
to remnants of the matrix in the ear {[}1{]}. An otologist often must
adopt the retroauricular transmastoid approach to overcome the limited
surgical view of the microscope, which inevitably leaves an obvious
surgical wound behind the ear.

Recently, transcanal endoscopic ear surgery (TEES) has been proven to be
an effective alternative to traditional MES for treating middle ear
disease in adults due to its wider and more flexible surgical view,
better mastoid function preservation, smaller surgical wound, shorter
surgical time, and shorter hospital stay {[}1-5{]}. However, the
feasibility of TEES in pediatric patients is still debatable because
children's external auditory canals (EACs) are narrower, shorter, and
curvier than those of adults {[}1{]}. In this study, the surgical
outcomes and surgical time (duration of surgery) were compared between
adult and pediatric patients who underwent TEES, and we also discussed
the feasibility of TEES in children.

\textbf{Design:}

A retrospective review of medical records ws conducted in this study.
Preoperative and postoperative evaluations included otoscopic
examination and audiometric assessment. Furthermore, for patients with
cholesteatomas, preoperative imaging was performed using temporal bone
high-resolution computed tomography (HRCT). We recorded the surgical
outcome, postoperative complications, preoperative and postoperative
audiometric results, and surgical time in detail to carry out the
comparison.

\textbf{Setting:}

The TEES was performed using 0- or 30-degree wide-angle endoscope with a
3-mm diameter and 14-cm length (HOPKINS\selectlanguage{ngerman}\textsuperscript{®} Telescopes,
Karl Storz, Germany). All operations were conducted by the same surgeon
(senior author). Three different TEES procedures were adopted in order
to manage different diseases.

Ventilation tube insertion (VTI) for OME

Ventilation tube insertion was performed under general anesthesia in
pediatric patients and under local anesthesia in adults. The procedure
included myringotomy on the anterior-inferior quadrant of the tympanic
membrane, followed by drainage of the middle ear fluid and interposition
of the ventilation tube through the ear drum. Different ventilation
tubes (Sheehy-Type Collar Buttons, Medtronic, USA, Inc) with diameters
of 1.02 and 1.27 mm were selected for pediatric and adult patients,
respectively. Irrigation with ofloxacin (3 mg/mL) (Tarivid; Daiichi
Sankyo, Japan) was performed following ventilation tube stabilization.

Tympanoplasty for COM without cholesteatoma

Tympanoplasty was also performed under general anesthesia for children
and under regional local anesthesia for adults (2\% lidocaine
hydrochloride and 1:50000 epinephrine) with injection on the skin of the
tragus and ear canal. The graft material (including the perichondrium
and cartilage) was harvested from the meatal surface of the tragus, and
the wound was sutured with Vicryl 5-0 (Coated VICRYL® polyglactin 910
Suture, Ethicon, US). After denuding the perforated edge of the ear
drum, a transmeatal incision (straight upward) was made to elevate the
tympanomeatal flap. All the inflammatory tissue in the tympanic cavity
was then completely removed, and the tympanic cavity was cleaned using
saline irrigation. Furthermore, the ossicular chain was checked, and
ossiculoplasty was simultaneously performed if such was deemed
necessary. The skin of the anterior canal and the annulus were elevated,
and surgifoam (Spongostan Gelatin Hemostatic Sponge, Ethicon, US) soaked
with ofloxacin (3 mg/mL) (Tarivid; Daiichi Sankyo, Japan) was placed in
the middle ear cavity. The perichondrium graft was introduced underneath
the perforated ear drum; then, the tympanomeatal flap was repositioned.
The ear canal was then packed with surgifoam soaked with ofloxacin.

TEES for Cholesteatoma

For this condition, the graft tissue, including the perichondrium and
cartilage, was also harvested from the meatal surface of the tragus.
Then, an elongated transmeatal incision was made to elevate the
tympanomeatal flap. Next, the scutum was drilled to expose the attic
area. The dissection was extended along the cholesteatoma to the bottom
of the matrix until the cholesteatoma could be completely removed. If
the ossicular chain was involved and destroyed by the cholesteatoma,
ossiculoplasty was performed simultaneously as necessary. The
reconstruction procedure was slightly modified according to the extent
of the dissection in each case. In patients who had limited
cholesteatomas confined within the attic, the tympanic cavity and scutum
were reconstructed using the composite cartilage and perichondrium
(close cavity procedure) (Figure 1) {[}20{]}. In patients who had
advanced disease involving the mastoid cavity proper, we reconstructed
only the tympanic cavity and left the mastoid antrum as an open cavity
in the ear canal (open cavity procedure).

The performance of all of the above TEES procedures left no surgical
wound outside the ear canal. After the operations, patients were
regularly followed up in the outpatient clinic for 18 to 48 months. For
patients who underwent tympanoplasty, successful surgery was defined as
complete healing of the tympanic membrane; for those with
cholesteatomas, it was defined as complete removal of the cholesteatoma
without any residual or recurrent disease during the postoperative
follow-up.

\textbf{Participants:}

This study was conducted from January 2014 to August 2016. We enrolled a
total of 31 ears of 20 pediatric patients (aged 3-18 years) and 102 ears
of 86 adult patients (aged 24-78 years) with chronic otitis media (COM)
who underwent TEES in this study. Among the subjects, 13 children (23
ears) and 23 adults (34 ears) had chronic otitis media with effusion
(OME), 4 children (5 ears) and 46 adults (51 ears) had COM without
cholesteatomas, and 3 children (3 ears) and 17 adults (17 ears) had
cholesteatomas.

Patient characteristics are summarized in Table 1; 53\% of the subjects
were male. The mean ages of the pediatric and adult patients were 8.4
and 49.5 years, respectively. The most frequent procedure among the
pediatric patients was VTI (74\%), followed by tympanoplasty (16\%), and
mastoidectomy (10\%); among adult patients, the majority underwent VTI
(33\%), followed by tympanoplasty (50\%), and mastoidectomy (17\%).

\textbf{Main outcome measures:}

Comparison of TEES in children and adults

To determine the feasibility of TEES in children, these two groups were
compared with respect to (1) surgical outcome, which included the rates
of surgical success, hearing restoration (postoperative hearing gain),
and postoperative complications, and (2) surgical time (duration of
surgery).

\textbf{Result:}

Surgical Outcomes

No complications were noted following the surgery in either of our study
groups. Regardless of the surgical procedure, all patients demonstrated
improvement in the air-bone gap after the surgery. The results showed no
significant difference between the pediatric and adult groups with
respect to the rates of surgical success and postoperative hearing gain;
the same was observed whether VTI, tympanoplasty, or cholesteatoma TEES
management was performed. Both VTI and mastoidectomy had 100\% success
rates in each group. All patients recovered well, with the patients
having either satisfactory ventilation tube function after VTI or no
residual or recurrent cholesteatoma after mastoidectomy. We found no
significant difference between children and adults regarding to the
success rate of tympanoplasty, although the rate was lower in the
pediatric patients (80\% in children vs. 96\% in adults, p=0.253) (Table
2).

We observed no significant difference between these two groups with
regard to rates of surgical success, postoperative complications, and
postoperative hearing gain when VTI, tympanoplasty, or TEES management
of cholesteatoma was performed. All patients achieved improved air-bone
gap, and none experienced residual or recurrent disease during the 18-
to 48-month postoperative follow-up after the management of
cholesteatoma. Therefore, we believe that TEES may also have a
satisfactory surgical outcome in children as well as in adults.

Surgical time

The surgical time for VTI in children was shorter than in adults
(pediatric group, 11.7 min; adult group, 19.1 min; p\textless{}0.05).
Because the procedure was performed under local anesthesia in adults;
the injection of the local anesthesia in the ear canal may account for
the longer surgical time. (Table 3)

The average surgical time for tympanoplasty was 89.6 min in all cases
and was longer in the pediatric patients than in the adult patients
(pediatric group, 118 min; adult group, 86.6 min; p\textless{}0.05).
(Table 3)

Our study results revealed that the surgical time for tympanoplasty was
significantly longer in the pediatric patients than in the adult
patients. Children's ear canals are narrower than those of adults at the
orifice and isthmus, which increases the difficulty of endoscopic
transcanal manipulation; these factors may have also increased the
surgical time {[}21{]}. However, the average surgical time in the
pediatric group still fell within satisfactory limits.

The management of cholesteatoma required the longest surgical time
(average of all cases, 156 min); this was not surprising due to it being
a more sophisticated procedure. However, no difference was observed
between the pediatric and adult groups with regard to the surgical time
(pediatric group, 158.3 min; adult group, 155.6 min; p=0.897). (Table 3)

In the treatment of cholesteatoma, no statistically significant
difference was found between these two groups with respect to surgical
time because the TEES management of cholesteatoma is quite a
sophisticated and complicated procedure in both children and adults;
therefore, it generally has a longer surgical time regardless of the
group.

\textbf{Discussion:}

The feasibility of TEES in pediatric patients

In recent years, an increasing number of studies have proven the
benefits of TEES in managing middle ear diseases {[}10-20{]}. For the
management of cholesteatoma, better visualization of the residual
cholesteatoma in the hidden space can be provided by an endoscope {[}1,
5, 6, 10-20{]}. Such an endoscope can also provide a high-resolution
image in order to clearly identify the tympanic segment of the facial
nerve. The facial recess can be easily explored using an endoscope with
an angle-view without curetting or drilling the surrounding structure
around the facial nerve {[}4, 9{]}. Furthermore, with the transcanal
endoscope-assisted middle ear surgery, most of the healthy structures
and mastoid air cells, as well as the mucosal gas exchange and mastoid
buffer, can be preserved, which are crucial for restoring middle ear
function and reducing post-surgical morbidity {[}1, 2, 6, 20{]}. Muaaz
et al. have also suggested that the time needed for endoscopic ear
surgery is shorter than that required for traditional microscopic ear
surgery. Using the endoscopic transcanal approach facilitates faster
access to the pathologic lesion directly through the ear canal without
drilling the mastoid cavity, which may thus significantly reduce the
surgical time {[}4{]}.

Most of the previous studies were conducted in adult patients, while few
were conducted in pediatric patients. Studies on the applicability of
TEES in pediatric patients are lacking, and thus the efficacy and
feasibility of TEES in children remains controversial. The external
auditory canal (EAC) in children is shorter and narrower than that of
adults, and whether this may limit the application of TEES in pediatric
patients with middle ear disease is still under investigation. In a
study by Sun et al. on the anatomical applicability of TEES in children,
the authors provided anatomical evidence and suggested that TEES can be
a safe and effective alternative in the treatment of middle ear disease
in children with appropriate endoscopes and instruments {[}21{]}. Some
authors have already reported the successful clinical application of
endoscopes in middle ear surgery in children {[}22-24{]}.

Our study showed that the pediatric patients can have as good surgical
outcomes (including the rates of surgical success, postoperative
complications, and postoperative hearing gain) as adult patients,
regardless of the surgical procedure. The surgical time required for
TEES management of cholesteatoma was similar in both the pediatric and
the adult patients. Although the surgical time of tympanoplasty was
longer in children, it still fell within an acceptable range.

Study limitations

We have only begun to adopt TEES for the management of middle ear
disease in recent years. The number of patients in our study was still
limited, especially in the pediatric group. Furthermore, the follow-up
period was not long enough (18-to 48 months) to obtain long-term
results. We think that additional studies with more patients and
long-term follow-up may be required to generate more definitive
conclusions.

\textbf{Conclusion:}

We believe that TEES can be successfully and effectively used in the
treatment of middle ear disease in both adults and children, even in
complicated cholesteatoma cases. However, further studies involving a
larger number of patients are warranted to confirm our hypothesis.

\textbf{Data Availability Statement:}

The data that support the findings of this study are available from the
corresponding author upon reasonable request.

\textbf{References:}

\begin{enumerate}
\tightlist
\item
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\item
  Marchioni D, Soloperto D, Rubini A, Villari D, Genovese E, Artioli F,
  Presutti L. Endoscopic exclusive transcanal approach to the tympanic
  cavity cholesteatoma in pediatric patients: our experience. Int J
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\item
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\item
  Tarabichi M. Endoscopic management of limited attic cholesteatoma.
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  James AL. Endoscopic middle ear surgery in children. Otolaryngol Clin
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  Marchioni D, Mattioli F, Alicandri-Ciufelli M, Presutti L. Endoscopic
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\item
  Thomassin JM, Duchon-Doris JM, Emram B, Rud C, Conciatori J, Vilcoq P.
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  Yung MM. The use of rigid endoscopes in cholesteatoma surgery. J
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  Good GM, Isaacson G. Otoendoscopy for improved pediatric cholesteatoma
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\item
  Hanna BM, Kivekas I, Wu YH, Guo LJ, Lin H, Guidi, J, Poe D. Minimally
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  Badr-el-Dine M. Value of ear endoscopy in cholesteatoma surgery. Otol
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  Sajjadi H. Endoscopic middle ear and mastoid surgery for
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  Marchioni D, Alicandri-Ciufelli M, Grammatica A, Mattioli F, Presutti
  L. Pyramidal eminence and subpyramidal space: an endoscopic anatomical
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  Presutti L, Gioacchini FM, Alicandri-Ciufelli M, Villari D, Marchioni
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\end{enumerate}

\textbf{Tables:}

\textbf{Table 1}

Patient characteristics\selectlanguage{english}
\begin{longtable}[]{@{}lllllll@{}}
\toprule
\textbf{Variable} & \textbf{VTI} & \textbf{VTI} & \textbf{Tympanoplasty}
& \textbf{Tympanoplasty} & \textbf{Mastoidectomy} &
\textbf{Mastoidectomy}\tabularnewline
& Children & Adults & Children & Adults & Children &
Adults\tabularnewline
\textbf{Ears (number)} & 23 & 34 & 5 & 51 & 3 & 17\tabularnewline
\textbf{Mean age (years)} & 7.6 & 50.1 & 11.2 & 50.5 & 10 &
45.1\tabularnewline
\textbf{Age range (years)} & 3-18 & 24-78 & 6-15 & 27-78 & 5-16 &
26-60\tabularnewline
\textbf{Male sex (\%)} & 60.9\% & 82.4\% & 20.0\% & 42.0\% & 33.3\% &
35.3\%\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 2}

Comparison of surgical outcome of TEES between pediatric and adult
patients\selectlanguage{english}
\begin{longtable}[]{@{}llllllllll@{}}
\toprule
\textbf{Variable} & \textbf{VTI} & \textbf{VTI} & \textbf{VTI} &
\textbf{Tympanoplasty} & \textbf{Tympanoplasty} & \textbf{Tympanoplasty}
& \textbf{Mastoidectomy} & \textbf{Mastoidectomy} &
\textbf{Mastoidectomy}\tabularnewline
& Children (23) & Adults (34) & P & Children (5) & Adults (51) & P &
Children (3) & Adults (17) & P\tabularnewline
\textbf{Hearing gain (dB)} & 18.3 & 17.8 & 0.932 & 7.4 & 10.3 & 0.386 &
5.2 & 11.3 & 0.337\tabularnewline
\textbf{Preoperative air-bone gap} & 23.5 & 24.3 & 0.783 & 21 & 24.8 &
0.321 & 28.5 & 29.7 & 0.866\tabularnewline
\textbf{Postoperative air-bone gap} & 4.8 & 9.9 & 0.051 & 13.7 & 14.5 &
0.842 & 23.3 & 18.5 & 0.517\tabularnewline
\textbf{Success rate (\%)} & 100 & 100 & - & 80 & 96 & 0.253 & 100 & 100
& -\tabularnewline
\textbf{Postoperative complication rate (\%)} & 0 & 0 & -- & 0 & 0 & --
& 0 & 0 & --\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 3}

Comparison of surgical time of TEES between pediatric and adult patients\selectlanguage{english}
\begin{longtable}[]{@{}llllllllll@{}}
\toprule
\textbf{Variable} & \textbf{VTI} & \textbf{VTI} & \textbf{VTI} &
\textbf{Tympanoplasty} & \textbf{Tympanoplasty} & \textbf{Tympanoplasty}
& \textbf{Mastoidectomy} & \textbf{Mastoidectomy} &
\textbf{Mastoidectomy}\tabularnewline
& Children (23) & Adults (34) & P & Children (5) & Adults (51) & P &
Children (3) & Adults (17) & P\tabularnewline
\textbf{Surgical time (min)} & 11.7 & 19.1 & \textless{} 0.05 & 118 &
86.6 & \textless{} 0.05 & 158.3 & 155.6 & 0.897\tabularnewline
\bottomrule
\end{longtable}

\textbf{Figures:}

\textbf{Figure 1}

\textbf{Congenital cholesteatoma removal using TEES in a 5-year-old
girl} : A) After elevating the tympanomeatal flap, the cholesteatoma
behind the corda tympani was visible. Co = cholesteatoma; C = corda
tympani nerve; Tm = tympanomeatal flap; B) After drilling the scutum,
the surgeon carefully removed the cholesteatoma; C) The incus was
destroyed, and the stapes could not be identified during surgery.
Therefore, the destroyed incus was removed. I = destroyed incus; D) The
residual cholesteatoma at the sinus tympanum and the matrix at the oval
window were removed. O = oval window; E) Water irrigation of the middle
ear; F) Identification of the location of the foot plate and facial
nerve. Fp = foot plate; Fn = facial nerve; G) The scutum was
reconstructed using tragus cartilage. Meanwhile, the ossicular chain was
restored using total ossicular replacement prosthesis. T = tragus
cartilage; To = total ossicular replacement prosthesis (TORP); H)
Replacement of the tympanomeatal flap\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

\textbf{Permission of citation}

As the illustrator~of \textbf{``\emph{Transcanal Endoscopic Ear Surgery
for Congenital Cholesteatoma: A Preliminary Report,}''} I grant the
authors the right to publish the material both online and in print in a
scientific medical journal regarding the figures in the article
``\textbf{A Comparative Study of Transcanal Endoscopic Ear Surgery in
Pediatric and Adult Patients''} submitted to \emph{Otolaryngology-Head
and Neck Surgery} .\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/Figure-1/Figure-1}

\end{center}
\end{figure}

\selectlanguage{english}
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